NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
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
The physician has ordered Coumadin (sodium warfarin) for a client with a history of clots. The nurse should tell the client to avoid which of the following vegetables?
Correct Answer: B
Rationale: Cauliflower is high in vitamin K, which can counteract the anticoagulant effects of warfarin, so it should be limited.
Question 3 of 5
A 4 days postpartum client who is gravida 3, para 3, is examined by the home health nurse during her first postpartum home visit. The nurse notes that she has a pink vaginal discharge with a serosanguineous consistency. The nurse would most accurately chart the client's lochia as:
Correct Answer: C
Rationale: Lochia rubra is bloody with clots and occurs 1-3 days postpartum. There is no such term as lochia rosa. Lochia serosa is a pink-brown discharge with a serosanguineous consistency that occurs 4-9 days postpartum. Lochia alba is yellow to white in color and occurs approximately 10 days postpartum.
Question 4 of 5
A client diagnosed with severe anemia is to receive 2 U of packed red blood cells. Prior to starting the blood transfusion, the nurse must:
Correct Answer: A
Rationale: A baseline set of vital signs is necessary to determine if any transfusion reactions occur as the blood product is being administered. The only companion fluid to be used during a blood transfusion is normal saline. The calcium in Ringer's lactate can cause clotting. Only a blood administration set should be used. A microdrip tube would cause lysis of the red blood cells. Proper identification of the recipient and the blood product must be validated by at least two people.
Question 5 of 5
The client is admitted with a diagnosis of gestational trophoblastic disease. Which symptom is most likely to be present?
Correct Answer: A
Rationale: Gestational trophoblastic disease (e.g. molar pregnancy) causes markedly elevated hCG levels due to abnormal trophoblastic proliferation. Fetal heart tones are absent uterine size is larger and hypotension is not typical.