NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
The nurse is teaching a client with a history of celiac disease about dietary modifications. The nurse should tell the client to avoid:
Correct Answer: A
Rationale: Celiac disease requires a gluten-free diet to prevent intestinal damage, so avoiding gluten-containing foods is essential.
Question 2 of 5
A client diagnosed with severe anemia is to receive 2 U of packed red blood cells. Prior to starting the blood transfusion, the nurse must:
Correct Answer: A
Rationale: A baseline set of vital signs is necessary to determine if any transfusion reactions occur as the blood product is being administered. The only companion fluid to be used during a blood transfusion is normal saline. The calcium in Ringer's lactate can cause clotting. Only a blood administration set should be used. A microdrip tube would cause lysis of the red blood cells. Proper identification of the recipient and the blood product must be validated by at least two people.
Question 3 of 5
Early in her ninth month of pregnancy, a client has been diagnosed as having mild preeclampsia. In counseling her about her diet, the nurse must emphasize the importance of:
Correct Answer: D
Rationale: Women with pregnancy-induced hypertension have a reduced plasma volume secondary to venous vessel constriction, not hypovolemia; therefore, sodium restriction is not recommended. It is suggested that these women avoid extremely salty foods. Drinking six to eight glasses of water per day facilitates optimal fluid volume and renal perfusion, but it will not decrease the venous vessel constriction of pregnancy-induced hypertension. Carbohydrate needs increase during pregnancy, specifically during the second and third trimesters, but they have not been linked to pregnancy-induced hypertension. Loss of urinary protein (proteinuria) is associated with increased permeability of the large protein molecules with pregnancy-induced hypertension. Additional dietary protein also helps increase the plasma colloidal osmotic pressure. Diets deficient in protein have been linked to pregnancy-induced hypertension.
Question 4 of 5
As the client reaches 6cm dilation,the nurse notes late decelerations on the fetal monitor. What is the most likely explanation of this pattern?
Correct Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency where reduced placental blood flow during contractions causes fetal hypoxia. Cord compression causes variable decelerations head compression causes early decelerations and sleep does not cause decelerations.
Question 5 of 5
A client with a history of a stroke is receiving tPA (alteplase). The nurse should:
Correct Answer: A
Rationale: tPA, a thrombolytic, increases bleeding risk, requiring close monitoring for signs like hematuria or hematoma. It’s given over 1 hour, glucose is unrelated, and fluids are not restricted.