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NCLEX NCLEX-RN Exam Questions
National Council Licensure Examination - NCLEX-RN (Page 23 )

Updated On: 24-Feb-2026
Page 23 of 345
PDF with 862 Questions

A child is admitted to the emergency room with her mother. Her mother states that she has been exposed to chickenpox. During the assessment, the nurse would note a characteristic rash:

  1. That is covered with vesicular scabs all in the macular stage
  2. That appears profusely on the trunk and sparsely on the extremities
  3. That first appears on the neck and spreads downward
  4. That appears especially on the cheeks, which gives a"slapped-cheek" appearance

Answer(s): B

Explanation:

(A) A rash with vesicular scabs in all stages (macule, papule, vesicle, and crusts). (B) A rash that appears profusely on the trunk and sparsely on the extremities. (C) A rash that first appears on the neck and spreads downward is characteristic of rubeola and rubella. (D) A rash, especially on the cheeks, that gives a "slapped-cheek" appearance is characteristic of roseola.



Which of the following would differentiate acute from chronic respiratory acidosis in the assessment of the trauma client?

  1. Increased PaCO2
  2. Decreased PaO2
  3. Increased HCO3
  4. Decreased base excess

Answer(s): C

Explanation:

(A) Increased CO2 will occur in both acute and chronic respiratory acidosis. (B) Hypoxia does not determine acid-base status. (C) Elevation of HCO3 is a compensatory mechanism in acidosis that occurs almost immediately, but it takes hours to show any effect and days to reach maximum compensation. Renal disease and diuretic therapy may impair the ability of the kidneys to compensate. (D) Base excess is a nonrespiratory contributor to acid-base balance. It would increase to compensate for acidosis.



Which of the following would differentiate acute from chronic respiratory acidosis in the assessment of the trauma client?

  1. Increased PaCO2
  2. Decreased PaO2
  3. Increased HCO3
  4. Decreased base excess

Answer(s): C

Explanation:

(A) Increased CO2 will occur in both acute and chronic respiratory acidosis. (B) Hypoxia does not determine acid-base status. (C) Elevation of HCO3 is a compensatory mechanism in acidosis that occurs almost immediately, but it takes hours to show any effect and days to reach maximum compensation. Renal disease and diuretic therapy may impair the ability of the kidneys to compensate. (D) Base excess is a nonrespiratory contributor to acid-base balance. It would increase to compensate for acidosis.



When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the nurse take?

  1. Continue monitoring because this is a normal occurrence.
  2. Turn client on right side.
  3. Decrease IV fluids.
  4. Report to physician or midwife.

Answer(s): D

Explanation:

(A) This is not a normal occurrence. Late decelerations need prompt intervention for immediate infant recovery. (B) To increase O2 perfusion to the unborn infant, the mother should be placed on her left side. (C) IV fluids should be increased, not decreased. (D) Immediate action is warranted, such as reporting findings, turning mother on left side, administering O2, discontinuing oxytocin (Pitocin), assessing maternal blood pressure and the labor process, preparing for immediate cesarean delivery, and explaining plan of action to client.



When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the nurse take?

  1. Continue monitoring because this is a normal occurrence.
  2. Turn client on right side.
  3. Decrease IV fluids.
  4. Report to physician or midwife.

Answer(s): D

Explanation:

(A) This is not a normal occurrence. Late decelerations need prompt intervention for immediate infant recovery. (B) To increase O2 perfusion to the unborn infant, the mother should be placed on her left side. (C) IV fluids should be increased, not decreased. (D) Immediate action is warranted, such as reporting findings, turning mother on left side, administering O2, discontinuing oxytocin (Pitocin), assessing maternal blood pressure and the labor process, preparing for immediate cesarean delivery, and explaining plan of action to client.






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