NCLEX-RN
NCLEX RN Practice Questions Quizlet Questions
Extract:
Question 1 of 5
The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the:
Correct Answer: A
Rationale: The phlebostatic axis (4th intercostal space, mid-axillary line) is the standard reference point for accurate central venous pressure measurement.
Question 2 of 5
A client with an artificial eye is too ill to remove the eye, but the lids are crusted and irritated, so the nurse must remove the prosthesis for cleaning and to inspect the eye socket. The nurse has washed hands and applied disposable gloves. Place the remaining steps to removing the prosthesis (Roman numerals) in the correct order.
Order the Items
Source Container
Correct Answer: A,D,B,C
Rationale: Prosthesis removal: Retract upper lid (I), retract lower lid (IV), slip finger under prosthesis (II), break suction and remove (III).
Question 3 of 5
The nurse is preparing to administer a dose of metoprolol (Lopressor) to a client with hypertension. The client’s heart rate is 58 beats per minute. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: metoprolol is a beta-blocker, and a heart rate of 58 beats per minute is below the threshold for administration, requiring physician notification
Question 4 of 5
A client arrives in the emergency room after a motor vehicle accident. Witnesses tell the nurse that they observed the client's head hit the side of the car door. Nursing assessment findings include BP 70/34, heart rate 130, and respirations 22. Which is the client's most appropriate priority nursing diagnosis?
Correct Answer: B
Rationale: Hypotension (BP 70/34) and tachycardia (HR 130) indicate hypovolemic shock, likely from blood loss. Fluid volume deficit is the priority diagnosis to address life-threatening hypovolemia.
Question 5 of 5
As the client reaches 8cm dilation, the nurse notes a pattern on the fetal monitor that shows a drop in the fetal heart rate of 30 bpm beginning at the peak of the contraction and ending at the end of the contraction. The FHR baseline is 165-175 bpm with variability of 0-2 bpm. What is the most likely explanation of this pattern?
Correct Answer: D
Rationale: Late decelerations (FHR drop at contraction peak) with minimal variability suggest uteroplacental insufficiency, impairing fetal oxygenation.