NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
While caring for a client in the second stage of labor, the nurse notices a pattern of early decelerations. The nurse should:
Correct Answer: D
Rationale: Early decelerations are benign, caused by fetal head compression during labor, and require only documentation, as they do not indicate fetal distress.
Question 2 of 5
A client with a history of peptic ulcer disease is admitted with complaints of hematemesis. The nurse should give priority to:
Correct Answer: B
Rationale: Hematemesis indicates possible gastrointestinal bleeding, so monitoring vital signs is critical to assess for hypovolemia and shock.
Question 3 of 5
A female client at 36 weeks' gestation is experiencing preterm labor. Her physician has prescribed two doses of betamethasone 12 mg IM q24h. The nurse explains that she is receiving this drug to:
Correct Answer: C
Rationale: Respiratory distress syndrome occurs in the newborn, not the fetus. It may be treated postnatally with surfactant therapy. Betamethasone is a corticosteroid, not an anti-infective drug; therefore, its use would not prevent uterine infection. Betamethasone binds with glucocorticoid receptors in alveolar cells to increase production of surfactant, thus increasing lung maturity in the preterm fetus. Betamethasone does not affect uteroplacental circulatory exchange.
Question 4 of 5
A child is to receive heparin sodium five units per kilogram of body weight by subcutaneous route every four hours. The child weighs 52.8 lb. How many units should the child receive in a 24 hour period?
Correct Answer: 720
Rationale: Weight: 52.8 lb ÷ 2.2 = 24 kg. Dose: 5 units/kg × 24 kg = 120 units/dose. Frequency: every 4 hours = 6 doses/day.
Total: 120 × 6 = 720 units.
Question 5 of 5
A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is NPO with IV fluids infusing at 100 mL/hour. He is experiencing excruciating abdominal pain. Based on an analysis of these data, which nursing diagnosis would receive the highest priority?
Correct Answer: A
Rationale: Relief of pain is the primary goal of nursing intervention because this client is experiencing acute pain. Fluid volume deficit is being treated with IV fluid replacement. Knowledge deficit will not be addressed at this time because a client in acute pain is not ready to learn. Alteration in nutrition is the third priority after relief of pain and fluid volume deficit.