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
The client is receiving a continuous infusion of propofol (Diprivan) for sedation. Which assessment is most important?
Correct Answer: A
Rationale: Propofol can cause respiratory depression, so monitoring respiratory rate is critical to detect apnea or hypoventilation. Blood pressure, pulse, and temperature are monitored but are less immediate concerns.
Question 3 of 5
Assessment of the client with pericarditis may reveal which of the following?
Correct Answer: C
Rationale: No S3 or S4 are noted with pericarditis. No change in pulse pressure occurs. The symptoms of pericarditis vary with the cause, but they usually include chest pain, dyspnea, tachycardia, rise in temperature, and friction rub caused by fibrin or other deposits. The pain seen with pericarditis typically worsens with deep inspiration. Tamponade is not typically seen early on, and no change in pulse pressure occurs.
Question 4 of 5
A student nurse is observing a neurological nurse perform an assessment. When the nurse asks the client to "stick out his tongue," the nurse is assessing the function of which cranial nerve?
Correct Answer: D
Rationale: The hypoglossal nerve (XII) controls tongue movement. Sticking out the tongue assesses its function. Optic (II) affects vision, olfactory (I) affects smell, and vagus (X) affects visceral functions.
Question 5 of 5
The nurse is teaching a client with a history of psoriasis about skin care. The nurse should tell the client to:
Correct Answer: A
Rationale: Moisturizing the skin helps reduce dryness and scaling in psoriasis, improving skin barrier function and comfort.