NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The physician prescribes phenytoin (Dilantin) for a client with seizure disorders. Phenytoin can only be mixed with which of the following solutions?
Correct Answer: D
Rationale: Phenytoin is compatible only with normal saline and should be mixed only with normal saline for administration.
Question 2 of 5
In working with a manipulative client, which of the following nursing interventions would be most appropriate?
Correct Answer: C
Rationale: This answer is incorrect. Bargaining is a manipulative act, which the nurse could expect from the client. This answer is incorrect. Confrontation is an effective nursing strategy with manipulative behavior. Redirection is appropriate for the client who is out of touch with reality. This answer is correct. Manipulative clients must abide by consistent rules. This answer is incorrect. Manipulation is kept at a minimum if the same staff person is assigned to the client. Often the client will attempt to play staff persons against each other.
Question 3 of 5
A 2-day-old infant boy has been diagnosed with an atrial septal defect due to a persistent patent foramen ovale. When explaining the diagnosis to the mother, the nurse includes in the discussion the function of the foramen ovale. In fetal circulation, the foramen ovale allows a portion of the blood to bypass the:
Correct Answer: B
Rationale: The foramen ovale permits a percentage of the blood to shunt from the right atrium to the left atrium. The blood then goes to the left ventricle, permitting systemic fetal circulation with blood containing a higher O2 saturation. As the blood shunts from the right atrium to the left atrium, the pulmonary system is bypassed. The fetus receives O2 from the maternal circulation, thereby permitting the partial bypass of the pulmonary system. The foramen ovale is located in the atrial septum of the heart and does not affect the liver. The superior vena cava returns blood to the heart, bringing blood to the location of the foramen ovale.
Question 4 of 5
Painless vaginal bleeding in the last trimester may be caused by:
Correct Answer: C
Rationale: Placenta previa causes painless vaginal bleeding due to the low-lying placenta separating from the uterine wall.
Question 5 of 5
A client with a T6 injury six months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?
Correct Answer: B
Rationale: Facial flushing and severe hypertension suggest autonomic dysreflexia, often triggered by a distended bladder in spinal cord injury. Assessing and relieving the trigger (
B) is priority. Notifying the physician (
A), oxygen (
C), or fluids (
D) is secondary.