NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
A client with a history of Crohn's disease is admitted with a small bowel obstruction. The nurse should give priority to:
Correct Answer: A
Rationale: Small bowel obstruction in Crohn's disease can cause fluid loss through vomiting or sequestration, making monitoring for dehydration the priority to prevent hypovolemia.
Question 2 of 5
The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue healing?
Correct Answer: A
Rationale: Vitamin C (ascorbic acid) is essential in promoting wound healing and collagen formation. Vitamin B1 (thiamine) maintains normal gastrointestinal (GI) functioning, oxidizes carbohydrates, and is essential for normal functioning of nervous tissue. Vitamin D regulates absorption of calcium and phosphorus from the GI tract and helps prevent rickets. Vitamin A is necessary for the formation and maintenance of skin and mucous membranes. It is also essential for normal growth and development of bones and teeth.
Question 3 of 5
While the RN is assessing a mother's perineum on her 2nd postpartum day after having a vaginal delivery, the RN notes a large ecchymotic area located to the left of the mother's perineum. Which one of the following interventions should the RN initiate at this time?
Correct Answer: C
Rationale: Warm sitz baths increase circulation, promote healing, and reduce edema in a traumatized perineum, making it appropriate for an ecchymotic area.
Question 4 of 5
At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her contractions are every 5 minutes and last 60 seconds, her cervix is closed, and the suture placed around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is still intact. She is very concerned about delivering prematurely. She asks the RN, 'What is the greatest risk to my baby if it is born prematurely?' The RN's answer should be:
Correct Answer: D
Rationale: Any infant would be at risk for hyperglycemia because the infant's liver is missing the islets of Langerhans, which secrete insulin to break down glucose for cellular use. Prematurity is not an added risk for hyperglycemia. Both premature and mature infants can be at risk for hypoglycemia if their mother had gestational diabetes during pregnancy or entered the pregnancy with diabetes mellitus. These infants are exposed to high levels of maternal glucose while in utero, which causes the islets of Langerhans in the infant's liver to produce insulin. After birth when the umbilical cord is severed, the generous amount of maternal blood glucose is eliminated; however, there is continued islet cell hyperactivity in the infant's liver, which can lead to excessive insulin levels and depleted blood glucose. Mature infants are born with an immature GI system. The nervous control of the stomach is incomplete at birth, salivary glands are immature at birth, and the intestinal tract is sterile. This is not the greatest risk to a premature infant. The greatest risk to a premature infant is the lack of development of the lungs, which can lead to respiratory distress syndrome due to insufficient surfactant production.
Question 5 of 5
A client with a history of endometrial cancer is admitted with complaints of vaginal bleeding. The nurse should give priority to:
Correct Answer: A
Rationale: Vaginal bleeding in endometrial cancer may indicate recurrence, so monitoring for recurrence is the priority.