NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a diagnosis of gestational trophoblastic disease. Which laboratory value is most likely to be elevated?
Correct Answer: A
Rationale: Gestational trophoblastic disease (e.g. molar pregnancy) causes markedly elevated hCG levels due to abnormal trophoblastic tissue growth. AFP estriol and progesterone are not typically elevated in this condition.
Question 2 of 5
The doctor has ordered a restricted fluid intake for a 2-year-old child with a head injury. Normal fluid intake for a child of 2 years is:
Correct Answer: C
Rationale: Normal intake for a child of 2 years is about 1600 mL in 24 hours.
Question 3 of 5
The nurse is caring for a client with a history of a colostomy who is experiencing leakage around the stoma. The nurse should:
Correct Answer: C
Rationale: Leakage around a colostomy stoma often indicates a poor skin barrier fit, requiring adjustment or resizing. Larger appliances, alcohol, and irrigation do not address the issue.
Question 4 of 5
A client is admitted with suspected pneumothorax. Which finding is most significant in confirming the diagnosis?
Correct Answer: A
Rationale: Tracheal deviation to the unaffected side is a hallmark of tension pneumothorax, indicating mediastinal shift due to air trapping, confirming the diagnosis.
Question 5 of 5
The mother of a client is apprehensive about taking home her 2 year old who was diagnosed with asthma after being admitted to the emergency room with difficulty breathing and cyanosis. She asks the nurse what symptoms she should look for so that this problem will not happen again. The nurse instructs her to watch for the following early symptoms:
Correct Answer: C
Rationale: The child with asthma may not have fever unless there is an underlying infection. Edema of the eyes will not be present because the child with asthma is more likely to have dehydration related to excessive water loss during the work of breathing. All of these symptoms indicate decreased oxygenation and are early symptoms of asthma. Coughing and wheezing are not early signs of difficulty.