NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
The client is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate action?
Correct Answer: A
Rationale: A blood glucose of 200 mg/dL indicates hyperglycemia, a common TPN complication requiring immediate action to adjust infusion or administer insulin. Weight gain, low-grade fever, and dry lips are less urgent.
Question 2 of 5
At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her contractions are every 5 minutes and last 60 seconds, her cervix is closed, and the suture placed around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is still intact. She is very concerned about delivering prematurely. She asks the RN, 'What is the greatest risk to my baby if it is born prematurely?' The RN's answer should be:
Correct Answer: D
Rationale: Any infant would be at risk for hyperglycemia because the infant's liver is missing the islets of Langerhans, which secrete insulin to break down glucose for cellular use. Prematurity is not an added risk for hyperglycemia. Both premature and mature infants can be at risk for hypoglycemia if their mother had gestational diabetes during pregnancy or entered the pregnancy with diabetes mellitus. These infants are exposed to high levels of maternal glucose while in utero, which causes the islets of Langerhans in the infant's liver to produce insulin. After birth when the umbilical cord is severed, the generous amount of maternal blood glucose is eliminated; however, there is continued islet cell hyperactivity in the infant's liver, which can lead to excessive insulin levels and depleted blood glucose. Mature infants are born with an immature GI system. The nervous control of the stomach is incomplete at birth, salivary glands are immature at birth, and the intestinal tract is sterile. This is not the greatest risk to a premature infant. The greatest risk to a premature infant is the lack of development of the lungs, which can lead to respiratory distress syndrome due to insufficient surfactant production.
Question 3 of 5
Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:
Correct Answer: A
Rationale: These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. Fluid intake should be increased to prevent dehydration. Environmental stimuli should be decreased to prevent precipitation of seizures. Application of restraints may cause the client to increase his or her physical activity and may eventually lead to exhaustion.
Question 4 of 5
Which information should be given to the client using a TENS unit?
Correct Answer: B
Rationale: Prolonged use of a TENS unit can cause skin irritation due to electrode adhesion or electrical stimulation. Electrocution is not a risk with battery-operated units, placement requires specific guidance, and lotions may interfere with electrode contact.
Question 5 of 5
Which of the following statements reflects Kohlberg's theory of the moral development of the preschool-age child?
Correct Answer: D
Rationale: In Kohlberg's preconventional stage (preschool age), morality is based on consequences (punishment or reward). Obeying adults or pleasing others reflects later stages.