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
The nurse has just received the change of shift report and is preparing to make rounds. Which client should the nurse assess first?
Correct Answer: C
Rationale: The client admitted one hour ago with rales and shortness of breath indicates potential acute respiratory distress, possibly from pulmonary edema or pneumonia, requiring immediate assessment. The other clients are stable or less urgent.
Question 3 of 5
While the RN is assessing a mother's perineum on her 2nd postpartum day after having a vaginal delivery, the RN notes a large ecchymotic area located to the left of the mother's perineum. Which one of the following interventions should the RN initiate at this time?
Correct Answer: C
Rationale: Warm sitz baths increase circulation, promote healing, and reduce edema in a traumatized perineum, making it appropriate for an ecchymotic area.
Question 4 of 5
One afternoon 3 weeks into his alcohol treatment program, a client says to the nurse, 'It's really not all my fault that I have a drinking problem. Alcoholism runs in my family. Both my grandfather and father were heavy drinkers.' The nurse's best response would be:
Correct Answer: B
Rationale: Focusing is an effective therapeutic strategy. This response, however, allows the client to 'defocus' off the topic of learning how to accept responsibility for his behavior and future growth. The nurse can educate the client about both the 'genetic risk' for the development of alcoholism and ways to make long-term healthy lifestyle changes. This response is inappropriately confrontational and condescending to the client. Reflection of content can be an effective verbal therapeutic technique. It is used inappropriately here.
Question 5 of 5
A client has developed diabetes insipidus after removal of a pituitary tumor. Which finding would the nurse expect?
Correct Answer: A
Rationale: Diabetes insipidus causes polyuria due to deficient antidiuretic hormone, leading to excessive water loss. Hypertension (
B), polyphagia (
C), and hyperkalemia (
D) are not typical.