NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
Following the delivery of a healthy newborn, a client has developed thrombophlebitis and is receiving heparin IV. What are the signs and symptoms of a heparin overdose for which the nurse would need to observe during postpartum care of the client?
Correct Answer: D
Rationale: Hematuria, ecchymosis, and epistaxis are the most common signs and symptoms of a heparin overdose, indicating bleeding tendencies.
Question 2 of 5
A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching?
Correct Answer: B
Rationale: Diarrhea is a complication of tube feedings that can lead to dehydration. Diarrhea may be the result of hypertonic formulas that can draw fluid into the bowel. Other causes of diarrhea may be bacterial contamination, fecal impaction, medications, and low albumin. A consistent weight gain of more than 0.22 kg/day (1/2 lb/day) over several days should be reported promptly. The client should be evaluated for fluid volume excess. Elevating the client's head prevents reflux and thus formula from entering the airway. Bacteria proliferate rapidly in enteral formulas and can cause gastroenteritis and even sepsis.
Question 3 of 5
The client at 34 weeks gestation is admitted with a diagnosis of preterm premature rupture of membranes (PPROM). The nurse should monitor for which complication?
Correct Answer: D
Rationale: PPROM increases the risk of chorioamnionitis (infection) preterm delivery (due to loss of amniotic fluid) and fetal distress (from infection or cord compression). All are potential complications requiring monitoring.
Question 4 of 5
Diphenoxylate hydrochloride and atropine sulfate (Lomotil) is prescribed for the client with ulcerative colitis. Which of the following nursing observations indicates that the drug is having a therapeutic effect?
Correct Answer: B
Rationale: Lomotil, an antidiarrheal, slows intestinal motility, reducing diarrhea frequency in ulcerative colitis. Decreased diarrhea stools (
B) indicates therapeutic effect. Absent peristalsis (
A), increased cramping (
C), or girth (
D) suggest complications or ineffectiveness.
Question 5 of 5
A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period was February 16, with 3 days of spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to be:
Correct Answer: A
Rationale: Naegele's rule is as follows: add 7 days to the 1st day of the last menstrual period, subtract 3 months, and then add 1 year. Naegele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naegele's rule. Naegele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naegele's rule. Naegele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naegele's rule.