NCLEX RN Nursing Exam

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Question 1 of 5.

Which of the following findings would be abnormal in a postpartal woman?

A. Chills shortly after delivery

B. Pulse rate of 60 bpm in morning on first postdelivery day

C. Urinary output of 3000 mL on the second day after delivery

D. An oral temperature of 101Ã‚Â°F (38.3Ã‚Â°C) on the third day after delivery

Explanation: 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 100.4Ã‚Â°F (38Ã‚Â°C) may occur after delivery as a result of exertion and dehydration of labor. However, any temperature greater than 100.4Ã‚Â°F needs further investigation to identify any infectious process.

Question 2 of 5.

A client tells the nurse that she takes St. John's wort (hypericum perforatum) three times a day for mild depression. The nurse should tell the client that:

A. St. John's wort seldom relieves depression.

B. She should avoid eating aged cheese.

C. Skin reactions increase with the use of sunscreen.

D. The herbal is safe to use with other antidepressants.

Explanation: St. John's wort increases photosensitivity, so sunscreen use may paradoxically increase skin reactions; clients should be cautioned about sun exposure.

Question 3 of 5.

An adolescent client hospitalized with anorexia nervosa is described by her parents as 'the perfect child.' When planning care for the client, the nurse should:

A. Allow her to choose what foods she will eat

B. Provide activities to foster her self-identity

C. Encourage her to participate in morning exercise

D. Provide a private room near the nurse's station

Explanation: Anorexia nervosa is often linked to issues of control and identity; activities fostering self-identity help address underlying psychological factors.

Question 4 of 5.

The mother of a child with chickenpox wants to know if there is a medication that will shorten the course of the illness. Which medication is sometimes used to speed healing of the lesions and shorten the duration of fever and itching?

A. Zovirax (acyclovir)

B. Varivax (varicella vaccine)

C. VZIG (varicella-zoster immune globulin)

D. Periactin (cyproheptadine)

Explanation: Acyclovir (Zovirax) is an antiviral that can reduce the severity and duration of chickenpox symptoms, including lesions, fever, and itching.

Question 5 of 5.

The physician has ordered an IV bolus of Solu-Medrol (methylprednisolone sodium succinate) in normal saline for a client admitted with a spinal cord injury. Solu-Medrol has been shown to be effective in:

A. Preventing spasticity associated with cord injury

B. Decreasing the need for mechanical ventilation

C. Improving motor and sensory functioning

D. Treating post injury urinary tract infections

Explanation: High-dose methylprednisolone within 8 hours of spinal cord injury can improve motor and sensory outcomes by reducing inflammation and edema.

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When planning care for the passive-aggressive client, the nurse includes the following goal: