NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
In discussing the plan of care for a child with chronic nephrosis with the mother, the nurse identifies that the purpose of weighing the child is to:
Correct Answer: D
Rationale: Weighing a child with nephrosis is to assess for edema, not nutrition. (B,
C) This is not the purpose for weighing the child. Weight and measurement are the primary ways of evaluating edema and fluid shifts.
Question 2 of 5
A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea, vomiting, and sore throat for the past several days. In caring for a young child with symptoms of influenza, the mother must be cautioned about:
Correct Answer: A
Rationale: Aspirin should never be given to children with influenza because of the possibility of causing Reye's syndrome. Pepto-Bismol is also classified as a salicylate and should be avoided. Depending on the severity of symptoms, the child may be receiving IV therapy or clear liquids. The disease has a 1-3 day incubation period and affected children are most infectious 24 hours before and after the onset of symptoms. Although viral pneumonia can be a complication of influenza, this would not be an initial priority.
Question 3 of 5
The nurse caring for a client who has pneumonia, which is caused by a gram-positive bacteria, inspects her sputum. Because the client's pneumonia is caused by a gram-positive bacteria, the nurse expects to find the sputum to be:
Correct Answer: B
Rationale: Bright red sputum with streaks is associated with pneumonia caused by gram-negative bacteria, such as Klebsiella pneumonia. Pneumococcal pneumonia, caused by gram-positive bacteria, has a characteristic productive cough with green or rust-colored sputum. Green-colored sputum is more characteristic of Pseudomonas than of gram-positive bacterial pneumonia. Pink-tinged and frothy sputum is more characteristic of pulmonary edema than of gram-positive bacterial pneumonia.
Question 4 of 5
The nurse is caring for a client with a diagnosis of placenta previa. Which intervention is most appropriate?
Correct Answer: A
Rationale: Placenta previa requires bedrest to minimize bleeding risk by reducing cervical pressure.
Tocolytics are not typically used vaginal delivery is contraindicated and antibiotics are not indicated unless infection is present.
Question 5 of 5
The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?
Correct Answer: C
Rationale: Bradycardia is an expected assessment during the postpartum period. Diuresis can occur during labor and the postpartum period and is an expected physiological adaptation. A return of rubra after the serosa period may indicate a postpartal complication. Diaphoresis, especially at night, is an expected physiological change and does not indicate an infectious process. Bradycardia, diuresis, and diaphoresis are normal postpartum physiological responses to adjust the cardiac output and blood volume to the nonpregnant state.