NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on a full-strength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the following?
Correct Answer: A
Rationale: Once the feeding tube placement is confirmed in the stomach, aspiration can occur if the client's stomach becomes too full. When suctioning the trachea, if secretions resemble tube feeding, the client has aspirated the feeding.
Question 2 of 5
A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U+1 in contrast to the previous assessment of U-2. The immediate nursing response is to:
Correct Answer: D
Rationale: Methergine is given following placental delivery to promote uterine contractions and prevent hemorrhage. Methergine may be administered in this clinical situation, but fundal massage would be the first response. Removal of retained placental fragments is done by the physician and is not the first response. If the fundus rises and is deviated, particularly to the right, the nurse should suspect bladder distention secondary to bladder and urethral trauma associated with birth and decreased bladder tone following delivery.
Therefore, women have a diminished sensation to void. A boggy fundus rises and is indicative of blood pooling, predisposing the woman to clot formation. Massage the uterus until firm.
Too vigorous massage will result in atonia. Clots may be expelled by a kneading motion of the uterus by the nurse.
Question 3 of 5
A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful?
Correct Answer: A
Rationale: Acorn squash and brussels sprouts are potassium-rich, indicating successful teaching. The other options contain fewer potassium-rich foods.
Question 4 of 5
The nurse is caring for a client with a history of a myocardial infarction who is receiving Nitroglycerin. The nurse should monitor the client for:
Correct Answer: A
Rationale: Nitroglycerin, a vasodilator, commonly causes hypotension due to decreased preload. Tachycardia is possible but secondary, and hyperglycemia/fever are unrelated.
Question 5 of 5
The nurse is caring for a client with a diagnosis of gestational diabetes. Which laboratory test is most appropriate to monitor?
Correct Answer: C
Rationale: Hemoglobin A1c reflects long-term glucose control and fasting blood glucose monitors daily management in gestational diabetes. Both tests are appropriate to ensure optimal maternal and fetal outcomes.