NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 of 5
In cleansing the perineal area around the site of catheter insertion, the nurse would:
Correct Answer: B
Rationale: Wiping away from the urinary meatus removes microorganisms from the insertion point, decreasing the risk of bladder infection. The other options increase infection risk or are inappropriate.
Question 2 of 5
A 35-year-old client has returned to her room following surgery on her right femur. She has an IV of D5 in one-half normal saline infusing at 125 mL/hr and is receiving morphine sulfate 10-15 mg IM q4h prn for pain. She last voided 5-1/2 hours ago when she was given her preoperative medication. In monitoring and promoting return of urinary function after surgery, the nurse would:
Correct Answer: C
Rationale: Provision of food and fluid promotes bowel elimination. Nutritional needs postoperatively are determined by the physician, not the client. Increasing IV fluids postoperatively will not cause a client to void. Any change in rate of administration of IV fluids should be determined by the physician. The postoperative client with normal kidney function who cannot void 8 hours after surgery is retaining urine. The client may need catheterization or medication. The physician must provide orders for both as necessary. Although morphine sulfate can cause urinary retention, withholding pain medication will not ensure that the client will void. The client with uncontrolled pain will probably not be able to void.
Question 3 of 5
A client with a history of renal failure is admitted with complaints of shortness of breath. The nurse should expect the client to have:
Correct Answer: A
Rationale: Renal failure impairs acid excretion, leading to metabolic acidosis, which can cause compensatory hyperventilation and shortness of breath.
Question 4 of 5
A client has a tentative diagnosis of myasthenia gravis. The nurse recognizes that myasthenia gravis involves:
Correct Answer: B
Rationale: Myasthenia gravis is caused by autoantibodies blocking acetylcholine receptors, interrupting nerve impulse transmission to muscles, leading to weakness.
Question 5 of 5
The client is admitted with a diagnosis of preterm labor. Which fetal monitoring technique is most appropriate?
Correct Answer: C
Rationale: Preterm labor requires fetal monitoring to assess well-being. Non-stress tests evaluate fetal heart rate and biophysical profiles assess multiple parameters (e.g. movement amniotic fluid). Both are appropriate.