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
Which statement made by the student nurse indicates the need for further teaching regarding the administration of heparin?
Correct Answer: D
Rationale: Heparin is administered subcutaneously without aspiration, as aspirating can cause tissue damage and increase bleeding risk. The other statements are correct: heparin is injected 1–2 inches from the umbilicus, massage is avoided to prevent hematoma, and PTT is monitored to assess therapeutic effect.
Question 3 of 5
The nurse is caring for an organ donor client with a severe head injury from an MVA. Which of the following is most important when caring for the organ donor client?
Correct Answer: A
Rationale: Maintaining BP at 90 mmHg or greater ensures organ perfusion, critical for organ viability in a donor. Normal temperature (
B) is important but secondary, low hematocrit (
C) is not a goal, and 300 mL/hr urine output (
D) is excessive.
Question 4 of 5
The nurse is evaluating the laboratory value results of a client after a craniotomy for a pituitary tumor. Which values cause the nurse to suspect a diabetes insipidus complication?
Correct Answer: A, B
Rationale: Diabetes insipidus causes dilute urine (low specific gravity,
A) and hypernatremia (158 mEq/L,
B) from excessive water loss. Potassium (
C), hemoglobin (
D), and chloride (E) are normal and unrelated.
Question 5 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.