NCLEX Questions, NCLEX RN Predictor Exam Questions, NCLEX-RN

Extract:

Question 1 of 5

The nurse assesses a client on the second postpartum day and finds a dark red discharge on the peripad. The stain appears to be about 5 inches long. Which of the following correctly describes the character and amount of lochia?

Correct Answer: D

Rationale: Lochia alba occurs approximately 10 days after birth and is yellow to white. A discharge is classified as light when less than a 4-inch stain exists. Lochia serosa is pink to brown and occurs 3-4 days after delivery. A stain is classified as heavy when a peripad is saturated in 1 hour. Lochia granulosa is not a proper classification. Lochia rubra is red, consisting mainly of blood, debris, and bacteria, and lasts from the time of delivery to 3-4 days afterward. A stain is classified as moderate when less than a 6-inch stain exists.

Question 2 of 5

The nurse is working in the trauma unit of the emergency room when a 24-year-old female is admitted after an MVA. The client is bleeding profusely and a blood transfusion is ordered. Which would the nurse be prepared to administer without a type and crossmatch?

A. AB positive B. AB negative C. O positive D. O negative

Correct Answer: D

Rationale: O negative blood is the universal donor, safe for transfusion without type and crossmatch in emergencies. AB positive (
A), AB negative (
B), and O positive (
C) risk incompatibility.

Question 3 of 5

A 3-year-old child is in the burn unit following a home accident. The first sign of sepsis in burned children is:

A. Disorientation B. Low-grade fever C. Diarrhea D. Hypertension

Correct Answer: A

Rationale: Disorientation is the first sign of sepsis in burn children. Low-grade fever is not indicative of sepsis. Diarrhea is not indicative of sepsis. Hypertension is not indicative of sepsis.

Question 4 of 5

During his hospitalization, a 3-year-old child has become unusually aggressive in his play activities. His parents report this change in behavior to the primary nurse. How could the nurse explain the child's change in behavior?

A. Deep-seated feelings of hostility B. A lack of interest in socializing C. Usual behavior for this child D. A coping response

Correct Answer: D

Rationale: Play provides the child with opportunities for coping and adaptation. Aggression during play activities indicates a coping response to hospitalization.

Question 5 of 5

Which of the following would indicate the need for further teaching for the client with COPD? The client verbalizes the need to:

A. Eat high-calorie, high-protein foods B. Take vitamin supplementation C. Eliminate intake of milk and milk products D. Eat small, frequent meals

Correct Answer: C

Rationale: Protein is vital for the maintenance of muscle to aid in breathing. A high-calorie diet using higher fat than carbohydrate content is given because clients are unable to breathe off the excess CO2 that is an end product of carbohydrate metabolism. Inadequate nutritional status, in particular, deficiencies in vitamins A and C, decreases resistance to infection. Milk does not make mucus thicker. It may coat the back of the throat and make it feel thicker. Rinsing the mouth with water after drinking milk will prevent this problem. Small, frequent meals minimize a fullness sensation and reduce pressure on the diaphragm. The work of breathing and SOB are also reduced.