NCLEX-RN Exam
Question 1 of 5.
A male client is being treated in the burn unit for third-degree burns on his head, neck, and upper chest received in the last 24 hours. The nurse is evaluating the effectiveness of fluid resuscitation. Which of the following indicates effective fluid balance?
A. His weight increases from 165 to 175 lb.
B. His urine output is equal to his total fluid intake.
C. His urine output has been >35 mL/hr for the past 12 hours.
D. His blood pressure is 94/62.
Explanation: A weight gain of 10 lb represents a state of overhydration. He is losing fluids through insensible losses; a urine output equal to his intake indicates that he is receiving too little fluids. A urine output greater than his intake indicates that he is receiving adequate fluid resuscitation to account for urinary and insensible losses. A blood pressure of 94/62 indicates a state of underhydration and inadequate circulatory volume.
Question 2 of 5.
After attending a company picnic, several clients are admitted to the emergency room with E. coli food poisoning. The most likely source of infection is:
A. Hamburger
B. Hot dog
C. Potato salad
D. Baked beans
Explanation: Undercooked hamburger is a common source of E. coli, particularly E. coli O157:H7, which can contaminate ground beef.
Question 3 of 5.
A client with paranoid schizophrenia is brought to the hospital by her elderly parents. During the assessment, the client's mother states, 'Sometimes she is more than we can manage.' Based on the mother's statement, the most appropriate nursing diagnosis is:
A. Ineffective family coping related to parental role conflict
B. Care-giver role strain related to chronic situational stress
C. Altered family process related to impaired social interaction
D. Altered parenting related to impaired growth and development
Explanation: The mother's statement reflects caregiver role strain due to the chronic stress of managing a child with paranoid schizophrenia, impacting the parents' ability to cope.
Question 4 of 5.
A client with obsessive compulsive personality disorder annoys his co-workers with his rigid-perfectionistic attitude and his preoccupation with trivial details. An important nursing intervention for this client would be:
A. Helping the client develop a plan for changing his behavior
B. Contracting with him for the time he spends on a task
C. Avoiding a discussion of his annoying behavior because it will only make him worse
D. Encouraging him to set a time schedule and deadlines for himself
Explanation: Setting time schedules and deadlines helps manage the client's perfectionism and preoccupation with details, promoting efficiency without confrontation.
Question 5 of 5.
The nurse has just received the change of shift report. Which client should the nurse assess first?
A. A client with a supratentorial tumor awaiting surgery
B. A client admitted with a suspected subdural hematoma
C. A client recently diagnosed with akinetic seizures
D. A client transferring to the neuro rehabilitation unit
Explanation: A suspected subdural hematoma is a medical emergency due to potential brain compression, requiring immediate assessment.
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