NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
The nurse is conducting a physical assessment on a client with mild anemia. Which of the following would the nurse expect to observe?
Correct Answer: C
Rationale: Mild anemia reduces oxygen-carrying capacity leading to fatigue and activity intolerance. Heart murmurs increased respiratory rate or frequent infections are not typical findings in mild anemia unless complications arise.
Question 2 of 5
When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the nurse take?
Correct Answer: D
Rationale: This is not a normal occurrence. Late decelerations need prompt intervention for immediate infant recovery.
To increase O2 perfusion to the unborn infant, the mother should be placed on her left side. IV fluids should be increased, not decreased. Immediate action is warranted, such as reporting findings, turning mother on left side, administering O2, discontinuing oxytocin (Pitocin), assessing maternal blood pressure and the labor process, preparing for immediate cesarean delivery, and explaining plan of action to client.
Question 3 of 5
The usual treatment for diabetes insipidus is with IM or SC injection of vasopressin tannate in oil. Nursing care related to the client receiving IM vasopressin tannate would include:
Correct Answer: D
Rationale: Weight should be obtained daily. Fluid is not restricted but is given according to urine output. The medication does not have to be stored in a refrigerator. Holding the vial under warm water for 10-15 minutes or rolling between your hands and shaking vigorously before drawing medication into the syringe activates the medication in the oil solution.
Question 4 of 5
A 50-year-old male client is to receive chemotherapy. The physician's orders include antiemetics. When planning his care, the nurse should take into consideration that antiemetics are best administered in the following way:
Correct Answer: B
Rationale: Nausea is more difficult to control if antiemetics are withheld until nausea is experienced. Antiemetics should be given prophylactically at the beginning of chemotherapy and continued on an around-the-clock basis to prevent nausea. Combinations of antiemetics give the best control for nausea by blocking various causes of nausea induced by chemotherapy. Antiemetics should be given around the clock during the course of chemotherapy. This prevents nausea from developing and prevents anticipatory nausea during subsequent chemotherapy administrations.
Question 5 of 5
Nursing care for the parents of a child with a congenital heart defect would include:
Correct Answer: B
Rationale: It is important to discuss with parents the need to treat the child as they would any other children, but they must be truthful and honest with the child about the heart defect. As the child grows older, explanations can go into greater depth. Parents of children with congenital heart defects go through a grieving process over the loss of their 'healthy' child. The nurse needs to recognize these feelings and give the parents a role in the child's care when they are ready. Anger and resentment are normal feelings that must be dealt with appropriately. Parents may go through a second grieving process after the repair of the cardiac defect. During this grieving period, they mourn the loss of the 'defective' child who now may be essentially 'normal.'