NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A 28-year-old woman was admitted to the hospital for a thyroidectomy. Postoperatively she is taken to the postanesthesia care unit for several hours. In preparing for the client's return to her room, which nursing measure best demonstrates the nurse's thorough understanding of possible postthyroidectomy complications?
Correct Answer: C
Rationale: Dressing changes are done as necessary for bleeding. However, frequently, post-thyroidectomy bleeding may not be visible on the dressing, but blood may drain down the back of the neck by gravity. Narcotics are administered for acute pain as necessary. They are not necessarily given on return of the client to her room. The most serious postthyroidectomy complication is ineffective airway and breathing pattern related to tracheal compression and edema. A tracheostomy set, O2, and suction should be available at bedside for at least the first 24 hours postoperatively. Impaired verbal communication may occur due to laryngeal edema or nerve damage, but most commonly, it occurs due to endotracheal intubation. The client is usually able to communicate but is hoarse.
Question 2 of 5
Which observation would the nurse expect to make after an amniotomy?
Correct Answer: C
Rationale: After an amniotomy the nurse expects clear amniotic fluid. Greenish fluid suggests meconium dark yellow may indicate infection and red fluid indicates bleeding all of which are abnormal.
Question 3 of 5
The client's membranes rupture during labor. The fetal heart rate suddenly drops to 90 bpm. The nurse's first action should be to:
Correct Answer: B
Rationale: A sudden drop in fetal heart rate to 90 bpm after membrane rupture suggests possible umbilical cord prolapse or compression. Turning the client to her left side improves placental perfusion and may relieve cord compression. Oxygen and notifying the physician are secondary and increasing IV fluid is less urgent.
Question 4 of 5
A pregnant client complains of varicosities in the third trimester. Which of the following activities should she be advised to avoid?
Correct Answer: D
Rationale: Sitting with the legs crossed at the ankles does not interfere with circulation or create pressure points. TED stockings will help to reduce the varicosity by supporting the vein. Stockings must be applied with legs elevated. Support pantyhose help to reduce the varicosity by supporting the vein. They also provide support to the uterus and allow for better return circulation. Hose must be applied like TED stockings. Knee-high stockings create constriction and pressure points that interfere with circulation in the lower extremities.
Question 5 of 5
The nurse is preparing to administer both regular and NPH insulin to a client with diabetes. Place in sequence the correct method for completing this task.
Correct Answer: C, D, B, A
Rationale:
To prevent contamination: Inject air into regular insulin vial (
C), then NPH vial (
D). Withdraw regular insulin (
B), then NPH insulin (
A). Regular insulin is clear, drawn first to avoid clouding with NPH.