NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
Which of the following findings would be abnormal in a postpartal woman?
Correct Answer: D
Rationale: Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous response or to vasomotor changes. If not followed by a fever, it is clinically innocuous. The pulse rate during the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt to the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. Urinary output increases during the early postpartal period (12-24 hours) owing to diuresis. The kidneys must eliminate an estimated 2000-3000 mL of extracellular fluid associated with a normal pregnancy. A temperature of 100.4°F (38°
C) may occur after delivery as a result of exertion and dehydration of labor. However, any temperature greater than 100.4°F needs further investigation to identify any infectious process.
Question 2 of 5
A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report:
Correct Answer: C
Rationale: Autonomic dysreflexia is an exaggerated reflex of the autonomic nervous system causing vasoconstriction and elevated blood pressure, often presenting with headache and facial flushing. The other symptoms listed are not associated with this condition.
Question 3 of 5
A client who uses a respiratory inhaler asks the nurse to explain how he can know when half his medication is empty so that he can refill his prescription. The nurse should tell the client to:
Correct Answer: B
Rationale: Dropping the inhaler in water to see if it floats is a practical way to estimate remaining medication; a half-empty inhaler will float, while a full one sinks.
Question 4 of 5
The nurse who is caring for a client with pneumonia assesses that the client has become increasingly irritable and restless. The nurse realizes that this is a result of:
Correct Answer: C
Rationale: Maintaining bed rest helps to decrease the O2 needs of the tissues, which decreases dyspnea and workload on the respiratory system. The semi-Fowler or high-Fowler position is necessary to aid in lessening pressure on the diaphragm from the abdominal organs, which facilitates comfort and easier breathing patterns. Cerebral hypoxia causes the client with pneumonia to be increasingly irritable and restless and results from the client not obtaining enough O2 to meet metabolic needs. Proper hydration facilitates liquefaction of mucus trapped in the bronchioles and alveoli and enhances expectoration. Unless contraindicated, a reasonable amount of IV fluids to be administered is at least 2.5-3 liters in a 24-hour period.
Question 5 of 5
To facilitate maximum air exchange, the nurse should position the client in:
Correct Answer: B
Rationale: The orthopneic position is a sitting position that allows maximum lung expansion.