NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of a mastectomy who is receiving radiation therapy. The nurse should teach the client to:
Correct Answer: C
Rationale: Avoiding sun exposure to the radiated area prevents further skin damage and irritation. Lotion, air exposure, and heating pads can worsen skin integrity.
Question 2 of 5
A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report:
Correct Answer: C
Rationale: Autonomic dysreflexia is an exaggerated reflex of the autonomic nervous system causing vasoconstriction and elevated blood pressure, often presenting with headache and facial flushing. The other symptoms listed are not associated with this condition.
Question 3 of 5
A female client at 30 weeks' gestation is brought into the emergency department after falling down a flight of stairs. On examination, the physician notes a rigid, boardlike abdomen; FHR in the 160s; and stable vital signs. Considering possible abdominal trauma, which obstetric emergency must be anticipated?
Correct Answer: A
Rationale: Abruptio placentae, the complete or partial separation of the placenta from the uterine wall, can be caused by external trauma. When hemorrhage is concealed, one sign is a rapid increase in uterine size with rigidity. Ectopic pregnancy occurs when the embryo implants itself outside the uterine cavity. Massive uterine rupture occurs during labor when the uterine contents are extruded through the uterine wall. It is usually due to weakness from a pre-existing uterine scar and trauma from instruments or an obstetrical intervention. Placenta previa is the condition in which the placenta is implanted in the lower uterine segment and either completely or partially covers the cervical os.
Question 4 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 5 of 5
The physician has ordered intravenous fluid with potassium for a client admitted with gastroenteritis and dehydration. Before adding potassium to the intravenous fluid, the nurse should:
Correct Answer: A
Rationale: Potassium supplementation requires adequate renal function to prevent hyperkalemia. Assessing urinary output ensures the kidneys are functioning before adding potassium.