NCLEX RN· Full Length · RN NCLEX Practice Test
Full Question & Rationale Repository
Showing all 10 practice questions with expert explanatory rationales.
A client has just received an epidural block. She is laboring on her right side. The nurse notes that her blood pressure has dropped from 132/68 to 78/42 mm Hg. The nurse's first action would be to:
Expert Explanatory Rationale
Correct Answer: Increase the rate of IV fluids and start O₂ by mask
Nursing measures to support fetal oxygenation and promote maternal blood pressure would precede calling the physician. Systolic pressures below 100 mm Hg or a reduction in the systolic pressure of >30% necessitate treatment. Assessing the blood pressure in 5 minutes may allow for further fetal and/or maternal compromise. Turning the client on her left side will promote uteroplacental perfusion and is appropriate.
Oxytocin (Pitocin) increases the strength of uterine contractions and may cause maternal hypotension; thus it is an inappropriate drug for use in this clinical situation. IV fluids would be increased to expand the circulating blood volume and promote increased blood pressure. Turning the mother to her left lateral side promotes uteroplacental perfusion.
IV fluids are administered to increase the circulating blood volume, and O₂ is administered to promote fetal oxygenation and decrease the nausea accompanying the hypotension.
The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to:
Expert Explanatory Rationale
Correct Answer: Cleanse and wipe the perineum from front to back
(Tom) Perineal hygiene is a clean procedure and does not require the client to wear gloves. A care provider should wear gloves to adhere to universal precautions. The pad should be applied from front to back to prevent contamination of the birth canal or urinary tract from rectal bacteria.
Wiping from front to back and discarding the wipe prevents contamination of the urinary tract and birth canal from rectal bacteria. The inner surface of the pad should not be touched to maintain asepsis.
The home health nurse is visiting a client with Paget's disease. An important part of preventive care for the client with Paget's disease is:
Expert Explanatory Rationale
Correct Answer: Keeping the environment free of clutter
Paget's disease weakens bones, increasing fracture risk. A clutter-free environment prevents falls, a key preventive measure. Dental care, vaccines, and vitamins are less specific.
Which assignment should not be delegated to the licensed practical nurse?
Expert Explanatory Rationale
Correct Answer: Starting a blood transfusion
Starting a blood transfusion requires RN-level assessment and monitoring due to the risk of transfusion reactions, which is outside the LPN's scope in most settings. Foley insertion, NG tube discontinuation, and sputum collection are within LPN scope.
Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, 'Begin oxytocin induction at 1 mU/min.' The nurse should:
Expert Explanatory Rationale
Correct Answer: Question the order
Oxytocin stimulates labor but should not be used until CPD (cephalopelvic disproportion) is ruled out in a dysfunctional labor. This answer is the correct protocol for oxytocin administration, but the medication should not be used until CPD is ruled out. This answer is the correct manner to interpret effective stimulation, but oxytocin should not be used until CPD is ruled out.
This answer is the appropriate nursing action because the scenario presents a dysfunctional labor pattern that may be caused by CPD. Oxytocin administration is contraindicated in CPD.
A male client is scheduled to have angiography of his left leg. The nurse needs to include which of the following when preparing the client for this procedure?
Expert Explanatory Rationale
Correct Answer: Validate that he is not allergic to iodine or shellfish.
Angiography, an invasive radiographic examination, involves the injection of a contrast solution (iodine) through a catheter that has been inserted into an artery. The client is kept on complete bed rest for 6-12 hours after the procedure. The extremity in which the catheter was inserted must be immobilized and kept straight during this time. The contrast dye, iodine, is nephrotoxic.
The client must be instructed to drink a large quantity of fluids to assist the kidneys in excreting this contrast media. The major complication of this procedure is hemorrhage. Vital signs are assessed every 15 minutes initially for signs of bleeding.
A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 lb from her 7th to 8th month; her face and hands indicate edema. She is diagnosed as having PIH and referred to the high-risk prenatal clinic. The client's weight increase is most likely due to:
Expert Explanatory Rationale
Correct Answer: Fluid retention
Overeating can lead to obesity, but not to edema. There is no indication of obesity prior to pregnancy. PIH is more prevalent in the underweight than in the obese in this age group. Hypertension can be due to kidney lesions, but it would have been apparent earlier in the pregnancy. The weight gain in PIH is due to the retention of sodium ions and fluid and is one of the three cardinal symptoms of PIH.
The nurse is planning care for the patient with celiac disease. In teaching about the diet, the nurse should instruct the patient to avoid which of the following for breakfast?
Expert Explanatory Rationale
Correct Answer: Puffed wheat
Celiac disease requires a gluten-free diet. Puffed wheat contains gluten and should be avoided. Bananas, puffed rice, and cornflakes (if certified gluten-free) are typically safe.
A patient refuses to take his dose of oral medication. The nurse tells the patient that if he does not take the medication that she will administer it by injection. The nurse's comments can result in a charge of:
Expert Explanatory Rationale
Correct Answer: Assault
Threatening to administer medication by injection against the patient's will constitutes assault, as it involves a threat of unwanted contact.
Which of the following is a classic manifestation of glomerulonephritis?
Expert Explanatory Rationale
Correct Answer: Hypertension
Hypertension is a classic manifestation of glomerulonephritis due to fluid retention and renal dysfunction. Lassitude and fatigue may occur but are less specific and vomiting/diarrhea are not typical.
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