NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
The physician has ordered a paracentesis for a client with severe abdominal ascites. Before the procedure, the nurse should:
Correct Answer: A
Rationale: Providing a urinal ensures the bladder is empty, reducing the risk of bladder puncture during paracentesis, a priority before the procedure.
Question 2 of 5
On admission to the postpartal unit, the nurse's assessment identifies the client's fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right. This is most likely an indication of:
Correct Answer: B
Rationale: A boggy displaced uterus in the immediate postpartum period is a sign of urinary distention. Because uterine ligaments are stretched, a full bladder can displace the uterus.
Question 3 of 5
Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who suffered partial- and full-thickness burns to 25% of her body?
Correct Answer: A
Rationale: Urinary output is a reliable indicator of renal perfusion, which in turn indicates that fluid resuscitation is adequate. IV fluids are adjusted based on the urinary output of the child during fluid resuscitation. Edema is an indication of increased capillary permeability following a burn injury. Hypertension is an indicator of fluid volume excess. Fontanelles close by 18 months of age.
Question 4 of 5
A new mother tells the nurse that she is getting a new microwave so that her husband can help prepare the baby's feedings. The nurse should:
Correct Answer: A
Rationale: Microwaving baby bottles can cause uneven heating, leading to burns, so it should be avoided; warming under running water or in a bottle warmer is safer.
Question 5 of 5
A primigravida with a blood type A negative is at 28 weeks' gestation. Today her physician has ordered a RhoGAM injection. Which statement by the client demonstrates that more teaching is needed related to this therapy?
Correct Answer: A
Rationale: RhoGAM is given to Rh-negative mothers to prevent the maternal Rh immune response to fetal Rh-positive antigens. If the infant is Rh positive, the mother will receive another dose postdelivery to prevent maternal sensitization. Prevention of maternal sensitization will protect future pregnancies because the mother's blood will be free of antibodies against her fetus. RhoGAM prevents maternal sensitization to Rh-positive blood.