NCLEX-RN
Evaluation Questions
Extract:
Question 1 of 5
A client has begun medication therapy with betaxolol. The nurse determines that the client is experiencing the intended effect of therapy if which observation is noted?
Correct Answer: D
Rationale: Betaxolol is a beta-adrenergic blocking agent used to lower blood pressure, relieve angina, or eliminate dysrhythmias. Side/adverse effects include bradycardia and symptoms of heart failure, such as weight gain and increased edema.
Question 2 of 5
The nurse assesses a client after abdominal surgery who has a nasogastric (NG) tube in place that is connected to suction. Which observation by the nurse indicates most reliably that the tube is functioning properly?
Correct Answer: D
Rationale: An NG tube connected to suction is used postoperatively to decompress and rest the bowel. The gastrointestinal tract lacks peristaltic activity as a result of manipulation during surgery. The client should not experience symptoms of ileus (nausea and vomiting) if the tube is functioning properly. Although the nurse makes pertinent observations of the tube to ensure that it is secure and properly connected to suction, the client is assessed for the effect. A pain indicator of 3 is an expected finding in a postoperative client.
Question 3 of 5
An older client is a victim of elder abuse. He and his family have been attending counseling sessions for the past month. Which statement, made by the abusive family member, would indicate an understanding of more positive coping skills?
Correct Answer: C
Rationale: Elder abuse is sometimes caused by family members who are being expected to care for their aging parents. This care can cause the family to become overextended, frustrated, or financially depleted. Knowing where to turn in the community for assistance with caring for an aging family member can bring much-needed relief. Using these alternatives is a positive coping skill for many families. The rest of the options are statements of good faith or promises, which may or may not be kept in the future.
Question 4 of 5
The nurse has provided self-care activity instructions to a client after the insertion of an internal cardioverter-defibrillator (ICD). The nurse determines that further instruction is needed if the client makes which statement?
Correct Answer: B
Rationale: The client should avoid activities like swimming, driving, or operating heavy equipment until cleared by the healthcare provider, as these could pose risks related to the ICD function or sudden cardiac events. The other statements reflect appropriate self-care measures: avoiding rough contact protects the insertion site, avoiding strenuous activities prevents triggering the ICD, and avoiding electromagnetic sources minimizes interference with the device.
Question 5 of 5
The nurse is reviewing a plan of care prepared by a nursing student for an infant being admitted to the hospital with a diagnosis of congestive heart failure. Which intervention should the nurse recognize as needing revision?
Correct Answer: D
Rationale: Awaking the child is not therapeutic in this situation. Measures that will decrease the workload on the heart include limiting the time that the infant is allowed to bottle-feed or breast-feed, elevating the head of the bed, allowing for uninterrupted rest periods, and providing oxygen during stressful periods.