NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a diagnosis of molar pregnancy. Which complication is most likely to occur?
Correct Answer: A
Rationale: Molar pregnancy can progress to choriocarcinoma a malignant tumor in rare cases. Fetal distress and preterm labor are not risks as there is no viable fetus and hypoglycemia is unrelated.
Question 2 of 5
The client is admitted with a diagnosis of molar pregnancy. Which laboratory test is most likely to be ordered?
Correct Answer: A
Rationale: Serum hCG levels are markedly elevated in molar pregnancy and are the primary test for diagnosis and monitoring. CBC and urinalysis may be ordered for general assessment but are less specific.
Question 3 of 5
A client has been in labor for 10 hours. Her contractions have become hypoactive and slowed in duration. The fetus is at 0 station, cervix is dilated 8 cm and effaced 90%. The physician orders an oxytocin (Pitocin) infusion to be started at once. The RN begins the oxytocin infusion. It is important that the RN discontinue the infusion if which one of the following occur?
Correct Answer: A
Rationale: Contractions less than 2 minutes apart indicate hyperstimulation, which can reduce uterine blood flow, leading to fetal hypoxia. The infusion should be discontinued to prevent complications.
Question 4 of 5
The nurse is caring for a client with a history of a mastectomy who is receiving Tamoxifen (Nolvadex). The nurse should teach the client to:
Correct Answer: A
Rationale: Tamoxifen increases the risk of endometrial cancer, so vaginal bleeding must be reported immediately. Sun exposure, caffeine, and fluid intake are not primary concerns.
Question 5 of 5
A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:
Correct Answer: D
Rationale: This change in blood pressure may not be significant and does not indicate a widening pulse pressure, a late sign of increased ICP. It is important to continue to monitor for change in blood pressure. Acetaminophen may be ineffective in relieving headache after head injury. Stronger analgesics are contraindicated because they mask neurological signs and may depress the CNS. Pulse rates between 68 bpm and 76 bpm are within normal limits for a 14-year-old child. It is important to monitor for a consistent drop in pulse rate, which is a late sign of increasing ICP. An elevated temperature is abnormal and requires further assessment and medical intervention. The temperature may be unrelated to the head injury, but CNS infection is serious and difficult to control.