NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
The nurse documents a client's surgical incision as having red granulated tissue. This indicates that the wound is:
Correct Answer: D
Rationale: The wound is healing properly and is filled with red granulated tissue and fragile capillaries.
Question 2 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?
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 3 of 5
The client is diagnosed with a hiatal hernia. Which instruction should the nurse include in the teaching plan?
Correct Answer: C
Rationale: Avoiding lying down after meals prevents acid reflux in hiatal hernia. Small meals, elevating the head of the bed, and avoiding caffeine are also recommended.
Question 4 of 5
A client with a laryngectomy returns from surgery with a nasogastric tube in place. The primary reason for placement of the nasogastric tube is to:
Correct Answer: B
Rationale: A nasogastric tube post-laryngectomy decompresses the stomach, preventing vomiting and aspiration, which could stress the surgical site. Swelling, contamination, and mucosa healing are secondary.
Question 5 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.