NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
In counseling a client, the nurse emphasizes the danger signals during pregnancy. On the next visit, the client identifies which of the following as a danger signal that should be reported immediately?
Correct Answer: D
Rationale: Backache is a common complaint during pregnancy. Proper body mechanics, pelvic rock, back rubs, and other comfort measures should relieve the discomfort. In the presence of uterine contractions, the backache would radiate to the lower abdomen. Colostrum is normal and can be present anytime in the second half of pregnancy. Constipation and hemorrhoids are common and do need attention, but they do not constitute a dangerous situation. Visual changes are possibly related to PIH. The client should be assessed immediately to rule out or prevent worsening of PIH.
Question 2 of 5
A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:
Correct Answer: B
Rationale: Fetal heart tones detectable by Doppler around 10-12 weeks and consistently by 20 weeks are the most definitive sign of pregnancy. HCG uterine enlargement and breast changes are presumptive or probable signs.
Question 3 of 5
A term neonate has experienced no distress at birth and has an Apgar score of 9. Her mother has asked to breastfeed her following delivery. Immediately after birth, the neonate was most susceptible to heat loss. The most appropriate intervention to conserve heat loss and promote bonding is to:
Correct Answer: C
Rationale: A radiant warmer maintains an optimal thermal environment by use of a thermal skin sensor taped to the infant. The warmer limits parental attachment, so, although appropriate, it is not an intervention that promotes infant attachment. Warmed blankets prevent heat loss in the neonate by conduction. In addition, tactile stimuli promote crying and lung expansion. This intervention does not promote attachment, however. Skin-to-skin contact is an effective way to conserve heat after delivery and promotes parental attachment following birth in the healthy term infant. The first period of reactivity lasts approximately 30 minutes following birth. A strong sucking reflex and an active, awake newborn characterize this period. Surfaces of objects warmer than the infant promote overheating by conduction, and neonatal hyperthermia may result.
Question 4 of 5
The leukemic client is prescribed a low-bacteria diet. Which does the nurse expect to be included in this diet?
Correct Answer: A
Rationale: A low-bacteria diet for leukemia includes cooked foods (e.g., cooked spinach and celery) to minimize infection risk. Raw foods like lettuce (
B), strawberries (
C), and cauliflower (
D) pose higher bacterial risks.
Question 5 of 5
Which of the following would indicate the need for further teaching for the client with COPD? The client verbalizes the need to:
Correct Answer: C
Rationale: Protein is vital for the maintenance of muscle to aid in breathing. A high-calorie diet using higher fat than carbohydrate content is given because clients are unable to breathe off the excess CO2 that is an end product of carbohydrate metabolism. Inadequate nutritional status, in particular, deficiencies in vitamins A and C, decreases resistance to infection. Milk does not make mucus thicker. It may coat the back of the throat and make it feel thicker. Rinsing the mouth with water after drinking milk will prevent this problem. Small, frequent meals minimize a fullness sensation and reduce pressure on the diaphragm. The work of breathing and SOB are also reduced.