NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent:
Correct Answer: B
Rationale: A three-way system of bladder irrigation will cleanse the bladder and prevent formation of blood clots. A catheter obstructed by clots or other debris will cause prostatic distention and hemorrhage.
Question 2 of 5
A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:
Correct Answer: A
Rationale: The water seal prevents air from entering the pleural space, maintaining negative pressure for lung re-expansion.
Question 3 of 5
A vaginal exam reveals that the cervix is 4cm dilated,with intact membranes and a fetal heart tone rate of 160-170 bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:
Correct Answer: B
Rationale: External fetal monitoring is appropriate when membranes are intact as internal monitoring requires ruptured membranes. The cervix is not closed fetal heart tones are normal and contraction intensity is irrelevant to external monitoring.
Question 4 of 5
One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:
Correct Answer: B
Rationale: Blood pressure can remain normotensive in a state of hypovolemia. Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. Skin turgor is not a reliable indicator for assessing hydration in a burn client. Fluid intake does not indicate adequacy of fluid resuscitation in a burn client.
Question 5 of 5
A client scheduled for disc surgery tells the nurse that she frequently uses the herbal supplement kava-kava (piper methysticum). The nurse should notify the doctor because kava-kava:
Correct Answer: A
Rationale: Kava-kava can potentiate the effects of anesthesia and analgesics, increasing the risk of excessive sedation or respiratory depression, necessitating physician awareness.