NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is:
Correct Answer: A
Rationale:
Stephens-Johnson syndrome is a toxic effect of phenytoin. Folate deficiency is a side effect of phenytoin, but not a toxic effect. Leukopenic aplastic anemia is a toxic effect of carbamazepine (Tegretol). Granulocytosis and nephrosis are toxic effects of trimethadione (Tridione).
Question 2 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 3 of 5
The client is admitted with a diagnosis of acute glomerulonephritis. Which assessment finding is most expected?
Correct Answer: A
Rationale: Hematuria is a hallmark of acute glomerulonephritis due to glomerular inflammation and damage, leading to blood in the urine. Hypertension, weight gain, and oliguria are more common than hypotension, weight loss, or clear urine.
Question 4 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.
Question 5 of 5
A client with a history of alcoholism is admitted with a diagnosis of cirrhosis. The nurse can expect the client to exhibit:
Correct Answer: A
Rationale: Cirrhosis impairs liver function, leading to portal hypertension and hypoalbuminemia, causing lower extremity edema. Dilated pupils, warm skin, and bradycardia are not typical.