NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of Addison’s disease. Which finding indicates a potential adrenal crisis?
Correct Answer: A
Rationale: Adrenal crisis in Addison’s disease causes hypotension (e.g., 90/60 mmHg) due to cortisol and aldosterone deficiency, leading to shock. Weight gain, normal sodium, and normal heart rate are not indicative.
Question 2 of 5
Diphenoxylate hydrochloride and atropine sulfate (Lomotil) is prescribed for the client with ulcerative colitis. Which of the following nursing observations indicates that the drug is having a therapeutic effect?
Correct Answer: B
Rationale: Lomotil, an antidiarrheal, slows intestinal motility, reducing diarrhea frequency in ulcerative colitis. Decreased diarrhea stools (
B) indicates therapeutic effect. Absent peristalsis (
A), increased cramping (
C), or girth (
D) suggest complications or ineffectiveness.
Question 3 of 5
A client with a history of a tonsillectomy is being discharged. The nurse should teach the client to:
Correct Answer: C
Rationale: Excessive swallowing post-tonsillectomy may indicate bleeding, a serious complication requiring immediate reporting. Gargling, cold liquids, and straws may irritate the surgical site.
Question 4 of 5
A 27-year-old healthy primigravida is brought to the labor and birthing room by her husband at 32 weeks' gestation. She experienced a sudden onset of painless vaginal bleeding. Following an ultrasound examination, the diagnosis of bleeding secondary to complete placenta previa is made. Expected assessment findings concerning the abdomen would include:
Correct Answer: C
Rationale: A rigid, boardlike abdomen is an assessment finding indicative of placenta abruptio. A cause of postbirth hemorrhage is uterine atony. With placenta previa, uterine tone is within normal range. The placenta is located directly over the cervical os in complete previa. Blood will escape through the os, resulting in the uterus and abdomen remaining soft and relaxed. In placenta abruptio, hypertonicity of the uterus is caused by the entrapment of blood between the placenta and uterine wall, a retroplacental bleed. This does not exist in placenta previa.
Question 5 of 5
When caring for a postoperative cholecystectomy client, the nurse assesses patency and documents drainage of the T-tube. The nurse recognizes that the expected amount of drainage during the first 24 hours postoperatively is:
Correct Answer: C
Rationale: During the first 24 hours after surgery, the drainage is normally 300-500 mL and then decreases to about 200 mL in 24 hours during the next 3-4 days. This range is the amount of drainage after the first 24 hours postoperatively. During the first 24 hours, it is 300-500 mL. During the first 24 hours after surgery, this range is the expected amount of drainage. The expected amount of drainage during the first 24 hours is 300-500 mL. An output of >500 mL should be reported to the physician, because an occlusion of some type, caused by a retained gallstone or an inflammatory process within the biliary drainage system, is evident.