NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
Azulfidine (Sulfasalazine) may be ordered for a client who has ulcerative colitis. Which of the following is a nursing implication for this drug?
Correct Answer: C
Rationale: Sulfasalazine commonly causes skin rash and diarrhea, which should be monitored. The other options are not relevant nursing implications.
Question 2 of 5
When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is:
Correct Answer: A
Rationale:
Stephens-Johnson syndrome is a toxic effect of phenytoin. Folate deficiency is a side effect of phenytoin, but not a toxic effect. Leukopenic aplastic anemia is a toxic effect of carbamazepine (Tegretol). Granulocytosis and nephrosis are toxic effects of trimethadione (Tridione).
Question 3 of 5
The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:
Correct Answer: C
Rationale: Epidural anesthesia can diminish bladder sensation leading to urinary retention. Hourly catheterization prevents bladder distention and complications. The other reasons are not accurate or relevant to epidural effects.
Question 4 of 5
A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U+1 in contrast to the previous assessment of U-2. The immediate nursing response is to:
Correct Answer: D
Rationale: Methergine is given following placental delivery to promote uterine contractions and prevent hemorrhage. Methergine may be administered in this clinical situation, but fundal massage would be the first response. Removal of retained placental fragments is done by the physician and is not the first response. If the fundus rises and is deviated, particularly to the right, the nurse should suspect bladder distention secondary to bladder and urethral trauma associated with birth and decreased bladder tone following delivery.
Therefore, women have a diminished sensation to void. A boggy fundus rises and is indicative of blood pooling, predisposing the woman to clot formation. Massage the uterus until firm.
Too vigorous massage will result in atonia. Clots may be expelled by a kneading motion of the uterus by the nurse.
Question 5 of 5
A client with a history of endometrial cancer is admitted with complaints of vaginal bleeding. The nurse should give priority to:
Correct Answer: A
Rationale: Vaginal bleeding in endometrial cancer may indicate recurrence, so monitoring for recurrence is the priority.