NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a postoperative client when the client becomes nonresponsive and pale,with a BP of 90/40. The nurse recognizes that the necessary intervention at this time is to:
Correct Answer: B
Rationale: Hypotension (BP 90/40) pallor,and nonresponsiveness suggest hypovolemic shock likely from postoperative bleeding. Increasing the IV infusion rate (e.g. saline) restores volume. Trendelenburg is controversial atropine treats bradycardia,and the emergency cart is secondary to immediate fluid resuscitation.
Question 2 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 3 of 5
A client with a history of peptic ulcer disease is admitted with complaints of hematemesis. The nurse should give priority to:
Correct Answer: B
Rationale: Hematemesis indicates possible gastrointestinal bleeding, so monitoring vital signs is critical to assess for hypovolemia and shock.
Question 4 of 5
Assessment of the client with pericarditis may reveal which of the following?
Correct Answer: C
Rationale: No S3 or S4 are noted with pericarditis. No change in pulse pressure occurs. The symptoms of pericarditis vary with the cause, but they usually include chest pain, dyspnea, tachycardia, rise in temperature, and friction rub caused by fibrin or other deposits. The pain seen with pericarditis typically worsens with deep inspiration. Tamponade is not typically seen early on, and no change in pulse pressure occurs.
Question 5 of 5
A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:
Correct Answer: A
Rationale: The water seal prevents air from entering the pleural space, maintaining negative pressure for lung re-expansion.