NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is receiving oxytocin for labor induction. The fetal heart rate shows variable decelerations. The nurse’s first action should be to:
Correct Answer: B
Rationale: Variable decelerations suggest umbilical cord compression. Repositioning the client (e.g. to the left side or knee-chest position) may relieve compression and is the first action. Stopping oxytocin or notifying the physician may be needed if repositioning is ineffective.
Question 2 of 5
The nurse is preparing to administer a dose of lorazepam (Ativan) for anxiety. Which assessment is most important before administration?
Correct Answer: B
Rationale: Lorazepam, a benzodiazepine, can cause respiratory depression, so assessing respiratory rate is critical before administration. Other vital signs are monitored but are less specific.
Question 3 of 5
A client with Hodgkin's lymphoma is receiving Platinol (cisplatin). To help prevent nephrotoxicity, the nurse should:
Correct Answer: B
Rationale: Cisplatin is nephrotoxic, and adequate hydration helps dilute the drug and protect the kidneys, reducing the risk of renal damage.
Question 4 of 5
A 50-year-old male client is to receive chemotherapy. The physician's orders include antiemetics. When planning his care, the nurse should take into consideration that antiemetics are best administered in the following way:
Correct Answer: B
Rationale: Nausea is more difficult to control if antiemetics are withheld until nausea is experienced. Antiemetics should be given prophylactically at the beginning of chemotherapy and continued on an around-the-clock basis to prevent nausea. Combinations of antiemetics give the best control for nausea by blocking various causes of nausea induced by chemotherapy. Antiemetics should be given around the clock during the course of chemotherapy. This prevents nausea from developing and prevents anticipatory nausea during subsequent chemotherapy administrations.
Question 5 of 5
A male client is undergoing cardiac tests. He has been instructed to wear a Holter monitor. The nurse knows she has included the appropriate information in her teaching when the client tells her:
Correct Answer: C
Rationale: The client should leave the electrodes in place during the entire time the test is ordered. He should not even remove the electrodes for bathing. The Holter monitor will record cardiac electrical activity but will not record damage to his myocardium. The client should keep a record of all of his activities so the physician can correlate the ECG findings with his activities. The client should continue doing his regular activities. The purpose of the Holter monitor is to record heart activity during routine activities.