NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 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 2 of 5
The nurse is assessing a client with a suspected tension pneumothorax. Which of the following interventions is the highest priority?
Correct Answer: B
Rationale: Preparing for needle decompression is the highest priority in tension pneumothorax to relieve pressure and restore lung function.
Question 3 of 5
A client with a diagnosis of myasthenia gravis is prescribed pyridostigmine (Mestinon). The nurse should teach the client to take the medication:
Correct Answer: B
Rationale: Pyridostigmine should be taken with food to reduce gastrointestinal side effects like nausea.
Question 4 of 5
The nurse notices drops of a liquid on the hallway floor of a health care facility. The nurse should do which of the following first?
Correct Answer: C
Rationale: Posting 'wet floor' signs first ensures immediate safety by alerting others to the hazard, preventing slips.
Then, the nurse can proceed with cleanup or notify appropriate personnel.
Question 5 of 5
Before the nurse administers I.V. replacement of 5% dextrose in water with potassium chloride, what nursing intervention must be completed first?
Correct Answer: B
Rationale: Evaluating electrolyte levels, especially potassium, is critical before administering potassium chloride to prevent hyperkalemia. Adding potassium at the bedside is unsafe, and priming or checking rates follows.