Free NCLEX RN Exam
Question 1 of 5.
The client is admitted to the intensive care unit following a coronary artery bypass graft. The nurse checks the vital signs and notes a heart rate of 120 beats per minute, blood pressure of 70/40, and respiration of 32 breaths per minute. The nurse suspects hypovolemic shock. Which assessment tools would contribute to a diagnosis of hypovolemic shock?
A. Hemoglobin of 5 g
B. Central venous pressure of 2 mm of mercury
C. Pulmonary artery wedge pressure of 16 mm of mercury
D. Hematocrit of 22%
E. Troponin (T 1) level of 4 mcg/L
Explanation: Hypovolemic shock involves low blood volume, reflected by low hemoglobin (5 g, A), low central venous pressure (2 mmHg, B), and low hematocrit (22%, D). Normal pulmonary artery wedge pressure (16 mmHg, C) suggests no left heart failure. Elevated troponin (E) indicates myocardial damage, not volume status.
Question 2 of 5.
A client hospitalized with cirrhosis has developed abdominal ascites. The nurse should provide the client with snacks that provide additional:
A. Sodium
B. Potassium
C. Protein
D. Fat
Explanation: Ascites in cirrhosis is linked to hypoalbuminemia; increasing protein intake helps restore albumin levels, reducing fluid accumulation.
Question 3 of 5.
During a unit card game, a client with acute mania begins to sing loudly as she starts to undress. The nurse should:
A. Ignore the client's behavior.
B. Exchange the cards for a checker board.
C. Send the other clients to their rooms.
D. Cover the client and walk her to her room.
Explanation: Covering the client and escorting her to a private area maintains dignity and safety, de-escalating the situation caused by manic behavior.
Question 4 of 5.
A client with a history of phenylketonuria is seen at the local family planning clinic. After completing the client's intake history, the nurse provides literature for a healthy pregnancy. Which statement indicates that the client needs further teaching?
A. I can help control my weight by switching from sugar to Nutrasweet.
B. I need to resume my old diet before becoming pregnant.
C. I need to eliminate most sources of phenylalanine from my diet.
D. Fresh fruits and raw vegetables will make excellent between-meal snacks.
Explanation: Nutrasweet (aspartame) contains phenylalanine, which is harmful in phenylketonuria, so this statement indicates a need for further teaching.
Question 5 of 5.
A client has a tentative diagnosis of myasthenia gravis. The nurse recognizes that myasthenia gravis involves:
A. Loss of the myelin sheath in portions of the brain and spinal cord
B. An interruption in the transmission of impulses from nerve endings to muscles
C. Progressive weakness and loss of sensation that begins in the lower extremities
D. Loss of coordination and stiff 'cogwheel' rigidity
Explanation: Myasthenia gravis is caused by autoantibodies blocking acetylcholine receptors, interrupting nerve impulse transmission to muscles, leading to weakness.