NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
An adult client is admitted to the emergency department after a burn injury. The burn initially affected the upper half of the client's anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran causing subsequent burn injuries to the entire face (anterior half of the head), and the upper half of the posterior torso. Using the rule of nines, the extent of the burn injury would be what percent?
Correct Answer: 31.50%
Rationale: According to the rule of nines, with the initial burn, the upper half of the anterior torso equals 9% and the lower half of both arms equals 9%. The subsequent burn included the anterior half of the head equaling 4.5% and the upper half of posterior torso equaling 9%. This totals 31.5%.
Question 2 of 5
Which of the following discharge instructions about thermal injury should be given to a client with peripheral vascular disease? Select all that apply.
Correct Answer: B,C,E,G
Rationale: Clients with peripheral vascular disease should wear warm clothing, check bath water temperature, avoid crossing legs to maintain circulation, and use sunscreen to protect skin. Electric heating pads, hot water bottles, and heating blankets risk burns due to impaired sensation.
Question 3 of 5
The nurse is discharging a client who has been hospitalized for preterm labor. The client needs further instruction when the nurse is
Correct Answer: A
Rationale: Suspecting a bladder infection requires immediate medical evaluation, not just a visit to the obstetrician, as infections can trigger preterm labor. The other statements reflect correct understanding of preterm labor management.
Question 4 of 5
The nurse is caring for a client with a history of chronic obstructive pulmonary disease who is receiving oxygen therapy. Which of the following flow rates is most appropriate for this client?
Correct Answer: A
Rationale: A flow rate of 1-2 L/min via nasal cannula is appropriate for COPD clients to avoid suppressing their hypoxic respiratory drive.
Question 5 of 5
A client with a history of rheumatoid arthritis is prescribed etanercept (Enbrel). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Etanercept, a biologic, increases infection risk due to immunosuppression.