NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
A client who had transurethral resection of the prostate complains of dribbling urine after his Foley catheter is removed on the second postoperative day. The nurse notes that the client had $200 \mathrm{~mL}$ of urine output in the last 8 hours with a $1,000 \mathrm{~mL}$ intake. Which of the following interventions is a priority for the nurse at this time?
Correct Answer: B
Rationale: Low urine output and dribbling post-TURP suggest possible bladder distention, which requires immediate assessment to prevent complications. Other interventions may follow based on findings.
Question 2 of 5
You are caring for a group of elderly clients, many of whom are affected with multiple chronic disorders and are also, at times, affected with some acute disorders that require medical and nursing attention. As you are caring for these clients some will need a new medication regimen for an acute disorder. You should consider that fact that the elderly population is at risk for more side effects, adverse drug reactions, and toxicity and over dosages of medications because the elderly have a (n):
Correct Answer: C
Rationale: Elderly individuals often have decreased hepatic metabolism due to reduced liver function, which affects drug metabolism and increases the risk of side effects, adverse reactions, and toxicity.
Question 3 of 5
A client with Alzheimer's disease is started on a low dose of lorazepam (Ativan) because of agitation and a sleep disturbance. The nurse should assess the client for which of the following?
Correct Answer: D
Rationale: Lorazepam, a benzodiazepine, can cause anticholinergic side effects such as dry mouth, constipation, or confusion, especially in elderly clients with Alzheimer's. Extrapyramidal effects are associated with antipsychotics, and vomiting is less common.
Question 4 of 5
A client with a history of liver failure is prescribed lactulose (Cephulac). The nurse should monitor the client for which of the following therapeutic effects?
Correct Answer: A
Rationale: Lactulose reduces ammonia levels by promoting its excretion in hepatic encephalopathy.
Question 5 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.