NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
The primary reason that an increase in heart rate (100 bpm) detrimental to the client with a myocardial infarction (MI) is that:
Correct Answer: D
Rationale: Decreased stroke volume and blood pressure will occur secondary to decreased diastolic filling. Tachycardia primarily decreases diastole; systolic time changes very little. Contractility decreases owing to the decreased filling time and decreased time for fiber lengthening. Decreased O2 supply due to decreased time for filling of the coronary arteries increases ischemia and infarct size. Tachycardia primarily robs the heart of diastolic time, which is the primary time for coronary artery filling.
Question 2 of 5
A client is pregnant for the fourth time and has had three normal vaginal deliveries. She is in active labor and fully dilated. Suddenly she calls, 'Nurse, the baby is coming.' As the nurse responds to her call, which one of the following observations should the nurse make first?
Correct Answer: A
Rationale: The nurse must assess the labor status to determine if birth is imminent. The nurse may note perineal bulging, crowning, or birth of the head to ascertain labor status. Assessing uterine contractions is one intervention to ascertain labor status. Based on the client's cry, it is not the intervention of choice. If delivery of the infant is imminent, preparing a clean or sterile area for delivery is appropriate, but labor status must be established, whether delivery is imminent, by perineal assessment. Assessing FHR is one intervention to ascertain fetal well-being. Based on the client's cry, this is not the intervention of choice.
Question 3 of 5
The nurse is caring for a client with a nasogastric tube for decompression. Which action is most appropriate to ensure proper function?
Correct Answer: C
Rationale: Checking nasogastric tube placement (e.g., via pH or aspiration) before feedings or medications ensures the tube is in the stomach, preventing aspiration. Irrigation frequency depends on protocol, clamping may cause reflux, and supine positioning risks aspiration.
Question 4 of 5
Which emergency interventions should be carried out for the patient with a venomous snake bite of the right hand?
Correct Answer: A, E
Rationale: Snake bite management includes lying down (
A) to reduce venom spread and immobilizing the limb below heart level (E) to slow circulation. Oral antihistamines (
B) are ineffective acutely, history (
C) is secondary, and anti-venin testing (
D) is controversial and not routine.
Question 5 of 5
The nurse is caring for a client with a history of Rh sensitization. The physician orders a Kleihauer-Betke test. The purpose of this test is to:
Correct Answer: A
Rationale: The Kleihauer-Betke test quantifies fetal blood in maternal circulation critical in Rh sensitization to determine the dose of RhoGAM needed to prevent maternal antibody formation. It does not assess lung maturity antibodies or amniotic fluid volume.