NCLEX Questions, NCLEX-RN Exam Practice Questions, NCLEX-RN Questions, Nurselytic

Questions 157

NCLEX-RN

NCLEX-RN Test Bank

NCLEX-RN Exam Practice Questions

Extract:


Question 1 of 5

Which of the following factors affects the accuracy of pulse oximetry readings?

Correct Answer: A, B, C

Rationale: Pulse oximetry accuracy is reduced by poor circulation (
A), improper probe placement (
B), and bright lighting (
C). Dark skin (
D) has minimal impact with modern sensors.

Question 2 of 5

The nurse is caring for a client with a history of chronic kidney disease. The nurse should expect the client to have:

Correct Answer: A

Rationale: Chronic kidney disease reduces erythropoietin production, causing anemia, a common complication.

Question 3 of 5

A 24-hours' postpartum client complains of discomfort at the episiotomy site. On assessment, the nurse notes the episiotomy is without signs of infection. To relieve the discomfort, the nurse should first:

Correct Answer: A

Rationale: Warm, moist heat will promote circulation and provide comfort. A sitz bath should be tried before medication is given. Pain medication can be given when other comfort measures such as a sitz bath and topical applications are ineffective. Kegel exercises facilitate sitting by decreasing tension on the episiotomy. They will not be effective for pain control or sustained comfort level. Ice packs are appropriate to apply in the first 12 hours post-delivery to produce vasoconstriction and to reduce edema to the area.

Question 4 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 5 of 5

A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL system to record her obstetrical history, the nurse should record:

Correct Answer: C

Rationale: G=3 (current pregnancy), T=1 (term birth), P=1 (preterm birth), A=0 (no abortions), L=2 (living children).

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