NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
The postpartum nurse should include which of the following instructions to breast-feeding mothers?
Correct Answer: C
Rationale: Limiting initial feeding times will only delay nipple soreness as well as the establishment of the letdown reflex, thus encouraging engorgement from clogged ducts and ductules. Soap should be avoided because it may be excessively drying, predisposing nipples to cracking. For optimal milk production, an additional 500 kcal over maintenance levels are needed daily. Lipase, not lactose, emulsifies the fat in breast milk, making it almost totally digestible by infants.
Question 2 of 5
A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching?
Correct Answer: B
Rationale: Diarrhea is a complication of tube feedings that can lead to dehydration. Diarrhea may be the result of hypertonic formulas that can draw fluid into the bowel. Other causes of diarrhea may be bacterial contamination, fecal impaction, medications, and low albumin. A consistent weight gain of more than 0.22 kg/day (1/2 lb/day) over several days should be reported promptly. The client should be evaluated for fluid volume excess. Elevating the client's head prevents reflux and thus formula from entering the airway. Bacteria proliferate rapidly in enteral formulas and can cause gastroenteritis and even sepsis.
Question 3 of 5
A client with a history of a gastrectomy is being taught about dietary management. The nurse should encourage the client to:
Correct Answer: A
Rationale: After a gastrectomy, eating six small meals a day prevents dumping syndrome by reducing gastric overload. Avoiding fluids with meals and taking vitamins are helpful, but small meals are primary.
Question 4 of 5
When caring for a postoperative cholecystectomy client, the nurse assesses patency and documents drainage of the T-tube. The nurse recognizes that the expected amount of drainage during the first 24 hours postoperatively is:
Correct Answer: C
Rationale: During the first 24 hours after surgery, the drainage is normally 300-500 mL and then decreases to about 200 mL in 24 hours during the next 3-4 days. This range is the amount of drainage after the first 24 hours postoperatively. During the first 24 hours, it is 300-500 mL. During the first 24 hours after surgery, this range is the expected amount of drainage. The expected amount of drainage during the first 24 hours is 300-500 mL. An output of >500 mL should be reported to the physician, because an occlusion of some type, caused by a retained gallstone or an inflammatory process within the biliary drainage system, is evident.
Question 5 of 5
The client at 34 weeks gestation is admitted with a diagnosis of preterm premature rupture of membranes (PPROM). The nurse should monitor for which complication?
Correct Answer: D
Rationale: PPROM increases the risk of chorioamnionitis (infection) preterm delivery (due to loss of amniotic fluid) and fetal distress (from infection or cord compression). All are potential complications requiring monitoring.