NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 of 5
The primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed toward:
Correct Answer: A
Rationale: Maintaining the hydration level is the focus for nursing intervention because dehydration enhances the sickling process. Both oral and parenteral fluids are used. The pain is a result of the sickling process. Analgesics or narcotics will be used for symptom relief, but the underlying cause of the pain will be resolved with hydration. Serious bacterial infections may result owing to splenic dysfunction. This is true at all times, not just during the acute period of a crisis. O2 therapy is used for symptomatic relief of the hypoxia resulting from the sickling process. Hydration is the primary intervention to alleviate the dehydration that enhances the sickling process.
Question 2 of 5
A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin. The nurse's first intervention should be to:
Correct Answer: C
Rationale: FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. The physician should be notified, but this is not the first intervention the nurse should do. The standard of care for an induction according to the Association of Women's Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. Contractions lasting 60-90 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor.
Question 3 of 5
Which nursing assessment indicates that involutional changes have occurred in a client who is three days postpartum?
Correct Answer: A
Rationale: A firm fundus three finger widths below the umbilicus by day three postpartum indicates normal uterine involution, as the uterus contracts and descends.
Question 4 of 5
The nurse is performing discharge teaching to the parents of a seven-year-old who has been diagnosed with asthma. Which sports activity would be most appropriate for this client?
Correct Answer: B
Rationale: Swimming is ideal for asthma patients, as the warm, humid air reduces bronchospasm risk. Baseball (
A), football (
C), and track (
D) involve outdoor or high-exertion activities that may trigger asthma.
Question 5 of 5
A newborn weighing 7 pounds at birth should be expected to weigh pounds by one year of age.
Correct Answer: 21 pounds
Rationale: Newborns typically triple their birth weight by one year. 7 lbs × 3 = 21 lbs.