NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U+1 in contrast to the previous assessment of U-2. The immediate nursing response is to:
Correct Answer: D
Rationale: Methergine is given following placental delivery to promote uterine contractions and prevent hemorrhage. Methergine may be administered in this clinical situation, but fundal massage would be the first response. Removal of retained placental fragments is done by the physician and is not the first response. If the fundus rises and is deviated, particularly to the right, the nurse should suspect bladder distention secondary to bladder and urethral trauma associated with birth and decreased bladder tone following delivery.
Therefore, women have a diminished sensation to void. A boggy fundus rises and is indicative of blood pooling, predisposing the woman to clot formation. Massage the uterus until firm.
Too vigorous massage will result in atonia. Clots may be expelled by a kneading motion of the uterus by the nurse.
Question 2 of 5
The client at 34 weeks gestation is admitted with a diagnosis of preterm premature rupture of membranes (PPROM). The nurse should monitor for which complication?
Correct Answer: D
Rationale: PPROM increases the risk of chorioamnionitis (infection) preterm delivery (due to loss of amniotic fluid) and fetal distress (from infection or cord compression). All are potential complications requiring monitoring.
Question 3 of 5
After 7 hours in restraints and a total of 30-mg haloperidol in divided doses, a client complains of stiffness in his neck and his tongue 'pulling to one side.' These extrapyramidal symptoms (EPS) will most likely be relieved by the administration of:
Correct Answer: B
Rationale: Benztropine acts to reduce EPS by blocking excess CNS cholinergic activity associated with dopamine deficiency in the basal ganglia by displacing acetylcholine at the receptor site.
Question 4 of 5
The nurse is teaching a client with a history of hypertension about medication adherence. The nurse should tell the client to:
Correct Answer: A
Rationale: Adherence to antihypertensives is critical in hypertension to maintain blood pressure control and prevent complications.
Question 5 of 5
A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching?
Correct Answer: B
Rationale: Diarrhea is a complication of tube feedings that can lead to dehydration. Diarrhea may be the result of hypertonic formulas that can draw fluid into the bowel. Other causes of diarrhea may be bacterial contamination, fecal impaction, medications, and low albumin. A consistent weight gain of more than 0.22 kg/day (1/2 lb/day) over several days should be reported promptly. The client should be evaluated for fluid volume excess. Elevating the client's head prevents reflux and thus formula from entering the airway. Bacteria proliferate rapidly in enteral formulas and can cause gastroenteritis and even sepsis.