NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 91:

  A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching concerning the warfarin therapy?

  A. "If you forget to take your morning dose, double the night time dose."

  B. "You should take aspirin instead of acetaminophen (Tylenol) for headaches."

  C. "Carry a medications alert card with you at all times."

  D. "You should use a straight-edge razor when shaving your arms and legs."

  Correct Answer: C

  (A) Warfarin must always be taken exactly as directed. Clients should be instructed never to skip or double up on their dosage. (B) Aspirin decreases platelet aggregation, which would potentiate the effects of the coumadin. (C) Healthcare providers need to be aware of persons on warfarin therapy prior to the initiation of any diagnostic tests and/or surgery to help prevent bleeding complications. (D) An electric razor should be used to prevent accidental cutting, which can lead to bleeding.

• Question 92:

  A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains of severe abdominal pain. Assessment reveals abdominal rigidity and distention, increased temperature, and tachycardia. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has developed:

  A. Gastritis

  B. Evisceration

  C. Peritonitis

  D. Pulmonary embolism

  Correct Answer: C

  (A) Assessment findings for gastritis would reveal anorexia, nausea and vomiting, epigastric fullness and tenderness, and discomfort. (B) Evisceration is the extrusion of abdominal viscera as a result of trauma or sutures failing in a surgical incision. (C) Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and fluid into the abdominal cavity. This causes infection and irritation. (D) Assessment findings of pulmonary embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath, anxiety or panic, and wheezing and coughing often accompanied by blood-tinged sputum.

• Question 93:

  A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements?

  A. "When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices."

  B. "If I have any side effects from my medicines, I will take an extra dose of Cogentin."

  C. "When I get home, I should be able to taper myself off the Haldol because the voices are gone now."

  D. "As soon as I leave here, I'm throwing away my medicines. I never thought I needed them anyway."

  Correct Answer: A

  (A) The client verbalizes that he is responsible for compliance and keeping the treatment team member informed of progress. This behavior puts him at the lowest risk for relapse. (B) Noncompliance is a major cause of relapse. This statement reflects lack of responsibility for his own health maintenance. (C) This statement reflects lack of insight into the importance of compliance. (D) This statement reflects no insight into his illness or his responsibility in health maintenance.

• Question 94:

  A female client is started on warfarin (Coumadin) 5 mg po bid. To adequately evaluate the effectiveness of the warfarin therapy, the nurse must know that this medication:

  A. Dissolves any clots already formed in the arteries

  B. Prevents the conversion of prothrombin to thrombin

  C. Interferes with the synthesis of vitamin K-dependent clotting factors

  D. Stimulates the manufacturing of platelets

  Correct Answer: C

  (A) Thrombolytic agents (e.g., streptokinase) directly activate plasminogen, dissolving fibrin deposits, which in turn dissolves clots that have already formed. (B) Heparin prevents the formation of clots by potentiating the effects of antithrombin III and the conversion of prothrombin to thrombin. (C) Warfarin prevents the formation of clots by interfering with the hepatic synthesis of the vitamin K-dependent clotting factors. (D) Platelets initiate the coagulation of blood by adhering to each other and the site of injury to form platelet plugs.

• Question 95:

  To prevent transmission of bacterial meningitis, the nurse would instruct an infected baby's mother to:

  A. Avoid touching the baby while in the room.

  B. Stay outside of the baby's room.

  C. Wear a gown and gloves and wash her hands before and after leaving the room.

  D. Wear a mask while in the room.

  Correct Answer: C

  (A) The mother should be allowed and encouraged to touch her baby. (B) With care, transmission can be prevented. There is no need for the mother to stay outside the room. (C) Everyone entering the baby's room should take appropriate measures to prevent transmission of pathogens. (D) Wearing a mask will not protect against transmission of pathogens.

• Question 96:

  During the active phase of rheumatic fever, the nurse teaches parents of a child with acute rheumatic fever to assist in minimizing joint pain and promoting healing by:

  A. Putting all joints through full range-of-motion twice daily

  B. Massaging the joints briskly with lotion or liniment after bath

  C. Immobilizing the joints in functional position using splints, rolls, and pillows

  D. Applying warm water bottle or heating pads over involved joints

  Correct Answer: C

  (A) Any movement of the joint causes severe pain. (B) Touching or moving the joint causes severe pain. (C) Immobilization in a functional position allows the joint to rest and heal. (D) Pressure from the warm water bottle or pads can cause severe pain or burning of the skin.

• Question 97:

  The mother of a client is apprehensive about taking home her 2 year old who was diagnosed with asthma after being admitted to the emergency room with difficulty breathing and cyanosis. She asks the nurse what symptoms she should look for so that this problem will not happen again. The nurse instructs her to watch for the following early symptoms:

  A. Fever, runny nose, and hyperactivity

  B. Changes in breathing pattern, moodiness, fatigue, and edema of eyes

  C. Fatigue, dark circles under the eyes, changes in breathing pattern, glassy eyes, and moodiness

  D. Fever, cough, paleness, and wheezing

  Correct Answer: C

  (A) The child with asthma may not have fever unless there is an underlying infection. (B) Edema of the eyes will not be present because the child with asthma is more likely to have dehydration related to excessive water loss during the work of breathing. (C) All of these symptoms indicate decreased oxygenation and are early symptoms of asthma. (D) Coughing and wheezing are not early signs of difficulty.

• Question 98:

  The initial focus when providing nursing care for a child with rheumatic fever during the acute phase of the illness should be to:

  A. Maintain contact with her parents

  B. Provide for physical and psychological rest

  C. Provide a nutritious diet

  D. Maintain her interest in school

  Correct Answer: B

  (A) This goal is helpful, but rest is essential during the acute phase. (B) Rest is essential for healing to occur and for pain to be relieved. (C) This goal is important, but rest is essential. (D) This goal should be part of the plan of care, but it is not the priority during the acute phase.

• Question 99:

  A 30-year-old client has been admitted to the psychiatric service with the diagnosis of schizophrenia. He tells the nurse that when the woman he had been dating broke up with him, the CIA had replaced her with an identical twin. The client is experiencing:

  A. Grandiose delusions

  B. Paranoid delusions

  C. Auditory hallucinations

  D. Visual hallucinations

  Correct Answer: B

  (A) There are no indications that the client's thoughts reflect special powers or talents characteristic of grandiosity. (B) The client's thought content is fixed, false, persecutory, and suspicious in nature, which is characteristic of paranoid delusions. (C, D) The client is not demonstrating a sensory experience.

• Question 100:

  The mother of a preschooler reports to the nurse that he frequently tells lies. The admission assessment of the child indicates possible child abuse. The nurse knows that his:

  A. Behavior is not normal, and a child psychiatrist should be consulted.

  B. Mother is lying to protect herself.

  C. Lying is normal behavior for a preschool child who is learning to separate fantasy from reality.

  D. Behavior indicates a developmental delay, because preschoolers should be able to tell right from wrong.

  Correct Answer: C

  (A) Because preschoolers often tell "stories" as they learn to differentiate fantasy from reality, the child's behavior is normal. (B) The nurse has no reason to believe the child's mother is lying, because children of his age often tell lies. (C) The child's lying is actually "storytelling" as he learns to separate fantasy from reality, a normal developmental task for his age group. (D) The child's behavior is consistent with his age and does not indicate a developmental delay.