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 peptic ulcer disease is admitted with complaints of hematemesis. The nurse should give priority to:
Correct Answer: B
Rationale: Hematemesis indicates possible gastrointestinal bleeding, so monitoring vital signs is critical to assess for hypovolemia and shock.
Question 3 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 4 of 5
A client with cancer who is receiving chemotherapeutic drugs has been given injections of pegfilgastrim (Neulasta). Which laboratory value reveals that the drug is producing the desired effect?
Correct Answer: B
Rationale: Pegfilgastrim stimulates neutrophil production, increasing white blood cell counts. A WBC of 6,000/mm (
B) indicates effectiveness. Hemoglobin (
A), platelets (
C), and hematocrit (
D) are not directly affected.
Question 5 of 5
The nurse is caring for a client with a history of a fractured pelvis who is in skeletal traction. The nurse should:
Correct Answer: D
Rationale: Monitoring for infection at pin sites prevents osteomyelitis in skeletal traction. Turning is limited, weights must hang freely, and lotion is unnecessary.