NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A client with a history of a colostomy is being discharged. The nurse should teach the client to:
Correct Answer: B
Rationale: High-fiber foods can cause blockages or excessive output in a colostomy. Bag changes depend on output, alcohol irritates the stoma, and irrigation is not always required.
Question 2 of 5
Pin care is a part of the care plan for a client who is in skeletal traction. When assessing the site of pin insertion, which one of the following findings would the nurse know as an indicator of normal wound healing?
Correct Answer: B
Rationale: Exudate (moist, active drainage) is a clinical sign of wound infection. Crust (dry, scaly) is part of the normal stages of wound healing and should not be removed from around the pin site. It usually sloughs off after the underlying tissue has healed. Edema (swelling) is a clinical sign of wound infection. Erythema (redness) is a clinical sign of wound infection.
Question 3 of 5
The physician has ordered a homocysteine blood level on a client.
Correct Answer: A
Rationale: Homocysteine levels rise with vitamin B12 deficiency, as B12 is needed for its metabolism. Deficiencies in vitamins C (
B), A (
C), and E (
D) do not significantly affect homocysteine.
Question 4 of 5
The client is admitted with a diagnosis of ectopic pregnancy. Which symptom is most characteristic of this condition?
Correct Answer: A
Rationale: Ectopic pregnancy often presents with sudden sharp abdominal pain due to tubal stretching or rupture. Painless bleeding is more typical of placenta previa and fever or edema are not characteristic.
Question 5 of 5
The nurse is ready to begin an exam on a nine-month-old infant who is sitting quietly on his mother's lap. Which should the nurse do first?
Correct Answer: B
Rationale: When examining an infant, the nurse should start with the least invasive procedures to maintain the infant’s calm state. Listening to heart and lung sounds is non-invasive and can be done while the infant is quiet. Checking the Babinski reflex, palpating the abdomen, or checking tympanic membranes may cause discomfort and disrupt the exam.