NCLEX-RN
Evaluation Questions
Extract:
Question 1 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.
Question 2 of 5
A client regularly takes nonsteroidal antiinflammatory drugs (NSAIDs) and misoprostol has been added to the medication regimen. The nurse should monitor the client for the relief of which sign/symptom?
Correct Answer: D
Rationale: The client who regularly takes NSAIDs is prone to gastric mucosal injury, which gives the client epigastric pain as a symptom. Misoprostol is administered to prevent this occurrence. Diarrhea can be a side effect of the medication, but its relief is not an intended effect. Bleeding and infection are unrelated to the question.
Question 3 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 4 of 5
The nurse is monitoring a male client with a spinal cord injury who is experiencing spinal shock. Which findings indicate that the spinal shock is resolving?
Correct Answer: C,D,E,F
Rationale: Spinal shock is associated with acute injury to the spinal cord with temporary suppression of reflexes controlled by segments below the level of injury. It may last for 1 to 6 weeks. Indications that spinal shock is resolving include return of reflexes, development of hyperreflexia rather than flaccidity, and return of reflex emptying of the bladder. The return of the bulbocavernous reflex in male clients is also an early indicator of recovery from spinal shock. Babinski's reflex (dorsiflexion of the great toe with fanning of the other toes when the sole of the foot is stroked) is an early returning reflex. The gag reflex is not lost in spinal shock; therefore, its presence is not an indication of resolving spinal shock.
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.