NCLEX Practice Test RN
Question 1 of 5.
A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse?
A. Keep breathing with your abdominal muscles as long as you can.
B. Make sure you take a deep cleansing breath as the contractions start, focus on an object, and breathe about 16-20 times a minute with shallow chest breaths.
C. Find a comfortable position before you start a contraction. Once the contraction has started, take slow breaths using your abdominal muscles.
D. If a woman in labor listens to her body and takes rapid, deep breaths, she will be able to deal with her contractions quite well.
Explanation: Lamaze childbirth preparation teaches the use of chest, not abdominal, breathing. In Lamaze preparation, every patterned breath is preceded by a cleansing breath; as labor progresses, shallow, paced breathing is found to be effective. It is important to assume a comfortable position in labor, but the Lamaze-prepared laboring woman is taught to breathe with her chest, not abdominal, muscles. When deep chest breathing patterns are used in Lamaze preparation, they are slowly paced at a rate of 6-9 breaths/min.
Question 2 of 5.
A healthcare worker is referred to the nursing office with a suspected latex allergy. The first symptom of latex allergy is usually:
A. Oral itching after eating bananas
B. Swelling of the eyes and mouth
C. Difficulty in breathing
D. Swelling and itching of the hands
Explanation: Latex allergy often first presents as localized skin reactions, such as swelling and itching of the hands, due to direct contact with latex products.
Question 3 of 5.
During the change of shift report, a nurse writes in her notes that she suspects illegal drug use by a client assigned to her care. During the shift, the notes are found by the client's daughter. The nurse could be sued for:
A. Libel
B. Slander
C. Malpractice
D. Negligence
Explanation: Libel involves written defamatory statements, such as unverified suspicions of drug use in notes accessible to others, potentially harming the client's reputation.
Question 4 of 5.
A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:
A. Decreased blood pressure and constricted pupils
B. Increased heart rate and increased respirations
C. Increased respirations and increased blood pressure
D. Anoxia and absence of the cough reflex
Explanation: Cholinergic crisis, often from excessive anticholinesterase medication, causes parasympathetic overstimulation, leading to decreased blood pressure and constricted pupils.
Question 5 of 5.
During morning assessments, the nurse finds that a client's nephrostomy tube has been clamped. The nurse's first action should be to:
A. Assess the drainage bag.
B. Check for bladder distention.
C. Unclamp the tubing.
D. Irrigate the tubing.
Explanation: Unclamping the nephrostomy tube is the priority to restore urine flow and prevent complications like hydronephrosis or infection.