NCLEX-RN Sample Question

Question

The nurse cares for clients on the medical/surgical unit. After receiving report, which client should the nurse see FIRST?

  • 1. A newly admitted client diagnosed with appendicitis. The client reports acute right-sided abdominal pain.
  • 2. An older client diagnosed with a urinary tract infection. The client is confused, restless, and yelling.
  • 3. A client diagnosed with a head injury due to a motor vehicle accident. Glasgow Coma Scale is 11.
  • 4. A client diagnosed with heart failure (HF). The client requires hourly urine outputs and vital signs.

Answer

1. A newly admitted client diagnosed with appendicitis. The client reports acute right-sided abdominal pain.

INCORRECT- expected outcome

2. An older client diagnosed with a urinary tract infection. The client is confused, restless, and yelling.

INCORRECT- older adults have atypical reactions to infection; can potentially develop delirium

3. A client diagnosed with a head injury due to a motor vehicle accident. Glasgow Coma Scale is 11.

CORRECT- GCS indicates moderate neurological damage; head injury causes increased intracranial pressure with change in LOC; assess immediately

4. A client diagnosed with heart failure (HF). The client requires hourly urine outputs and vital signs.

INCORRECT- assess for shortness of breath, cardiac function; potential problem

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