NCLEX-RN
NCLEX-RN Exam Questions
Question 1 of 5
A 32-year-old mother of two was brought to the hospital by her husband. He reported that his wife could no longer manage the house and children. She does not sleep and talks day and night. She has purchased some very expensive clothes. The nurse noted that the client speaks rapidly and changes the subject irrationally. This is an example of:
Correct Answer: A
Rationale: Rapidly moving from one topic to another without following any logical sequence is called flight of ideas, characteristic of manic behavior.
Question 2 of 5
The nurse is caring for a client with a tracheostomy. Which action is a priority to prevent complications?
Correct Answer: A
Rationale: Suctioning as needed prevents airway obstruction from mucus buildup, a priority to maintain patency and prevent respiratory distress. Cuff management, tie changes, and infection monitoring are important but secondary to airway maintenance.
Question 3 of 5
The nurse is caring for a laboring client. Assessment data include cervical dilation 9 cm; contractions every 1-2 minutes; strong, large amount of 'bloody show.' The most appropriate nursing goal for this client would be:
Correct Answer: C
Rationale: In transition (9 cm dilation, frequent contractions), helping the client maintain control is critical due to intense contractions and emotional challenges.
Question 4 of 5
A vaginal exam reveals that the cervix is 4cm dilated,with intact membranes and a fetal heart tone rate of 160-170 bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:
Correct Answer: B
Rationale: External fetal monitoring is appropriate when membranes are intact as internal monitoring requires ruptured membranes. The cervix is not closed fetal heart tones are normal and contraction intensity is irrelevant to external monitoring.
Question 5 of 5
A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is being given digoxin. Prior to administering the medication, the nurse should:
Correct Answer: C
Rationale: Digoxin should not be given to adults with an apical pulse <60 bpm. Digoxin should be given to children with an apical pulse >100 bpm. With a pulse <100 bpm, the medication should be withheld and the physician notified. Prior to digoxin administration in both children and adults, an apical pulse should be taken for 1 full minute. Aside from the rate per minute, the nurse should note any sudden increase or decrease in heart rate, irregular rhythm, or regularization of a chronic irregular heart rhythm. Early indications of digoxin toxicity, such as visual disturbances, occur rarely as initial signs in children.