NCLEX - National Council Licensure Examination Test #22 1

Question 1

A nurse is caring for a client who is 24 hours post-thyroidectomy. The client reports tingling around the mouth and in the fingertips. Which finding should the nurse assess for next?

Accepted Answer

Positive Chvostek's sign

Answer

Tingling around the mouth and fingertips after thyroidectomy suggests hypocalcemia due to accidental removal or damage to the parathyroid glands. Chvostek's sign (facial muscle twitching when tapping the cheek) is a classic indicator of hypocalcemia and should be assessed immediately.

Question 2

A nurse is assessing a client receiving a blood transfusion who develops chills, low back pain, and red-tinged urine 15 minutes after the infusion begins. Which action should the nurse take first?

Accepted Answer

Stop the transfusion immediately

Answer

The client is exhibiting signs of an acute hemolytic transfusion reaction, which is life-threatening. The priority action is to stop the transfusion immediately to prevent further hemolysis, then maintain IV access with normal saline and notify the provider.

Question 3

A nurse is caring for a client with chronic kidney disease who has a serum potassium level of 6.2 mEq/L. Which finding on the cardiac monitor requires the nurse's immediate attention?

Accepted Answer

Peaked T waves

Answer

Hyperkalemia first manifests on the ECG as peaked (tall, narrow) T waves. This is an early and critical sign of cardiac toxicity from elevated potassium and requires immediate intervention to prevent progression to ventricular fibrillation or asystole.

Question 4

A nurse is reinforcing teaching with a client who has been prescribed warfarin therapy. Which statement by the client indicates a need for further teaching?

Accepted Answer

'I will take aspirin if I develop a headache.'

Answer

Aspirin inhibits platelet aggregation and, when combined with warfarin, significantly increases the risk of bleeding. The client should be instructed to avoid aspirin and NSAIDs and to use acetaminophen for pain relief unless otherwise directed by the provider.

Question 5

A nurse is assessing a client who is 8 hours postoperative following an appendectomy. The client reports pain rated 7/10 and has absent bowel sounds and a firm, distended abdomen. Which action should the nurse take first?

Accepted Answer

Notify the surgeon of the findings

Answer

A firm, distended abdomen with absent bowel sounds in the early postoperative period may indicate peritonitis or internal bleeding, both of which are surgical emergencies. The nurse must notify the surgeon immediately before administering pain medication or initiating other interventions.

NCLEX Practice Test

NCLEX Practice Test

NCLEX - National Council Licensure Examination Test #22 1