NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The nurse enters the room of a client on which a 'do not resuscitate' order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, 'please save her!' The nurse's action would be:
Correct Answer: D
Rationale: (A, B,
C) The last request from the husband overrides the decision not to initiate resuscitation efforts. The nurse should begin cardiopulmonary resuscitation unless a living will and durable power of attorney are in force. In the meantime, the nurse should talk with the husband and notify the doctor.
Question 2 of 5
A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent:
Correct Answer: B
Rationale: A three-way system of bladder irrigation will cleanse the bladder and prevent formation of blood clots. A catheter obstructed by clots or other debris will cause prostatic distention and hemorrhage.
Question 3 of 5
A type I diabetic client delivers a male newborn. The newborn is 45 minutes old. What is the primary nursing goal in the nursery during the first hours for this newborn?
Correct Answer: B
Rationale: The infant will be at risk for hypoglycemia because of excess insulin production.
Question 4 of 5
A client with a gastrointestinal bleed has an NG tube to low continuous wall suction. Which technique is the correct procedure for the nurse to utilize when assessing bowel sounds?
Correct Answer: B
Rationale: Clamping the NG tube prevents suction noise, allowing accurate auscultation of bowel sounds. pH testing (
A) assesses gastric contents, irrigation (
C) is for patency, and high suction (
D) interferes with auscultation.
Question 5 of 5
The nurse is caring for a client diagnosed with metastatic cancer of the bone. The client is exhibiting mental confusion and a BP of 150/100. Which laboratory value would correlate with the client's symptoms reflecting a common complication with this diagnosis?
Correct Answer: B
Rationale: Hypercalcemia (calcium 13 mg/dL) is a common complication of bone metastases, causing confusion and hypertension. Hyperkalemia (
A), low phosphorus (
C), and normal sodium (
D) are less likely causes.