NCLEX-RN
Mock NCLEX RN Exam Questions
Extract:
Question 1 of 5
Which nursing implication is appropriate for a client undergoing a paracentesis?
Correct Answer: A
Rationale: A full bladder impedes ascitic fluid withdrawal during paracentesis, so the client should void beforehand.
Question 2 of 5
The nurse is preparing to receive a client from admitting with tumor lysis syndrome (TLS). Which of the following would the nurse expect to find on the laboratory and patient history sections of the chart?
Correct Answer: A,C,D,E
Rationale: TLS causes hyperkalemia (
C), hyperuricemia (
D), and mental changes (E) due to electrolyte imbalances and low blood pressure (
A) from fluid shifts. Hyperactivity (
B) is not typical.
Question 3 of 5
The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin,the nurse should monitor for:
Correct Answer: B
Rationale: Pitocin (oxytocin) can cause uterine hyperstimulation leading to reduced placental perfusion and fetal bradycardia (heart rate <110 bpm). Monitoring for fetal bradycardia is critical. Hypoglycemia hyperreflexia and fetal movement frequency are not directly related to Pitocin complications.
Question 4 of 5
A client is in early labor. Her fetus is in a left occipitoanterior (LOA) position; fetal heart sounds are best auscultated just:
Correct Answer: A
Rationale: In LOA, the fetus's back is on the mother's left anterior side, so fetal heart sounds are best heard below the umbilicus on the left.
Question 5 of 5
The nurse has been assigned a client who delivered a 6-lb, 12-oz baby boy vaginally 40 minutes ago. The initial assessment of greatest importance for this client would be:
Correct Answer: D
Rationale: The length of labor has little bearing on the fourth stage of labor. The type of labor and delivery is significant. The type of episiotomy will affect the client's comfort level. However, the nurse's assessment and implementations center on prevention of hemorrhage during the fourth stage of labor. The amount of bleeding from the episiotomy or hematoma formation is of higher priority than the type of episiotomy. The amount of IV fluid to be infused is a nursing function to be attended to; however, it is lower in priority than determining if hemorrhaging is occurring. Character of the fundus would be the priority nursing assessment because changes in uterine tone may identify possible postpartum hemorrhage.