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NCLEX Practice Test RN Questions

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Question 1 of 5

The nurse is caring for an obstetrical client in early labor. After the rupture of membranes, the nurse should give priority to:

Correct Answer: B

Rationale: After rupture of membranes, assessing fetal heart tones is critical to detect distress, such as cord prolapse. Monitoring, anesthesia, and catheterization are secondary priorities.

Question 2 of 5

A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?

Correct Answer: D

Rationale: Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation.

Question 3 of 5

A 2-year-old toddler is hospitalized with epiglottitis. In assessing the toddler, the nurse would expect to find:

Correct Answer: C

Rationale: A productive cough is not associated with epiglottitis. Children with epiglottitis seldom have expiratory stridor. Inspiratory stridor is more common due to edema of the supraglottic tissues. Because of difficulty with swallowing, drooling often accompanies epiglottitis. Crackles are not heard in the lower lobes with epiglottitis because the infection is usually confined to the supraglottic structures.

Question 4 of 5

A 38-year-old pregnant woman visits her nurse practitioner for her regular prenatal checkup. She is 30 weeks' gestation. The nurse should be alert to which condition related to her age?

Correct Answer: D

Rationale: Iron-deficiency anemia can occur throughout pregnancy and is not age related. STDs can occur prior to or during pregnancy and are not age related. Intrauterine growth retardation is an abnormal process where fetal development and maturation are delayed. It is not age related. Physical risks for the pregnant client older than 35 include increased risk for PIH, cesarean delivery, fetal and neonatal mortality, and trisomy.

Question 5 of 5

A client admitted to the psychiatric unit claims to be the Pope and insists that he will not be kept away from his followers. The most likely explanation for the client's delusion is:

Correct Answer: C

Rationale: Delusions of grandeur, like claiming to be the Pope, often stem from low self-esteem in psychiatric disorders like schizophrenia, compensating for feelings of inadequacy. The other factors are less specific.

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