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NCLEX-RN PDF DEMO:
QUESTION NO: 1
A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report:
A. Dizziness and tachypnea
B. Circumoral pallor and lightheadedness
C. Headache and facial flushing
D. Pallor and itching of the face and neck
Answer: C
Explanation:
(A) Tachypnea is not a symptom. (B) Circumoral pallor is not a symptom. (C) Autonomic dysreflexia is an uninhibited and exaggerated reflex of the autonomic nervous system to stimulation, which results in vasoconstriction and elevated blood pressure. (D) Pallor and itching are not symptoms.
QUESTION NO: 2
A client states to his nurse that "I was told by the doctor not to take one of my drugs because it seems to have caused decreasing blood cells." Based on this information, which drug might the nurse expect to be discontinued?
A. Prednisone
B. Timolol maleate (Blocadren)
C. Garamycin (Gentamicin)
D. Phenytoin (Dilantin)
Answer: D
Explanation:
(A) Prednisone is not linked with hematological side effects. (B) Timolol, a -adrenergic blocker is metabolized by the liver. It has not been linked to blood dyscrasia. (C) Gentamicin is ototoxic and nephrotoxic. (D) Phenytoin usage has been linked to blood dyscrasias such as aplastic anemia. The drug most commonly linked to aplastic anemia is chloramphenicol (Chlormycetin).
QUESTION NO: 3
Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who suffered partial- and fullthickness burns to 25% of her body?
A. Urine output
B. Edema
C. Hypertension
D. Bulging fontanelle
Answer: A
Explanation:
(A) Urinary output is a reliable indicator of renal perfusion, which in turn indicates that fluid resuscitation is adequate. IV fluids are adjusted based on the urinary output of the child during fluid resuscitation. (B) Edema is an indication of increased capillary permeability following a burn injury.
(C) Hypertension is an indicator of fluid volume excess. (D) Fontanelles close by 18 months of age.
QUESTION NO: 4
One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:
A. Blood pressure
B. Level of consciousness
C. Skin turgor
D. Fluid intake
Answer: B
Explanation:
(A)
Blood pressure can remain normotensive in a state of hypovolemia. (B) Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. (C) Skin turgor is not a reliable indicator for assessing hydration in a burn client.
(D)
Fluid intake does not indicate adequacy of fluid resuscitation in a burn client.
QUESTION NO: 5
A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will teach her to:
A. Limit activities which require focusing (close vision)
B. Take more frequent naps
C. Use artificial tears
D. Wear a patch over one eye
Answer: D
Explanation:
(A)
Limiting activities requiring close vision will not alleviate the discomfort of double vision.
(B)
Frequent naps may be comforting, but they will not prevent double vision. (C) Artificial tears are necessary in the absence of a corneal reflex, but they have no effect on diplopia.
(D)
An eye patch over either eye will eliminate the effects of double vision during the time the eye patch is worn. An eye patch is safe for a person with an intact corneal reflex.
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Updated: May 27, 2022