NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of heart failure. Which discharge instruction is most important?
Correct Answer: A
Rationale: Daily weight monitoring detects fluid retention early in heart failure, allowing timely intervention. Exercise should be moderate, sodium restricted, and pain relievers used cautiously.
Question 2 of 5
A 9-month-old infant was diagnosed with nonorganic failure to thrive. During her hospitalization, primary nurses were assigned to initiate all infant feedings. The infant's parents question why they cannot feed their own child. Which of the following responses would be most appropriate by the nurse?
Correct Answer: A
Rationale: Consistent primary care nurses can better interpret infant cues and note feeding behaviors, which is critical in managing nonorganic failure to thrive.
Question 3 of 5
Which of the following nursing orders should be included in the plan of care for a client with hepatitis C?
Correct Answer: A
Rationale: Universal precautions are critical due to the bloodborne nature of hepatitis C. The other options are not appropriate for hepatitis C care.
Question 4 of 5
A client has just received an epidural block. She is laboring on her right side. The nurse notes that her blood pressure has dropped from 132/68 to 78/42 mm Hg. The nurse's first action would be to:
Correct Answer: D
Rationale: Nursing measures to support fetal oxygenation and promote maternal blood pressure would precede calling the physician. Systolic pressures below 100 mm Hg or a reduction in the systolic pressure of >30% necessitate treatment. Assessing the blood pressure in 5 minutes may allow for further fetal and/or maternal compromise. Turning the client on her left side will promote uteroplacental perfusion and is appropriate. Oxytocin (Pitocin) increases the strength of uterine contractions and may cause maternal hypotension; thus it is an inappropriate drug for use in this clinical situation. IV fluids would be increased to expand the circulating blood volume and promote increased blood pressure. Turning the mother to her left lateral side promotes uteroplacental perfusion. IV fluids are administered to increase the circulating blood volume, and O2 is administered to promote fetal oxygenation and decrease the nausea accompanying the hypotension.
Question 5 of 5
The client is admitted with a diagnosis of chorioamnionitis. Which symptom is most likely to be present?
Correct Answer: A
Rationale: Chorioamnionitis an infection of the amniotic fluid and membranes typically causes maternal fever. Fetal macrosomia decreased contractions and hypotension are not primary symptoms.