NCLEX-RN
Evaluation Questions
Extract:
Question 1 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 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 has taught a client who is prescribed a xanthine bronchodilator about beverages to avoid. The nurse determines that the client understands the information if the client chooses which beverage from the dietary menu?
Correct Answer: D
Rationale: Cola, coffee, and chocolate contain xanthine and should be avoided by the client who is taking a xanthine bronchodilator. This could lead to an increased incidence of cardiovascular and central nervous system side effects that can occur with the use of these types of bronchodilators.
Question 4 of 5
The nurse has given the client information about the use of sublingual nitroglycerin tablets prescribed for as-needed use if chest pain occurs. Which client statement helps assure the nurse that the client understands how to self-administer the medication?
Correct Answer: D
Rationale: Nitroglycerin may be self-administered sublingually 5 to 10 minutes before an activity that triggers chest pain. Tablets should be discarded 3 to 6 months after opening the bottle (per expiration date), and a new bottle of pills should be obtained from the pharmacy. Nitroglycerin is unstable and is affected by heat and cold, so it should not be kept close to the body (warmth) in a shirt pocket; rather, it should be kept in a jacket pocket or a purse. Headache often occurs with early use and diminishes in time. Acetaminophen may be used to treat headache.
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.