NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
A client with a history of chronic lymphocytic leukemia is admitted with complaints of fever. The nurse should give priority to:
Correct Answer: A
Rationale: Fever in chronic lymphocytic leukemia suggests possible infection, a serious complication due to immunosuppression, so monitoring for infection is the priority.
Question 2 of 5
In assessing the nature of the stool of a client who has cystic fibrosis, what would the nurse expect to see?
Correct Answer: B
Rationale: Clay-colored stools indicate dysfunction of the liver or biliary tract. In the early stages of cystic fibrosis, fat absorption is primarily affected resulting in fat, foul, frothy, bulky stools. Dark brown stools indicate normal passage through the colon. Blood-tinged stools indicate dysfunction of the gastrointestinal (GI) tract.
Question 3 of 5
The nurse is caring for a client with a history of diverticulitis. Which meal selection indicates that the client understands the dietary teaching?
Correct Answer: B
Rationale: Clients with diverticulitis should follow a low-residue diet during flare-ups to reduce bowel irritation. Baked chicken, rice, and an apple are low in fiber and suitable. The other options contain high-fiber or irritating foods (e.g., spinach, whole wheat, garlic).
Question 4 of 5
A client with inflammatory bowel disease (IBD) requires an ileostomy. The nurse would instruct the client to do which of the following measures as an essential part of caring for the stoma?
Correct Answer: D
Rationale: Meticulous cleansing of the peristomal skin prevents irritation and infection, essential for ileostomy care. Stoma massage (
A) is unnecessary, high-fiber foods like nuts (
B) may cause blockages, and limiting fluids (
C) risks dehydration.
Question 5 of 5
A female client is started on warfarin (Coumadin) 5 mg po bid. To adequately evaluate the effectiveness of the warfarin therapy, the nurse must know that this medication:
Correct Answer: C
Rationale: Thrombolytic agents (e.g., streptokinase) directly activate plasminogen, dissolving fibrin deposits, which in turn dissolves clots that have already formed. Heparin prevents the formation of clots by potentiating the effects of antithrombin III and the conversion of prothrombin to thrombin. Warfarin prevents the formation of clots by interfering with the hepatic synthesis of the vitamin K-dependent clotting factors. Platelets initiate the coagulation of blood by adhering to each other and the site of injury to form platelet plugs.