NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
A 24-hours' postpartum client complains of discomfort at the episiotomy site. On assessment, the nurse notes the episiotomy is without signs of infection. To relieve the discomfort, the nurse should first:
Correct Answer: A
Rationale: Warm, moist heat will promote circulation and provide comfort. A sitz bath should be tried before medication is given. Pain medication can be given when other comfort measures such as a sitz bath and topical applications are ineffective. Kegel exercises facilitate sitting by decreasing tension on the episiotomy. They will not be effective for pain control or sustained comfort level. Ice packs are appropriate to apply in the first 12 hours post-delivery to produce vasoconstriction and to reduce edema to the area.
Question 2 of 5
A client with a history of leukemia is admitted with complaints of fatigue. The nurse should expect the client to have:
Correct Answer: A
Rationale: Leukemia impairs bone marrow function, reducing red blood cell production and causing anemia, which leads to fatigue.
Question 3 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 4 of 5
A client with a C4 spinal cord injury has been placed in traction with cervical tongs. Nursing care should include:
Correct Answer: D
Rationale: Sterile pin care prevents infection at the cervical tong insertion sites, a critical nursing responsibility. Releasing traction, loosening pins, or elevating the bed risks spinal instability.
Question 5 of 5
A 20-year-old female has a prescription for Sumycin (tetracycline). While teaching the client how to take her medicine, the nurse learns that the client is also taking an oral contraceptive. Which instruction should be included in the teaching plan?
Correct Answer: D
Rationale: Tetracyclines can reduce the effectiveness of oral contraceptives by altering gut flora, affecting estrogen metabolism. This increases the risk of unintended pregnancy, requiring backup contraception.