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
The Joint Commission on the Accreditation of Healthcare Organizations mandates standardized 'hand off' change of shift reporting. Which of the following is a standardized 'hand off' change of shift reporting system that you may want to consider for implementation on your nursing care unit?
Correct Answer: C
Rationale: ISBAR is a standardized hand-off reporting system (Introduction, Situation, Background, Assessment, Recommendation) recommended by The Joint Commission for effective communication during shift changes.
Question 3 of 5
The nurse is caring for a client with a suspected urinary tract infection. Which symptom is most common?
Correct Answer: A
Rationale: Dysuria (painful urination) is the most common symptom of a urinary tract infection, reflecting bladder or urethral irritation.
Question 4 of 5
A client has been defibrillated at 360 joules (monophasic) and the attempts to convert the ventricular fibrillation (VF) were unsuccessful. Based on an evaluation of the situation, the nurse determines that which action is best?
Correct Answer: C
Rationale: Defibrillation is an asynchronous countershock used to terminate pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF). The defibrillator is charged to 120 to 200 joules (biphasic) or 300 joules (monophasic) for 1 countershock from the defibrillator, and then CPR is immediately resumed and continued for 5 cycles or about 2 minutes. The rhythm is reassessed after 2 minutes and if VF or pulseless VT continues, the defibrillator is charged to give a second shock at the same energy level previously used. CPR is resumed after the shock if needed and the life support protocol is continued. There is no information in the question to indicate that life support should be terminated. Sodium bicarbonate may be prescribed but is not the best action. Giving CPR for 5 minutes may not help oxygenation to the brain and myocardium and is not the best action.
Question 5 of 5
A client with a history of chronic kidney disease is prescribed sevelamer (Renagel). The nurse should explain that this medication works by:
Correct Answer: B
Rationale: Sevelamer binds phosphate in the gut, reducing serum phosphate levels in chronic kidney disease.