NCLEX-RN
Evaluation Questions
Extract:
Question 1 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 2 of 5
The nurse caring for a client with Graves' disease is concerned about the client's calorie intake because of the resulting hypercatabolic state of the disorder. Which situation indicates a successful outcome for this concern?
Correct Answer: C
Rationale: Graves' disease causes a state of chronic nutritional and caloric deficiency caused by the metabolic effects of excessive T3 and T4. Clinical manifestations are weight loss and increased appetite.
Therefore, it is a nutritional goal that the client will not lose additional weight and he or she will gradually return to the ideal body weight, if necessary.
To accomplish this, the client must be encouraged to eat frequent high-calorie, high-protein, and high-carbohydrate meals and snacks.
Question 3 of 5
The nurse is reviewing the results of a client's phenytoin level that was drawn that morning. The nurse is preparing to discharge once the level is therapeutic. Which result indicates that this goal has been met?
Correct Answer: C
Rationale: The therapeutic range for serum phenytoin levels is 10 to 20 mcg/mL (39.68 to 79.36 mcmol/L) in clients with normal serum albumin levels and renal function. A level below this range indicates that the client is not receiving sufficient medication and is at risk for seizure activity. In this case, the medication dose should be adjusted upward. A level above the therapeutic range indicates that the client is entering the toxic range and is at risk for toxic side effects of the medication.
Question 4 of 5
The nurse instructs a parent regarding the appropriate actions to take when the toddler has a temper tantrum. Which statement by the parent indicates a successful outcome of the teaching?
Correct Answer: A
Rationale: Ignoring a negative attention-seeking behavior is considered the best way to extinguish it, provided that the child is safe from injury. Option 2 is untrue and negative. Option 3 gives attention to the tantrum and also exceeds the recommended time of 1 minute per year of age for a time-out. Providing candy for rewards is unhealthy and unlikely to be effective at the end of the day.
Question 5 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.