NCLEX-RN
NCLEX RN Practice Questions Exam Cram Questions
Extract:
Question 1 of 5
A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolette. Which action is a nursing priority?
Correct Answer: B
Rationale: When a newborn is placed in a warming isolette due to difficulty maintaining temperature, the priority action is to continuously monitor the neonate's temperature to prevent overheating. Using heat lamps is unsafe as their temperature cannot be regulated, potentially causing harm. Warming medications and fluids before administration is not necessary in this situation. While touching the neonate with cold hands may startle them, it does not pose a safety risk compared to monitoring and controlling the temperature.
Question 2 of 5
While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?
Correct Answer: B
Rationale: Massage the fundus. The nurse's first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery. Checking vital signs, offering a bedpan, or checking for perineal lacerations are important assessments but addressing the boggy uterus and vaginal bleeding due to uterine atony takes precedence in this situation.
Question 3 of 5
The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet?
Correct Answer: A
Rationale: In celiac disease, individuals are intolerant to gluten found in wheat, barley, rye, and oats.
Therefore, it is crucial to eliminate these grains from the diet. Rice, corn, or millet are safe alternatives for individuals with celiac disease. Oatmeal is generally avoided unless specifically labeled as gluten-free due to possible cross-contamination. Rye toast and white bread contain gluten and should be avoided in celiac disease. Vitamin supplements may also be necessary to address deficiencies caused by dietary restrictions.
Question 4 of 5
A victim of domestic violence states, 'If I were better, I would not have been beaten.' Which feeling best describes what the victim may be experiencing?
Correct Answer: C
Rationale: The correct answer is self-blame. In this scenario, the victim is attributing the abuse to their own inadequacies or faults, thinking that if they were different, the abuse would not occur. This is a common response seen in victims of domestic violence, where they wrongly internalize the blame for the abuser's actions. Fear (
Choice
A) is a valid emotion, but in this case, the victim is not expressing fear but rather self-blame. Helplessness (
Choice
B) is also a common feeling in victims of domestic violence, but in this specific statement, the victim is demonstrating self-blame. Rejection (
Choice
D) does not accurately reflect the victim's statement and emotional response in the given scenario.
Question 5 of 5
After surgery for an imperforate anus, an infant returns with a red and edematous colostomy stoma. What action should the nurse take based on this finding?
Correct Answer: B
Rationale: A red and edematous colostomy stoma is a common finding immediately after surgery, and these changes are expected to decrease over time. As the stoma heals, it usually becomes pink without signs of abnormal drainage, swelling, or skin breakdown.
Therefore, the appropriate action for the nurse is to document these normal findings. Elevating the buttocks, applying ice, or calling the primary health care provider are unnecessary interventions at this stage.