NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of Rh sensitization. The physician orders a Kleihauer-Betke test. The purpose of this test is to:
Correct Answer: A
Rationale: The Kleihauer-Betke test quantifies fetal blood in maternal circulation critical in Rh sensitization to determine the dose of RhoGAM needed to prevent maternal antibody formation. It does not assess lung maturity antibodies or amniotic fluid volume.
Question 2 of 5
The nurse is teaching a client with a history of celiac disease about dietary modifications. The nurse should tell the client to avoid:
Correct Answer: A
Rationale: Celiac disease requires a gluten-free diet to prevent intestinal damage, so avoiding gluten-containing foods is essential.
Question 3 of 5
A pregnant client is at the clinic for a third trimester prenatal visit. During this examination, it has been determined that her fetus is in a vertex presentation with the occiput located in her right anterior quadrant. On her chart this would be noted as:
Correct Answer: B
Rationale: The fetus in the right occipitoposterior position would be presenting with the occiput in the maternal right posterior quadrant. Fetal position is defined by the location of the fetal presenting part in the four quadrants of the maternal pelvis. The right occipitoanterior is a fetus presenting with the occiput in mother's right anterior quadrant. The fetus in right sacroanterior position would be presenting a sacrum, not an occiput. The fetus in left occipitoanterior position would be presenting with the occiput in the mother's left anterior quadrant.
Question 4 of 5
An 8-week-old infant has been diagnosed with gastroesophageal reflux. The nurse is teaching the infant's mother to care for the infant at home. Which one of the following statements by the nurse is appropriate regarding the infant's home care?
Correct Answer: D
Rationale: Elevating the child's head to a 30-degree angle is the recommended position for gastroesophageal reflux. The supine position predisposes the child to aspiration. Small, frequent feedings with thickened formula are recommended to minimize vomiting. Antacids should be given at the same time as the feeding to improve their buffering action. The infant should be kept still after feedings to reduce the risk of vomiting and aspiration. Vigorous activities should be carried out before feedings.
Question 5 of 5
A 56-year-old psychiatric inpatient has had recurring episodes of depression and chronic low self-esteem. She feels that her family does not want her around, experiences a sense of helplessness, and has a negative view of herself. To assist the client in focusing on her strengths and positive traits, a strategy used by the nurse would be to:
Correct Answer: B
Rationale: The nurse should encourage activities gradually, as client's energy level and tolerance for shared activities improve. Activities that focus on strengths and accomplishments, with uncomplicated tasks, minimize failure and increase self-worth. Asking a client to set a goal to make all decisions about attending group activities is unrealistic, and such decisions are not always under the client's control; this sets up the client for further failure and possibly decreased self-worth. Encouragement toward independence does promote increased feelings of self-worth; however, clients may need assistance with decision making and problem solving for various situations and on an individual basis.