NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
A vaginal exam of a laboring client reveals that the fetus is at 0 station. This assessment means that:
Correct Answer: C
Rationale: A 0 station means the presenting part of the fetus is level with the ischial spines indicating engagement in the pelvis. It does not indicate a lack of descent transverse lie or immediate risk of precipitate delivery.
Question 2 of 5
Diabetes during pregnancy requires tight metabolic control of glucose levels to prevent perinatal mortality. When evaluating the pregnant client, the nurse knows the recommended serum glucose range during pregnancy is:
Correct Answer: A
Rationale: The recommended range is 70-120 mg/dL to reduce the risk of perinatal mortality. (B, C,
D) These levels are not recommended. The higher the blood glucose, the worse the prognosis for the fetus. Hypoglycemia can also have detrimental effects on the fetus.
Question 3 of 5
A 52-year-old client who underwent an exploratory laparotomy for a bowel obstruction begins to complain of hunger on the third postoperative day. His nasogastric (NG) tube was removed this morning, and he has an IV of D5W with 0.45% normal saline running at 125 mL/hr. He asks when he can get rid of his IV and start eating. The nurse recognizes that he will be able to begin taking oral fluids and nourishment when:
Correct Answer: C
Rationale: The absence of wound infection is related to his surgical wound and not to postoperative GI functioning and return of peristalsis. Routine postoperative protocol involves detection of bowel sounds and return of peristalsis before introduction of clear liquids, followed by progression of full liquids and a regular diet versus a full regular meal first. Routine postoperative protocol for bowel obstruction is to assess for the return of bowel sounds within 72 hours after major surgery, because that is when bowel sounds normally return. If unable to detect bowel sounds, the surgeon should be notified immediately and have the client remain NPO. Routine postoperative protocol for bowel obstruction and other major surgeries involves frequent monitoring of vital signs in the immediate postoperative period (in recovery room) and then every 4 hours, or more frequently if the client is unstable, on the nursing unit. This includes assessing for signs of hypovolemic shock. Vital signs usually stabilize within the first 24 hours postoperatively.
Question 4 of 5
The nurse is caring for a client with a history of a stroke who has expressive aphasia. The nurse should:
Correct Answer: C
Rationale: Expressive aphasia impairs speech production. A whiteboard facilitates communication. Simple sentences help, but writing aids are critical, and loud speech or limiting interaction is unhelpful.
Question 5 of 5
The nurse assesses a postoperative mastectomy client and notes the breath sounds are diminished in both posterior bases. The nurse's action should be to:
Correct Answer: A
Rationale: Decreased or absent breath sounds are frequently indicators of postoperative atelectasis. Arterial blood gases are not indicated because there is no other information indicating impending danger. Increasing O2 rate is not indicated without additional information. Removing the dressing is not indicated without additional information.