NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A female client admitted to the labor and delivery unit thinks her bag of water 'broke' approximately 2 hours ago. She is having mild contractions 5 minutes apart. The most immediate nursing intervention would be to:
Correct Answer: B
Rationale: Amniotic fluid is generally pale and straw colored. Meconium-stained amniotic fluid would indicate a previous hypoxic episode. This intervention, though appropriate, is not the immediate priority. With rupture of the membranes, the umbilical cord may prolapse if the presenting part does not fill the pelvis. Assessing FHR ascertains fetal well-being. More information regarding fetal status and assessing for membrane rupture is needed prior to contacting the physician. Nitrazine test paper differentiates amniotic fluid from urine. Amniotic fluid is normally alkaline in contrast to urine, which is acidic. This intervention, though appropriate, is not the immediate priority.
Question 2 of 5
The nurse is teaching a client with a history of eczema about skin care. The nurse should tell the client to:
Correct Answer: A
Rationale: Avoiding harsh soaps prevents skin irritation and dryness in eczema, maintaining the skin barrier.
Question 3 of 5
A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy:
Correct Answer: C
Rationale: The instillation of erythromycin ophthalmic preparation, not phototherapy, prevents ophthalmia neonatorum. The administration of vitamin K (AquaMEPHYTON) assists the infant's clotting mechanism. Excessive bilirubin accumulates when the infant's liver cannot handle the increased load caused by the breakdown of red blood cells postnatally. This excessive bilirubin seeps out of the blood and into the tissues, staining them yellow. Phototherapy accelerates the removal of bilirubin from the skin by breaking it down into substances that can be excreted in stool or urine. Phototherapy decreases levels of unconjugated bilirubin, thereby preventing kernicterus.
Question 4 of 5
The nurse has performed discharge teaching to a client in need of a high-iron diet. The nurse recognizes that teaching has been effective when the client selects which meal plan?
Correct Answer: B
Rationale: A high-iron diet includes iron-rich foods like veal and spinach. Sliced veal, spinach salad, and whole-wheat roll (
B) are optimal. Other options lack significant iron sources.
Question 5 of 5
A client develops complications following a hysterectomy. Blood cultures reveal Pseudomonas aeruginosa. The nurse expects that the physician would order an appropriate antibiotic to treat P. aeruginosa such as:
Correct Answer: A
Rationale: Cefoperazone is indicated in the treatment of infection with Pseudomonas aeruginosa. Clindamycin is not indicated in the treatment of infection with P. aeruginosa. Dicloxacillin is not indicated in the treatment of infection with P. aeruginosa. Erythromycin is not indicated in the treatment of infection with P. aeruginosa.