NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase?
Correct Answer: B
Rationale: In the taking-hold phase, the mother actively engages with the infant, such as calling the infant by name, indicating bonding.
Question 2 of 5
A client had a myocardial infarction 5 days ago. His physician has ordered an echocardiogram to determine how his myocardial infarction has affected his ventricular wall motion. When the client asks if this test is painful, an appropriate response is:
Correct Answer: B
Rationale: An echocardiogram is non-invasive, requiring the client to lie still while cool gel is applied for ultrasound imaging, with no pain involved.
Question 3 of 5
An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction?
Correct Answer: C
Rationale: Liquid stool can pass around an impaction, making it a key indicator. The other findings are not specific to fecal impaction.
Question 4 of 5
The nurse is caring for a client with a history of a spinal cord injury who is experiencing autonomic dysreflexia. The nurse should:
Correct Answer: C
Rationale: Autonomic dysreflexia is often triggered by bladder distension. Inserting a Foley catheter relieves the trigger. Vasodilators and positioning are secondary, and prone position is unsafe.
Question 5 of 5
A postpartum client complains of rectal pressure and severe pain in her perineum; this may be indicative of:
Correct Answer: D
Rationale: Afterbirth pains are a common complaint in the postpartum client, but they are located in the uterus. Constipation may cause rectal pressure but is not usually associated with 'severe pain.' Cystitis may cause pain, but the location is different. Hematomas are frequently associated with severe pain and pressure. Further assessments are indicated for this client.