NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When assessing the client’s response to the Pitocin, the nurse should give priority to:
Correct Answer: B
Rationale: Pitocin can cause uterine hyperstimulation, risking fetal distress. Checking the fetal heart rate is the priority to ensure fetal well-being. Blood pressure, contractions, and urinary output are monitored but are secondary to fetal status.
Question 2 of 5
Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?
Correct Answer: B
Rationale: While fresh fruit is low in protein, a milkshake is a better choice as it provides carbohydrates and some protein in a form that is easier to digest, which is crucial for clients with cirrhosis to avoid ammonia buildup. A milkshake is appropriate as it provides carbohydrates, which are needed to prevent protein catabolism, and has lower protein content compared to options like peanut butter or ham, reducing the risk of ammonia accumulation. (C,
D) Both saltine crackers with peanut butter and a ham and cheese sandwich are high in protein, which can increase ammonia levels, exacerbating hepatic encephalopathy.
Question 3 of 5
The nurse is caring for a client with a history of heart failure. Which discharge instruction is most important?
Correct Answer: A
Rationale: Daily weight monitoring detects fluid retention early in heart failure, allowing timely intervention. Exercise should be moderate, sodium restricted, and pain relievers used cautiously.
Question 4 of 5
An 18-month-old is admitted to the hospital with acute laryngotracheobronchitis. When assessing the respiratory status, the nurse should expect to find:
Correct Answer: A
Rationale: Acute laryngotracheobronchitis (croup) typically presents with inspiratory stridor and a harsh, barking cough due to subglottic airway inflammation.
Question 5 of 5
A client with angina is being discharged with a prescription for Transderm Nitro (nitroglycerin) patches. The nurse should tell the client to:
Correct Answer: D
Rationale: Cutting a nitroglycerin patch can alter the dose by disrupting the drug delivery system, so clients should be instructed to avoid this.