NCLEX RN Practice Questions Free
Question 1 of 5.
A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U+1 in contrast to the previous assessment of U-2. The immediate nursing response is to:
A. Administer methergine IM
B. Remove the retained placental fragments
C. Assist the client to the bathroom and provide cues to stimulate urination
D. Massage the fundus until firm
Explanation: Methergine is given following placental delivery to promote uterine contractions and prevent hemorrhage. Methergine may be administered in this clinical situation, but fundal massage would be the first response. Removal of retained placental fragments is done by the physician and is not the first response. If the fundus rises and is deviated, particularly to the right, the nurse should suspect bladder distention secondary to bladder and urethral trauma associated with birth and decreased bladder tone following delivery. Therefore, women have a diminished sensation to void. A boggy fundus rises and is indicative of blood pooling, predisposing the woman to clot formation. Massage the uterus until firm. Too vigorous massage will result in atonia. Clots may be expelled by a kneading motion of the uterus by the nurse.
Question 2 of 5.
A client is admitted with disseminated herpes zoster (shingles). According to the Centers for Disease Control Guidelines for Infection Control:
A. Airborne precautions will be needed.
B. No special precautions will be needed.
C. Only contact precautions will be needed.
D. Droplet precautions will be needed.
Explanation: Disseminated herpes zoster requires airborne precautions because the varicella-zoster virus can spread through respiratory droplets in immunocompromised patients.
Question 3 of 5.
The nurse is caring for an adolescent with a five-year history of bulimia. A common clinical finding in the client with bulimia is:
A. Extreme weight loss
B. Dental caries
C. Hair loss
D. Decreased temperature
Explanation: Frequent vomiting in bulimia exposes teeth to stomach acid, leading to dental caries (tooth decay), a common clinical finding.
Question 4 of 5.
The nurse is providing dietary teaching for a client with hypertension. Which food should be avoided by the client on a sodium-restricted diet?
A. Dried beans
B. Swiss cheese
C. Peanut butter
D. Colby cheese
Explanation: Colby cheese is high in sodium, which should be avoided on a sodium-restricted diet to manage hypertension, unlike the other options, which are lower in sodium.
Question 5 of 5.
The nurse caring for a client with closed chest drainage notes that the collection chamber is full.
A. Add more water to the suction-control chamber.
B. Remove the drainage using a 60 mL syringe.
C. Milk the tubing to facilitate drainage.
D. Prepare a new unit for continuing collection.
Explanation: A full collection chamber requires replacing the chest drainage unit to maintain effective drainage and prevent complications like tension pneumothorax.