NCLEX RN Free Practice Questions
Question 1 of 5.
A 52-year-old client who underwent an exploratory laparotomy for a bowel obstruction begins to complain of hunger on the third postoperative day. His nasogastric (NG) tube was removed this morning, and he has an IV of D5W with 0.45% normal saline running at 125 mL/hr. He asks when he can get rid of his IV and start eating. The nurse recognizes that he will be able to begin taking oral fluids and nourishment when:
A. It is determined that he has no signs of wound infection
B. He is able to eat a full meal without evidence of nausea or vomiting
C. The nurse can detect bowel sounds in all four quadrants
D. His blood pressure returns to its preoperative baseline level or greater
Explanation: The absence of wound infection is related to his surgical wound and not to postoperative GI functioning and return of peristalsis. Routine postoperative protocol involves detection of bowel sounds and return of peristalsis before introduction of clear liquids, followed by progression of full liquids and a regular diet versus a full regular meal first. Routine postoperative protocol for bowel obstruction is to assess for the return of bowel sounds within 72 hours after major surgery, because that is when bowel sounds normally return. If unable to detect bowel sounds, the surgeon should be notified immediately and have the client remain NPO. Routine postoperative protocol for bowel obstruction and other major surgeries involves frequent monitoring of vital signs in the immediate postoperative period (in recovery room) and then every 4 hours, or more frequently if the client is unstable, on the nursing unit. This includes assessing for signs of hypovolemic shock. Vital signs usually stabilize within the first 24 hours postoperatively.
Question 2 of 5.
The nurse is preparing to administer an injection to a six-month-old when she notices a white dot in the infant's right pupil. The nurse should:
A. Report the finding to the physician immediately.
B. Record the finding and give the infant's injection.
C. Recognize that the finding is a variation of normal.
D. Check both eyes for the presence of the red reflex.
Explanation: A white dot in the pupil (leukocoria) may indicate retinoblastoma or other serious conditions, requiring immediate reporting to the physician for evaluation.
Question 3 of 5.
A client with paranoid schizophrenia has an order for Thorazine (chlorpromazine) 400 mg orally twice daily. Which of the following symptoms should be reported to the physician immediately?
A. Fever, sore throat, weakness
B. Dry mouth, constipation, blurred vision
C. Lethargy, slurred speech, thirst
D. Fatigue, drowsiness, photosensitivity
Explanation: Fever, sore throat, and weakness may indicate agranulocytosis, a serious side effect of chlorpromazine requiring immediate medical attention.
Question 4 of 5.
The physician has ordered a paracentesis for a client with severe abdominal ascites. Before the procedure, the nurse should:
A. Provide the client with a urinal
B. Prep the area by shaving the abdomen
C. Encourage the client to drink extra fluids
D. Request an ultrasound of the abdomen
Explanation: Providing a urinal ensures the bladder is empty, reducing the risk of bladder puncture during paracentesis, a priority before the procedure.
Question 5 of 5.
A new mother tells the nurse that she is getting a new microwave so that her husband can help prepare the baby's feedings. The nurse should:
A. Explain that a microwave should never be used to warm the baby's bottles.
B. Tell the mother that microwaving is the best way to prevent bacteria in the formula.
C. Tell the mother to shake the bottle vigorously for one minute after warming in the microwave.
D. Instruct the parents to always leave the top of the bottle open while microwaving so heat can escape.
Explanation: Microwaving baby bottles can cause uneven heating, leading to burns, so it should be avoided; warming under running water or in a bottle warmer is safer.
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