NCLEX-RN
NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
The nurse is assessing a client who had a colon resection 2 days ago. The client states, 'I feel like my stitches have burst loose.' Upon further assessment, dehiscence of the wound is noted. The nurse should:
Correct Answer: B
Rationale: Dehiscence requires covering the wound with a sterile, saline-moistened dressing to prevent infection and protect exposed tissues. The other actions are inappropriate or harmful.
Question 2 of 5
Two days' postpartum, a nursing mother develops swollen, taut, and very painful breasts. Which of the following is the most likely cause?
Correct Answer: A
Rationale: Swollen, taut, and painful breasts two days postpartum are most likely due to engorgement (
A), a common condition as milk supply increases. Insufficient milk (
B), blocked ducts (
C), and mastitis (
D) present differently or later.
Question 3 of 5
The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug?
Correct Answer: C
Rationale: Carbamazepine can cause bone marrow suppression, leading to leukopenia. A WBC of 4,000/mm^3 is low, indicating a potential serious side effect requiring further evaluation.
Question 4 of 5
A client with a T6 injury 6 months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?
Correct Answer: B
Rationale: The symptoms suggest autonomic dysreflexia, often triggered by a distended bladder in spinal cord injury patients. Assessing and relieving the bladder is the priority after elevating the bed.
Question 5 of 5
The nurse is providing post-op education to a client who had a splenectomy. Which statement by the client indicates that the nurse's teaching was successful?
Correct Answer: D
Rationale: Post-splenectomy clients are at risk for infections and require vaccines like influenza, pneumococcal, and meningococcal, indicating successful teaching.