NCLEX NCLEX Certifications NCLEX-PN Questions & Answers

• Question 161:

  The nurse should utilize data about which of the following to provide information about the nutritional status of a client being evaluated for malnutrition?

  A. triceps skinfold measurement

  B. fasting blood glucose level

  C. hemoglobin A1c level

  D. serum lipid profile results

  Correct Answer: A

  Objective anthropometric measurements such as triceps skinfold and mid-arm circumference (MAC), along with weight, are usually used to diagnose malnutrition. While all the other choices represent tests that might provide useful information, they also might be affected by variables other than malnutrition.

• Question 162:

  During surgery, it is found that a client with adenocarcinoma of the rectum has positive peritoneal lymph nodes.

  What is the next most likely site of metastasis?

  A. brain

  B. bone

  C. liver

  D. mediastinum

  Correct Answer: C

  Colon tumors tend to spread through the lymphatics and portal vein to the liver.

  Although metastasis to the other sites listed is possible, the liver is most likely the first to be affected.

• Question 163:

  Paula is a 32-year-old woman seeking evaluation and treatment of major depressive symptoms.

  A major nursing priority during the assessment process includes which of the following?

  A. meaning of current stressors

  B. possibility of self-harm

  C. motivation to participate in treatment

  D. presence of alcohol or other drug use

  Correct Answer: B

  Unless the client is first assessed for self-harm or suicide potential, the staff might not observe the

  necessary degree of vigilance needed in the client's environment.

  Physical needs are the second most critical concern with a depressive client.

  Though the client may be encouraged to attend group therapy as part of the treatment plan, the client's

  safety takes precedence.

  Response to medication takes time and is not an initial concern.

• Question 164:

  A serious complication of a total hip replacement is displacement of the prosthesis.

  What is the primary sign of displacement?

  A. pain on movement and weight bearing

  B. hemorrhage

  C. affected leg appearing 1-2 inches longer

  D. edema in the area of the incision

  Correct Answer: A

  Pain on movement and weight bearing indicates pressure on the nerves or muscles caused by the

  dislocation.

  Other symptoms of dislocation include an inability to bear weight and a shortening of the affected leg.

  Edema is not a primary sign of displacement.

• Question 165:

  A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is under way and returning to the baseline at the end of the contraction.

  Which of the following nursing actions is most appropriate?

  A. Administer O2.

  B. Turn the client on her left side.

  C. Notify the physician.

  D. No action is necessary.

  Correct Answer: D

  It is an early deceleration as a result of head compression, and at this time no action is necessary. Close observation of the mother and baby is needed.

• Question 166:

  Nursing care for a client undergoing chemotherapy includes assessment for signs of bone marrow depression.

  Which finding accounts for some of the symptoms related to bone marrow depression?

  A. erythrocytosis

  B. leukocytosis

  C. polycythemia

  D. thrombocytopenia

  Correct Answer: D

  Thrombocytopenia is an abnormal decrease in the number platelets, which results in bleeding tendencies.

  Erythrocytosis is an abnormal increase in the number of circulating red blood cells.

  Leukocytosis is an increase in the number of white blood cells in the blood.

  Polycythemia is also an excess of red blood cells and is a synonym for erythrocytosis.

  With chemotherapy there is a decrease in red and white blood cells, not an increase.

• Question 167:

  Which of the following symptoms is most characteristic of a client with cancer of the lungs?

  A. exertional dyspnea

  B. persistent changing cough

  C. air hunger; dyspnea

  D. cough with night sweats

  Correct Answer: B

  The most common sign of cancer of the lung is a persistent cough that changes. Other signs are dyspnea,

  bloody sputum, and long-term pulmonary infection.

  Exertional dyspnea 1 is common with chronic obstructive pulmonary disease (COPD).

  Air hunger; dyspnea is common with asthma.

  Cough with night sweats is common with tuberculosis.

• Question 168:

  Which of the following needs immediate medical attention and emergency intervention?

  The client who __________.

  A. complains of sharp pain upon taking a deep breath and excessive coughing

  B. exhibits yellow, productive sputum, lowgrade fever, and crackles

  C. has a shift of the trachea to the left, with no breath sounds on the right

  D. has asthma and complains of an inability to catch her breath after exercise

  Correct Answer: C

  Choice "has a shift of the trachea to the left, with no breath sounds on the right" is indicative of a tension pneumothorax, which is considered a medical emergency. The respiratory system is severely compromised and venous return to the heart is affected. The mediastinal shift is to the unaffected side. Choice "complains of sharp pain upon taking a deep breath and excessive coughing" contains symptoms of pleurisy, and Choice "exhibits yellow, productive sputum, lowgrade fever, and crackles" lists symptoms of bronchitis. Neither are emergencies. The client in Choice "exhibits yellow, productive sputum, lowgrade fever, and crackles" should expect difficulty breathing after exercise when asthma is an existing condition and might need immediate attention if his rescue inhaler is ineffective.

• Question 169:

  One day postoperative, the client complains of dyspnea, and his respiratory rate (RR) is 35, slightly labored, and there are no breath sounds in the lower-right base.

  The nurse should suspect __________.

  A. cor pulmonale

  B. atelectasis

  C. pulmonary embolus

  D. cardiac tamponade

  Correct Answer: B

  The first three symptoms could be indicative of any of the conditions.

  The distinguishing symptom is the lack of breath sounds in the lower-right base, which is assessed when a

  portion of the lung has collapsed.

• Question 170:

  When assessing a client with early impairment of oxygen perfusion, such as pulmonary embolus, the nurse should expect to find restlessness and __________ symptoms.

  A. warm, dry skin

  B. bradychardia

  C. tachycardia

  D. eupnea

  Correct Answer: C

  The cardinal signs of respiratory problems and hypoxia are restlessness, diaphoresis, tachycardia, and

  cool skin.

  Bradycardia might occur much later in the process when the condition is severe.

  Eupnea is normal respirations in rate and depth.