NCLEX-RN
Evaluation Questions
Extract:
Question 1 of 5
A client is seen in the health care clinic, and a diagnosis of conjunctivitis is made. The nurse provides instructions to the client regarding the care of the disorder while at home. Which statement by the client indicates the need for further instruction?
Correct Answer: B
Rationale: Conjunctivitis is highly contagious. Antibiotic drops are usually administered four times a day. Ophthalmic analgesic ointment or drops may be instilled, especially at bedtime because discomfort becomes more noticeable when the eyelids are closed. When purulent discharge is present, saline eye irrigations or applications of warm compresses to the eye may be necessary before instilling the medication.
Question 2 of 5
The nurse is caring for a client who is in seclusion. Which client statement indicates to the nurse that the seclusion is no longer necessary?
Correct Answer: A
Rationale: Option 1 indicates that the client may be safely removed from seclusion. The client in seclusion must be assessed at regular intervals (usually every 15 to 30 minutes) for physical needs, safety, and comfort. Option 2 indicates a physical need that could be met with a urinal, bedpan, or commode; it does not indicate that the client has calmed down enough to leave the seclusion room. Option 3 could be an attempt to manipulate the nurse; it gives no indication that the client will control himself or herself when alone in the room. Option 4 could be handled by supportive communication or an as-needed medication, if indicated; it does not necessitate discontinuing seclusion.
Question 3 of 5
An adult client with hyperkalemia is prescribed sodium polystyrene sulfonate. Which serum potassium level is a clinical indicator of effective therapy?
Correct Answer: A
Rationale: The normal serum potassium level for an adult is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Option 1 is the only option that reflects a value within this range. The remaining options identify hyperkalemic levels.
Question 4 of 5
A goal for a postpartum client states, 'The client will remain free of infection during her hospital stay.' Which assessment data would support that the goal has been met?
Correct Answer: B
Rationale: Fever is the first indication of an infection.
Therefore, the absence of a fever indicates that an infection is not present. The remaining options are not associated with a postpartum infection.
Question 5 of 5
The nurse is caring for a client who has returned from the postanesthesia care unit after prostatectomy. The client has a three-way Foley catheter with an infusion of continuous bladder irrigation (CBI). Which color description of the urinary drainage should lead the nurse to determine that the flow rate is adequate?
Correct Answer: C
Rationale: The infusion of bladder irrigant is not at a preset rate; rather, it is increased or decreased to maintain urine that is a clear, pale yellow color or has just a slight pink tinge. The infusion rate should be increased if the drainage is cherry colored or if clots are seen. Alternatively, the rate can be slowed down slightly if the returns are as clear as water.