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Questions 227

NCLEX-PN

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Extract:


Question 1 of 5

The CVP reading of a client with partial thickness burns is 6 mm H2O. The nurse recognizes that the client:

Correct Answer: B

Rationale: A central venous pressure (CVP) reading of 6 mm H2O is within the normal range (2-8 mm H2O), indicating adequate fluid status. Answer A is incorrect because the client does not need additional fluids. Answer C is incorrect because a CVP of 6 does not suggest congestive failure. Answer D is incorrect because a diuretic is not indicated with a normal CVP.

Question 2 of 5

The client tells the nurse he has trigeminal neuralgia. What would the nurse expect in the client's history?

Correct Answer: B

Rationale: Trigeminal neuralgia causes severe facial pain, often triggered by stimuli like cold air, unlike lead exposure, ambulation issues, or leg pain.

Extract:

Which of the following individuals is at greatest risk for experiencing cerebral vascular accident?


Question 3 of 5

A 50-year-old African-American male with history of hypertension.

Correct Answer: A

Rationale: This patient has multiple risk factors for CVA: African-American race, male gender, age, and hypertension.

Extract:


Question 4 of 5

An 8-year-old boy has just had a fiberglass cast applied to his right lower leg following a fractured ankle. The nurse is discussing care of the cast with the parents. Which instruction should be included?

Correct Answer: B

Rationale: Checking toes for warmth ensures circulation, detecting complications like compartment syndrome early. Bathing, drying time, and leg position are incorrect for fiberglass casts.

Question 5 of 5

The nurse has taken the vital signs of a 95-year-old client: oral temperature = 98.6°F; pulse = 84 with a regular irregularity; respirations = 18; blood pressure = 140/86. Which nursing assessment(s) should be done first to obtain more data?

Correct Answer: A

Rationale: A regular irregularity in pulse suggests an arrhythmia, requiring an apical pulse for one minute to confirm and assess severity.

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