NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A 2-day-old infant boy has been diagnosed with an atrial septal defect due to a persistent patent foramen ovale. When explaining the diagnosis to the mother, the nurse includes in the discussion the function of the foramen ovale. In fetal circulation, the foramen ovale allows a portion of the blood to bypass the:
Correct Answer: B
Rationale: The foramen ovale permits a percentage of the blood to shunt from the right atrium to the left atrium. The blood then goes to the left ventricle, permitting systemic fetal circulation with blood containing a higher O2 saturation. As the blood shunts from the right atrium to the left atrium, the pulmonary system is bypassed. The fetus receives O2 from the maternal circulation, thereby permitting the partial bypass of the pulmonary system. The foramen ovale is located in the atrial septum of the heart and does not affect the liver. The superior vena cava returns blood to the heart, bringing blood to the location of the foramen ovale.
Question 2 of 5
A client who is gravida 1 para 1 vaginally delivered a 7-lb girl. She received a midline episiotomy at delivery. When assessing the level of her uterus immediately following delivery, the nurse would expect the fundus to be located:
Correct Answer: D
Rationale: Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. The uterus descends into the pelvic cavity at approximately 10-12 postpartal days and can no longer be palpated abdominally. Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. An enlarged uterus may indicate subinvolution or postpartal hemorrhage. Immediately following delivery, the uterus lies midline, about midway between the umbilicus and the symphysis pubis.
Question 3 of 5
Assessment of the client with pericarditis may reveal which of the following?
Correct Answer: C
Rationale: No S3 or S4 are noted with pericarditis. No change in pulse pressure occurs. The symptoms of pericarditis vary with the cause, but they usually include chest pain, dyspnea, tachycardia, rise in temperature, and friction rub caused by fibrin or other deposits. The pain seen with pericarditis typically worsens with deep inspiration. Tamponade is not typically seen early on, and no change in pulse pressure occurs.
Question 4 of 5
While caring for a client in the second stage of labor, the nurse notices a pattern of early decelerations. The nurse should:
Correct Answer: D
Rationale: Early decelerations are benign, caused by fetal head compression during labor, and require only documentation, as they do not indicate fetal distress.
Question 5 of 5
A client is admitted to the hospital in chronic renal failure. A low protein diet is ordered. The rationale for a low protein diet is that:
Correct Answer: A
Rationale: In chronic renal failure, a low protein diet reduces the production of nitrogenous wastes like blood urea nitrogen (BUN), easing the kidneys’ workload. It does not directly affect sodium, potassium, albumin, calcium, or phosphorus levels.