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
A female client at 36 weeks' gestation is experiencing preterm labor. Her physician has prescribed two doses of betamethasone 12 mg IM q24h. The nurse explains that she is receiving this drug to:
Correct Answer: C
Rationale: Respiratory distress syndrome occurs in the newborn, not the fetus. It may be treated postnatally with surfactant therapy. Betamethasone is a corticosteroid, not an anti-infective drug; therefore, its use would not prevent uterine infection. Betamethasone binds with glucocorticoid receptors in alveolar cells to increase production of surfactant, thus increasing lung maturity in the preterm fetus. Betamethasone does not affect uteroplacental circulatory exchange.
Question 4 of 5
Which of the following statements relevant to a suicidal client is correct?
Correct Answer: A
Rationale: This is a high-risk factor for potential suicide. A previous suicide attempt is a definite risk factor for subsequent attempts. Every threat of suicide should be taken seriously. The client should be asked directly about his or her intent to do bodily harm. The client is never hurt by direct, respectful questions.
Question 5 of 5
Which of the following are sources of dietary iron?
Correct Answer: B, D, F
Rationale: Iron-rich foods include molasses (
B), raisins (
D), and collards (F). Cheese (
A), carrots (
C), and peanut butter (E) are low in bioavailable iron.