NCLEX-RN Practice Test 2
10 free NCLEX-RN practice questions in the real exam format, covering the official content areas, with an explanation for every answer.
Question 1 of 10
Physiological AdaptationMedical Record
Postoperative Day 2, 0230: Client called out stating 'I suddenly can't catch my breath and something is wrong.' Reports sharp right-sided chest pain that worsens with each breath. Anxious and restless. Lungs clear to auscultation bilaterally; no cough. Right calf warm, tender and 3 cm larger in circumference than the left. Skin of chest and axillae free of petechiae. Alert and oriented x4. Right hip dressing dry and intact.
| Time | T | HR | RR | BP | SpO2 |
|---|---|---|---|---|---|
| 2000 (POD 1) | 37.2 °C (99.0 °F) | 84/min | 16/min | 132/78 mm Hg | 96% room air |
| 0230 (POD 2) | 37.6 °C (99.7 °F) | 122/min | 30/min | 118/70 mm Hg | 87% room air |
Enoxaparin 30 mg subcutaneously every 12 hours (last dose 2100; client refused the 0900 dose on POD 1 because of 'too many shots'). Oxygen per protocol to keep SpO2 at or above 92%. Weight bearing as tolerated with walker. Posterior hip precautions.
The nurse is caring for a 68-year-old client on postoperative day 2 after a right total hip arthroplasty and reviews the medical record.
Complete the diagram by selecting from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.