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
A client is admitted with acute adrenal crisis. During the intake assessment, the nurse can expect to find that the client has:
Correct Answer: A
Rationale: Acute adrenal crisis (Addisonian crisis) causes hypotension due to cortisol and aldosterone deficiency, leading to shock. Pulse is typically rapid, skin is cool, and urination decreases.
Question 3 of 5
The chart of a client with schizophrenia states that the client has echolalia. The nurse can expect the client to:
Correct Answer: B
Rationale: Echolalia in schizophrenia involves repeating words or phrases spoken by others, reflecting impaired communication. Rhyming, irrelevant details, or neologisms are different symptoms.
Question 4 of 5
Which of the following changes in blood pressure readings should be of greatest concern to the nurse when assessing a prenatal client?
Correct Answer: D
Rationale: (A, B,
C) The individual's systolic and diastolic changes are more significant than the relatively high initial blood pressure readings. The systolic pressure went up 12 mm Hg and the diastolic pressure 18 mm Hg. This is a more significant rise than the increases in A-C choices, and client should receive more frequent evaluations and care.
Question 5 of 5
The nurse practitioner determines that a client is approximately 9 weeks' gestation. During the visit, the practitioner informs the client about symptoms of physical changes that she will experience during her first trimester, such as:
Correct Answer: A
Rationale: Nausea and vomiting are experienced by almost half of all pregnant women during the first 3 months of pregnancy as a result of elevated human chorionic gonadotropin levels and changed carbohydrate metabolism. Quickening is the mother's perception of fetal movement and generally does not occur until 18-20 weeks after the last menstrual period in primigravidas, but it may occur as early as 16 weeks in multigravidas. During the first trimester there should be only a modest weight gain of 2-4 lb. It is not uncommon for women to lose weight during the first trimester owing to nausea and/or vomiting. Physical changes are not apparent until the second trimester, when the uterus rises out of the pelvis.