NCLEX Questions, NCLEX RN Practice Exam Questions, NCLEX-RN Questions, Nurselytic

Questions 149

NCLEX-RN

NCLEX-RN Test Bank

NCLEX RN Practice Exam Questions

Extract:


Question 1 of 5

The nurse is teaching feeding protocol to the spouse of a client who experienced a severe stroke. Which statement by the spouse indicates a need for further explanation by the nurse?

Correct Answer: B

Rationale: Turning on the television during meals can distract the client, increasing the risk of aspiration, and requires further teaching. Other statements are appropriate.

Question 2 of 5

A nurse is assessing a 33-year-old patient who underwent a cholecystectomy 18 hours prior. The nurse notes 500 mL of greenish-brown fluid has drained from the T-tube postoperatively. The nurse should

Correct Answer: A

Rationale: Greenish-brown drainage (bile) from a T-tube post-cholecystectomy is expected (up to 500-1000 mL/day initially). The nurse should document and monitor, not assume infection or intervene unnecessarily.

Question 3 of 5

The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:

Correct Answer: A

Rationale: A nosebleed may indicate worsening hypertension in preeclampsia, a critical symptom requiring immediate reporting.

Question 4 of 5

Which developmental milestone puts the 4-month-old infant at greatest risk for injury?

Correct Answer: D

Rationale: Rolling over at 4 months increases the risk of falling from elevated surfaces like changing tables, a common cause of injury.

Question 5 of 5

A vaginal exam reveals a breech presentation in a newly admitted client. The nurse should take which of the following actions at this time?

Correct Answer: B

Rationale: Applying the fetal heart monitor assesses fetal well-being in a breech presentation, guiding further management.

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