NCLEX - National Council Licensure Examination Test #23 1 — Questions and Answers
Question 1: A nurse is assessing a client with chronic kidney disease. Which laboratory value would the nurse expect to be elevated?
- Serum albumin
- Glomerular filtration rate
- Serum creatinine (Correct answer)
- Hemoglobin
Correct answer: Serum creatinine
In chronic kidney disease, the kidneys lose their ability to filter waste products, causing serum creatinine to accumulate and rise above normal levels. GFR decreases, not increases, and hemoglobin and albumin typically fall.
Question 2: A nurse is caring for a postoperative client who received general anesthesia 2 hours ago. The client is drowsy but arousable. Which action should the nurse prioritize?
- Encourage the client to ambulate immediately
- Position the client supine without a pillow
- Monitor oxygen saturation and respiratory rate every 15 minutes (Correct answer)
- Administer a full liquid diet
Correct answer: Monitor oxygen saturation and respiratory rate every 15 minutes
Residual anesthetic effects can depress the respiratory center, making respiratory monitoring the priority in the immediate postoperative period. Frequent assessment of O2 saturation and respiratory rate allows early detection of airway compromise.
Question 3: A nurse is teaching a client with heart failure about dietary restrictions. Which statement by the client indicates a need for further teaching?
- 'I will limit my fluid intake to 1.5 liters per day.'
- 'I should weigh myself every morning before eating.'
- 'I can use as much salt as I like because I take a diuretic.' (Correct answer)
- 'I will avoid canned soups and processed foods.'
Correct answer: 'I can use as much salt as I like because I take a diuretic.'
Clients with heart failure must restrict sodium intake regardless of diuretic use. Diuretics help remove excess fluid but do not eliminate the need for a low-sodium diet, which prevents fluid retention.
Question 4: A nurse is caring for a client receiving IV heparin therapy. Which finding requires the nurse to notify the provider immediately?
- aPTT value of 70 seconds (therapeutic range 60–100 seconds)
- Urine output of 40 mL/hour
- New onset of blood in the urine (Correct answer)
- Heart rate of 78 beats per minute
Correct answer: New onset of blood in the urine
Hematuria (blood in the urine) is a sign of bleeding, a serious complication of heparin therapy that requires immediate provider notification. An aPTT within therapeutic range and normal urine output are expected findings.
Question 5: A nurse is assessing a newborn at 5 minutes of life and assigns an Apgar score. Which finding would contribute to a lower score?
- Heart rate of 110 beats per minute
- Vigorous cry
- Blue hands and feet only
- No response to stimulation (Correct answer)
Correct answer: No response to stimulation
The Apgar score evaluates heart rate, respiratory effort, muscle tone, reflex irritability, and color. No response to stimulation scores 0 for reflex irritability, which lowers the total score. Blue hands and feet (acrocyanosis) score 1, while a heart rate above 100 and vigorous cry each score 2.
Question 6: A nurse is administering a blood transfusion. Fifteen minutes after starting the infusion, the client reports chills, back pain, and has a temperature of 38.9°C (102°F). What should the nurse do first?
- Slow the transfusion rate and continue monitoring
- Administer acetaminophen and continue the infusion
- Stop the transfusion and keep the IV line open with normal saline (Correct answer)
- Increase the flow rate to complete the transfusion quickly
Correct answer: Stop the transfusion and keep the IV line open with normal saline
These symptoms are classic signs of an acute hemolytic transfusion reaction, a life-threatening emergency. The nurse must stop the transfusion immediately and maintain IV access with normal saline to prevent hypotension and preserve kidney function while notifying the provider.
NCLEX - National Council Licensure Examination Test #23 1
A nurse is assessing a client with chronic kidney disease.
Which laboratory value would the nurse expect to be elevated?