NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
A postoperative TURP client is ordered continuous bladder irrigations. Later in the evening on the first postoperative day, he complains of increasing suprapubic pain. When assessing the client, the nurse notes diminished flow of bloody urine and several large blood clots in the drainage tubing. Which one of the following should be the initial nursing intervention?
Correct Answer: B
Rationale: The physician should be notified as problems arise, but in this case, the nurse can attempt to irrigate the Foley catheter first and call the physician if irrigation is unsuccessful. Notifying the physician of problems is a subsequent nursing intervention. This answer is correct. Assessing catheter patency and irrigating as prescribed are the initial priorities to maintain continuous bladder irrigation. Manual irrigation will dislodge blood clots that have blocked the catheter and prevent problems of bladder distention, pain, and possibly fresh bleeding. The Foley catheter would not be changed as an initial nursing intervention, but irrigation of the catheter should be done as ordered to dislodge clots that interfere with patency. Even though the client complains of increasing suprapubic pain, administration of a prescribed narcotic analgesic is not the initial priority. The effect of the medication may mask the symptoms of a distended bladder and lead to more serious complications.
Question 2 of 5
The nurse is preparing to administer insulin to a client with type 1 diabetes. The client is to receive 10 units of NPH insulin and 5 units of regular insulin in the same syringe. Which action is correct?
Correct Answer: A
Rationale:
To prevent contamination, draw up regular (clear) insulin first, then NPH (cloudy). Mixing in a vial (
C) is incorrect, and separate injections (
D) are unnecessary.
Question 3 of 5
A postpartum client complains of rectal pressure and severe pain in her perineum; this may be indicative of:
Correct Answer: D
Rationale: Afterbirth pains are a common complaint in the postpartum client, but they are located in the uterus. Constipation may cause rectal pressure but is not usually associated with 'severe pain.' Cystitis may cause pain, but the location is different. Hematomas are frequently associated with severe pain and pressure. Further assessments are indicated for this client.
Question 4 of 5
A client with a history of ulcerative colitis is admitted with complaints of bloody diarrhea. The nurse should give priority to:
Correct Answer: A
Rationale: Bloody diarrhea in ulcerative colitis can cause significant fluid and electrolyte loss, so monitoring for dehydration is the priority.
Question 5 of 5
A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:
Correct Answer: C
Rationale: Pain management is a priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy due to the surgical incision and tissue trauma, which can cause significant discomfort. Effective pain control is essential to promote recovery and patient comfort.