NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
On the third postpartum day, the nurse would expect the lochia to be:
Correct Answer: A
Rationale: This discharge occurs from delivery through the 3rd day. There is dark red blood, placental debris, and clots. This discharge occurs from days 4-10. The lochia is brownish, serous, and thin. This discharge occurs from day 10 through the 6th week. The lochia is yellowish white. This is not a classification of lochia but relates to the amount of discharge.
Question 2 of 5
A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony. Which of the following nursing implementations would be most effective in helping him cope with immobility?
Correct Answer: B
Rationale: Self-care is usually well received by the child, and it is one of the most useful interventions to help the child cope with immobility, providing a sense of control.
Question 3 of 5
The client is admitted with a diagnosis of preterm labor at 32 weeks gestation. The physician orders a tocolytic. The nurse should monitor for which complication?
Correct Answer: B
Rationale:
Tocolytics (e.g. nifedipine terbutaline) can cause maternal tachycardia as a side effect due to their effects on smooth muscle relaxation or beta-adrenergic stimulation. Fetal hypoglycemia macrosomia and maternal hypokalemia are not typical complications.
Question 4 of 5
A client was admitted with rib fractures and a pneumothorax, which were sustained as a result of a motor vehicle accident. A chest tube was placed on the left side to reinflate his lung, and he was transferred to a client unit. Twenty-four hours after admission he continues to have bloody sputum, develops increasing hypoxemia, and his chest x-ray shows patchy infiltrates. The nurse analyzes these symptoms as being consistent with:
Correct Answer: B
Rationale: Pulmonary contusions from blunt chest trauma cause alveolar edema and hemorrhage, leading to bloody sputum, hypoxemia, and patchy infiltrates on x-ray.
Question 5 of 5
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which intervention is most appropriate?
Correct Answer: A
Rationale: Postpartum endometritis is treated with antibiotics to address the uterine infection. Fetal heart tones are irrelevant postpartum cesarean delivery is not indicated and tocolytics are for preterm labor.