NCLEX-RN
Evaluation Questions
Extract:
Question 1 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 2 of 5
A woman in labor is receiving oxytocin by intravenous infusion. The nurse monitors the client, knowing that which finding indicates an adequate contraction pattern?
Correct Answer: D
Rationale: The preferred oxytocin dosage is the minimal amount necessary to maintain an adequate contraction pattern characterized by 3 to 5 contractions in a 10-minute period, with resultant cervical dilation. If contractions are more frequent than every 2 minutes, contraction quality may be decreased.
Question 3 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 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 clinic nurse is observing a student perform a complete physical assessment on a client. During the respiratory assessment, the clinic nurse determines that the student is using which physical assessment technique?
Correct Answer: C
Rationale:
To perform percussion, the nurse places the middle finger of the nondominant hand against the body's surface. The tip of the middle finger of the dominant hand strikes the top of the middle finger of the nondominant hand. Palpation is performed using the sense of touch. Inspection is the process of observation. Auscultation involves listening to the sounds produced by the body.