NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
A term neonate has experienced no distress at birth and has an Apgar score of 9. Her mother has asked to breastfeed her following delivery. Immediately after birth, the neonate was most susceptible to heat loss. The most appropriate intervention to conserve heat loss and promote bonding is to:
Correct Answer: C
Rationale: A radiant warmer maintains an optimal thermal environment by use of a thermal skin sensor taped to the infant. The warmer limits parental attachment, so, although appropriate, it is not an intervention that promotes infant attachment. Warmed blankets prevent heat loss in the neonate by conduction. In addition, tactile stimuli promote crying and lung expansion. This intervention does not promote attachment, however. Skin-to-skin contact is an effective way to conserve heat after delivery and promotes parental attachment following birth in the healthy term infant. The first period of reactivity lasts approximately 30 minutes following birth. A strong sucking reflex and an active, awake newborn characterize this period. Surfaces of objects warmer than the infant promote overheating by conduction, and neonatal hyperthermia may result.
Question 2 of 5
Which of the following would indicate the need for further teaching for the client with COPD? The client verbalizes the need to:
Correct Answer: C
Rationale: Protein is vital for the maintenance of muscle to aid in breathing. A high-calorie diet using higher fat than carbohydrate content is given because clients are unable to breathe off the excess CO2 that is an end product of carbohydrate metabolism. Inadequate nutritional status, in particular, deficiencies in vitamins A and C, decreases resistance to infection. Milk does not make mucus thicker. It may coat the back of the throat and make it feel thicker. Rinsing the mouth with water after drinking milk will prevent this problem. Small, frequent meals minimize a fullness sensation and reduce pressure on the diaphragm. The work of breathing and SOB are also reduced.
Question 3 of 5
The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about pursed-lip breathing. Which statement indicates understanding?
Correct Answer: B
Rationale: Pursed-lip breathing involves slow exhalation through pursed lips to prolong exhalation and reduce air trapping in COPD. Quick inhalation (
A), breath-holding (
C), and rapid breathing (
D) are incorrect.
Question 4 of 5
The nurse is assigning staff for the day. Which client should be assigned to the nursing assistant?
Correct Answer: B
Rationale: The 10-year-old two days post-appendectomy is stable and requires routine care (e.g., vital signs, hygiene), suitable for a nursing assistant. The other clients have conditions (bronchiolitis, cellulitis, fracture) requiring more complex assessments or interventions by licensed staff.
Question 5 of 5
Which statement is true regarding a patient with a Sengstaken-Blakemore tube?
Correct Answer: D
Rationale: A Sengstaken-Blakemore tube is used for esophageal variceal bleeding. Scissors must be kept at the bedside to cut the tube in case of airway obstruction from balloon migration. The gastric balloon (not esophageal) controls bleeding the tube has three lumens and esophageal balloon pressure is typically 20-25 mmHg.