NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 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 2 of 5
A client with a history of pneumonia is admitted with complaints of dyspnea. The nurse should give priority to:
Correct Answer: A
Rationale: Dyspnea in pneumonia indicates impaired gas exchange, so administering oxygen is the priority to improve oxygenation.
Question 3 of 5
The blood alcohol concentration of a client admitted following a motor vehicle accident is 460 mg/dL. The nurse should give priority to monitoring the client for:
Correct Answer: B
Rationale: A blood alcohol level of 460 mg/dL (0.46%) is life-threatening and can cause respiratory depression, a critical concern requiring close monitoring. Coordination loss and tachycardia are less immediate.
Question 4 of 5
When assessing the client with acute arterial occlusion, the nurse would expect to find:
Correct Answer: B
Rationale: Acute arterial occlusion causes ischemia, leading to tissue necrosis, which may present as minute blackened areas on the toes, indicating severe ischemia.
Question 5 of 5
A male client seeks counseling after his wife of 19 years threatened to divorce him. For most of their marriage, he has physically and verbally abused her. When asked about his behavior in the process of the nursing assessment, the client states, 'I was mean to my wife because she insists on cooking meals and wearing clothes that I do not like.' This defense mechanism is an example of:
Correct Answer: D
Rationale: Repression is blocking a desire from conscious expression. The client is conscious of his desires. Regression is returning to an earlier form of expression, which is not demonstrated here. Reaction formation is acting out the opposite of true feelings. The client felt anger concerning his wife's cooking and acted out his feelings. Rationalization is unconsciously falsifying an experience by giving a 'rational' explanation. The client is attempting to justify his behavior by giving an explanation.