NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 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 2 of 5
The nurse is assessing a client who had a colon resection two days ago. The client states, "I feel like my stitches have burst loose." Upon further assessment, dehiscence of the wound is noted. Which action should the nurse take?
Correct Answer: B
Rationale: Applying a sterile, saline-moistened dressing protects the dehisced wound and prevents infection. Prone positioning (
A) is inappropriate, atropine (
C) doesn’t address dehiscence, and an ACE bandage (
D) may worsen the condition.
Question 3 of 5
The cardiac client who exhibits the symptoms of disorientation, lethargy, and seizures may be exhibiting a toxic reaction to:
Correct Answer: B
Rationale: Side effects of digoxin include headache, hypotension, AV block, blurred vision, and yellow-green halos. Side effects of lidocaine include heart block, headache, dizziness, confusion, tremor, lethargy, and convulsions. Side effects of quinidine include heart block, hepatotoxicity, thrombocytopenia, and respiratory depression. Side effects of nitroglycerin include postural hypotension, headache, dizziness, and flushing.
Question 4 of 5
A 4 year old has an imaginary playmate, which concerns the mother. The nurse's best response would be:
Correct Answer: D
Rationale: This is normal for a preschooler, and a referral is not appropriate. Telling a parent not to worry is unhelpful. This response does not address the mother's concern. This response is incorrect. The behavior is normal and will usually disappear by the time the child enters school. This behavior is normal development for a preschooler.
Question 5 of 5
The nurse is caring for a client with a history of a myocardial infarction. The client is receiving TPA (alteplase). The nurse should monitor the client for:
Correct Answer: A
Rationale: TPA, a thrombolytic, increases bleeding risk by dissolving clots. Monitoring for bleeding (e.g., gums, urine) is critical. Hypertension, hypoglycemia, and hyperthermia are not primary concerns.