NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 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 2 of 5
The client is admitted with a diagnosis of vasa previa. Which delivery method is most likely to be planned?
Correct Answer: B
Rationale: Vasa previa with fetal vessels crossing the cervical os requires cesarean section to prevent vessel rupture and fetal exsanguination during vaginal delivery. Forceps or vacuum delivery increases risk.
Question 3 of 5
A client's congestive heart failure has been treated, and he will soon be discharged. Discharge teaching should include instruction to call the physician if he notices a 2-lb weight gain in a 24-hour period. Increased weight gain may indicate:
Correct Answer: B
Rationale: A 2-lb weight gain in 24 hours suggests fluid retention due to decreasing cardiac output, activating the renin-angiotensin-aldosterone system.
Question 4 of 5
The nurse is suctioning the tracheostomy of an adult client. The recommended pressure setting for performing tracheostomy suctioning on the adult client is:
Correct Answer: C
Rationale: Recommended suction pressure for adult tracheostomy is 80-120 mmHg to effectively remove secretions without causing trauma. Higher or lower pressures are less safe or effective.
Question 5 of 5
The client presents to the emergency room with a hyphema. Which action by the nurse would be appropriate?
Correct Answer: A
Rationale: A hyphema (blood in the anterior chamber of the eye) requires elevating the head to reduce intraocular pressure and applying ice to decrease swelling. The other actions are irrelevant to hyphema management.