NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a diagnosis of postpartum depression. Which intervention is most appropriate?
Correct Answer: A
Rationale: Postpartum depression requires mental health intervention such as referral to a psychiatrist for therapy or medication. Antibiotics fetal monitoring and tocolytics are irrelevant to this condition.
Question 2 of 5
Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:
Correct Answer: C
Rationale: A pulse rate below 60 bpm indicates bradycardia, a contraindication for digoxin due to the risk of worsening heart block. The nurse should withhold the dose and notify the physician.
Question 3 of 5
An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to:
Correct Answer: B
Rationale: A tension pneumothorax is an accumulation of air in the pleural space. Important physical assessment findings to confirm this condition include cyanosis, jugular vein distention, absent breath sounds on the affected side, distant heart sounds, and lowered blood pressure. Asthma is a disorder in which there is an airflow obstruction in the bronchioles and smaller bronchi secondary to bronchospasm, swelling of mucous membranes, and increased mucus production. Physical assessment reveals some important findings: agitation, nasal flaring, tachypnea, and expiratory wheezing. Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung in the alveolar and interstitial tissue and results in consolidation. Specific assessment findings to confirm this condition include decreased chest expansion caused by pleuritic pain, dullness on percussion over consolidated areas, decreased breath sounds, and increased vocal fremitus. A pulmonary embolus is the passage of a foreign substance (blood clot, fat, air, or amniotic fluid) into the pulmonary artery or its branches, with subsequent obstruction of blood supply to lung tissue. Specific assessment findings that confirm this condition include tachypnea, tachycardia, crackles (rales), transient friction rub, diaphoresis, edema, and cyanosis.
Question 4 of 5
The pediatric nurse charts that the parents of a 4-year-old child are very anxious. Which observation would indicate to the nurse unhealthy coping by these parents:
Correct Answer: D
Rationale: (A, B,
C) These methods are healthy ways of dealing with anxiety. Participation minimizes feelings of helplessness and powerlessness. It is important that parents have accurate information and that they seek support from sources available to them.
Question 5 of 5
A child is admitted with suspected epiglottitis. Which action is not a part of the nursing care?
Correct Answer: B
Rationale: Assessing the throat with a tongue blade is contraindicated in suspected epiglottitis as it may trigger airway obstruction. Vital signs oxygen and antibiotics are appropriate interventions.