NCLEX-RN
Evaluation Questions
Extract:
Question 1 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 2 of 5
A client has received a dose of an as-needed medication loperamide. The nurse evaluates the client after administration to determine if the client has relief of which sign/symptom?
Correct Answer: A
Rationale: Loperamide is an antidiarrheal agent, and it is commonly administered after loose stools. It is used for the management of acute diarrhea and also for chronic diarrhea, such as with inflammatory bowel disease. It can also be used to reduce the volume of drainage from an ileostomy. It is not intended to treat any of the other options.
Question 3 of 5
The nurse is assigned to care for a client diagnosed with acquired immunodeficiency syndrome (AIDS) who is receiving amphotericin B for a fungal respiratory infection. Which would indicate an adverse effect of the medication?
Correct Answer: A
Rationale: Clients receiving amphotericin B may develop hypokalemia, which can be severe and lead to extreme muscle weakness and electrocardiogram changes. Distal renal tubular acidosis commonly occurs, and this contributes to the development of hypokalemia. High potassium levels do not occur. The medication does not cause sodium, chloride, or calcium levels to fluctuate.
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
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.