NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
A 1-year-old is brought to the clinic with failure to thrive. Which assessment should the nurse prioritize?
Correct Answer: A
Rationale: Dietary intake history is critical in failure to thrive to identify inadequate caloric intake or feeding issues, guiding intervention.
Question 2 of 5
A child with the diagnosis of Hirschsprung's disease has a temporary colostomy. The nurse provides instructions to the parents about colostomy care at home. Which statement by the parents indicates their understanding of the instructions?
Correct Answer: B
Rationale: The parents are instructed to report signs of skin breakdown or stomal complications, such as ribbonlike stools or failure to pass flatus or stools, to the primary health care provider or the nurse. Moist, red granulation tissue may grow around an ostomy site and does not require special treatment. The remaining options are incorrect actions and considered contraindicated.
Question 3 of 5
A client returning from the postanesthesia care unit after transurethral resection of the prostate (TURP) has bladder irrigation running via a 3-way Foley catheter. The nurse should notify the primary health care provider if which color of urine is noted in the urinary drainage bag?
Correct Answer: B
Rationale: Bright red bleeding should be reported because it could indicate complications related to active bleeding. If the bladder irrigation is infusing at a sufficient rate, the urinary drainage will be pale pink. A dark pink color (sometimes referred to as punch-colored) indicates that the speed of the irrigation should be increased. Tea-colored urine is not seen after TURP but may be noted in the client with renal failure or other renal disorders.
Question 4 of 5
Identify this cardiac rhythm strip. Fill in the blank. A. Asystole B. Atrial flutter C. Supraventricular Tachycardia D. Premature Atrial Contractions
Correct Answer: A
Rationale: Asystole is a flatline rhythm indicating no electrical activity, assuming the strip matches this description.
Question 5 of 5
A client with type 1 diabetes mellitus is admitted with hyperglycemia. The nurse should assess the client for which of the following signs of diabetic ketoacidosis (DKA)? Select all that apply.
Correct Answer: A, B, D, E
Rationale: DKA presents with fruity breath (due to acetone), Kussmaul respirations (compensatory hyperventilation), polyuria (osmotic diuresis), and hypotension (dehydration). Bradycardia is not typical.