NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:
Correct Answer: B
Rationale: Blood pressure can remain normotensive in a state of hypovolemia. Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. Skin turgor is not a reliable indicator for assessing hydration in a burn client. Fluid intake does not indicate adequacy of fluid resuscitation in a burn client.
Question 2 of 5
The nurse is caring for a client with a history of a fractured pelvis who is in skeletal traction. The nurse should:
Correct Answer: D
Rationale: Monitoring for infection at pin sites prevents osteomyelitis in skeletal traction. Turning is limited, weights must hang freely, and lotion is unnecessary.
Question 3 of 5
A client who is gravida 1 para 1 vaginally delivered a 7-lb girl. She received a midline episiotomy at delivery. When assessing the level of her uterus immediately following delivery, the nurse would expect the fundus to be located:
Correct Answer: D
Rationale: Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. The uterus descends into the pelvic cavity at approximately 10-12 postpartal days and can no longer be palpated abdominally. Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. An enlarged uterus may indicate subinvolution or postpartal hemorrhage. Immediately following delivery, the uterus lies midline, about midway between the umbilicus and the symphysis pubis.
Question 4 of 5
When preparing a client for magnetic resonance imaging, the nurse should implement which of the following?
Correct Answer: C
Rationale: Removing jewelry and checking for metal implants prevents MRI-related injuries due to magnetic fields. Consent and atropine (
A), scrubbing (
B), and Benadryl (
D) are not standard for MRI prep.
Question 5 of 5
Following her surgery, a 5-year-old child will return to the pediatric unit with a long-arm cast. She experienced a supracondylar fracture of the humerus near the elbow. Which nursing action is most essential during the first 24 hours after surgery and cast application?
Correct Answer: D
Rationale: Neurovascular status of the extremity is of primary importance. The risk of circulatory impairment exists with any cast application, especially with fractures near the elbow.