NCLEX-RN NCLEX Exam Questions and Free Practice Test

Question 19

- (Topic 6)
Blood work reveals the following lab values for a client who has been diagnosed with anorexia nervosa: hemoglobin 9.6 g/dL, hemocrit 27%, potassium 2.7 mEq/L, sodium 126 mEq/L. The greatest danger to her at this time is:

A. Hypoglycemia from low-carbohydrate intake

B. Possible cardiac dysrhythmias secondary to hypokalemia

C. Dehydration from vomiting

D. Anoxia secondary to anemia

Correct Answer:B
(A) There is no lab data to support hypoglycemia. (B) Hypokalemia, caused by vomiting and decreased dietary intake of potassium, can result in life-threatening dysrhythmias. (C) Evidence of dehydration is not life threatening at this time, although fluid volume deficit does need to be addressed. (D) The client??s hemoglobin does not reflect a life threatening value sufficient to render the client anoxic.

Question 20

- (Topic 3)
After the RN is finished the initial assessment of a newborn baby and after the initial bonding between the newborn and the mother has taken place in the delivery room, the RN will bring the newborn to the well-baby nursery. Before the newborn is taken from the delivery room and brought to the well-baby nursery, the RN makes sure that which of the following interventions was completed?

A. The physician verifies the exact time of birth.

B. The nurse counts the instruments and sponges with the scrub nurse.

C. The nurse instills prophylactic ointment in the conjunctival sacs of the newborn??s eyes.

D. The nurse makes sure the mother and her newborn have been tagged with identical bands.

Correct Answer:D
(A) The delivery room personnel are responsible for verifying time of birth. (B) The scrub and circulating nurses count sponges and instruments. (C) This intervention is done in the nursery. (D) Tagging the mother and infant with identical bands is of utmost importance. The mother wears one band, and the newborn wears two. Identical numbers on the three bands provide identification for the newborn and the birth mother. Every time the newborn is brought to the mother after delivery, those bands are checked to be sure that the numbers are identical.

Question 21

- (Topic 3)
At 16 weeks?? gestation, a pregnant client is admitted to the maternity unit to have a McDonald procedure (cerclage) done. She tells the RN who is admitting her to the unit that her physician had explained what this procedure was, but that she did not understand. The RN explains to the client that the purpose for this procedure is to:

A. Reinforce an incompetent cervix

B. Repair the amniotic sac

C. Evaluate cephalopelvic disproportion

D. Dilate the cervix

Correct Answer:A
(A) The treatment most commonly uses the Shirodkar-Barter procedure (McDonald procedure) or cerclage to enforce the weakened cervix by encircling it with a suture at the level of the internal os. (B) There is no known procedure that is used to repair the amniotic sac. (C) Cephalopelvic disproportion is evaluated later in pregnancy. It is not related to this procedure. (D) No procedure is done to dilate the cervix at 16 weeks?? gestation unless the pregnancy is to be terminated.

Question 22

- (Topic 7)
One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:

A. Blood pressure

B. Level of consciousness

C. Skin turgor

D. Fluid intake

Correct Answer:B
(A) Blood pressure can remain normotensive in a state of hypovolemia. (B) Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. (C) Skin turgor is not a reliable indicator for assessing hydration in a burn client.
(D) Fluid intake does not indicate adequacy of fluid resuscitation in a burn client.

Question 23

- (Topic 1)
A type I diabetic client is diagnosed with cellulitis in his right lower extremity. The nurse would expect which of the following to be present in relation to his blood sugar level?

A. A normal blood sugar level

B. A decreased blood sugar level

C. An increased blood sugar level

D. Fluctuating levels with a predawn increase

Correct Answer:C
(A) Blood sugar levels increase when the body responds to stress and illness. (B) Blood sugar levels increase when the body responds to stress and illness. (C) Hyperglycemia occurs because glucose is produced as the body responds to the stress and illness of cellulitis. (D) Blood sugar levels remain elevated as long as the body responds to stress and illness.

Question 24

- (Topic 2)
A client is in early labor. Her fetus is in a left occipitoanterior (LOA) position; fetal heart sounds are best auscultated just:

A. Below the umbilicus toward left side of mother??s abdomen

B. Below the umbilicus toward right side of mother??s abdomen

C. At the umbilicus

D. Above the umbilicus to the left side of mother??s abdomen

Correct Answer:A
(A) LOA identifies a fetus whose back is on its mother??s left side, whose head is the presenting part, and whose back is toward its mother??s anterior. It is easiest to auscultate fetal heart tones (FHTs) through the fetus??s back. (B) The identified fetus??s back is on its mother??s left side, not right side. It is easiest to auscultate FHTs through the fetus??s back.
(C) In an LOA position, the fetus??s head is presenting with the back to the left anterior side of the mother. The umbilicus is too high of a landmark for auscultating the fetus??s heart rate through its back. (D) This is the correct auscultation point for a fetus in the left sacroanterior position, where the sacrum is presenting, not LOA.

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