NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
The nurse is ready to begin an exam on a nine-month-old infant who is sitting quietly on his mother's lap. Which should the nurse do first?
Correct Answer: B
Rationale: When examining an infant, the nurse should start with the least invasive procedures to maintain the infant’s calm state. Listening to heart and lung sounds is non-invasive and can be done while the infant is quiet. Checking the Babinski reflex, palpating the abdomen, or checking tympanic membranes may cause discomfort and disrupt the exam.
Question 2 of 5
The nurse is notified that a 27-year-old primigravida diagnosed with complete placenta previa is to be admitted to the hospital for a cesarean section. The client is now at 36 weeks' gestation and is presently having bright red bleeding of moderate amount. On admission, the nursing intervention that the nurse should give the highest priority to is:
Correct Answer: B
Rationale: These nursing actions are necessary prior to the cesarean section, but not immediately necessary to maintain physiological equilibrium. Determining the physiological status of the fetus would constitute the highest priority in evaluating and maintaining fetal life. These nursing actions are necessary prior to the cesarean section, but not immediately necessary百2.5.3.2 immediately necessary to maintain physiological equilibrium. These nursing actions are necessary prior to the cesarean section, but not immediately necessary to maintain physiological equilibrium.
Question 3 of 5
The nurse is caring for a client with a history of a seizure disorder who is receiving Valproic acid (Depakote). The nurse should monitor the client for:
Correct Answer: A
Rationale: Valproic acid can cause hepatotoxicity, requiring monitoring of liver enzymes. Hypotension, hyperglycemia, and weight loss are not primary side effects.
Question 4 of 5
A client with a history of lung cancer is admitted with complaints of hemoptysis. The nurse should give priority to:
Correct Answer: A
Rationale: Hemoptysis in lung cancer indicates potential airway compromise, so monitoring respiratory status is the priority.
Question 5 of 5
With a geriatric client, the nurse should also assess whether he has been obtaining a yearly vaccination against influenza. Why is this assessment important?
Correct Answer: C
Rationale: Older clients have less effective immune systems, increasing their risk for influenza complications, making yearly vaccination critical.