NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is:
Correct Answer: A
Rationale: Abdominal assessment follows the sequence: inspection, auscultation, palpation. Auscultation is done before palpation to avoid altering bowel sounds. Inspection identifies visible abnormalities first.
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 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately:
Correct Answer: C
Rationale: At 10 weeks, the fundus is located slightly above the symphysis pubis. At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus. At 20 weeks, the fundus is located approximately at the umbilicus. At 30 weeks, the fundal height is about 30 cm, or 10 cm above the umbilicus.
Question 4 of 5
The initial treatment for a client with a liquid chemical burn injury is to:
Correct Answer: B
Rationale: The use of large amounts of water to flush the area is recommended for chemical burns to dilute and remove the chemical. Neutralizing solutions may extend the burn, calcium chloride is not indicated, and lanolin is not beneficial initially.
Question 5 of 5
On admission to the inpatient unit, a 34-year-old client is able to follow simple directions, but with great difficulty. He is worried about how he can keep clean in such a public place and repeatedly dusts his bureau, straightens his bed, and adjusts the clothes in his closet. The client is experiencing a severe level of anxiety. Which response by the nurse would be most therapeutic in initially attempting to reduce his anxiety?
Correct Answer: B
Rationale: Acknowledging the anxiety and channeling it into some positive activity, such as a unit tour, is therapeutic and helps reduce anxiety by providing distraction and orientation.