NCLEX RN Exam Questions
Question 1 of 5.
The nurse is evaluating the client who was admitted eight hours ago for induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse?
A. Instruct the client to push
B. Perform a vaginal exam
C. Stop the infusion of Pitocin (oxytocin)
D. Place the client in a semi-Fowler’s position
Explanation: The most immediate action in cases of suspected fetal distress or hyperstimulation during labor induction with Pitocin is to stop the Pitocin infusion to reduce uterine stimulation and improve fetal oxygenation. Other actions like vaginal exams or pushing are inappropriate without further assessment, and positioning is secondary.
Question 2 of 5.
A client is diagnosed with stage II Hodgkin's lymphoma. The nurse recognizes that the client has involvement:
A. In a single lymph node or single site
B. In more than one node or single organ on the same side of the diaphragm
C. In lymph nodes on both sides of the diaphragm
D. In disseminated organs and tissues
Explanation: Stage II Hodgkin's lymphoma involves two or more lymph nodes or a single organ on the same side of the diaphragm, per the Ann Arbor staging system.
Question 3 of 5.
When caring for a client with an anterior cervical discectomy, the nurse should give priority to assessing for post-operative bleeding. The nurse should pay particular attention to:
A. Drainage on the surgical dressing
B. Complaints of neck pain
C. Bleeding from the mouth
D. Swelling in the posterior neck
Explanation: Swelling in the posterior neck may indicate a hematoma, which can compress the airway or spinal cord, making it a priority assessment post-cervical discectomy.
Question 4 of 5.
Which of the following combinations of foods is appropriate for an eight-month-old infant?
A. Cocoa-flavored cereal, orange juice, and strained meat
B. Graham crackers, strained prunes, and pudding
C. Rice cereal, bananas, and strained carrots
D. Mashed potatoes, strained beets, and whole milk
Explanation: Rice cereal, bananas, and strained carrots are developmentally appropriate, easily digestible foods for an eight-month-old, unlike the other options, which include choking hazards or inappropriate items like whole milk.
Question 5 of 5.
A client with HELLP syndrome is admitted to the labor and delivery unit for observation. The nurse knows that the client will have elevated:
A. Serum glucose levels
B. Liver enzymes
C. Pancreatic enzymes
D. Plasma protein levels
Explanation: HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is characterized by elevated liver enzymes, reflecting liver dysfunction.
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