NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
A therapeutic milieu is:
Correct Answer: D
Rationale: A therapeutic milieu is a structured environment designed to promote healing and recovery through consistency, safety, and therapeutic interactions.
Question 2 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 3 of 5
The nurse is assessing fetal presentation in a multiparous client. The fi gure below indicates which of the following types of presentations?
Correct Answer: C
Rationale: Although breech presentations are rare, footling breech occurs when there is an extension of the fetal knees and one or both feet protrude through the pelvis. In frank breech, there is flexion of the fetal thighs and extension of the knees. The feet rest at the sides of the fetal head. In complete breech, there is fl exion of the fetal thighs and knees; the fetus appears to be squatting. Vertex position occurs in 95% of deliveries; in such cases, the head is engaged in the pelvis.
Question 4 of 5
A client has a reddened area over a bony prominence. The nurse finds a nursing assistant massaging this area. The nurse should:
Correct Answer: D
Rationale: Massage over a reddened area on a bony prominence is contraindicated as it can further damage tissue and reduce blood flow, increasing the risk of pressure ulcers. The nurse should instruct the assistant to stop massaging the area to prevent harm.
Question 5 of 5
The nurse is teaching a client who is taking cyclosporine after renal transplant about medication information. The nurse should tell the client to be especially alert for which problem?
Correct Answer: D
Rationale: Cyclosporine is an immunosuppressant medication used to prevent transplant rejection. The client should be especially alert for signs and symptoms of infection while taking this medication and report them to the primary health care provider if experienced. The client is also taught about other side/adverse effects of the medication, including hypertension, increased facial hair, tremors, gingival hyperplasia, and gastrointestinal complaints. Some weight loss may occur, but this is not as significant as the onset of an infection.