NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
The nurse is performing an assessment on an elderly client who had a total hip repair this morning. Which assessment finding indicates that the patient is in pain?
Correct Answer: D
Rationale: Grimacing during care is a direct behavioral indicator of pain, common in post-operative patients. Elevated blood pressure, inability to concentrate, or dilated pupils may have other causes and are less specific.
Question 2 of 5
A client with a history of gout is prescribed allopurinol (Zyloprim). Which laboratory value should the nurse monitor closely?
Correct Answer: A
Rationale: Allopurinol reduces uric acid production in gout. Monitoring serum uric acid ensures therapeutic effect. Glucose (
B), potassium (
C), and hemoglobin (
D) are not directly affected.
Question 3 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 4 of 5
A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse anticipates the physician ordering:
Correct Answer: C
Rationale: Ampicillin is a safe antibiotic for pyelonephritis in pregnancy, with no known teratogenic effects.
Question 5 of 5
A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain. She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the following findings in the client's nursing assessment demand immediate nursing action?
Correct Answer: B
Rationale: Indigestion or nausea may accompany angina or myocardial infarction, but they do not indicate imminent danger for the client. Restlessness and apprehensiveness require immediate nursing action because they are indicative of very low oxygenation of body tissues and are frequently the first indication of impending cardiac or respiratory arrest. It is common for the cardiac client to experience fatigue and inability to physically tolerate long assessment sessions. A history of hypertension requires no immediate nursing intervention. In the situation described, the blood pressure is not given and therefore cannot be assumed to be elevated.