NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 of 5
In cleansing the perineal area around the site of catheter insertion, the nurse would:
Correct Answer: B
Rationale: Wiping away from the urinary meatus removes microorganisms from the insertion point, decreasing the risk of bladder infection. The other options increase infection risk or are inappropriate.
Question 2 of 5
On the first postpartal day, a client tells the nurse that she has been changing her perineal pads every 1/2 hour because they are saturated with bright red vaginal drainage. When palpating the uterus, the nurse assesses that it is somewhat soft, 1 fingerbreadth above the umbilicus, and midline. The nursing action to be taken is to:
Correct Answer: A
Rationale: Gentle massage and expression of clots will let the fundus return to a state of firmness, allowing the uterus to function as the 'living ligature.' A distended bladder may promote uterine atony; however, after determining the bladder is distended, the nurse would have the client void. Catheterization is only done if normal bladder function has not returned. Oxytocic medications are ordered and administered if the uterus does not remain contracted after gentle massage and determining if the bladder is empty. The client is not complaining of discomfort or pain; therefore, analgesics are not necessary.
Question 3 of 5
A client with a history of a stroke is being discharged. The nurse should teach the client to:
Correct Answer: B
Rationale: Assistive devices (e.g., cane, walker) promote safety and mobility post-stroke. Physical activity is encouraged, social interactions are beneficial, and sodium should be limited.
Question 4 of 5
A 26-year-old client has no children. She has had an abdominal hysterectomy. In the first 24 hours postoperatively, the nurse would be concerned if the client:
Correct Answer: B
Rationale: The client may be more tearful than normal due to the stress of the surgery and its implications for her future life. She would be expected to have pain following surgery. A temperature of 102°F indicates an infectious process. This is not a normal sequence to surgery and indicates a need for further assessment. The client is expected to have no bowel sounds for 24-48 hours after surgery because of the trauma to the bowel. Normal urine output is 30 mL/hr. This represents an output of 50 mL/hr, which is greater than normal.
Question 5 of 5
A client delivered a stillborn male at term. An appropriate action of the nurse would be to:
Correct Answer: C
Rationale: This is not a supportive statement. There are also no data to indicate the family's religious beliefs. Seeing their baby assists the parents in the grieving process. This gives them the opportunity to say 'good-bye.' Parents need time to get to know their baby. This is not a comforting statement when a baby has died. There are also no guarantees that the couple will be able to have another child.