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NO.1 A male client is experiencing extreme distress. He begins to pace up and down the corridor.
What nursing intervention is appropriate when communicating with the pacing client?
A. Increase the level of his supervision.
B. Walk with him as he paces.
C. Ask him to sit down. Speak slowly and use short, simple sentences.
D. Help him to recognize his anxiety.
Answer: B
NCLEX-RN Pass
Explanation:
(A) The nurse should not ask him to sit down. Pacing is the activity he has chosen to deal with his
anxiety. The nurse dealing with this client should speak slowly and with short, simplesentences. (B)
The client may already recognize the anxiety and is attempting to deal with it. (C) Walk with the client
as he paces. This gives support while he uses anxiety-generated energy. (D) Increasing the level of
supervision may be appropriate after he stops pacing. It would minimize self-injury and/or loss of
control.
NO.2 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?
A. Edema
B. Bulging fontanelle
C. Hypertension
D. Urine output
Answer: D
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.
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