NCLEX-RN Exam
Question 1 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:
A. The cervix is closed.
B. The membranes are still intact.
C. The fetal heart tones are within normal limits.
D. The contractions are intense enough for insertion of an internal monitor.
Explanation: 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 2 of 5.
After attending a company picnic, several clients are admitted to the emergency room with E. coli food poisoning. The most likely source of infection is:
A. Hamburger
B. Hot dog
C. Potato salad
D. Baked beans
Explanation: Undercooked hamburger is a common source of E. coli, particularly E. coli O157:H7, which can contaminate ground beef.
Question 3 of 5.
A client with paranoid schizophrenia is brought to the hospital by her elderly parents. During the assessment, the client's mother states, 'Sometimes she is more than we can manage.' Based on the mother's statement, the most appropriate nursing diagnosis is:
A. Ineffective family coping related to parental role conflict
B. Care-giver role strain related to chronic situational stress
C. Altered family process related to impaired social interaction
D. Altered parenting related to impaired growth and development
Explanation: The mother's statement reflects caregiver role strain due to the chronic stress of managing a child with paranoid schizophrenia, impacting the parents' ability to cope.
Question 4 of 5.
A client with obsessive compulsive personality disorder annoys his co-workers with his rigid-perfectionistic attitude and his preoccupation with trivial details. An important nursing intervention for this client would be:
A. Helping the client develop a plan for changing his behavior
B. Contracting with him for the time he spends on a task
C. Avoiding a discussion of his annoying behavior because it will only make him worse
D. Encouraging him to set a time schedule and deadlines for himself
Explanation: Setting time schedules and deadlines helps manage the client's perfectionism and preoccupation with details, promoting efficiency without confrontation.
Question 5 of 5.
The nurse has just received the change of shift report. Which client should the nurse assess first?
A. A client with a supratentorial tumor awaiting surgery
B. A client admitted with a suspected subdural hematoma
C. A client recently diagnosed with akinetic seizures
D. A client transferring to the neuro rehabilitation unit
Explanation: A suspected subdural hematoma is a medical emergency due to potential brain compression, requiring immediate assessment.
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