NCLEX-RN
NCLEX RN Practice Questions Quizlet
1. Which of the following medications taken by the patient is least likely to cause urine discoloration?
- A. Sulfasalazine
- B. Levodopa
- C. Phenolphthalein
- D. Aspirin
Correct answer: D
Rationale: The correct answer is Aspirin. Aspirin is not known to cause urine discoloration. Sulfasalazine is associated with causing orange-yellow discoloration of urine. Levodopa can cause darkening of urine to a brown or black color. Phenolphthalein has been linked to pink or red discoloration of urine. Therefore, among the options provided, Aspirin is the medication least likely to cause urine discoloration.
2. After assessing Mr. B, what is the initial action of the nurse?
- A. Immediately place the client in a negative-pressure room
- B. Set the client up to receive a bronchoscopy
- C. Contact the physician for antifungal medications
- D. Administer oxygen and assist the client to sit in the semi-Fowler's position
Correct answer: A
Rationale: The first action the nurse should take after assessing Mr. B is to administer oxygen and assist him to sit in the semi-Fowler's position. Administering oxygen helps improve tissue oxygenation, while sitting up in a semi-Fowler's position aids in better breathing and secretion clearance. Placing the client in a negative-pressure room is not the immediate priority unless isolation is needed. Performing a bronchoscopy or contacting the physician for antifungal medications is not the initial step in managing a client with suspected pneumonia.
3. A thirty-five-year-old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect?
- A. Atherosclerosis
- B. Diabetic nephropathy
- C. Autonomic neuropathy
- D. Somatic neuropathy
Correct answer: C
Rationale: In this case, the correct answer is autonomic neuropathy. Autonomic neuropathy affects the autonomic nerves, which control various bodily functions including the bladder. In diabetes, it can lead to bladder paralysis, resulting in symptoms like urgency to urinate and difficulty initiating urination. Atherosclerosis (choice A) is a condition involving the hardening and narrowing of arteries, not directly related to the inability to urinate in this context. Diabetic nephropathy (choice B) primarily affects the kidneys, leading to kidney damage, but does not typically cause urinary retention. Somatic neuropathy (choice D) involves damage to sensory nerves, not the autonomic nerves responsible for bladder control, making it less likely to be the cause of the urinary issue described in the question.
4. A patient comes to the emergency department with abdominal pain. Work-up reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Which of the following actions should the nurse expect?
- A. The patient will be admitted to the medicine unit for observation and medication.
- B. The patient will be admitted to the day surgery unit for sclerotherapy.
- C. The patient will be admitted to the surgical unit and resection will be scheduled.
- D. The patient will be discharged home to follow-up with his cardiologist in 24 hours.
Correct answer: C
Rationale: A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture, which can be life-threatening. The standard treatment for a rapidly enlarging abdominal aortic aneurysm is surgical intervention to prevent rupture. Therefore, the appropriate action for the nurse to expect is that the patient will be admitted to the surgical unit, and resection will be scheduled. Observation and medication (Choice A) are not sufficient for a rapidly enlarging aneurysm, and sclerotherapy (Choice B) is not typically used for aortic aneurysms. Discharging the patient home (Choice D) would be inappropriate and dangerous given the risk of rupture.
5. A client with myocardial infarction is receiving tissue plasminogen activator, alteplase (Activase, tPA). While on the therapy, the nurse plans to prioritize which of the following?
- A. Observe for neurological changes
- B. Monitor for any signs of renal failure
- C. Check the food diary
- D. Observe for signs of bleeding
Correct answer: D
Rationale: The priority concern for a client receiving thrombolytic medication, such as tissue plasminogen activator (alteplase), is to monitor for signs of bleeding. Thrombolytics work by converting plasminogen to plasmin, which degrades fibrin. This process can lead to the breakdown of both fibrin-bound plasminogen on thrombi surfaces and unbound plasminogen in the plasma. The resulting plasmin can degrade fibrin, fibrinogen, factor V, and factor VIII. Observing for signs of bleeding is crucial due to the increased risk of hemorrhage associated with thrombolytic therapy. Monitoring for neurological changes, signs of renal failure, or checking the food diary are not the immediate priorities compared to detecting and managing potential bleeding complications.
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