NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A client who is gravida 1 para 1 vaginally delivered a 7-lb girl. She received a midline episiotomy at delivery. When assessing the level of her uterus immediately following delivery, the nurse would expect the fundus to be located:
Correct Answer: D
Rationale: Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. The uterus descends into the pelvic cavity at approximately 10-12 postpartal days and can no longer be palpated abdominally. Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. An enlarged uterus may indicate subinvolution or postpartal hemorrhage. Immediately following delivery, the uterus lies midline, about midway between the umbilicus and the symphysis pubis.
Question 2 of 5
A postoperative TURP client returns from the recovery room to the general surgery unit and is in stable condition. One hour later the nurse assesses him and finds him to be confused and disoriented. She recognizes that this is most likely caused by:
Correct Answer: D
Rationale: Early signs of hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, and diaphoresis. Early signs of potassium depletion include muscular weakness or paralysis, tetany, postural hypotension, weak pulse, shallow respirations, apathy, weak voice, and electrocardiographic changes. Early signs of an elevated sodium level include dry oral mucous membranes, marked thirst, hypertension, tachycardia, oliguria or anuria, anxiety, and agitation. This answer is correct. Important early clinical findings of a decreased sodium concentration include confusion and disorientation. Hyponatremia can occur after a TURP because absorption during surgery through the prostate veins can increase circulating blood volume and decrease sodium concentration.
Question 3 of 5
The primary cause of anemia in a client with chronic renal failure is:
Correct Answer: D
Rationale: Chronic renal failure reduces erythropoietin production, impairing red blood cell production and causing anemia. Iron absorption, RBC destruction, and intrinsic factor are secondary or unrelated.
Question 4 of 5
During a change of shift, the oncoming nurse notes a discrepancy in the narcotic count. The nurse’s first action should be to:
Correct Answer: B
Rationale: A discrepancy in the narcotic count requires immediate investigation to ensure patient safety and compliance. Notifying the nursing supervisor is the first step, as they can initiate an internal review. The pharmacist, board, or director are notified later if needed.
Question 5 of 5
A client is admitted with suspected Legionnaires' disease. Which factor increases the risk of developing Legionnaires' disease?
Correct Answer: A
Rationale: Steroid use increases the risk of Legionnaires' disease by suppressing the immune system, making it easier for Legionella bacteria to cause infection.