NCLEX Questions, NCLEX-RN Exam Practice Questions, NCLEX-RN Questions, Nurselytic

Questions 157

NCLEX-RN

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NCLEX-RN Exam Practice Questions

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Question 1 of 5

A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately:

Correct Answer: C

Rationale: At 10 weeks, the fundus is located slightly above the symphysis pubis. At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus. At 20 weeks, the fundus is located approximately at the umbilicus. At 30 weeks, the fundal height is about 30 cm, or 10 cm above the umbilicus.

Question 2 of 5

A 50-year-old depressed client has recently lost his job. He has been reluctant to leave his hospital room. Nursing care would include:

Correct Answer: C

Rationale: The client should be encouraged to attend the unit activities. The nurse and client should choose a few activities for the client to attend that will be positive experiences for him. The nurse should encourage the client to discuss his feelings and to begin to deal with the depression. Depressed persons often have little appetite and poor fluid intake. Constipation is common. A calm, consistent level of stimuli is most effective. Sensory deprivation and overstimulation should be avoided.

Question 3 of 5

The nurse is caring for a client with a nasogastric tube for decompression. Which action is most appropriate to ensure proper function?

Correct Answer: C

Rationale: Checking nasogastric tube placement (e.g., via pH or aspiration) before feedings or medications ensures the tube is in the stomach, preventing aspiration. Irrigation frequency depends on protocol, clamping may cause reflux, and supine positioning risks aspiration.

Question 4 of 5

A 56-year-old psychiatric inpatient has had recurring episodes of depression and chronic low self-esteem. She feels that her family does not want her around, experiences a sense of helplessness, and has a negative view of herself. To assist the client in focusing on her strengths and positive traits, a strategy used by the nurse would be to:

Correct Answer: B

Rationale: The nurse should encourage activities gradually, as client's energy level and tolerance for shared activities improve. Activities that focus on strengths and accomplishments, with uncomplicated tasks, minimize failure and increase self-worth. Asking a client to set a goal to make all decisions about attending group activities is unrealistic, and such decisions are not always under the client's control; this sets up the client for further failure and possibly decreased self-worth. Encouragement toward independence does promote increased feelings of self-worth; however, clients may need assistance with decision making and problem solving for various situations and on an individual basis.

Question 5 of 5

A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse's best response is:

Correct Answer: D

Rationale: A family member is encouraged to stay with the client after return to the unit. The nurse has used an opportunity to do family teaching and allay fears by explaining temporary side effects of the treatment.

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