NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
The nurse is caring for a client in labor. The fetal heart rate is 80 bpm with moderate variability. The most appropriate initial action by the nurse is to:
Correct Answer: C
Rationale: A fetal heart rate of 80 bpm indicates bradycardia possibly due to cord compression or uteroplacental insufficiency. Repositioning the client to her left side improves placental perfusion and is the first action. Oxygen notifying the physician or increasing fluids are secondary.
Question 2 of 5
In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnosis as a priority?
Correct Answer: C
Rationale: Ulcerative colitis causes diarrhea, leading to significant fluid and electrolyte loss, making fluid volume deficit a priority nursing diagnosis to prevent dehydration and shock. Anxiety, skin integrity, and nutrition are secondary concerns.
Question 3 of 5
A client is admitted with disseminated herpes zoster (shingles). According to the Centers for Disease Control Guidelines for Infection Control:
Correct Answer: A
Rationale: Disseminated herpes zoster requires airborne precautions because the varicella-zoster virus can spread through respiratory droplets in immunocompromised patients.
Question 4 of 5
Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client's depression alert the nurse to prioritize problems and care by addressing which of the following problems first:
Correct Answer: C
Rationale: Anorexia and weight loss are problems that need attention in severe depression, but they can be addressed secondary to immediate concerns. Impaired thinking and confusion are problems in severe depression that are addressed with administration of medication, through group and individual psychotherapy, and through activity therapy as motivation and interest increase. Possible harm to self as with suicidal ideation; a suicide plan, means to execute plan; and/or overt gestures or an attempt must be addressed as an immediate concern and safety measures implemented appropriate to the risk of suicide. Rest and activity impairment may take time and further assessment to determine client's sleep pattern and amount of psychomotor retardation with the more immediate concern for safety present.
Question 5 of 5
The client with a history of diabetes insipidus is admitted with polyuria,polydipsia,and mental confusion. The priority intervention for this client is:
Correct Answer: B
Rationale: Mental confusion in diabetes insipidus may indicate severe dehydration or electrolyte imbalances. Checking vital signs is the priority to assess for instability (e.g. hypotension tachycardia) and guide immediate treatment. The other interventions are secondary.