NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
While caring for an elderly patient with hypertension, the nurse notes the following vital signs: BP of 140/40, pulse 120, respirations 36. The nurse's initial action should be to:
Correct Answer: A
Rationale: The vital signs indicate a wide pulse pressure (140/40), tachycardia (pulse 120), and tachypnea (respirations 36), suggesting possible cardiovascular or respiratory distress. The nurse should report these findings to the physician immediately for further evaluation, as they may indicate a serious condition like heart failure or shock.
Question 2 of 5
The client is admitted with a diagnosis of gestational trophoblastic disease. Which symptom is most characteristic?
Correct Answer: A
Rationale: Elevated hCG levels are the most characteristic symptom of gestational trophoblastic disease reflecting abnormal trophoblastic proliferation. Fetal heart tones are absent uterine size is larger and fever is not typical.
Question 3 of 5
The nurse is caring for a client with a diagnosis of gestational trophoblastic disease. Which intervention is most appropriate?
Correct Answer: A
Rationale: Gestational trophoblastic disease requires monitoring hCG levels to assess for resolution or progression to malignancy (e.g. choriocarcinoma).
Tocolytics fetal monitoring and vaginal delivery are not indicated as there is no viable fetus.
Question 4 of 5
The nurse provides a male client with diet teaching so that he can help prevent constipation in the future. Which food choices indicate that this teaching has been understood?
Correct Answer: D
Rationale: Oatmeal and fresh fruit provide fiber and bulk, which help prevent constipation. The other options lack sufficient fiber.
Question 5 of 5
A client presents to the emergency room with cyanosis, coughing, tachypnea, and tachycardia. She has a history of asthma. Arterial blood gas values are pH 7.28, PaO2 54, PaCO2 60, and HCO3 24. The nursing assessment of arterial blood gases indicate the presence of:
Correct Answer: B
Rationale: Respiratory acidosis is determined by low pH and elevated PaCO2.