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NCLEX NCLEX-RN Exam Syllabus Topics:

SectionWeightObjectives
Safe and Effective Care Environment17–33%- Safety and Infection Control
- Management of Care
Psychosocial Integrity6–12%
Physiological Integrity43–67%- Physiological Adaptation
- Basic Care and Comfort
- Pharmacological and Parenteral Therapies
- Reduction of Risk Potential
Health Promotion and Maintenance6–12%

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NCLEX National Council Licensure Examination(NCLEX-RN) Sample Questions (Q858-Q863):

NEW QUESTION # 858
A schizophrenic client has made sexual overtures toward her physician on numerous occasions. During lunch, the client tells the nurse, "My doctor is in love with me and wants to marry me." This client is using which of the following defense mechanisms?

Answer: A

Explanation:
Explanation/Reference:
Explanation:
(A) Displacement involves transferring feelings to a more acceptable object. (B) Projection involves attributing one's thoughts or feelings to another person. (C) Reaction formation involves transforming an unacceptable impulse into the opposite behavior. (D) Suppression involves the intentional exclusion of unpleasant thoughts or experiences.


NEW QUESTION # 859
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:

Answer: B

Explanation:
Explanation/Reference:
Explanation:
(A) 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. (B) Removal of retained placental fragments is done by the physician and is not the first response. (C) If the fundus rises and is deviated, particularly to theright, 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. (D) 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.


NEW QUESTION # 860
Which of the following findings would be abnormal in a postpartal woman?

Answer: C

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


NEW QUESTION # 861
In addition to changing the mother's position to relieve cord pressure, the nurse may employ the following measure (s) in the event that she observes the cord out of the vagina:

Answer: B

Explanation:
Explanation/Reference:
Explanation:
(A) Saline should be warmed; waiting 15 minutes may not keep the cord moist. (B) This choice does not specify what the sponge was "wet" with. (C) This measure would stop circulation to the fetus. (D) The cord should be kept warm and moist to maintain fetal circulation. This measure is an accepted nursing action.


NEW QUESTION # 862
When assessing the client 6 hours postpartum, the fundus is found to be U +3, displaced to the right of midline, and slightly boggy. The nurse would first:

Answer: B

Explanation:
(A)Oxytocin may not be necessary if the bladder is emptied and if the uterus remains firm, midline, and at about U11 after massage. (B) The same rationale as for answer "A" applies.
(C)A full bladder is the most common cause of uterine atony. If the bladder is full, it should be emptied and the uterus reassessed before further intervention. (D) If the bladder is full, the uteruswill not stay contracted or return to a normal position. Overly vigorous massage also encourages uterine atony.


NEW QUESTION # 863
......

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