NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A client with a T6 injury six months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?
Correct Answer: B
Rationale: Facial flushing and severe hypertension suggest autonomic dysreflexia, often triggered by a distended bladder in spinal cord injury. Assessing and relieving the trigger (
B) is priority. Notifying the physician (
A), oxygen (
C), or fluids (
D) is secondary.
Question 2 of 5
Which of the following nursing actions is essential to prevent drug-resistant tuberculosis?
Correct Answer: D
Rationale: Noncompliance with prescribed antituberculosis drug regimen is the primary cause of drug-resistant organisms. Noncompliance permits the mutation of organisms.
Question 3 of 5
The nurse caring for a client who has pneumonia, which is caused by a gram-positive bacteria, inspects her sputum. Because the client's pneumonia is caused by a gram-positive bacteria, the nurse expects to find the sputum to be:
Correct Answer: B
Rationale: Bright red sputum with streaks is associated with pneumonia caused by gram-negative bacteria, such as Klebsiella pneumonia. Pneumococcal pneumonia, caused by gram-positive bacteria, has a characteristic productive cough with green or rust-colored sputum. Green-colored sputum is more characteristic of Pseudomonas than of gram-positive bacterial pneumonia. Pink-tinged and frothy sputum is more characteristic of pulmonary edema than of gram-positive bacterial pneumonia.
Question 4 of 5
The primary cause of anemia in a client with chronic renal failure is:
Correct Answer: D
Rationale: Chronic renal failure reduces erythropoietin production, impairing red blood cell production and causing anemia. Iron absorption, RBC destruction, and intrinsic factor are secondary or unrelated.
Question 5 of 5
The physician orders the removal of an in-dwelling catheter the second post-operative day for a client with a prostatectomy. The client complains of pain and dribbling of urine the first time he voids. The nurse should tell the client that:
Correct Answer: D
Rationale: Pain and dribbling post-catheter removal after prostatectomy are common due to bladder irritation and will improve with time. Compresses, exercises, or reinsertion are not typically needed.