RN NCLEX-RN 3 — Questions and Answers
Question 1: A nurse is caring for a client in active labor whose fetal heart rate (FHR) shows late decelerations with each contraction. What is the priority nursing action?
- Prepare for immediate cesarean delivery
- Reposition the client to her left side (Correct answer)
- Increase the rate of the oxytocin infusion
- Document findings and reassess in 15 minutes
Correct answer: Reposition the client to her left side
Repositioning to the left lateral position relieves aortocaval compression, improving uteroplacental blood flow and is the first nursing action for late decelerations.
Question 2: A client with Addison's disease is admitted in adrenal crisis. Which IV fluid and medication does the nurse anticipate administering?
- D5W and insulin
- 0.9% NaCl and hydrocortisone (Correct answer)
- Lactated Ringer's and vasopressin
- 0.45% NaCl and fludrocortisone
Correct answer: 0.9% NaCl and hydrocortisone
Adrenal crisis is treated with isotonic saline to correct hypotension and dehydration, plus hydrocortisone to replace deficient glucocorticoids.
Question 3: A nurse administers the wrong medication to a client who experiences no adverse effects. What is the nurse's first action after recognizing the error?
- Complete an incident report and notify the supervisor
- Assess the client and monitor for adverse effects (Correct answer)
- Document the error in the nurse's notes
- Notify the pharmacy to correct the medication record
Correct answer: Assess the client and monitor for adverse effects
Client safety is always the priority; the nurse must first assess the client for any adverse reactions before reporting or documenting the error.
Question 4: A nurse is assessing a client with suspected pulmonary embolism (PE). Which clinical finding is most characteristic of PE?
- Gradual onset of productive cough with fever
- Sudden onset of pleuritic chest pain and dyspnea (Correct answer)
- Bilateral crackles with frothy sputum
- Dull chest pain relieved by sitting forward
Correct answer: Sudden onset of pleuritic chest pain and dyspnea
Sudden-onset pleuritic chest pain and dyspnea are hallmark symptoms of pulmonary embolism due to abrupt obstruction of pulmonary vasculature.
Question 5: A nurse is caring for a client receiving total parenteral nutrition (TPN). Which complication requires the most immediate intervention?
- Blood glucose of 180 mg/dL
- Temperature of 39.2°C (102.6°F) with chills (Correct answer)
- Weight gain of 0.5 kg over 24 hours
- Mild nausea without vomiting
Correct answer: Temperature of 39.2°C (102.6°F) with chills
Fever and chills in a TPN client suggest catheter-related bloodstream infection, a life-threatening complication requiring immediate assessment and blood cultures.
Question 6: A nurse is teaching a client with COPD pursed-lip breathing. What is the primary goal of this technique?
- Increase oxygen delivery to the alveoli
- Slow the respiratory rate to prevent hyperventilation
- Prevent airway collapse and promote CO2 elimination (Correct answer)
- Strengthen the diaphragm and accessory muscles
Correct answer: Prevent airway collapse and promote CO2 elimination
Pursed-lip breathing creates positive back-pressure that keeps airways open longer, facilitating more complete exhalation and CO2 removal.
Question 7: A nurse is caring for a client who is 12 hours post-thyroidectomy. The client reports tingling around the mouth and in the fingertips. What should the nurse assess next?
- Blood pressure for hypertensive urgency
- Trousseau's sign for hypocalcemia (Correct answer)
- Respiratory rate for laryngospasm onset
- Surgical site for signs of hemorrhage
Correct answer: Trousseau's sign for hypocalcemia
Perioral and digital tingling after thyroidectomy suggest inadvertent parathyroid removal causing hypocalcemia; Trousseau's sign confirms neuromuscular irritability.
RN NCLEX-RN 3
A nurse is caring for a client in active labor whose fetal heart rate (FHR) shows late decelerations with each contraction.
What is the priority nursing action?