NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
A two-month-old infant has just received her first Tetramune injection. The nurse should tell the mother that the immunization:
Correct Answer: C
Rationale: Tetramune protects against diphtheria, pertussis, tetanus, and H. influenzae b and is part of a series given at 2, 4, 6, and 15-18 months. It does not test susceptibility or cover MMRV.
Question 2 of 5
After a 10-year-old child with insulin-dependent diabetes mellitus receives her dinner tray, she tells the nurse that she hates broccoli and wants some corn on the cob. The nurse's appropriate response is:
Correct Answer: B
Rationale: Vegetable exchanges are allowed within the same group to maintain nutritional balance. Corn is classified as a starchy vegetable and counts as a bread exchange due to its carbohydrate content, which affects blood glucose levels. Not all vegetables are interchangeable; starchy vegetables like corn have different nutritional impacts than non-starchy ones like broccoli. Limiting to half an ear does not address the dietary classification and could confuse the child about proper exchanges.
Question 3 of 5
A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately:
Correct Answer: C
Rationale: At 10 weeks, the fundus is located slightly above the symphysis pubis. At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus. At 20 weeks, the fundus is located approximately at the umbilicus. At 30 weeks, the fundal height is about 30 cm, or 10 cm above the umbilicus.
Question 4 of 5
A client with a fractured leg is exhibiting shortness of breath, pain upon deep breathing, and hemoptysis. What do these clinical manifestations indicate to the nurse?
Correct Answer: B
Rationale: Shortness of breath, pleuritic pain, and hemoptysis are classic signs of pulmonary embolus, often associated with immobility from a fracture. CHF (
A) causes edema, ARDS (
C) causes diffuse respiratory failure, and tension pneumothorax (
D) causes tracheal deviation.
Question 5 of 5
What is the most effective method to identify early breast cancer lumps?
Correct Answer: D
Rationale: Mammograms are less effective than breast self-examination for the diagnosis of abnormalities in younger women, who have denser breast tissue. They are more effective for women older than 40. Up to 15% of early-stage breast cancers are detected by physical examination; however, 95% are detected by women doing breast self-examination. Ultrasound is used primarily to determine the location of cysts and to distinguish cysts from solid masses. Monthly breast self-examination has been shown to be the most effective method for early detection of breast cancer. Approximately 95% of lumps are detected by women themselves.