RN NCLEX-RN 3

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?

Accepted Answer

Reposition the client to her left side

Answer

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?

Accepted Answer

0.9% NaCl and hydrocortisone

Answer

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?

Accepted Answer

Assess the client and monitor for adverse effects

Answer

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?

Accepted Answer

Sudden onset of pleuritic chest pain and dyspnea

Answer

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?

Accepted Answer

Temperature of 39.2°C (102.6°F) with chills

Answer

Fever and chills in a TPN client suggest catheter-related bloodstream infection, a life-threatening complication requiring immediate assessment and blood cultures.

RN - Registered Nurse Practice Test

RN - Registered Nurse Practice Test

RN NCLEX-RN 3