NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 of 5
A client who has been receiving Urokinase (UPA) for deep vein thrombosis is noted to have dark brown urine in the urine collection bag. Which action should the nurse take immediately?
Correct Answer: D
Rationale: Dark brown urine may indicate hematuria, a potential side effect of Urokinase, a thrombolytic agent. The nurse should withhold the medication and notify the physician immediately to assess for bleeding complications. Vitamin K is used for warfarin reversal, irrigation is inappropriate, and fluids won’t address the issue.
Question 2 of 5
The client is admitted with a diagnosis of preterm labor. Which fetal monitoring technique is most appropriate?
Correct Answer: C
Rationale: Preterm labor requires fetal monitoring to assess well-being. Non-stress tests evaluate fetal heart rate and biophysical profiles assess multiple parameters (e.g. movement amniotic fluid). Both are appropriate.
Question 3 of 5
A 30-year-old client has just been treated in the ER for bruises and abrasions to her face and a broken arm from domestic violence, which has been increasing in frequency and intensity over the last few months. The nurse assesses her as being very anxious, fearful, bewildered, and feeling helpless as she states, 'I don't know what to do, I'm afraid to go home.' The best response by the nurse to the client would be:
Correct Answer: C
Rationale: A person in crisis needs support, assistance, and direction from a caregiver rather than just an instruction. A battered person may feel guilt and think that they cause the abuser's behavior; however, the abuser has the problem and goes through phases of violence. The nurse should provide support and guidance to the client in crisis by offering alternatives and assist in referrals. Focusing on help from law enforcement may be a very temporary solution, because the victim may be fearful of pressing charges. This answer does not address the crisis of going home.
Question 4 of 5
A 14-year-old boy has had diabetes for 7 years. He takes 30 U of NPH insulin and 10 U of regular insulin every morning at 7 AM. He eats breakfast at 7:30 AM and lunch at noon. What time should he expect the greatest risk for hypoglycemia?
Correct Answer: C
Rationale: This time is incorrect because regular insulin would peak after the teenager has eaten breakfast. This time is incorrect because it is after lunch when the NPH peaks. Regular insulin peaks in 2-3 hours and has a duration of 4-6 hours. NPH insulin's onset is 4-6 hours and peaks in 8-16 hours. Blood sugar would peak after meals and be lowest before meals and during the night. This time is incorrect because it is before the NPH and after the regular insulin peak times.
Question 5 of 5
The client is admitted with a diagnosis of acute leukemia. Which nursing intervention is the priority?
Correct Answer: B
Rationale: Acute leukemia causes immunosuppression, making infection prevention (e.g., hand hygiene, protective isolation) the priority to avoid life-threatening complications. Pain, glucose, and diet are secondary.