NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid:
Correct Answer: B
Rationale: Offering a pacifier can disrupt the surgical repair of a cleft lip by placing pressure on the suture line. Holding, providing a mobile, and offering sterile water are safe and comforting.
Question 2 of 5
One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:
Correct Answer: B
Rationale: Blood pressure can remain normotensive in a state of hypovolemia. Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. Skin turgor is not a reliable indicator for assessing hydration in a burn client. Fluid intake does not indicate adequacy of fluid resuscitation in a burn client.
Question 3 of 5
A 26-year-old female client presents at 10 weeks' gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her grandmother also has insulin-dependent diabetes. The client's previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches tall and her current weight is 130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following factors places her at risk for gestational diabetes?
Correct Answer: C
Rationale: Maternal age older than 30 years is an identified risk factor for diabetes. Age younger than 30 years is insignificant for diabetes unless there is a familial history of diabetes. The client's weight is appropriate for her height. Obesity or pregnancy weight >20% of the ideal weight is a contributing factor to the development of gestational diabetes. The birth of an infant weighing >9 lb (4000 g) is an identified risk factor for gestational diabetes. A familial history of heart disease is insignificant in the development of diabetes. However, a familial history of type II diabetes mellitus is identified as a risk factor in the development of diabetes during pregnancy.
Question 4 of 5
A client has been in labor for 10 hours. Her contractions have become hypoactive and slowed in duration. The fetus is at 0 station, cervix is dilated 8 cm and effaced 90%. The physician orders an oxytocin (Pitocin) infusion to be started at once. The RN begins the oxytocin infusion. It is important that the RN discontinue the infusion if which one of the following occur?
Correct Answer: A
Rationale: Contractions less than 2 minutes apart indicate hyperstimulation, which can reduce uterine blood flow, leading to fetal hypoxia. The infusion should be discontinued to prevent complications.
Question 5 of 5
The nurse is caring for a client with a history of a pulmonary embolism. The client is receiving Heparin. The nurse should monitor the client for:
Correct Answer: A
Rationale: Heparin, an anticoagulant, increases bleeding risk, including bleeding gums. Hypertension, tachypnea, and fever are not directly related to heparin therapy.