NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A client with a history of a brain tumor is scheduled for a craniotomy. The nurse should:
Correct Answer: B
Rationale: Antibiotics are often given preoperatively for a craniotomy to prevent infection. Shaving is per protocol, flat positioning may increase ICP, and exercises are taught post-op.
Question 2 of 5
The nurse is caring for a laboring client. Assessment data include cervical dilation 9 cm; contractions every 1-2 minutes; strong, large amount of 'bloody show.' The most appropriate nursing goal for this client would be:
Correct Answer: C
Rationale: In transition (9 cm dilation, frequent contractions), helping the client maintain control is critical due to intense contractions and emotional challenges.
Question 3 of 5
A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:
Correct Answer: D
Rationale: This change in blood pressure may not be significant and does not indicate a widening pulse pressure, a late sign of increased ICP. It is important to continue to monitor for change in blood pressure. Acetaminophen may be ineffective in relieving headache after head injury. Stronger analgesics are contraindicated because they mask neurological signs and may depress the CNS. Pulse rates between 68 bpm and 76 bpm are within normal limits for a 14-year-old child. It is important to monitor for a consistent drop in pulse rate, which is a late sign of increasing ICP. An elevated temperature is abnormal and requires further assessment and medical intervention. The temperature may be unrelated to the head injury, but CNS infection is serious and difficult to control.
Question 4 of 5
A male client is being treated in the burn unit for third-degree burns on his head, neck, and upper chest received in the last 24 hours. The nurse is evaluating the effectiveness of fluid resuscitation. Which of the following indicates effective fluid balance?
Correct Answer: C
Rationale: A weight gain of 10 lb represents a state of overhydration. He is losing fluids through insensible losses; a urine output equal to his intake indicates that he is receiving too little fluids. A urine output greater than his intake indicates that he is receiving adequate fluid resuscitation to account for urinary and insensible losses. A blood pressure of 94/62 indicates a state of underhydration and inadequate circulatory volume.
Question 5 of 5
The nurse working with a client who is out of control should follow a model of intervention that includes which of the following?
Correct Answer: A
Rationale: Approaching a client's aggressive behavior on a continuum of least restrictive care is in agreement with his or her rights (i.e., verbal methods to help maintain control, medication, seclusion, and restraints, as necessary). Approaching a client in a challenging manner is threatening and inappropriate. A non-challenging and calm approach reflects staff in control and may increase client's internal control. It is inappropriate to leave an aggressive client who is acting out alone. The nurse should acquire qualified help to prevent client from harm or injury to self or others. Moving a client to seclusion immediately for shouting is inappropriate. The nurse should offer the client an opportunity to control self with limit setting. The client should understand that the staff will assist with control if necessary (i.e., quietly accompany out of environment to decrease stimulation and allow for verbalization) employing the least restrictive care model of intervention.