NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 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.
Question 2 of 5
The client with a history of epilepsy is prescribed valproic acid (Depakote). Which laboratory test should the nurse monitor?
Correct Answer: A
Rationale: Valproic acid can cause hepatotoxicity, so liver function tests (e.g., AST, ALT) are monitored regularly. Renal function, blood counts, and electrolytes are less commonly affected.
Question 3 of 5
A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching?
Correct Answer: B
Rationale: Diarrhea is a complication of tube feedings that can lead to dehydration. Diarrhea may be the result of hypertonic formulas that can draw fluid into the bowel. Other causes of diarrhea may be bacterial contamination, fecal impaction, medications, and low albumin. A consistent weight gain of more than 0.22 kg/day (1/2 lb/day) over several days should be reported promptly. The client should be evaluated for fluid volume excess. Elevating the client's head prevents reflux and thus formula from entering the airway. Bacteria proliferate rapidly in enteral formulas and can cause gastroenteritis and even sepsis.
Question 4 of 5
Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis?
Correct Answer: A
Rationale: Adequate renal flow of 30 mL/hr is a necessity with potassium infusions because potassium is excreted renally. Because potassium level will decrease during correction of diabetic ketoacidosis, potassium will be infused even if plasma levels of potassium are normal. A small T wave is normal and desired on the electrocardiogram. A tall, peaked T-wave could indicate overinfusion of potassium and hyperkalemia. Glucose levels of <200 are desirable.
Question 5 of 5
One afternoon 3 weeks into his alcohol treatment program, a client says to the nurse, 'It's really not all my fault that I have a drinking problem. Alcoholism runs in my family. Both my grandfather and father were heavy drinkers.' The nurse's best response would be:
Correct Answer: B
Rationale: Focusing is an effective therapeutic strategy. This response, however, allows the client to 'defocus' off the topic of learning how to accept responsibility for his behavior and future growth. The nurse can educate the client about both the 'genetic risk' for the development of alcoholism and ways to make long-term healthy lifestyle changes. This response is inappropriately confrontational and condescending to the client. Reflection of content can be an effective verbal therapeutic technique. It is used inappropriately here.