NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A 26-year-old female client presents at 10 weeks' gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her grandmother also has insulin-dependent diabetes. The client's previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches tall and her current weight is 130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following factors places her at risk for gestational diabetes?
Correct Answer: C
Rationale: Maternal age older than 30 years is an identified risk factor for diabetes. Age younger than 30 years is insignificant for diabetes unless there is a familial history of diabetes. The client's weight is appropriate for her height. Obesity or pregnancy weight >20% of the ideal weight is a contributing factor to the development of gestational diabetes. The birth of an infant weighing >9 lb (4000 g) is an identified risk factor for gestational diabetes. A familial history of heart disease is insignificant in the development of diabetes. However, a familial history of type II diabetes mellitus is identified as a risk factor in the development of diabetes during pregnancy.
Question 2 of 5
The nurse is assessing a client with suspected hyperthyroidism. Which finding is most consistent with this diagnosis?
Correct Answer: C
Rationale: Tremors are a common sign of hyperthyroidism due to increased metabolic rate and sympathetic activity. Weight gain, bradycardia, and constipation are more typical of hypothyroidism.
Question 3 of 5
A 6-month-old infant has developmental delays. His weight falls below the 5th percentile when plotted on a growth chart. A diagnosis of failure to thrive is made. What behaviors might indicate the possibility of maternal deprivation?
Correct Answer: B
Rationale: Normal infant attachment behaviors include responding to touch and wanting to be held. Maternal deprivation behaviors include poor feeding, stiffening and refusal to eat, and inconsistencies in responsiveness. Attachment behavior includes maintaining eye contact. Maternal deprivation behaviors include displeasure with touch and physical contact.
Question 4 of 5
A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:
Correct Answer: A
Rationale: The water seal prevents air from entering the pleural space, maintaining negative pressure for lung re-expansion.
Question 5 of 5
The amniocentesis reveals that the patient has a high AFP level. The nurse is aware that a high level of AFP is associated with which of the following?
Correct Answer: A
Rationale: High alpha-fetoprotein (AFP) levels in amniotic fluid are associated with neural tube defects such as myelomeningocele (a type of spina bifida). Esophageal atresia omphalocele and Trisomy 21 (Down syndrome) are not typically associated with elevated AFP levels.