NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnosis as a priority?
Correct Answer: C
Rationale: Ulcerative colitis causes diarrhea, leading to significant fluid and electrolyte loss, making fluid volume deficit a priority nursing diagnosis to prevent dehydration and shock. Anxiety, skin integrity, and nutrition are secondary concerns.
Question 2 of 5
The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on a full-strength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the following?
Correct Answer: A
Rationale: Once the feeding tube placement is confirmed in the stomach, aspiration can occur if the client's stomach becomes too full. When suctioning the trachea, if secretions resemble tube feeding, the client has aspirated the feeding.
Question 3 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 4 of 5
A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching concerning the warfarin therapy?
Correct Answer: C
Rationale: Warfarin must always be taken exactly as directed. Clients should be instructed never to skip or double up on their dosage. Aspirin decreases platelet aggregation, which would potentiate the effects of the coumadin. Healthcare providers need to be aware of persons on warfarin therapy prior to the initiation of any diagnostic tests and/or surgery to help prevent bleeding complications. An electric razor should be used to prevent accidental cutting, which can lead to bleeding.
Question 5 of 5
The client is admitted with a diagnosis of gastroenteritis. Which precaution should the nurse implement?
Correct Answer: B
Rationale: Gastroenteritis is often caused by pathogens like norovirus, requiring contact precautions to prevent fecal-oral transmission. Standard precautions are insufficient, and droplet or airborne are not indicated.