NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
A client with a history of type 1 diabetes is admitted with diabetic ketoacidosis. The nurse should monitor the client for which of the following electrolyte imbalances? Select all that apply.
Correct Answer: A, C
Rationale: Diabetic ketoacidosis can cause hypokalemia (insulin shifts potassium) and hypophosphatemia (osmotic diuresis).
Question 2 of 5
The nurse assesses a client with diverticulitis and suspects peritonitis when which of the following symptoms is noted?
Correct Answer: B
Rationale: A rigid abdominal wall is a hallmark sign of peritonitis, indicating peritoneal inflammation, often due to perforation in diverticulitis.
Question 3 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 4 of 5
Which of the following outcomes is most appropriate for a nursing diagnosis of Ineffective tissue perfusion related to interruption of arterial flow? Select all that apply.
Correct Answer: A,C,D
Rationale: Warm extremities, reduced muscle pain, and self-care participation indicate improved perfusion; respiratory outcomes are unrelated.
Question 5 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.