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 post-operative client has an order for Demerol (meperidine) 75 mg and Phenergan (promethazine) 25 mg IM every 3-4 hours as needed for pain. The combination of the two medications produces a/an:
Correct Answer: B
Rationale: Meperidine (opioid) and promethazine (antihistamine) together produce a synergistic effect, enhancing pain relief and sedation. Promethazine potentiates meperidine’s effects.
Question 3 of 5
A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar puncture. In light of this procedure and developmental characteristics of this age group, which nursing measure is most appropriate?
Correct Answer: A
Rationale: The nurse should emphasize what is required to elicit cooperation and help to develop a sense of autonomy. The child may express discomfort verbally and should be encouraged to express his feelings. Selecting nonthreatening words to explain a procedure will prevent misinterpretation. When explaining the procedure to the parent with the child present, the nurse should use words that the child can understand to avoid misunderstanding.
Question 4 of 5
The nurse caring for a client who has pneumonia, which is caused by a gram-positive bacteria, inspects her sputum. Because the client's pneumonia is caused by a gram-positive bacteria, the nurse expects to find the sputum to be:
Correct Answer: B
Rationale: Bright red sputum with streaks is associated with pneumonia caused by gram-negative bacteria, such as Klebsiella pneumonia. Pneumococcal pneumonia, caused by gram-positive bacteria, has a characteristic productive cough with green or rust-colored sputum. Green-colored sputum is more characteristic of Pseudomonas than of gram-positive bacterial pneumonia. Pink-tinged and frothy sputum is more characteristic of pulmonary edema than of gram-positive bacterial pneumonia.
Question 5 of 5
While caring for a client in the second stage of labor, the nurse notices a pattern of early decelerations. The nurse should:
Correct Answer: D
Rationale: Early decelerations are benign, caused by fetal head compression during labor, and require only documentation, as they do not indicate fetal distress.