NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
The nurse is assigned to a client with jaundice and collects the following data: poor appetite, nausea, and two episodes of emesis in the past 2 hours. The nurse should make which of the following nursing diagnoses?
Correct Answer: A
Rationale: Poor appetite, nausea, and vomiting indicate inadequate nutritional intake, supporting the diagnosis of imbalanced nutrition.
Question 2 of 5
A client is trying to lose weight at a moderate pace. The client eliminates 1,000 calories per day from his normal intake, how many pounds would he lose in 1 week?
Correct Answer: A
Rationale: A 1,000-calorie daily deficit equals 7,000 calories per week. Since 3,500 calories approximate one pound of fat, the client would lose about 2 pounds per week.
Question 3 of 5
Which of the following indicates that a 5-month-old weighing 15 lb and being treated for dehydration has a normal urine output? The urine output is:
Correct Answer: A
Rationale: Normal urine output for an infant is 1 to 2 mL/kg/hour, indicating adequate hydration. Higher outputs may suggest overhydration or other issues.
Question 4 of 5
An adult client has been admitted to the hospital with a 3-day history of uncontrolled vomiting and diarrhea. Which should the nurse assess for in this client? Select all that apply.
Correct Answer: D,E
Rationale: The client described in the question will most likely be dehydrated because of uncontrolled vomiting and diarrhea. The nurse assesses this client for weight loss, lethargy, or headache; sunken eyes; poor skin turgor (such as tenting); flat neck and peripheral veins; tachycardia; and low blood pressure.
Question 5 of 5
An adult client is admitted to the emergency department after a burn injury. The burn initially affected the upper half of the client's anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran causing subsequent burn injuries to the entire face (anterior half of the head), and the upper half of the posterior torso. Using the rule of nines, the extent of the burn injury would be what percent?
Correct Answer: 31.50%
Rationale: According to the rule of nines, with the initial burn, the upper half of the anterior torso equals 9% and the lower half of both arms equals 9%. The subsequent burn included the anterior half of the head equaling 4.5% and the upper half of posterior torso equaling 9%. This totals 31.5%.