NCLEX-RN
Evaluation Questions
Extract:
Question 1 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 2 of 5
The nurse is assessing a client with gestational hypertension who was admitted to the hospital 48 hours ago. Which current assessment data would indicate that the condition has not yet resolved?
Correct Answer: C
Rationale: Client complaints of headache or blurred vision indicate a worsening of the condition and warrant immediate further evaluation. The remaining options are all signs that the gestational hypertension is being resolved.
Question 3 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.
Question 4 of 5
A client has been taking nadolol for the past month. Which finding would indicate a therapeutic effect of the medication?
Correct Answer: D
Rationale: Nadolol is a beta-adrenergic blocking agent that is used to treat hypertension.
Therefore, a blood pressure within the normal range would indicate an effective response to the medication. Based on this information the remaining options are unrelated to the action of this medication.
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.