NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar puncture. In light of this procedure and developmental characteristics of this age group, which nursing measure is most appropriate?
Correct Answer: A
Rationale: The nurse should emphasize what is required to elicit cooperation and help to develop a sense of autonomy. The child may express discomfort verbally and should be encouraged to express his feelings. Selecting nonthreatening words to explain a procedure will prevent misinterpretation. When explaining the procedure to the parent with the child present, the nurse should use words that the child can understand to avoid misunderstanding.
Question 2 of 5
A client with a history of a stroke is being taught to use a communication board. The nurse should:
Correct Answer: C
Rationale: Placing the communication board on the client’s strong side facilitates use, especially with hemiplegia. Loud speech, complex sentences, and limiting gestures are unhelpful.
Question 3 of 5
The nurse is caring for a client with a diagnosis of molar pregnancy. Which complication is most likely to occur?
Correct Answer: A
Rationale: Molar pregnancy can progress to choriocarcinoma a malignant tumor in rare cases. Fetal distress and preterm labor are not risks as there is no viable fetus and hypoglycemia is unrelated.
Question 4 of 5
The client will be more comfortable and the results more accurate when the nurse prepares the client for Leopold's maneuvers by having her:
Correct Answer: A
Rationale: A full bladder would cause discomfort and possible urinary incontinence during the exam. The left side-lying position would not accommodate the exam. The head of the exam table or bed can be slightly elevated to prevent supine hypotension. Arms extended over the head would cause the abdomen to be tighter and less easily palpable. Forcing fluids would encourage a full bladder, which is not desired for the exam.
Question 5 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.