NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of ectopic pregnancy. Which risk factor is most likely to be present?
Correct Answer: A
Rationale: Pelvic inflammatory disease (PI
D) is a major risk factor for ectopic pregnancy as it can scar the fallopian tubes impairing embryo transport. Gestational diabetes hypertension and multiple gestations are not strongly associated.
Question 2 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 3 of 5
Which of the following should the nurse anticipate receiving as an as-needed order for a postoperative carotid endarterectomy client?
Correct Answer: A
Rationale: It is important to maintain a normal to slightly lower pressure to prevent the graft from blowing and excessive pressure to surgical vascular areas. (B, C,
D) None of these drugs is related to managing the problem at hand. Also, none of the problems for which these drugs would be indicated is expected with this type of surgery, except if there is a prior history.
Question 4 of 5
The client's membranes rupture during labor. The fetal heart rate suddenly drops to 90 bpm. The nurse's first action should be to:
Correct Answer: B
Rationale: A sudden drop in fetal heart rate to 90 bpm after membrane rupture suggests possible umbilical cord prolapse or compression. Turning the client to her left side improves placental perfusion and may relieve cord compression. Oxygen and notifying the physician are secondary and increasing IV fluid is less urgent.
Question 5 of 5
A female client admitted to the labor and delivery unit thinks her bag of water 'broke' approximately 2 hours ago. She is having mild contractions 5 minutes apart. The most immediate nursing intervention would be to:
Correct Answer: B
Rationale: Amniotic fluid is generally pale and straw colored. Meconium-stained amniotic fluid would indicate a previous hypoxic episode. This intervention, though appropriate, is not the immediate priority. With rupture of the membranes, the umbilical cord may prolapse if the presenting part does not fill the pelvis. Assessing FHR ascertains fetal well-being. More information regarding fetal status and assessing for membrane rupture is needed prior to contacting the physician. Nitrazine test paper differentiates amniotic fluid from urine. Amniotic fluid is normally alkaline in contrast to urine, which is acidic. This intervention, though appropriate, is not the immediate priority.