NCLEX-RN
NCLEX RN Practice Questions with Answers Questions
Extract:
Question 1 of 5
A client has undergone a vaginal hysterectomy. Which interventions should the nurse include in the client's nursing care plan to decrease the risk of deep vein thrombosis or thrombophlebitis? Select all that apply.
Correct Answer: A,C,E
Rationale: The client is at risk for deep vein thrombosis or thrombophlebitis after this surgery, as for any other major surgery. For this reason, the nurse implements measures that will prevent this complication. Ambulation, pneumatic compression boots, range-of-motion exercises, and antiembolism stockings are all helpful. The nurse should avoid elevating the knees using the knee gatch in the bed, which inhibits venous return and places the client more at risk for deep vein thrombosis or thrombophlebitis.
Question 2 of 5
Which of the following steps is the final step that is used during the physical assessment of the abdomen?
Correct Answer: C
Rationale: The standard sequence for abdominal assessment is inspection, auscultation, percussion, and palpation (light then deep). Deep palpation is the final step to assess for organ size or abnormalities.
Question 3 of 5
A nurse is caring for a client with a suspected myocardial infarction. Which of the following laboratory results should the nurse prioritize?
Correct Answer: A
Rationale: Troponin is a specific marker for myocardial damage and is critical in diagnosing myocardial infarction. Other results are less specific to this condition.
Question 4 of 5
You are working in a community pediatric health clinic. Which developmental task should you apply into your practice?
Correct Answer: A
Rationale: According to Erikson's developmental stages, preschool children (ages 3-5) are in the stage of Initiative vs. Guilt, where they develop a sense of purpose through exploration and play. This is the appropriate developmental task to apply in a pediatric clinic for this age group.
Question 5 of 5
The nurse should instruct the client prescribed docusate to monitor for which intended effect of the medication?
Correct Answer: D
Rationale: Docusate is a stool softener that promotes absorption of water into the stool, producing a softer consistency of stool. The intended effect is relief or prevention of constipation. The medication does not relieve abdominal pain, relieve heartburn, or decrease the amount of fat in the stools.