NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
The nurse is assessing a client with suspected hypovolemic shock. Which finding is most indicative?
Correct Answer: A
Rationale: Tachycardia is a hallmark of hypovolemic shock, compensating for reduced blood volume. Hypothermia (
B) is secondary, bradypnea (
C) is atypical, and hypertension (
D) is not associated.
Question 2 of 5
Early in her ninth month of pregnancy, a client has been diagnosed as having mild preeclampsia. In counseling her about her diet, the nurse must emphasize the importance of:
Correct Answer: D
Rationale: Women with pregnancy-induced hypertension have a reduced plasma volume secondary to venous vessel constriction, not hypovolemia; therefore, sodium restriction is not recommended. It is suggested that these women avoid extremely salty foods. Drinking six to eight glasses of water per day facilitates optimal fluid volume and renal perfusion, but it will not decrease the venous vessel constriction of pregnancy-induced hypertension. Carbohydrate needs increase during pregnancy, specifically during the second and third trimesters, but they have not been linked to pregnancy-induced hypertension. Loss of urinary protein (proteinuria) is associated with increased permeability of the large protein molecules with pregnancy-induced hypertension. Additional dietary protein also helps increase the plasma colloidal osmotic pressure. Diets deficient in protein have been linked to pregnancy-induced hypertension.
Question 3 of 5
A 4 days postpartum client who is gravida 3, para 3, is examined by the home health nurse during her first postpartum home visit. The nurse notes that she has a pink vaginal discharge with a serosanguineous consistency. The nurse would most accurately chart the client's lochia as:
Correct Answer: C
Rationale: Lochia rubra is bloody with clots and occurs 1-3 days postpartum. There is no such term as lochia rosa. Lochia serosa is a pink-brown discharge with a serosanguineous consistency that occurs 4-9 days postpartum. Lochia alba is yellow to white in color and occurs approximately 10 days postpartum.
Question 4 of 5
What is the most effective method to identify early breast cancer lumps?
Correct Answer: D
Rationale: Mammograms are less effective than breast self-examination for the diagnosis of abnormalities in younger women, who have denser breast tissue. They are more effective for women older than 40. Up to 15% of early-stage breast cancers are detected by physical examination; however, 95% are detected by women doing breast self-examination. Ultrasound is used primarily to determine the location of cysts and to distinguish cysts from solid masses. Monthly breast self-examination has been shown to be the most effective method for early detection of breast cancer. Approximately 95% of lumps are detected by women themselves.
Question 5 of 5
After a 10-year-old child with insulin-dependent diabetes mellitus receives her dinner tray, she tells the nurse that she hates broccoli and wants some corn on the cob. The nurse's appropriate response is:
Correct Answer: B
Rationale: Vegetable exchanges are allowed within the same group to maintain nutritional balance. Corn is classified as a starchy vegetable and counts as a bread exchange due to its carbohydrate content, which affects blood glucose levels. Not all vegetables are interchangeable; starchy vegetables like corn have different nutritional impacts than non-starchy ones like broccoli. Limiting to half an ear does not address the dietary classification and could confuse the child about proper exchanges.