NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening complications may occur initially, so the nurse will monitor him closely for serum:
Correct Answer: D
Rationale: When diabetic ketoacidosis exists, intracellular dehydration occurs and potassium leaves the cells and enters the vascular system, thus increasing the serum level beyond an acceptable range. When insulin and fluids are administered, cell walls are repaired and potassium is transported back into the cells. Normal serum potassium levels range from 3.5-5.0 mEq/L.
Question 2 of 5
The nurse is caring for a client with a recent stroke. Which position is most appropriate for this client?
Correct Answer: C
Rationale: Side-lying with the head elevated 30 degrees reduces intracranial pressure and promotes venous drainage in stroke clients, minimizing complications like cerebral edema. Supine, prone, or sitting positions may increase pressure or risk aspiration.
Question 3 of 5
An 82-year-old former restaurant owner walks to the nursing station and states, 'I have to go. The restaurant opens at 11 am.' Which response by the nurse is the most appropriate?
Correct Answer: C
Rationale: This response cuts off communication with the client. It does not address her feelings. Reality orientation frequently does not work alone. Feelings must be addressed. Telling a client to calm down is frequently ineffective. Reminiscence is used here to reorient and recall past pleasant events. Talking about the restaurant will allay anxiety. This response may confirm to the client that she indeed does still own a restaurant, buying into her confusion. Her feelings and anxiety require nursing intervention.
Question 4 of 5
The nurse writes the following nursing diagnosis for a client in acute renal failure--Impaired gas exchange related to:
Correct Answer: A
Rationale: Red blood cell production is impaired in renal failure owing to impaired erythropoietin production. This causes a decrease in the delivery of oxygen to the tissue and impairs gas exchange. The conversion of vitamin D to its physiologically active form is impaired in renal failure. In renal failure, a decrease in red blood cell production occurs owing to an impaired production of erythropoietin, leading to impaired gas exchange at the cellular level. The decreased production of renin in renal failure causes an increased production of aldosterone causing sodium and water retention.
Question 5 of 5
A client with a history of a colostomy is being discharged. The nurse should teach the client to:
Correct Answer: B
Rationale: High-fiber foods can cause blockages or excessive output in a colostomy. Bag changes depend on output, alcohol irritates the stoma, and irrigation is not always required.