NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to:
Correct Answer: B
Rationale: This baby probably will cry, which should be prevented because it will increase his intracranial pressure (ICP). Asking the mother to wait until the baby is asleep may help.
Question 2 of 5
A client with a history of peptic ulcer disease is admitted with complaints of hematemesis. The nurse should give priority to:
Correct Answer: B
Rationale: Hematemesis indicates possible gastrointestinal bleeding, so monitoring vital signs is critical to assess for hypovolemia and shock.
Question 3 of 5
A client has returned to the unit following a left femoral popliteal bypass graft. Six hours later, his dorsalis pedis pulse cannot be palpated, and his foot is cool and dusky. The nurse should:
Correct Answer: B
Rationale: The physician should be notified immediately because the client is losing blood supply to his left foot and is in danger of losing the foot and/or leg.
Question 4 of 5
After attending a company picnic, several clients are admitted to the emergency room with E. coli food poisoning. The most likely source of infection is:
Correct Answer: A
Rationale: Undercooked hamburger is a common source of E. coli, particularly E. coli O157:H7, which can contaminate ground beef.
Question 5 of 5
A postoperative TURP client returns from the recovery room to the general surgery unit and is in stable condition. One hour later the nurse assesses him and finds him to be confused and disoriented. She recognizes that this is most likely caused by:
Correct Answer: D
Rationale: Early signs of hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, and diaphoresis. Early signs of potassium depletion include muscular weakness or paralysis, tetany, postural hypotension, weak pulse, shallow respirations, apathy, weak voice, and electrocardiographic changes. Early signs of an elevated sodium level include dry oral mucous membranes, marked thirst, hypertension, tachycardia, oliguria or anuria, anxiety, and agitation. This answer is correct. Important early clinical findings of a decreased sodium concentration include confusion and disorientation. Hyponatremia can occur after a TURP because absorption during surgery through the prostate veins can increase circulating blood volume and decrease sodium concentration.