NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
The client at 34 weeks gestation is admitted with a diagnosis of preterm premature rupture of membranes (PPROM). The nurse should monitor for which complication?
Correct Answer: D
Rationale: PPROM increases the risk of chorioamnionitis (infection) preterm delivery (due to loss of amniotic fluid) and fetal distress (from infection or cord compression). All are potential complications requiring monitoring.
Question 2 of 5
The elderly client is being discharged following a total knee replacement. To facilitate independence, the nurse should instruct the client/family to do which of the following?
Correct Answer: A, B, C, D, E, G
Rationale: Elevated commode seats (
A), removing rugs (
B), grab bars (
C), medic alert monitors (
D), nightlights (E), and bedside walkers (G) promote safety and independence. Foot protectors (F) are unrelated to mobility, and elevated side rails (H) may trap the client, increasing fall risk.
Question 3 of 5
A client with B negative blood requires a blood transfusion during surgery. If no B negative blood is available, the client should be transfused with:
Correct Answer: C
Rationale: O negative blood is the universal donor type, safe for all recipients, including B negative, as it lacks A, B, and Rh antigens, minimizing transfusion reactions.
Question 4 of 5
A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U+1 in contrast to the previous assessment of U-2. The immediate nursing response is to:
Correct Answer: D
Rationale: Methergine is given following placental delivery to promote uterine contractions and prevent hemorrhage. Methergine may be administered in this clinical situation, but fundal massage would be the first response. Removal of retained placental fragments is done by the physician and is not the first response. If the fundus rises and is deviated, particularly to the right, the nurse should suspect bladder distention secondary to bladder and urethral trauma associated with birth and decreased bladder tone following delivery.
Therefore, women have a diminished sensation to void. A boggy fundus rises and is indicative of blood pooling, predisposing the woman to clot formation. Massage the uterus until firm.
Too vigorous massage will result in atonia. Clots may be expelled by a kneading motion of the uterus by the nurse.
Question 5 of 5
A client is admitted with suspected Hodgkin's lymphoma. The diagnosis is confirmed by the:
Correct Answer: B
Rationale: Hodgkin's lymphoma is diagnosed by the presence of Reed-Sternberg cells in lymph node biopsy, a hallmark of the disease.