NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of Rh sensitization. The physician orders a Kleihauer-Betke test. The purpose of this test is to:
Correct Answer: A
Rationale: The Kleihauer-Betke test quantifies fetal blood in maternal circulation critical in Rh sensitization to determine the dose of RhoGAM needed to prevent maternal antibody formation. It does not assess lung maturity antibodies or amniotic fluid volume.
Question 2 of 5
Which of the following changes in blood pressure readings should be of greatest concern to the nurse when assessing a prenatal client?
Correct Answer: D
Rationale: (A, B,
C) The individual's systolic and diastolic changes are more significant than the relatively high initial blood pressure readings. The systolic pressure went up 12 mm Hg and the diastolic pressure 18 mm Hg. This is a more significant rise than the increases in A-C choices, and client should receive more frequent evaluations and care.
Question 3 of 5
The primary reason that an increase in heart rate (100 bpm) detrimental to the client with a myocardial infarction (MI) is that:
Correct Answer: D
Rationale: Decreased stroke volume and blood pressure will occur secondary to decreased diastolic filling. Tachycardia primarily decreases diastole; systolic time changes very little. Contractility decreases owing to the decreased filling time and decreased time for fiber lengthening. Decreased O2 supply due to decreased time for filling of the coronary arteries increases ischemia and infarct size. Tachycardia primarily robs the heart of diastolic time, which is the primary time for coronary artery filling.
Question 4 of 5
A client returns to the cardiovascular intensive care unit following his coronary artery bypass graft. In planning his care, the most important electrolyte the nurse needs to monitor will be:
Correct Answer: C
Rationale: Potassium will need to be closely monitored because of its effects on the heart. Hypokalemia could result in supraventricular tachyarrhythmias.
Question 5 of 5
The nurse is caring for a client following a right nephrolithotomy. Post-operatively, the client should be positioned:
Correct Answer: C
Rationale: Positioning on the left side helps reduce pressure on the surgical site (right kidney) and promotes drainage and comfort post-nephrolithotomy.