RN NCLEX Practice Test
Question 1 of 5.
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:
A. Call the physician immediately and give dopamine IM
B. Turn her on her left side and recheck her blood pressure in 5 minutes
C. Administer oxytocin (Pitocin) immediately and increase the rate of IV fluids
D. Increase the rate of IV fluids and start O2 by mask
Explanation: 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.
Question 2 of 5.
The nurse is observing the ambulation of a client recently fitted for crutches. Which observation requires nursing intervention?
A. Two finger widths are noted between the axilla and the top of the crutch.
B. The client bears weight on his hands when ambulating.
C. The crutches and the client's feet move alternately.
D. The client bears weight on his axilla when standing.
Explanation: Bearing weight on the axilla can cause nerve damage (e.g., brachial plexus injury); crutches should support weight on the hands.
Question 3 of 5.
A client with angina is being discharged with a prescription for Transderm Nitro (nitroglycerin) patches. The nurse should tell the client to:
A. Shave the area before applying the patch
B. Remove the old patch and clean the skin with alcohol
C. Cover the patch with plastic wrap and tape it in place
D. Avoid cutting the patch because it will alter the dose
Explanation: Cutting a nitroglycerin patch can alter the dose by disrupting the drug delivery system, so clients should be instructed to avoid this.
Question 4 of 5.
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:
A. Malpractice
B. Assault
C. Negligence
D. Battery
Explanation: Threatening to administer medication by injection against the patient's will constitutes assault, as it involves a threat of unwanted contact.
Question 5 of 5.
An 18-month-old is admitted to the hospital with acute laryngotracheobronchitis. When assessing the respiratory status, the nurse should expect to find:
A. Inspiratory stridor and harsh cough
B. Strident cough and drooling
C. Wheezing and intercostal retractions
D. Expiratory wheezing and nonproductive cough
Explanation: Acute laryngotracheobronchitis (croup) typically presents with inspiratory stridor and a harsh, barking cough due to subglottic airway inflammation.
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