RN NCLEX Practice Test
Question 1 of 5.
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:
A. Begin the oxytocin induction as ordered
B. Increase the dosage by 2 mU/min increments at 15-minute intervals
C. Maintain the dosage when duration of contractions is 40-60 seconds and frequency is at 2-1/2-4 minute intervals
D. Question the order
Explanation: 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.
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.