NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of glaucoma. The nurse should expect the client to have:
Correct Answer: A
Rationale: Glaucoma causes increased intraocular pressure, damaging the optic nerve and leading to peripheral vision loss, a hallmark symptom.
Question 2 of 5
A female client has married recently. A month ago she visited her physician with complaints of burning on urination. She was given a prescription for trimethoprim-sulfamethoxazole (Bactrim) DS bid for 10 days. She was admitted through the emergency room on Saturday evening complaining of flank pain. Her temperature was 104°F. A preliminary urinalysis revealed 31 bacteria along with red and white blood cells Rankings blood cells in the urine. A preliminary diagnosis of pyelonephritis was made. During a nursing admission assessment, which statement by the client demonstrates a possible cause for pyelonephritis?
Correct Answer: C
Rationale: Although it is important that the client drink adequate fluids while treating a bladder infection with trimethoprim-sulfamethoxazole, the failure to do so will not cause pyelonephritis. A stricture or abnormality may cause the progression of bladder infection to urinary tract infection, but this is rare. There is no indication in this situation that this has occurred. The most common cause of pyelonephritis is improper treatment of bladder infections. The client typically feels better after several days, discontinues the medication, and saves the remainder for the next occurrence of a bladder infection. For this reason, it is imperative to provide client education related to completion of the prescribed medication. There is no evidence that infection in another body system could cause pyelonephritis.
Question 3 of 5
A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:
Correct Answer: D
Rationale: This change in blood pressure may not be significant and does not indicate a widening pulse pressure, a late sign of increased ICP. It is important to continue to monitor for change in blood pressure. Acetaminophen may be ineffective in relieving headache after head injury. Stronger analgesics are contraindicated because they mask neurological signs and may depress the CNS. Pulse rates between 68 bpm and 76 bpm are within normal limits for a 14-year-old child. It is important to monitor for a consistent drop in pulse rate, which is a late sign of increasing ICP. An elevated temperature is abnormal and requires further assessment and medical intervention. The temperature may be unrelated to the head injury, but CNS infection is serious and difficult to control.
Question 4 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 5 of 5
The client is admitted with a suspected bowel obstruction. Which diagnostic test is most likely to confirm the diagnosis?
Correct Answer: A
Rationale: An abdominal X-ray is the initial test to confirm bowel obstruction, showing air-fluid levels or dilated loops of bowel. Barium enema and colonoscopy are contraindicated due to perforation risk, and ultrasound is less specific.