NCLEX-RN
NCLEX RN Practice Questions with Answers Questions
Extract:
Question 1 of 5
An infant is at risk for an ileus after surgery to correct intussusception. Which observation should the nurse not include in an assessment for this complication?
Correct Answer: A
Rationale: Urine specific gravity is unrelated to assessing for ileus, which involves monitoring bowel sounds, stool characteristics, and gastric output to detect gastrointestinal function.
Question 2 of 5
A client receiving chemotherapy has a platelet count of 15,000 mm³ (15 x 10â¹/L). Based on this laboratory result, which form of precautions should the nurse implement?
Correct Answer: B
Rationale: When the platelet count is less than 20,000 mm³ (20 x 10â¹/L), the client is at risk for bleeding, and the nurse should institute bleeding precautions. Contact precautions are initiated in a client who has drainage from wounds that may be infectious. Respiratory precautions are instituted for a client with a respiratory infection that is transmitted by the airborne route. Neutropenic precautions would be instituted for a client with a low neutrophil count.
Question 3 of 5
After explaining to a multigravid client at 36 weeks' gestation who is diagnosed with severe hydramnios about the possible complications of this condition, which of the following statements indicates that the client needs further instruction?
Correct Answer: D
Rationale: Severe hydramnios increases risks like preterm labor, requiring activity restrictions; continuing physically demanding work indicates a need for further teaching.
Question 4 of 5
The nurse is providing bottle-feeding instructions to the mother of a newborn infant. The nurse provides instructions regarding the amount of formula to be given, knowing that what is the approximate stomach capacity for a newborn?
Correct Answer: B
Rationale: The stomach capacity of a newborn is approximately 10 to 20 mL. It is 30 to 90 mL for a 1-week-old infant and 75 to 100 mL for a 2- to 3-week-old infant.
Question 5 of 5
A client receiving a blood transfusion begins to have chills and headache within the first 15 minutes of the transfusion. The nurse should first:
Correct Answer: C
Rationale: Chills and headache suggest a transfusion reaction, requiring immediate discontinuation of the transfusion to prevent further complications.