NCLEX-RN Practice Questions with Nurse Brennan

Question 1: A nurse is caring for a postoperative patient who has not voided for 8 hours following abdominal surgery. What is the first action the nurse should take?

A. Insert a Foley catheter

B. Increase the patient's oral fluid intake

C. Perform a bladder scan

D. Notify the healthcare provider

Correct Answer: C. Perform a bladder scan

Rationale: Performing a bladder scan is a non-invasive method used to assess bladder volume and determine whether urinary retention is present. This will guide further interventions, such as the need for catheterization. Increasing fluid intake or notifying the provider could follow based on the scan's results, but they are not the immediate steps.

Question 2: A nurse is teaching a client newly diagnosed with hypertension about lifestyle modifications. Which statement by the client indicates a need for further teaching?

A. "I will monitor my blood pressure regularly."

B. "I should limit sodium intake to about 2,300 mg a day."

C. "I will increase my physical activity to at least 150 minutes of moderate exercise per week."

D. "I should drink two glasses of red wine every night for heart health."

Correct Answer: D. "I should drink two glasses of red wine every night for heart health."

Rationale: While moderate alcohol consumption might be beneficial for some individuals, drinking two glasses of red wine every night is not recommended, especially for someone with hypertension, as it could lead to increased blood pressure. Limiting sodium, increasing physical activity, and monitoring blood pressure are correct lifestyle modifications.

Question 3: A nurse is assessing a newborn and notes the presence of a cephalhematoma. What is the most important information the nurse should provide to the parents regarding this condition?

A. "This condition may result in permanent brain damage."

B. "This swelling does not cross the suture lines of the skull."

C. "This area should be massaged regularly to aid absorption."

D. "This typically disappears within a few days."

Correct Answer: B. "This swelling does not cross the suture lines of the skull."

Rationale: Cephalhematomas are subperiosteal hemorrhages that do not cross suture lines due to their subperiosteal location. They generally resolve on their own over several weeks. It does not require massage, and it does not cause permanent brain damage.

Question 4: A nurse is conducting discharge teaching for a client who has a new prescription for warfarin. Which statement by the client indicates a need for further teaching?

A. "I will follow up with regular blood tests to monitor my INR levels."

B. "I should eat a consistent amount of green leafy vegetables."

C. "I will take aspirin for headaches."

D. "I should use a soft toothbrush to prevent gum bleeding."

Correct Answer: C. "I will take aspirin for headaches."

Rationale: Aspirin is an antiplatelet agent and can increase the risk of bleeding when taken with warfarin, an anticoagulant. It’s important for clients to avoid aspirin or other NSAIDs unless specifically directed by a healthcare provider when they are taking warfarin. The other statements indicate an understanding of warfarin therapy and safety precautions.

Question 5: A patient with congestive heart failure (CHF) is prescribed furosemide. What is the most important patient education point for the nurse to emphasize?

A. "Limit your intake of fluids to prevent fluid overload."

B. "You may experience a slight increase in your heart rate."

C. "Increase your consumption of bananas and oranges."

D. "Avoid standing quickly to prevent dizziness."

Correct Answer: C. "Increase your consumption of bananas and oranges."

Rationale: Furosemide is a loop diuretic that can cause potassium loss. Patients are often advised to consume foods high in potassium, such as bananas and oranges, to prevent hypokalemia. While managing fluid intake and preventing orthostatic hypotension (dizziness on standing up) are also important, the risk of electrolyte imbalance is crucial to address with furosemide.

Question 6: A nurse is reviewing the laboratory results of a client who is receiving heparin therapy for deep vein thrombosis (DVT). Which laboratory test should the nurse monitor to ensure therapeutic anticoagulation?

A. Platelet count

B. Prothrombin time (PT)

C. Hematocrit

D. Activated partial thromboplastin time (aPTT)

Correct Answer: D. Activated partial thromboplastin time (aPTT)

Rationale: aPTT is the appropriate test for monitoring the therapeutic level of heparin. It measures the effectiveness of heparin therapy in preventing clot formation by evaluating the time it takes blood to clot. PT is used to monitor warfarin therapy, while platelet count and hematocrit provide other clinical information.