Fundamentals of Nursing NCLEX RN Questions
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Question 1 of 5.
Extract:Item 1 of 1 • Assessment Neurological: Alert and Oriented x 4; anxious affect Cardiovascular: S1, S2 heart tones; all peripheral pulses palpable; no edema Gastrointestinal: Distended abdomen; absent bowel sounds; hiccups; reports persistent nausea Genitourinary: Denies dysuria; voiding every 3-4 hours with straw-colored urine Musculoskeletal: Full range of motion in all extremities; steady gait Integumentary: Incision is approximated; moderate dry sanguineous drainage was noted on the dressing. Pain: Reports incision pain as a 3 based on a scale of 0-10. • Vital Signs Blood Pressure 119/75 mm Hg Temperature 99° F (37° C) Heart rate 90/min Respiratory rate 17 breaths per minute Oxygen saturation 97% on room air
The nurse is caring for a client two days postoperative following a partial colectomy.Complete the sentence below from the list of options: The client is at risk of developing --------------based on the client's------------------------
- A. paralytic ileus
- B. wound infection
- C. intractable pain
- D. integumentary assessment
- E. pain assessment
- F. gastrointestinal assessment
- A. paralytic ileus
- F. gastrointestinal assessment
Correct arrangement
Explanation: The client exhibits signs of paralytic ileus, as evidenced by the gastrointestinal assessment findings (distended abdomen, absent bowel sounds, nausea, and hiccups). The clinical data do not support wound infection as it is too early in the postoperative period for this to occur, and the client has no other manifestations supporting this finding. Pain is expected in the postoperative period, and the current pain rating is mild-to-moderate (3). In contrast, intractable pain would be suggested by pain not relieved by medication and at a severe level.
Question 2 of 5.
A nurse is caring for a 90-year-old client who has been bedridden at home for two weeks. Which of the following is not an expected finding due to immobility?
A. A decrease in bone density
B. Loss of short-term memory
C. Atelectasis
D. High serum calcium level
Explanation: Immobility causes bone density loss, atelectasis, and high serum calcium due to bone resorption, but short-term memory loss is not directly related to immobility.
Question 3 of 5.
The nurse cares for a client and receives a phone call from the laboratory department regarding a critical sodium level of 122 mEq/L (mmol/L) [135-145 mEq/L, mmol/L]. The nurse should take which initial action?
A. Notify the primary healthcare provider (PHCP)
B. Implement seizure precautions
C. Read back the result for verification
D. Recollect the laboratory specimen
Explanation: Reading back the critical result verifies accuracy, the first step before further action. Notifying the provider, seizure precautions, or recollecting follow verification.
Question 4 of 5.
The nurse is teaching at an interdisciplinary conference focused on age-related changes. Which of the following are expected in the older adult? Select all that apply.
A. Fatty tissue is redistributed
B. Skin becomes less elastic
C. Cardiac output increases
D. Muscle mass increases
E. Hormone production increases
F. Visual and hearing acuity diminishes
Explanation: Aging involves fat redistribution, less elastic skin, and diminished sensory acuity. Cardiac output, muscle mass, and hormone production decrease.
Question 5 of 5.
The nurse is recommending respite care to a client and their caregiver. The nurse understands that this care is designed to
A. Improve the quality of life of clients and families who are experiencing problems related to life-threatening illnesses.
B. Provide a variety of health and social services to specific patient populations.
C. Have clients live with comfort, independence, and dignity while easing the pain of terminal illness.
D. Offers short-term relief by providing caregivers who support the ill, disabled, or frail older adults time to relax.
Explanation: Respite care provides temporary relief for caregivers, allowing them rest. Other options describe palliative or comprehensive care services.
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