NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
The nurse who is caring for a client with pneumonia assesses that the client has become increasingly irritable and restless. The nurse realizes that this is a result of:
Correct Answer: C
Rationale: Maintaining bed rest helps to decrease the O2 needs of the tissues, which decreases dyspnea and workload on the respiratory system. The semi-Fowler or high-Fowler position is necessary to aid in lessening pressure on the diaphragm from the abdominal organs, which facilitates comfort and easier breathing patterns. Cerebral hypoxia causes the client with pneumonia to be increasingly irritable and restless and results from the client not obtaining enough O2 to meet metabolic needs. Proper hydration facilitates liquefaction of mucus trapped in the bronchioles and alveoli and enhances expectoration. Unless contraindicated, a reasonable amount of IV fluids to be administered is at least 2.5-3 liters in a 24-hour period.
Question 2 of 5
The nurse is assessing a client with suspected diabetic ketoacidosis. Which finding is most expected?
Correct Answer: A
Rationale: Kussmaul respirations (rapid, deep breathing) are a compensatory mechanism in diabetic ketoacidosis to eliminate excess carbon dioxide and correct acidosis. Hypotension, tachycardia, and clear breath sounds are more common.
Question 3 of 5
A client is admitted with suspected pneumothorax. Which finding is most significant in confirming the diagnosis?
Correct Answer: A
Rationale: Tracheal deviation to the unaffected side is a hallmark of tension pneumothorax, indicating mediastinal shift due to air trapping, confirming the diagnosis.
Question 4 of 5
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which vital sign change is most likely to be observed?
Correct Answer: D
Rationale: Postpartum endometritis a uterine infection can cause fever (from infection) tachycardia (from systemic response) and hypotension (in severe cases). All vital sign changes may be observed.
Question 5 of 5
The nurse is caring for a client with a closed head injury. Which finding should be reported to the doctor immediately?
Correct Answer: D
Rationale: Unequal pupils suggest increased intracranial pressure or neurological deterioration in a head injury, requiring immediate reporting. The other findings are within normal or less urgent ranges.