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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 21 )

Updated On: 12-Jan-2026
Page 21 of 345
PDF with 862 Questions

A 1000-mL dose of lactated Ringer's solution is to be infused in 8 hours. The drop factor for the tubing is 10 gtt/mL. How many drops per minute should the nurse administer?

  1. 125 gtt/min
  2. 48 gtt/min
  3. 20 gtt/min
  4. 21 gtt/min

Answer(s): D

Explanation:

(A) This answer is a miscalculation. (B) This answer is a miscalculation. (C) This answer has not been rounded off to an even number. (D) 20.8, or 21 gtt/min.



While the RN is assessing a mother's perineum on her 2nd postpartum day after having a vaginal delivery, the RN notes a large ecchymotic area located to the left of the mother's perineum. Which one of the following interventions should the RN initiate at this time?

  1. Have the client expose the area to air.
  2. Apply ice to the perineum.
  3. Encourage the client to take warm sitz baths.
  4. Inform the physician.

Answer(s): C

Explanation:

(A) The area is bruised and painful. This action would do nothing to help with the healing process of the perineum or to provide comfort. (B) Ice is effective immediately after birth to reduce edema and discomfort, but not on the 2nd postpartum day. (C) Sitz baths are useful if the perineum has been traumatized, because the moist heat increases circulation to the area to promote healing, relaxes tissue, and decreases edema. (D) The physician is not notified of bruising, but if a hematoma is present, then the physician is notified.



At 32 weeks' gestation, a client is scheduled for a fetal activity test (nonstress test). She calls the clinic and asks the RN, "How do I prepare for the test I am scheduled for?" The RN will most likely inform her of the following instructions to help prepare her for the test:

  1. "You need to know that an IV is always started before the test."
  2. "You will need to drink 6 to 8 glasses of water to fill your bladder."
  3. "Do not eat any food or drink any liquids before the test is started."
  4. "You will have to remain as still as you possibly can."

Answer(s): D

Explanation:

(A) An IV line is not started in a nonstress test, because this test is used as an indicator of fetal well-being.
This test measures fetal activity and heart rate acceleration. (B) The bladder does not have to be full prior to this test. It is not a sonogram test where a full bladder enables other structures to be scanned. (C) It has been proved that eating or drinking liquids prior to the test can assist in increasing fetal activity. (D) Any maternal activity will interfere with the results of the test.



An elective saline abortion has been performed on a 3- week primigravida. Following the procedure, the nurse should be alert for which early side effect?

  1. Water satiety
  2. Thirst
  3. Edema
  4. Diabetes insipidus

Answer(s): B

Explanation:

(A) If the client is experiencing water satiety, there is no more desire for water. (B) Absorption of saline into circulation rather than into amniotic sac increases serum sodium and desire for water. (C) Edema can be a late side effect caused by water intoxication. (D) Diabetes insipidus occurs as a result of deficient antidiuretic hormone.



A 79-year-old client with Alzheimer's disease is exhibiting significant memory impairment, cognitive impairment, extremely impaired judgment in social situations, and agitation when placed in a new situation or around unfamiliar people. The nurse should include the following strategy in the client's care:

  1. Maintain routines and usual structure and adhere to schedules.
  2. Encourage the client to attend all structured activities on the unit, whether she wants to or not.
  3. Ask the client to go to an activity once. If she gives no response right away, change the question around, asking the same thing.
  4. Give the client two or three choices to decide what she wants to do.

Answer(s): A

Explanation:

(A) Alzheimer's clients cope poorly with changes in routine because of memory deficits. Schedule changes cause confusion and frustration, whereas adhering to schedules is helpful and supports orientation. (B) Insisting that the client go to all unit activities may antagonize her and increase her agitation because of cognitive impairments. It may be better to allow the client time for calming down or distraction rather than to insist that she attend every activity. (C) When repeating a question, allow time first for a response; then use the same words the second time to avoid further confusion. (D) The nurse should avoid giving several choices at once. Cognitively impaired clients will become more frustrated with making decisions.



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