NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 of 5
The client is admitted with a diagnosis of acute leukemia. Which nursing intervention is the priority?
Correct Answer: B
Rationale: Acute leukemia causes immunosuppression, making infection prevention (e.g., hand hygiene, protective isolation) the priority to avoid life-threatening complications. Pain, glucose, and diet are secondary.
Question 2 of 5
A client with a history of phenylketonuria is seen at the local family planning clinic. After completing the client's intake history, the nurse provides literature for a healthy pregnancy. Which statement indicates that the client needs further teaching?
Correct Answer: A
Rationale: Nutrasweet (aspartame) contains phenylalanine, which is harmful in phenylketonuria, so this statement indicates a need for further teaching.
Question 3 of 5
In working with mental health clients who are prescribed medication that must be taken on a routine basis, it is important for education to begin when the drug therapy is initiated. One of the first steps in the teaching process is to:
Correct Answer: D
Rationale: (A, B,
C) The nurse must first obtain information regarding the client's perception of the medication regimen. The first step in the teaching process is to determine the client's perception.
Question 4 of 5
A client who has been receiving Urokinase (UPA) for deep vein thrombosis is noted to have dark brown urine in the urine collection bag. Which action should the nurse take immediately?
Correct Answer: D
Rationale: Dark brown urine may indicate hematuria, a potential side effect of Urokinase, a thrombolytic agent. The nurse should withhold the medication and notify the physician immediately to assess for bleeding complications. Vitamin K is used for warfarin reversal, irrigation is inappropriate, and fluids won’t address the issue.
Question 5 of 5
The client is admitted to the unit with a diagnosis of abruptio placenta. Which finding is most significant when assessing this client?
Correct Answer: C
Rationale: Abruptio placenta involves placental separation which can compromise fetal oxygenation leading to abnormal fetal heart tones (e.g. bradycardia or late decelerations). This is the most significant finding as it indicates fetal distress. Bleeding pain and rigidity are relevant but secondary to fetal well-being.