Source: NCLEX Review 3500, Lippincott Williams & Wilkins, 2004.
1. The physician orders hourly urine output measurement for a postoperative client. The nurse records the following amounts of output for 2 consecutive hours: 8 a.m., 50 ml; 9 a.m., 60 ml. Based on these amounts, which action should the nurse take?
1. Continue to monitor and record hourly urine output.
2. Notify the physician.
3. Irrigate the indwelling urinary catheter.
4. Increase the I.V. fluid infusion rate.
2. A client with gross heart failure must be monitored closely after starting diuretic therapy. What's the most accurate indicator of this client's status?
1. Fluid intake and output
2. Urine specific gravity
3. Vital signs
4. Weight
3. A client is recovering from an acute myocardial infarction (MI). During the first week of recovery, the nurse should stay alert for which abnormal heart sound that signifies inflammation of the pericardial sac?
1. Opening snap
2. Graham Steell's murmur
3. Ejection click
4. Pericardial friction rub
4. During each prenatal checkup, the nurse obtains the client's weight and blood pressure and measures fundal height. What's another essential part of each prenatal checkup?
1. Evaluting the client for edema
2. Measuring the client's hemoglobin level
3. Obtaining pelvic measurement
4. Determining the client's Rh factor
5. During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates:
1. cranial nerves I and II
2. cranial nerves III and V
3. cranial nerves VI and VIII
4. cranial nerves IX and X
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Answers to NCLEX practice questions
1.1
Rationale: Normal urine output for an adult is about 1 ml/minute (60 ml/hour). Therefore, this client's output is normal. Beyond continued evaluation, no nursing action is warranted.
2.4
Rationale: Heart failure typically causes fluid overload, resulting in weight gain. Therefore, weight is the most accurate indicator of this client's status. A 1-pound gain or loss is equivalent to 500 ml. Fluid intake and output and vital signs are less accurate than weight. Urine specific gravity reflects urine concentration, indicating overhydration or dehydration; although helpful, it isn't the most accurate indicator because it can be influenced by numerous factors.
3.4
Rationale: A pericardial friction rub, which sounds like squeaky leather, may occur during the first week after an MI. Resulting from inflammation of the pericardial sac, this abnormal heart sound arises as the roughened parietal and visceral layers of the pericardium rub against each other. Certain stenosed valves may cause a brief, high-pitched opening snap heard early in diastole. Graham Steell's murmur is a high-pitched, blowing murmur with a decrescendo pattern; heard during diastole, it indicates pulmonary insufficiency, such as from pulmonary hypertension or a congenital pulmonary valve defect. An ejection click, associated with mitral valve prolapse or a rigid, calcified aortic valve, causes a high-pitched sound during systole.
4.1
Rationale: During each prenatal checkup, the nurse should evaluate the client for edema, a possible sign of pregnancy-induced hypertension (PIH). If edema exists, the nurse should assess for high blood pressure and proteinuria--other signs of PIH. Hemoglobin is measured during the first prenatal visit and again at 24 to 28 weeks' gestation and at 36 weeks' gestation. The pelvis is measured and the Rh factor determined during the first prenatal visit.
5.4
Rationale: Swallowing is a motor function of cranial nerves IX and X. Cranial nerves I, II, and VIII don't possess motor function. The motor functions of cranial nerve III include extraocular eye movement, eyelid elevation, and pupil constriction. The motor function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement.
Source: NCLEX Review 3500, Lippincott Williams & Wilkins, 2004.
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