NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
For which of the following should the nurse be especially alert when caring for a term neonate, who weighed 10 lb at birth, 1 hour after a vaginal delivery?
Correct Answer: A
Rationale: The neonate would be considered large for gestational age (LG
A) because the neonate weighs more than 4,000 g (90th percentile). Hypoglycemia is a problem for the LGA neonate because glycogen stores are quickly used to maintain the weight. Other complications like hyperbilirubinemia may occur, but hypoglycemia is the priority concern within the first hour.
Question 2 of 5
A client is receiving a continuous infusion of heparin. The nurse notes a partial thromboplastin time (PTT) of 120 seconds. What should the nurse do first?
Correct Answer: A
Rationale: A PTT of 120 seconds is significantly above the therapeutic range (1.5 to 2 times normal), indicating a risk of bleeding. Stopping the infusion is the first action to prevent harm.
Question 3 of 5
The nurse is caring for a client who has just returned to the nursing unit after an intravenous pyelogram (IVP). Which of the following nursing interventions is most appropriate at this time?
Correct Answer: A
Rationale: Encouraging a large fluid intake post-IVP helps flush the contrast dye from the kidneys, reducing the risk of nephrotoxicity.
Question 4 of 5
The mother of a child with newly diagnosed Duchenne's muscular dystrophy asks how her child developed the disease. The nurse formulates a response incorporating which of the following statements about its transmission?
Correct Answer: D
Rationale: Duchenne's muscular dystrophy is an X-linked recessive disorder, typically carried by females and transmitted to male children, who are more likely to express the disease.
Question 5 of 5
The nurse should instruct the parent of a child who is taking valproic acid (Depakene) that the child will need to have routine blood analyses consisting of which of the following?
Correct Answer: B
Rationale: Valproic acid requires monitoring of amylase (for pancreatitis) and platelet levels (for thrombocytopenia).