NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
A client develops a temperature of 102°F following coronary artery bypass surgery. The nurse should notify the physician immediately because elevations in temperature:
Correct Answer: C
Rationale: Fever post-CABG increases metabolic demand, potentially decreasing cardiac output in a compromised heart, requiring immediate attention. Tamponade and rejection have other signs.
Question 2 of 5
Following a gastric resection, a 70-year-old client is admitted to the postanesthesia care unit. He was extubated prior to leaving the suite. On arrival at the postanesthesia care unit, the nurse should:
Correct Answer: A
Rationale: Adequate air exchange and tissue oxygenation depend on competent respiratory function. Checking the airway is the nurse's priority action. Obtaining the vital signs is an important action, but it is secondary to airway management. Reorienting a client to time, place, and person after surgery is important, but it is secondary to airway and vital signs. Airway management takes precedence over physician's orders unless they specifically relate to airway management.
Question 3 of 5
The client is admitted with a diagnosis of chorioamnionitis. Which symptom is most likely to be present?
Correct Answer: A
Rationale: Chorioamnionitis an infection of the amniotic fluid and membranes typically causes maternal fever. Fetal macrosomia decreased contractions and hypotension are not primary symptoms.
Question 4 of 5
The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years. Which of the following data is most likely significant in relation to the cause of the low blood pressure?
Correct Answer: B
Rationale: (A,
D) Decreased pulse volume and increased pulse rate are signs of an acute hypotensive episode. Inadequate fluid volume when taking vasodilators can result in a drop in blood pressure when vasodilation starts to physiologically occur as an action of the drug. A potassium level of 3.3 would not be associated with a significant drop in blood pressure.
Question 5 of 5
A long-term goal for the nurse in planning care for a depressed, suicidal client would be to:
Correct Answer: B
Rationale: This statement represents a short-term goal. Long-term therapy should be directed toward assisting the client to cope effectively with stress. Suicide contracts represent short-term interventions. This statement represents an unrealistic goal. Stressful situations cannot be avoided in reality.