NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of a pulmonary embolism. The client is receiving Heparin. The nurse should monitor the client for:
Correct Answer: A
Rationale: Heparin, an anticoagulant, increases bleeding risk, including bleeding gums. Hypertension, tachypnea, and fever are not directly related to heparin therapy.
Question 2 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 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 postoperative TURP client returns from the recovery room to the general surgery unit and is in stable condition. One hour later the nurse assesses him and finds him to be confused and disoriented. She recognizes that this is most likely caused by:
Correct Answer: D
Rationale: Early signs of hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, and diaphoresis. Early signs of potassium depletion include muscular weakness or paralysis, tetany, postural hypotension, weak pulse, shallow respirations, apathy, weak voice, and electrocardiographic changes. Early signs of an elevated sodium level include dry oral mucous membranes, marked thirst, hypertension, tachycardia, oliguria or anuria, anxiety, and agitation. This answer is correct. Important early clinical findings of a decreased sodium concentration include confusion and disorientation. Hyponatremia can occur after a TURP because absorption during surgery through the prostate veins can increase circulating blood volume and decrease sodium concentration.
Question 5 of 5
The primary cause of anemia in a client with chronic renal failure is:
Correct Answer: D
Rationale: Chronic renal failure reduces erythropoietin production, impairing red blood cell production and causing anemia. Iron absorption, RBC destruction, and intrinsic factor are secondary or unrelated.