NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
Which of the following nursing interventions has the highest priority for the client scheduled for an intravenous pyelogram?
Correct Answer: B
Rationale: Intravenous pyelogram uses iodine-based contrast, which can cause allergic reactions, especially in clients with shellfish/iodine allergies. Identifying allergies is the highest priority for safety.
Question 2 of 5
A 24-year-old male client is admitted with a diagnosis of sickle cell anemia. The nurse discusses his disease with him and emphasizes the following information:
Correct Answer: B
Rationale: Bleeding is not a symptom of sickle cell anemia or sickle cell crisis. Decreased blood viscosity leads to sickling of red blood cells. Increased fluid intake maintains adequate circulating blood volume and decreases the chance of sickling. Hypoxia leads to sickling of cells. Flying in nonpressurized planes places the client in a situation of low O2 tension, which can lead to sickling. Male and female clients with sickle cell disease can pass the trait on to their offspring.
Therefore, this client should receive genetic counseling prior to having children.
Question 3 of 5
A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report:
Correct Answer: C
Rationale: Autonomic dysreflexia is an exaggerated reflex of the autonomic nervous system causing vasoconstriction and elevated blood pressure, often presenting with headache and facial flushing. The other symptoms listed are not associated with this condition.
Question 4 of 5
A 19-year-old primigravida is admitted to the labor and delivery suite of the hospital. Her husband is accompanying her. The couple tells the nurse that this is the first hospital admission for her. The client's vaginal exam indicates she is 3 cm dilated, 80% effaced, and at -0 station. Based on the vaginal exam, she is in:
Correct Answer: D
Rationale: The second stage of labor is from full cervical dilation through birth of the baby. The three phases of this stage include latency or resting, descent, and final transition. The client is less than fully dilated so she is not in stage 2. The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor. The third stage of labor is from the birth of the baby until the delivery of the placenta. The client is less than fully dilated. The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor.
Question 5 of 5
The client with a history of seizures is prescribed phenytoin (Dilantin). Which instruction should the nurse include in the teaching plan?
Correct Answer: B
Rationale: Alcohol can interact with phenytoin, increasing toxicity or reducing efficacy, so it should be avoided. Milk does not prevent GI upset, stopping medication requires physician guidance, and extra doses are dangerous.