NCLEX-RN
RN NCLEX Next Gen Questions Questions
Extract:
Question 1 of 5
While obtaining the vital signs on a mother who delivered a healthy newborn 2 hours ago the nurse notes that the mother's temperature is 102°F. Which is the appropriate nursing action at this time?
Correct Answer: A
Rationale: Vital signs usually return to normal within the first hour postpartum if no complications arise. A slight elevation in the temperature may be noted if the client is experiencing dehydrating effects that can occur from labor. A temperature of 102°F indicates infection, and the primary health care provider should be notified. The remaining options are inaccurate nursing interventions for a temperature of 102°F 2 hours after delivery.
Question 2 of 5
A client with schizophrenia is responding well to risperidone (Risperdal) and is no longer psychotic. After teaching the client about managing his illness, which of the following statements reflects a need for further education?
Correct Answer: A
Rationale: Concern about affording daily medication suggests a need for further education on resources or adherence strategies, as non-adherence risks relapse. Other statements reflect appropriate understanding.
Question 3 of 5
A client has nephrotic syndrome. To aid in the resolution of the client's edema, the physician orders 25% albumin. In addition to an absence of edema, the nurse should evaluate the client for which expected outcome?
Correct Answer: B
Rationale: Albumin increases oncotic pressure, pulling fluid into the vascular space, which may elevate blood pressure. Crackles, cerebral edema, or cool extremities would indicate complications.
Question 4 of 5
A client experiencing a mild panic attack has the following arterial blood gas (ABG) results: pH 7.49, PCO2 31 mm Hg, PaO2 97 mm Hg, HCO3 22 mEq/L. The nurse reviews the results and determines that the client has which acid-base disturbance?
Correct Answer: D
Rationale: Acidosis is defined as a pH of less than 7.35, whereas alkalosis is defined as a pH of greater than 7.45. Respiratory alkalosis is present when the PCO2 is less than 35, whereas respiratory acidosis is present when the PCO2 is greater than 45. Metabolic acidosis is present when the HCO3 is less than 22 mEq/L, whereas metabolic alkalosis is present when the HCO3 is greater than 26 mEq/L. This client's ABGs are consistent with respiratory alkalosis.
Question 5 of 5
You will be providing nursing care prior to, during and after electroconvulsive therapy for your client who is severely depressed. Which of the following is an appropriate nursing intervention for this client?
Correct Answer: C
Rationale: Headache is a common side effect of ECT, and educating the client about this prepares them for post-procedure expectations.