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 client with a history of liver failure is admitted with complaints of confusion. The nurse should expect the client to have:
Correct Answer: A
Rationale: Liver failure impairs ammonia detoxification, leading to hyperammonemia, which causes hepatic encephalopathy and confusion.
Question 3 of 5
A client is being treated for congestive heart failure. His medical regimen consists of digoxin (Lanoxin) 0.25 mg po daily and furosemide 20 mg po bid. Which laboratory test should the nurse monitor?
Correct Answer: C
Rationale: Furosemide is a nonpotassium-sparing loop diuretic. Hypokalemia is a common side effect of furosemide and may enhance digoxin toxicity.
Question 4 of 5
The nurse is teaching circumcision care to the mother of a newborn. Which statement indicates that the mother needs further teaching?
Correct Answer: C
Rationale: Using a heat lamp is incorrect and could cause burns or delay healing. Petroleum gauze, cleaning, and monitoring for infection are appropriate circumcision care practices.
Question 5 of 5
A client with pregnancy-induced hypertension is scheduled for a C-section. Before surgery, the nurse should keep the client:
Correct Answer: C
Rationale: The left lateral position improves uteroplacental blood flow in pregnancy-induced hypertension, reducing fetal distress risk. Right-sided, supine, or knee-chest positions are less optimal.