NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
Upon admission to the hospital, a client reports having "the worst headache I've ever had." The nurse should give the highest priority to which action?
Correct Answer: C
Rationale: A severe headache may indicate a neurological emergency (e.g., subarachnoid hemorrhage). Neuro checks (
C) assess for deterioration. Pain medication (
A), oxygen (
B), and Foley (
D) are secondary.
Question 2 of 5
The nurse is assessing a client following the removal of a pituitary tumor. The nurse notes that the urinary output has increased and that the urine is very dilute. The nurse should give priority to:
Correct Answer: A
Rationale: Increased, dilute urine post-pituitary surgery suggests diabetes insipidus due to decreased antidiuretic hormone, requiring immediate physician notification.
Question 3 of 5
Which of the following instructions should be included in the nurse's teaching regarding oral contraceptives?
Correct Answer: B
Rationale: Antibiotics can reduce the effectiveness of oral contraceptives by altering gut flora necessitating an alternate birth control method during antibiotic use. Weight gain and menstrual changes are common and doubling pills is not the correct protocol for missed doses.
Question 4 of 5
Which of the following findings would be abnormal in a postpartal woman?
Correct Answer: D
Rationale: Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous response or to vasomotor changes. If not followed by a fever, it is clinically innocuous. The pulse rate during the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt to the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. Urinary output increases during the early postpartal period (12-24 hours) owing to diuresis. The kidneys must eliminate an estimated 2000-3000 mL of extracellular fluid associated with a normal pregnancy. A temperature of 100.4°F (38°
C) may occur after delivery as a result of exertion and dehydration of labor. However, any temperature greater than 100.4°F needs further investigation to identify any infectious process.
Question 5 of 5
The client with a history of preterm labor is being monitored at 28 weeks gestation. The physician orders betamethasone (Celestone). The rationale for administering betamethasone is to:
Correct Answer: C
Rationale: Betamethasone a corticosteroid is given to women in preterm labor (24-34 weeks) to enhance fetal lung maturity by promoting surfactant production reducing the risk of respiratory distress syndrome. It does not prevent infection stimulate labor or prevent bleeding.