NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:
Correct Answer: B
Rationale: Blood pressure can remain normotensive in a state of hypovolemia. Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. Skin turgor is not a reliable indicator for assessing hydration in a burn client. Fluid intake does not indicate adequacy of fluid resuscitation in a burn client.
Question 2 of 5
One week ago, a 21-year-old client with a diagnosis of bipolar disorder was started on lithium 300 mg po qid. A lithium level is ordered. The client's level is 1.3 mEq/L. The nurse recognizes that this level is considered to be:
Correct Answer: A
Rationale: This answer is correct. The therapeutic range is 1.0-1.5 mEq/L in the acute phase. Maintenance control levels are 0.6-1.2 mEq/L. (B,
C) This answer is incorrect. A level of 1.3 mEq/L is within therapeutic range. This answer is incorrect.
Toxic poisoning is usually at the 2.0 level or higher.
Question 3 of 5
The nurse is caring for a client with a colostomy. Which finding requires immediate intervention?
Correct Answer: D
Rationale: A significantly protruding stoma may indicate prolapse, a complication requiring immediate intervention to prevent ischemia or obstruction. Pink stoma, cramping, and liquid stool are normal or less urgent.
Question 4 of 5
A female client has married recently. A month ago she visited her physician with complaints of burning on urination. She was given a prescription for trimethoprim-sulfamethoxazole (Bactrim) DS bid for 10 days. She was admitted through the emergency room on Saturday evening complaining of flank pain. Her temperature was 104°F. A preliminary urinalysis revealed 31 bacteria along with red and white blood cells Rankings blood cells in the urine. A preliminary diagnosis of pyelonephritis was made. During a nursing admission assessment, which statement by the client demonstrates a possible cause for pyelonephritis?
Correct Answer: C
Rationale: Although it is important that the client drink adequate fluids while treating a bladder infection with trimethoprim-sulfamethoxazole, the failure to do so will not cause pyelonephritis. A stricture or abnormality may cause the progression of bladder infection to urinary tract infection, but this is rare. There is no indication in this situation that this has occurred. The most common cause of pyelonephritis is improper treatment of bladder infections. The client typically feels better after several days, discontinues the medication, and saves the remainder for the next occurrence of a bladder infection. For this reason, it is imperative to provide client education related to completion of the prescribed medication. There is no evidence that infection in another body system could cause pyelonephritis.
Question 5 of 5
The nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which finding indicates magnesium toxicity?
Correct Answer: A
Rationale: A respiratory rate of 10 breaths per minute suggests magnesium toxicity as magnesium sulfate depresses the central nervous system including respiratory drive. Normal reflexes adequate urine output and BP of 140/90 do not indicate toxicity.