NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
A client with a history of a burn injury is receiving Silvadene (silver sulfadiazine). The nurse should monitor the client for:
Correct Answer: A
Rationale: Silver sulfadiazine can cause neutropenia, requiring monitoring of white blood cell counts. Hyperkalemia, hypoglycemia, and hypertension are not typical side effects.
Question 2 of 5
The physician has ordered Coumadin (sodium warfarin) for a client with a history of clots. The nurse should tell the client to avoid which of the following vegetables?
Correct Answer: B
Rationale: Cauliflower is high in vitamin K, which can counteract the anticoagulant effects of warfarin, so it should be limited.
Question 3 of 5
A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately:
Correct Answer: C
Rationale: At 10 weeks, the fundus is located slightly above the symphysis pubis. At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus. At 20 weeks, the fundus is located approximately at the umbilicus. At 30 weeks, the fundal height is about 30 cm, or 10 cm above the umbilicus.
Question 4 of 5
After an infant is delivered by cesarean delivery and placed on the warmer, the RN dries and assesses the infant. At 1 and 5 minutes after birth, the RN does the Apgar scoring of the infant. The RN knows that because this infant was delivered by cesarean section, he is at increased risk for having which one of the following:
Correct Answer: C
Rationale: Infants delivered by cesarean section are at higher risk for respiratory distress syndrome because they do not experience chest compression in the birth canal, which helps expel lung fluid.
Question 5 of 5
On admission to the inpatient unit, a 34-year-old client is able to follow simple directions, but with great difficulty. He is worried about how he can keep clean in such a public place and repeatedly dusts his bureau, straightens his bed, and adjusts the clothes in his closet. The client is experiencing a severe level of anxiety. Which response by the nurse would be most therapeutic in initially attempting to reduce his anxiety?
Correct Answer: B
Rationale: Acknowledging the anxiety and channeling it into some positive activity, such as a unit tour, is therapeutic and helps reduce anxiety by providing distraction and orientation.