NCLEX RN Nursing Exam
Question 1 of 5.
A postoperative TURP client is ordered continuous bladder irrigations. Later in the evening on the first postoperative day, he complains of increasing suprapubic pain. When assessing the client, the nurse notes diminished flow of bloody urine and several large blood clots in the drainage tubing. Which one of the following should be the initial nursing intervention?
A. Call the physician about the problem
B. Irrigate the Foley catheter
C. Change the Foley catheter
D. Administer a prescribed narcotic analgesic
Explanation: The physician should be notified as problems arise, but in this case, the nurse can attempt to irrigate the Foley catheter first and call the physician if irrigation is unsuccessful. Notifying the physician of problems is a subsequent nursing intervention. This answer is correct. Assessing catheter patency and irrigating as prescribed are the initial priorities to maintain continuous bladder irrigation. Manual irrigation will dislodge blood clots that have blocked the catheter and prevent problems of bladder distention, pain, and possibly fresh bleeding. The Foley catheter would not be changed as an initial nursing intervention, but irrigation of the catheter should be done as ordered to dislodge clots that interfere with patency. Even though the client complains of increasing suprapubic pain, administration of a prescribed narcotic analgesic is not the initial priority. The effect of the medication may mask the symptoms of a distended bladder and lead to more serious complications.
Question 2 of 5.
A client tells the nurse that she takes St. John's wort (hypericum perforatum) three times a day for mild depression. The nurse should tell the client that:
A. St. John's wort seldom relieves depression.
B. She should avoid eating aged cheese.
C. Skin reactions increase with the use of sunscreen.
D. The herbal is safe to use with other antidepressants.
Explanation: St. John's wort increases photosensitivity, so sunscreen use may paradoxically increase skin reactions; clients should be cautioned about sun exposure.
Question 3 of 5.
An adolescent client hospitalized with anorexia nervosa is described by her parents as 'the perfect child.' When planning care for the client, the nurse should:
A. Allow her to choose what foods she will eat
B. Provide activities to foster her self-identity
C. Encourage her to participate in morning exercise
D. Provide a private room near the nurse's station
Explanation: Anorexia nervosa is often linked to issues of control and identity; activities fostering self-identity help address underlying psychological factors.
Question 4 of 5.
The mother of a child with chickenpox wants to know if there is a medication that will shorten the course of the illness. Which medication is sometimes used to speed healing of the lesions and shorten the duration of fever and itching?
A. Zovirax (acyclovir)
B. Varivax (varicella vaccine)
C. VZIG (varicella-zoster immune globulin)
D. Periactin (cyproheptadine)
Explanation: Acyclovir (Zovirax) is an antiviral that can reduce the severity and duration of chickenpox symptoms, including lesions, fever, and itching.
Question 5 of 5.
The physician has ordered an IV bolus of Solu-Medrol (methylprednisolone sodium succinate) in normal saline for a client admitted with a spinal cord injury. Solu-Medrol has been shown to be effective in:
A. Preventing spasticity associated with cord injury
B. Decreasing the need for mechanical ventilation
C. Improving motor and sensory functioning
D. Treating post injury urinary tract infections
Explanation: High-dose methylprednisolone within 8 hours of spinal cord injury can improve motor and sensory outcomes by reducing inflammation and edema.