NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 of 5
The parents of a child with cystic fibrosis ask what determines the prognosis of the disease. The nurse knows that the greatest determinant of the prognosis is:
Correct Answer: A
Rationale: Pulmonary involvement is the primary determinant of prognosis in cystic fibrosis, as progressive lung disease is the leading cause of morbidity and mortality.
Question 2 of 5
A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin. The nurse's first intervention should be to:
Correct Answer: C
Rationale: FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. The physician should be notified, but this is not the first intervention the nurse should do. The standard of care for an induction according to the Association of Women's Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. Contractions lasting 60-90 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor.
Question 3 of 5
The nurse is assessing a client who had a colon resection two days ago. The client states, "I feel like my stitches have burst loose." Upon further assessment, dehiscence of the wound is noted. Which action should the nurse take?
Correct Answer: B
Rationale: Applying a sterile, saline-moistened dressing protects the dehisced wound and prevents infection. Prone positioning (
A) is inappropriate, atropine (
C) doesn’t address dehiscence, and an ACE bandage (
D) may worsen the condition.
Question 4 of 5
During a unit card game, a client with acute mania begins to sing loudly as she starts to undress. The nurse should:
Correct Answer: D
Rationale: Covering the client and escorting her to a private area maintains dignity and safety, de-escalating the situation caused by manic behavior.
Question 5 of 5
A 45-year-old male client was admitted to a chemical dependency treatment center following legal problems related to alcohol abuse. He states, 'I know that alcohol is a problem for some people, but I can stop whenever I want to. I'm never sick or miss work, and no one can complain about me.' During the initial assessment, the best response by the nurse would be:
Correct Answer: B
Rationale: Direct confrontation initially is nontherapeutic and may result in the client becoming frustrated and wanting to leave. A positive, supportive attitude builds trust, and identifying positive strength raises self-esteem. Offering help allows the client to feel that he is not alone in dealing with problems. Asking the client why or to give an explanation for his behavior puts him in a position of having to justify his behavior to the nurse. Giving approval or placing a value on feelings or a behavior may limit the client's freedom to behave in a way that may displease another. This response may lead to seeking praise instead of progress.