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Real NCLEX NCLEX-RN PDF Questions [2025] - Get Success With Best Results
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NCLEX National Council Licensure Examination(NCLEX-RN) Sample Questions (Q110-Q115):
NEW QUESTION # 110
A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular disorder. She arrives in her room via stretcher and requires assistance to move to her bed. The nurse notes that her left leg is cold to touch.
She complains of having recently experienced muscle spasms in that leg. To determine if these muscle spasms are indicative of intermittent claudication, the nurse would begin her assessment with the following question:
- A. "Have you had any lesions of the affected leg that have been difficult to heal?"
- B. "Would you describe the intensity, duration, and symptoms associated with your pain?"
- C. "Do your muscle spasms occur following rest, walking, or exercising?"
- D. "Do you experience swelling at the end of the day in the affected and unaffected leg?"
Answer: C
Explanation:
Explanation
(A) Describing pain is an important aspect of the assessment; however, assessing activity preceding muscle spasms is equally important. (B) Edema may occur with peripheral vascular disease, but it is not of particular importance in assessing intermittent claudication. (C) Lesions may be present with peripheral vascular disease, but they are not an indication of intermittent claudication. (D) With intermittent claudication, muscle spasms occur intermittently, mainly with walking and after exercising. Rest may relieve muscle spasms.
NEW QUESTION # 111
During the active phase of rheumatic fever, the nurse teaches parents of a child with acute rheumatic fever to assist in minimizing joint pain and promoting healing by:
- A. Massaging the joints briskly with lotion or liniment after bath
- B. Applying warm water bottle or heating pads over involved joints
- C. Immobilizing the joints in functional position using splints, rolls, and pillows
- D. Putting all joints through full range-of-motion twice daily
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Any movement of the joint causes severe pain. (B) Touching or moving the joint causes severe pain.
(C) Immobilization in a functional position allows the joint to rest and heal. (D) Pressure from the warm water bottle or pads can cause severe pain or burning of the skin.
NEW QUESTION # 112
The nurse assesses a client's monitor strip and finds the following: uterine contractions every 3-4 minutes, lasting 60-70 seconds; FHR baseline 134-146 bpm, with accelerations to 158 bpm with fetal movement.
Which nursing intervention is appropriate?
- A. Notify physician of nonreassuring FHR pattern.
- B. Evaluate to see if the monitor strip is reassuring.
- C. Start IV for fetal distress and administer O2 at 6-8 liters by mask.
- D. Turn the client to her left side.
Answer: B
Explanation:
Explanation
(A) These indices are within normal parameters; therefore, the nurse does not need to contact the physician.
(B) The purpose of turning a client to her left side is to maximize uteroplacental blood flow. Based on the above assessment, there is no indication that blood flow is compromised. (C) These interventions are appropriate nursing interventions for late and prolonged decelerations. Following these interventions, the nurse should notify the physician. These indices are within normal parameters; therefore, the nurse does not need to start an IV and administer O2. (D) Variations of 20 bpm above or below the baseline FHR is considered normal. Normal FHRs range from 120-160 bpm. As the fetus moves, the FHR increases, and accelerations often occur in concert with contractions. During the active phase of labor, the frequency of uterine contractions is every 2-4 minutes, with an appropriate duration of 60 sec.
NEW QUESTION # 113
A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is NPO with IV fluids infusing at 100 mL/hour. He is experiencing excruciating abdominal pain. Based on an analysis of these data, which nursing diagnosis would receive the highest priority?
- A. Knowledge deficit related to treatment regimen
- B. Pain related to stimulation of nerve endings associated with obstruction of the pancreatic tract
- C. Fluid volume deficit related to vomiting and nasogastric tube drainage
- D. Altered nutrition: less than body requirements, related to inadequate intake associated with current anorexia, nausea, vomiting, and digestive enzyme loss
Answer: B
Explanation:
(A)
Relief of pain is the primary goal of nursing intervention because this client is experiencing acute pain. (B) Fluid volume deficit is being treated with IV fluid replacement.
(C)
Knowledge deficit will not be addressed at this time because a client in acute pain is not ready to learn. (D) Alteration in nutrition is the third priority after relief of pain and fluid volume deficit.
NEW QUESTION # 114
An expected response to sodium polystyrene sulfonate (Kayexalate) is:
- A. Increase in serum magnesium
- B. Decrease in serum calcium
- C. Increase in serum HCO3
- D. Decrease in serum potassium
Answer: D
Explanation:
(A) Sodium polystyrene sulfonate administration will not increase serum magnesium. Hypermagnesemia is virtually unknown except for clients in renal failure. (B) Sodium polystyrene sulfonate administration is not known to increase serum bicarbonate. (C) Decrease in serum potassium, the expected response of sodium polystyrene sulfonate, is secondary to the binding of this drug and potassium in the colon, and potassium is removed through the feces. (D) Serum calcium may actually increase with sodium polystyrene sulfonate administration, especially if calcium chloride is administered concurrently with this drug.
NEW QUESTION # 115
......
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