NCLEX-RN
NCLEX RN Practice Questions with Answers Questions
Extract:
Question 1 of 5
Which of the following should the nurse identify as a priority nursing diagnosis for an infant with intussusception?
Correct Answer: C
Rationale: Acute pain is the priority nursing diagnosis for an infant with intussusception due to bowel obstruction causing severe abdominal pain. Fluid volume and gas exchange may be concerns but are secondary.
Question 2 of 5
A multigravid client at 34 weeks' gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client's contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews the physician orders (see chart). Which of the following orders should the nurse initiate first?
Correct Answer: A
Rationale: Fetal and contraction monitoring is the priority to assess fetal well-being and labor progression, guiding further interventions.
Question 3 of 5
The nurse is caring for a client who has just undergone a lumbar puncture. Which of the following interventions is most appropriate in the immediate post-procedure period?
Correct Answer: B
Rationale: Keeping the client flat for 4-6 hours post-lumbar puncture reduces the risk of spinal headache due to cerebrospinal fluid leakage.
Question 4 of 5
Methylergonovine maleate is prescribed for a woman who has just delivered a healthy newborn. Which is the priority assessment to complete before administering the medication?
Correct Answer: C
Rationale: Methylergonovine maleate, an oxytocic, is an agent used to prevent or control postpartum hemorrhage by contracting the uterus. The immediate dose is administered intramuscularly, and then, if still needed, it is administered orally. It causes uterine contractions and may elevate the blood pressure. A priority assessment before administration of methylergonovine maleate is blood pressure. Methylergonovine maleate is to be administered cautiously in the presence of hypertension, and the primary health care provider should be notified if hypertension is present. Options 1 and 2 are general components of care in the postpartum period. Option 4 is most specifically related to the administration of magnesium sulfate.
Question 5 of 5
The nurse assesses a client and notes that he has a weak, irregular pulse, as well as soft, flabby muscles. The nurse should assess the client further for:
Correct Answer: C
Rationale: Weak, irregular pulse and flabby muscles are signs of hypokalemia, which affects muscle and cardiac function. The other conditions present differently.