Questions for the NCLEX-RN were updated on : Nov 21 ,2025
On the third postpartum day, the nurse would expect the lochia to be:
A
Explanation:
(A) This discharge occurs from delivery through the 3rd day. There is dark red blood, placental debris,
and clots. (B) This discharge occurs from days 4–10. The lochia is brownish, serous, and thin. (C) This
discharge occurs from day 10 through the 6thweek. The lochia is yellowish white. (D) This is not a
classification of lochia but relates to the amount of discharge.
Which stage of labor lasts from delivery of the baby to delivery of the placenta?
B
Explanation:
(A) This stage is from complete dilatation of the cervix to delivery of the fetus. (B) This is the correct
stage for the definition. (C) This stage lasts for about 2 hours after the delivery of the placenta. (D)
There is no fifth stage of labor.
A pregnant client is having a nonstress test (NST). It is noted that the fetal heart beat rises 20 bpm,
lasting 20 seconds, every time the fetus moves. The nurse explains that:
C
Explanation:
(A) The test results were normal, so there would be no need to repeat to determine results. (B) There
are no data to indicate further tests are needed, because the result of the NST was normal. (C) An
NST is reported as reactive if there are two to three increases in the fetal heart rate of 15 bpm,
lasting at least 15 seconds during a 15-minute period. (D) The NST results were normal, so there was
no fetal distress.
A client delivered a stillborn male at term. An appropriate action of the nurse would be to:
C
Explanation:
(A) This is not a supportive statement. There are also no data to indicate the family’s religious beliefs.
(B) Seeing their baby assists the parents in the grieving process. This gives them the opportunity to
say “good-bye.” (C) Parents need time to get to know their baby. (D) This is not a comforting
statement when a baby has died. There are also no guarantees that the couple will be able to have
another child.
A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow.
Appropriate nursing actions to help control hyperventilating include:
C
Explanation:
(A) An adult diazepam dosage for treatment of anxiety is 2–10 mg PO 2–4 times daily. The order as
written would place a client at risk for overdose. (B) A high room temperature could increase
hyperventilating episodes by stimulating the respiratory system. (C) Breath holding and breathing
into a paper bag may be useful in controlling hyperventilation. Both measures increase CO2
retention. (D) Distraction will not prevent or control hyperventilation caused by anxiety or fear.
A couple is experiencing difficulties conceiving a baby. The nurse explains basal body temperature
(BBT) by instructing the female client to take her temperature:
D
Explanation:
(A) Monitoring temperature twice a day predicts the biphasic pattern of ovulation. (B) Prediction of
ovulation relies on consistency in taking temperature. (C) Nightly rectal temperatures are more
accurate in predicting ovulation. (D) Activity changes the accuracy of basal body temperature and
ability to detect the luteinizing hormone surge.
A client develops complications following a hysterectomy. Blood cultures reveal Pseudomonas
aeruginos
a. The nurse expects that the physician would order an appropriate antibiotic to treat P. aeruginosa
such as:
A
Explanation:
(A) Cefoperazone is indicated in the treatment of infection withPseudomonas aeruginosa.(B)
Clindamycin is not indicated in the treatment of infection withP. aeruginosa.(C) Dicloxacillin is not
indicated in the treatment of infection withP. aeruginosa.(D) Erythromycin is not indicated in the
treatment of infection withP. aeruginosa.
A 29-year-old client is admitted for a hysterectomy. She has repeatedly told the nurses that she is
worried about having this surgery, has not slept well lately, and is afraid that her husband will not
find her desirable after the surgery. Shortly into the preoperative teaching, she complains of a
tightness in her chest, a feeling of suffocation, lightheadedness, and tingling in her hands. Her
respirations are rapid and deep. Assessment reveals that the client is:
D
Explanation:
(A) Classic symptoms of a heart attack include heaviness or squeezing pain in the chest, pain
spreading to the jaw, neck, and arm. Nausea and vomiting, sweating, and shortness of breath may be
present. The client does not exhibit these symptoms. (B) Clients suffering from anxiety or fear prior
to surgical procedures may develop hyperventilation. This client is not seeking attention. (C)
Symptoms of complete airway obstruction include not being able to speak, and no airflow between
the nose and mouth. Breath sounds are absent. (D) Tightness in the chest; a feeling of suffocation;
lightheadedness; tingling in the hands; and rapid, deep respirations are signs and symptoms of
hyperventilation. This is almost always a manifestation of anxiety.
A 35-year-old client is admitted to the hospital for elective tubal ligation. While the nurse is doing
preoperative teaching, the client says, “The anesthesiologist said she was going to give me balanced
anesthesi
a. What exactly is that?” The best explanation for the nurse to give the client would be that balanced
anesthesia:
D
Explanation:
(A) Regional anesthesia does not produce loss of consciousness and is indicated for excision of moles,
cysts, and endoscopic surgeries. (B) Varying amounts of anesthetic agents are used when employing
balanced anesthesia. Amounts depend on age, weight, condition of the client, and surgical
procedure. (C) General anesthesia is a drug-induced depression of the central nervous system that
produces loss of consciousness and decreased muscle activity. (D) Balanced anesthesia is a
combination of a number of anesthetic agents that produce a smooth induction, appropriate depth
of anesthesia, and appropriate muscle relaxation with minimal complications.
A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She
complains of severe abdominal pain. Assessment reveals abdominal rigidity and distention,
increased temperature, and tachycardi
a. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has
developed:
C
Explanation:
(A) Assessment findings for gastritis would reveal anorexia, nausea and vomiting, epigastric fullness
and tenderness, and discomfort. (B) Evisceration is the extrusion of abdominal viscera as a result of
trauma or sutures failing in a surgical incision. (C) Peritonitis, inflammation of the peritoneum, can
occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and fluid into
the abdominal cavity. This causes infection and irritation. (D) Assessment findings of pulmonary
embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath,
anxiety or panic, and wheezing and coughing often accompanied by blood-tinged sputum.
A 25-year-old client is admitted for a tonsillectomy. She tells the nurse that she has had episodes of
muscle cramps, weakness, and unexplained temperature elevation. Many years ago her father died
shortly after surgery after developing a high fever. She further tells the nurse that her surgeon is
having her take dantrolene sodium (Dantrium) prophylactically prior to her tonsillectomy. Dantrolene
sodium is ordered preoperatively to reduce the risk or prevent:
B
Explanation:
(A, D) Dantrolene sodium is a peripheral skeletal muscle relaxant and would have no effect on a
postoperative infection. (B) Dantrolene sodium is indicated prophylactically for clients with
malignant hyperthermia or with a family history of the disorder. The mortality rate for malignant
hyperthermia is high. (C) Neuroleptic malignant syndrome is an exercise-induced muscle pain and
spasm and is unrelated to malignant hyperthermia.
Following a gastric resection, a 70-year-old client is admitted to the postanesthesia care unit. He was
extubated prior to leaving the suite. On arrival at the postanesthesia care unit, the nurse should:
A
Explanation:
(A) Adequate air exchange and tissue oxygenation depend on competent respiratory function.
Checking the airway is the nurse’s priority action. (B) Obtaining the vital signs is an important action,
but it is secondary to airway management. (C) Reorienting a client to time, place, and person after
surgery is important, but it is secondary to airway and vital signs. (D) Airway management takes
precedence over physician’s orders unless they specifically relate to airway management.
A child is to receive atropine 0.15 mg (1/400 g) as part of his preoperative medication. A vial
containing atropine 0.4 mg (1/150 g)/mL is on hand. How much atropine should be given?
B
Explanation:
(A, C) Information was incorrectly placed in the formula, resulting in an incorrect answer. (B) The
answer is correct.
0.4 mg = 1 mL:0.15 mg 5 = mL
0.4 x = 0.15
x = 0.15/0.4
x = 0.375 or 0.38 mL
(D) Sufficient information is provided to determine the amount of atropine to administer. The
amount of atropine available and the amount of atropine ordered is required to determine the
amount of atropine to be given.
The family member of a child scheduled for heart surgery states, “I just don’t understand this open-
heart or closed-heart business. I’m so confused! Can you help me understand it?” The nurse explains
that patent ductus arteriosus repair is:
B
Explanation:
(A) Patent ductus arteriosus repair is a closed-heart procedure. The client is not placed on a heart-
lung machine. (B) Patent ductus arteriosus is a ductus arteriosus that does not close shortlyafter
birth but remains patent. Repair is a closed-heart procedure involving ligation of the patent ductus
arteriosus. (C) Coronary artery bypass graft surgery is an open-heart surgical procedure in which
blocked coronary arteries are bypassed using vessel grafts. (D) Percutaneous transluminal coronary
angioplasty is a closedheart procedure that improves coronary blood flow by increasing the lumen
size of narrowed vessels.
A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The
child is being given digoxin. Prior to administering the medication, the nurse should:
C
Explanation:
(A) Digoxin should not be given to adults with an apical pulse < 60 bpm. (B) Digoxin should be given
to children with an apical pulse > 100 bpm. With a pulse < 100 bpm, the medication should be
withheld and the physician notified. (C) Prior to digoxin administration in both children and adults,
an apical pulse should be taken for 1 full minute. Aside from the rate per minute, the nurse should
note any sudden increase or decrease in heart rate, irregular rhythm, or regularization of a chronic
irregular heart rhythm. (D) Early indications of digoxin toxicity, such as visual disturbances, occur
rarely as initial signs in children.