NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which vital sign change is most likely to be observed?
Correct Answer: D
Rationale: Postpartum endometritis a uterine infection can cause fever (from infection) tachycardia (from systemic response) and hypotension (in severe cases). All vital sign changes may be observed.
Question 2 of 5
A burn client's care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?
Correct Answer: A
Rationale: Minimal bacteria in wound cultures indicates no localized infection, supporting the outcome. Cloudy urine (
B), elevated WBC (
C), and fever (
D) suggest possible infection.
Question 3 of 5
A 17-year-old pregnant client who is gravida 1, para 0, is at 36 weeks' gestation. Based on the nurse's knowledge of the maternal physiological changes in pregnancy, which of these findings would be of concern?
Correct Answer: B
Rationale: Edema of the face, hands, or pitting edema after 12 hours of bed rest may be indicative of preeclampsia and would be of great concern to the healthcare provider.
Question 4 of 5
The nurse is in the hallway and one of the visitors faints. The nurse should:
Correct Answer: B
Rationale: Sitting the client up defeats the goal of re-establishing cerebral blood flow. Elevating the legs anatomically redirects blood flow to the cerebral area. This strategy is a nice general comfort measure after the victim has regained consciousness. This strategy is not as effective a strategy in helping the client to regain consciousness as elevating the legs.
Question 5 of 5
A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony. Which of the following nursing implementations would be most effective in helping him cope with immobility?
Correct Answer: B
Rationale: Self-care is usually well received by the child, and it is one of the most useful interventions to help the child cope with immobility, providing a sense of control.