NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
When the nurse checks the fundus of a client on the first postpartum day,she notes that the fundus is firm level with the umbilicus and displaced to the side. The next action the nurse should take is to:
Correct Answer: A
Rationale: A displaced fundus on the first postpartum day is often due to bladder distention which pushes the uterus aside. Checking for bladder distention (e.g. by palpation or encouraging voiding) is the next step to correct the displacement.
Question 2 of 5
The physician has ordered Coumadin (sodium warfarin) for a client with a history of clots. The nurse should tell the client to avoid which of the following vegetables?
Correct Answer: B
Rationale: Cauliflower is high in vitamin K, which can counteract the anticoagulant effects of warfarin, so it should be limited.
Question 3 of 5
A client presents to the emergency room with cyanosis, coughing, tachypnea, and tachycardia. She has a history of asthma. Arterial blood gas values are pH 7.28, PaO2 54, PaCO2 60, and HCO3 24. The nursing assessment of arterial blood gases indicate the presence of:
Correct Answer: B
Rationale: Respiratory acidosis is determined by low pH and elevated PaCO2.
Question 4 of 5
The sputum of a client remains positive for the tubercle bacillus even though the client has been taking Laniazid (isoniazid) in combination with other antituberculars. The nurse recognizes that the client taking isoniazid should have a negative sputum culture within:
Correct Answer: D
Rationale: Effective antitubercular therapy, including isoniazid, typically results in a negative sputum culture within three months, indicating control of active infection.
Question 5 of 5
A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately:
Correct Answer: C
Rationale: At 10 weeks, the fundus is located slightly above the symphysis pubis. At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus. At 20 weeks, the fundus is located approximately at the umbilicus. At 30 weeks, the fundal height is about 30 cm, or 10 cm above the umbilicus.