NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the nurse take?
Correct Answer: D
Rationale: This is not a normal occurrence. Late decelerations need prompt intervention for immediate infant recovery.
To increase O2 perfusion to the unborn infant, the mother should be placed on her left side. IV fluids should be increased, not decreased. Immediate action is warranted, such as reporting findings, turning mother on left side, administering O2, discontinuing oxytocin (Pitocin), assessing maternal blood pressure and the labor process, preparing for immediate cesarean delivery, and explaining plan of action to client.
Question 2 of 5
A 10-year-old has been diagnosed with acute poststreptococcal glomerulonephritis. The clinical findings were proteinuria, moderately elevated blood pressure, and periorbital edema. Which dietary plan is most appropriate for this client?
Correct Answer: B
Rationale: A high-protein diet is usually indicated because protein is excreted in urine. Protein restriction is usually prescribed with severe azotemia. The kidneys usually enlarge in these children, and sodium and water are retained. Fluid restriction may be ordered to help reduce edema; however, monitoring for dehydration is indicated. A high-cholesterol diet would not be indicated for any child, especially one with elevated blood pressure.
Question 3 of 5
A client with a history of lung cancer is admitted with complaints of hemoptysis. The nurse should give priority to:
Correct Answer: A
Rationale: Hemoptysis in lung cancer indicates potential airway compromise, so monitoring respiratory status is the priority.
Question 4 of 5
A client is being monitored using a central venous pressure monitor. If the CVP is 1 cm of water, the nurse should:
Correct Answer: A
Rationale: A CVP of 1 cm of water (normal range 2–8 mmHg or 3–10 cm H2O) is low, suggesting hypovolemia or decreased venous return. The nurse should notify the physician immediately for further evaluation and possible fluid administration.
Question 5 of 5
At her first prenatal visit, a 21-year-old woman who is gravida 2, para 0, ab 1, is currently at 32 weeks' gestation and has a history of drug abuse, smoking, and occasional ethyl alcohol use. Fetal ultrasound tests indicate poor fetal growth. The most likely reason for the infant's intrauterine growth retardation is:
Correct Answer: C
Rationale: Compounds in cigarettes and some illicit drugs cause maternal vasoconstriction and a subsequent reduction in O2 availability for the fetus, leading to intrauterine growth retardation. Alcohol consumption also decreases birth weight.