NCLEX-RN
NCLEX RN Practice Questions with Answers Questions
Extract:
Question 1 of 5
A client has undergone a vaginal hysterectomy. Which interventions should the nurse include in the client's nursing care plan to decrease the risk of deep vein thrombosis or thrombophlebitis? Select all that apply.
Correct Answer: A,C,E
Rationale: The client is at risk for deep vein thrombosis or thrombophlebitis after this surgery, as for any other major surgery. For this reason, the nurse implements measures that will prevent this complication. Ambulation, pneumatic compression boots, range-of-motion exercises, and antiembolism stockings are all helpful. The nurse should avoid elevating the knees using the knee gatch in the bed, which inhibits venous return and places the client more at risk for deep vein thrombosis or thrombophlebitis.
Question 2 of 5
A client with the diagnosis of leukemia is receiving chemotherapy. When the registered nurse (RN) notes that the white blood cell (WBC) count is 4000 mm^3 (4 x 10^9/L), the new nurse caring for the client is informed about the results. Which intervention identified by the new nurse indicates a need for further teaching?
Correct Answer: D
Rationale: Padding the side rails and removing all hazardous and sharp objects from the environment would be instituted if the client is at risk for bleeding. This client is at risk for infection. When the WBC count is less than 5000 mm^3 (5 x 10^9/L), visitors should be screened for the presence of infection, and any visitors or staff with colds or respiratory infections should not be allowed in the client's room. All live plants, flowers, and stuffed animals are removed from the client's room. The client is placed on a low-bacteria diet that excludes raw fruits and vegetables.
Question 3 of 5
A client with a history of heart failure is prescribed enalapril (Vasotec). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A, B
Rationale: Enalapril, an ACE inhibitor, can cause hyperkalemia and hypotension.
Question 4 of 5
The nurse is caring for a client with a history of heart failure who is receiving furosemide (Lasix). Which laboratory value should the nurse monitor closely?
Correct Answer: A
Rationale: Furosemide, a loop diuretic, can cause hypokalemia due to potassium loss in urine. Monitoring serum potassium is critical to prevent arrhythmias or muscle weakness.
Question 5 of 5
Assessment of a primigravid client in active labor reveals a cervix dilated to 5 cm and completely effaced, with the fetus at -1 station. The client has indicated that she wants a 'natural childbirth' with no analgesia or anesthesia. The client's husband has been present since their arrival at the birthing unit. The physician enters the room and tells the client that it is time for an epidural anesthetic. Which of the following would be the nurse's best action at this time?
Correct Answer: B
Rationale: Advocating for the client's stated preference for natural childbirth ensures autonomy and respects her birth plan.