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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 66 )

Updated On: 25-Jan-2026
Page 66 of 345
PDF with 862 Questions

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?

  1. Urine output
  2. Edema
  3. Hypertension
  4. Bulging fontanelle

Answer(s): 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.



The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:

  1. Immediate treatment of mild PIH includes the administration of a variety of medications
  2. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation
  3. Self-discipline is required to control caloric intake throughout the pregnancy
  4. The client may not recognize the early symptoms of PIH

Answer(s): D

Explanation:

(A) Mild PIH is not treated with medications. (B) Emotional stress is not the cause of blood pressure elevation in PIH. (C) Excessive caloric intake is not the cause of weight gain in PIH. (D) The client most frequently is not aware of the signs and symptoms in mild PIH.



A client is experiencing muscle weakness and lethargy. His serum K+is 3.2. What other symptoms might he exhibit?

  1. Tetany
  2. Dysrhythmias
  3. Numbness of extremities
  4. Headache

Answer(s): B

Explanation:

(A) Tetany is seen with low calcium. (B) Low potassium causes dysrhythmias because potassium is responsible for cardiac muscle activity. (C) Numbness of extremities is seen with high potassium. (D) Headache is not associated with potassium excess or deficiency.



Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include:

  1. Cleanse area around the meatus twice a day
  2. Empty the catheter drainage bag at least daily
  3. Change the catheter tubing and bag every 48 hours
  4. Maintain fluid intake of 1200­1500 mL every day

Answer(s): A

Explanation:

(A) Catheter site care is to be done at least twice daily to prevent pathogen growth at the catheter insertion site. (B) Catheter drainage bags are usually emptied every 8 hours to prevent urine stasis and pathogen growth. (C) Tubing and collection bags are not changed this often, because research studies have not demonstrated the efficacy of this practice. (D) Fluid intake needs to be in the 2000­2500 mL range if possible to help irrigate the bladder and prevent infection.



The nurse is teaching a mother care of her child's spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be:

  1. "Blowing air under the cast using a hair dryer on cool setting often relieves itching."
  2. "Slide a ruler under the cast and scratch the area."
  3. "Guide a towel under and through the cast and moveit back and forth to relieve the itch."
  4. "Gently thump on cast to dislodge dried skin that causes the itching."

Answer(s): A

Explanation:

(A) Cool air will often relieve pruritus without damaging the cast or irritating the skin. (B) The nurse should never force anything under the cast, because the cast may become damaged and skin breakdown may occur. (C) Forcing an object under the cast could lead to cast damage and skin breakdown. The object may become lodged under the cast necessitating cast removal. (D) This technique does not dislodge skin cells. It could damage the cast and cause skin breakdown.



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