NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
The client returns to the recovery room following repair of an abdominal aneurysm. Which finding would require further investigation?
Correct Answer: B
Rationale: Urinary output of 20 mL/hour is below the expected minimum of 30 mL/hour, indicating potential renal compromise or hypoperfusion, common risks after aneurysm repair. This requires further investigation. The other findings are within acceptable post-operative ranges.
Question 2 of 5
A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy:
Correct Answer: C
Rationale: The instillation of erythromycin ophthalmic preparation, not phototherapy, prevents ophthalmia neonatorum. The administration of vitamin K (AquaMEPHYTON) assists the infant's clotting mechanism. Excessive bilirubin accumulates when the infant's liver cannot handle the increased load caused by the breakdown of red blood cells postnatally. This excessive bilirubin seeps out of the blood and into the tissues, staining them yellow. Phototherapy accelerates the removal of bilirubin from the skin by breaking it down into substances that can be excreted in stool or urine. Phototherapy decreases levels of unconjugated bilirubin, thereby preventing kernicterus.
Question 3 of 5
A physician's order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a microdrip tubing set. How many drops per minute should the nurse administer?
Correct Answer: C
Rationale: 50 gtt/min.
Question 4 of 5
A male client is undergoing cardiac tests. He has been instructed to wear a Holter monitor. The nurse knows she has included the appropriate information in her teaching when the client tells her:
Correct Answer: C
Rationale: The client should leave the electrodes in place during the entire time the test is ordered. He should not even remove the electrodes for bathing. The Holter monitor will record cardiac electrical activity but will not record damage to his myocardium. The client should keep a record of all of his activities so the physician can correlate the ECG findings with his activities. The client should continue doing his regular activities. The purpose of the Holter monitor is to record heart activity during routine activities.
Question 5 of 5
The nurse writes the following nursing diagnosis for a client in acute renal failure--Impaired gas exchange related to:
Correct Answer: A
Rationale: Red blood cell production is impaired in renal failure owing to impaired erythropoietin production. This causes a decrease in the delivery of oxygen to the tissue and impairs gas exchange. The conversion of vitamin D to its physiologically active form is impaired in renal failure. In renal failure, a decrease in red blood cell production occurs owing to an impaired production of erythropoietin, leading to impaired gas exchange at the cellular level. The decreased production of renin in renal failure causes an increased production of aldosterone causing sodium and water retention.