NCLEX RN Nursing Exam

NCLEX RN Nursing Exam Related

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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 101°F (38.3°C) on the third day after delivery
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.

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The nurse is caring for a client with a history of Raynaud’s disease. The nurse should expect the client to have:

  • A. Color changes in fingers
  • B. Joint swelling
  • C. Fever
  • D. Chest pain
Correct Answer: A

Rationale: Raynaud’s disease causes vasospasms, leading to color changes (white, blue, red) in the fingers triggered by cold or stress.

A client with a history of breast cancer is admitted with complaints of fatigue. The nurse should give priority to:

  • A. Monitoring for anemia
  • B. Administering pain medication
  • C. Monitoring blood pressure
  • D. Administering chemotherapy
Correct Answer: A

Rationale: Fatigue in breast cancer may indicate anemia, so monitoring for anemia is the priority.

The nurse is caring for a client with a history of chronic kidney disease. Which dietary restriction is most important?

  • A. Low potassium
  • B. Low calcium
  • C. Low magnesium
  • D. Low iron
Correct Answer: A

Rationale: Chronic kidney disease impairs potassium excretion, risking hyperkalemia, which can cause arrhythmias. Low potassium diets are critical. Calcium, magnesium, and iron are less commonly restricted.

A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours' postburn?

  • A. Fluid volume deficit secondary to alteration in skin integrity
  • B. Alteration in comfort secondary to alteration in skin integrity
  • C. Alteration in sensation secondary to third-degree burn
  • D. Alteration in airway integrity secondary to edema of neck and face, which in turn is secondary to alteration in skin integrity
Correct Answer: D

Rationale: Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure to continually assess this client's airway status could result in poor ventilation and oxygenation, in addition to an inability to intubate the client secondary to excessive edema formation in the neck.

The nurse is reviewing the results of a sweat test taken from a child with cystic fibrosis. Which finding supports the client's diagnosis?

  • A. A sweat potassium concentration less than 40 mEq/L
  • B. A sweat chloride concentration greater than 60 mEq/L
  • C. A sweat potassium concentration greater than 40 mEq/L
  • D. A sweat chloride concentration less than 40 mEq/L
Correct Answer: B

Rationale: A sweat chloride concentration >60 mEq/L is diagnostic for cystic fibrosis due to defective chloride channels. Potassium levels are not diagnostic, and low chloride is normal.

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