NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
The nurse is developing a plan of care for a client with a newly created ileostomy. The priority nursing diagnosis for this client is:
Correct Answer: A
Rationale: Excessive fluid loss from a new ileostomy can lead to dehydration, making risk for deficient fluid volume the priority nursing diagnosis to ensure physiological stability.
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
At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her contractions are every 5 minutes and last 60 seconds, her cervix is closed, and the suture placed around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is still intact. She is very concerned about delivering prematurely. She asks the RN, 'What is the greatest risk to my baby if it is born prematurely?' The RN's answer should be:
Correct Answer: D
Rationale: Any infant would be at risk for hyperglycemia because the infant's liver is missing the islets of Langerhans, which secrete insulin to break down glucose for cellular use. Prematurity is not an added risk for hyperglycemia. Both premature and mature infants can be at risk for hypoglycemia if their mother had gestational diabetes during pregnancy or entered the pregnancy with diabetes mellitus. These infants are exposed to high levels of maternal glucose while in utero, which causes the islets of Langerhans in the infant's liver to produce insulin. After birth when the umbilical cord is severed, the generous amount of maternal blood glucose is eliminated; however, there is continued islet cell hyperactivity in the infant's liver, which can lead to excessive insulin levels and depleted blood glucose. Mature infants are born with an immature GI system. The nervous control of the stomach is incomplete at birth, salivary glands are immature at birth, and the intestinal tract is sterile. This is not the greatest risk to a premature infant. The greatest risk to a premature infant is the lack of development of the lungs, which can lead to respiratory distress syndrome due to insufficient surfactant production.
Question 4 of 5
A 27-year-old man was diagnosed with type I diabetes 3 months ago. Two weeks ago he complained of pain, redness, and tenderness in his right lower leg. He is admitted to the hospital with a slight elevation of temperature and vague complaints of 'not feeling well.' At 4:30 PM on the day of his admission, his blood glucose level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to:
Correct Answer: C
Rationale: Four ounces of orange juice will raise blood sugar to a normal level and sustain it until dinner, preventing hypoglycemia. The other options either raise blood sugar too high or are insufficient.
Question 5 of 5
The client is admitted with a diagnosis of gestational diabetes. Which intervention is most appropriate?
Correct Answer: D
Rationale: Gestational diabetes requires blood glucose monitoring to maintain control fetal heart tone monitoring to assess fetal well-being and potentially other interventions.
Tocolytics are not indicated unless preterm labor occurs.