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NCLEX RN Nursing Exam Questions

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Question 1 of 5

A 55-year-old client is admitted with a diagnosis of renal calculi. He presented with severe right flank pain, nausea, and vomiting. The most important nursing action for him at this time is:

Correct Answer: C

Rationale: Straining urine provides for assessment of calculi and evaluation of calculi descent through ureters and urethra.

Question 2 of 5

To correctly assess the oxygen saturation level of an adult client, the pulse oximeter should not be placed on the:

Correct Answer: C

Rationale: A pulse oximeter should not be placed on an extremity with a blood pressure cuff, as cuff inflation can interrupt blood flow and cause inaccurate readings. Fingers, earlobes, and the nose are acceptable sites when circulation is adequate.

Question 3 of 5

A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician?

Correct Answer: C

Rationale: Normal hematocrit in infant is 28%-42%. A 60% hematocrit may indicate polycythemia, a common complication of cyanotic heart disease.

Question 4 of 5

A client with a history of bipolar disorder is receiving Lithium. The nurse should teach the client to:

Correct Answer: B

Rationale: Lithium can cause dehydration and toxicity, so increasing fluid intake is essential. Salty foods are not contraindicated, meals are optional, and weight loss is not a primary concern.

Question 5 of 5

A 35-year-old client is admitted to the hospital with diabetic ketoacidosis. Results of arterial blood gases are pH 7.2, PaO2 90, PaCO2 45, and HCO3 16. The nursing assessment of arterial blood gases indicate the presence of:

Correct Answer: D

Rationale: Metabolic acidosis is determined by low pH and HCO3.

Similar Questions

During the assessment, the nurse observes a client scratching his skin. He has been admitted to rule out Laennec's cirrhosis of the liver. The nurse knows the pruritus is directly related to:
The physician has ordered intravenous fluid with potassium for a client admitted with gastroenteritis and dehydration. Before adding potassium to the intravenous fluid, the nurse should:
A male client has burns over 90% of his body after an automobile accident resulting in a fire. He was trapped inside the auto and pulled out by a bystander. After several months in the hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization the nursing staff has been aware of psychological changes the client faces after burns over a large portion of his body resulting in disfigurement. The nursing staff can best foster the client's self-esteem by:
The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
The nurse is assessing a client following the removal of a pituitary tumor. The nurse notes that the urinary output has increased and that the urine is very dilute. The nurse should give priority to:

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