NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
A nurse is caring for a woman who delivered a term neonate at 6 a.m. At 4 p.m., the woman has a distended bladder and is reporting pain of 5 on a scale of 1 to 10. The nurse reviews the client's output record. What should the nurse do first?
Correct Answer: D
Rationale: A distended bladder causing pain requires immediate relief via catheterization to prevent complications like urinary retention or bladder injury.
Question 2 of 5
A client with a spinal cord injury is at risk for autonomic dysreflexia. Which symptom should the nurse monitor for?
Correct Answer: C
Rationale: Severe headache is a key sign of autonomic dysreflexia, often triggered by bladder or bowel issues.
Question 3 of 5
The nurse is teaching a client with a new diagnosis of type 1 diabetes about sick day management. Which of the following instructions should be included? Select all that apply.
Correct Answer: A, B, D, E
Rationale: Continuing insulin, frequent glucose monitoring, fluid intake, and contacting the provider prevent complications during illness.
Question 4 of 5
A client with chronic kidney disease is on a fluid restriction. How should the nurse calculate the client's daily fluid intake?
Correct Answer: A
Rationale: Fluid intake in chronic kidney disease is typically calculated as urine output plus 500 mL to replace insensible losses while preventing fluid overload.
Question 5 of 5
The nurse is caring for a client post-cataract surgery. Which instruction should the nurse include in discharge teaching?
Correct Answer: A
Rationale: Avoiding bending at the waist prevents increased intraocular pressure, which could complicate recovery post-cataract surgery.