NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
The following nursing diagnosis is written for a comatose client with cirrhosis of the liver and secondary splenomegaly--High risk for injury: Increased susceptibility to bleeding related to:
Correct Answer: B
Rationale: There is a decreased absorption of vitamin K with cirrhosis of the liver. This decrease impairs blood coagulation and the formation of prothrombin. Thrombocytopenia, an increased destruction of platelets, occurs secondary to hypersplenism. A diminished function of the Kupffer cells occurs with cirrhosis of the liver, causing the client to become more susceptible to infections. A decrease in the synthesis of fibrinogen and clotting factors VII, IX, and X occurs with cirrhosis of the liver and increases the susceptibility to bleeding.
Question 2 of 5
A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is ototoxic, the nurse would implement which of the following measures?
Correct Answer: A
Rationale: The first nursing measure is to instruct the client in which drug side effects to report. Discontinuing the drug is not an independent nursing intervention and may compromise client care. Audiometric testing will detect hearing loss, but it does not indicate a potential cause. Equalizing middle ear pressure will not prevent hearing loss.
Question 3 of 5
The nurse is assessing elderly clients at a community center.
Correct Answer: D
Rationale: Rales bilaterally indicate possible pulmonary edema or infection, which are serious conditions requiring immediate attention. Dry mouth (
A), height loss (
B), and stiffened joints (
C) are common in aging but less urgent.
Question 4 of 5
Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis?
Correct Answer: A
Rationale: Adequate renal flow of 30 mL/hr is a necessity with potassium infusions because potassium is excreted renally. Because potassium level will decrease during correction of diabetic ketoacidosis, potassium will be infused even if plasma levels of potassium are normal. A small T wave is normal and desired on the electrocardiogram. A tall, peaked T-wave could indicate overinfusion of potassium and hyperkalemia. Glucose levels of <200 are desirable.
Question 5 of 5
Which of the following describes a positive Kernig's sign?
Correct Answer: A
Rationale: A positive Kernig’s sign is pain or resistance when flexing the hip and extending the knee often indicating meningeal irritation (e.g. meningitis). The other options describe different symptoms or signs unrelated to Kernig’s.