NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 101:

  On the third postpartum day, the nurse would expect the lochia to be:

  A. Rubra

  B. Serosa

  C. Alba

  D. Scant

  Correct Answer: A

  (A) This discharge occurs from delivery through the 3rd day. There is dark red blood, placental debris, and clots. (B) This discharge occurs from days 4?0. The lochia is brownish, serous, and thin. (C) This discharge occurs from day 10 through the 6thweek. The lochia is yellowish white. (D) This is not a classification of lochia but relates to the amount of discharge.

• Question 102:

  Cystic fibrosis is transmitted as an autosomal recessive trait. This means that:

  A. Mothers carry the gene and pass it to their sons

  B. Fathers carry the gene and pass it to their daughters

  C. Both parents must have the disease for a child to have the disease

  D. Both parents must be carriers for a child to have the disease

  Correct Answer: D

  (A) Cystic fibrosis is not an X-linked or sex-linked disease. (B) The only characteristic on the Y chromosome is the trait for hairy ears. (C) Both parents do not need to have the disease but must be carriers. (D) If a trait is recessive, two genes (one from each parent) are necessary to produce an affected child.

• Question 103:

  Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following statements by the client would validate an understanding of his medication?

  A. "I would notify my physician immediately if I experience nausea, vomiting, and double vision."

  B. "I could stop taking this medication when I begin to feel better."

  C. "I should only take the medication if my heart rate is greater than 100 bpm."

  D. "I should always take this medication with an antacid."

  Correct Answer: A

  (A) The first signs of digoxin toxicity include abdominal pain, anorexia, nausea, vomiting, and visual disturbances. The physician should be notified if any of these symptoms are experienced. (B) The positive inotropic effects of digoxin increase cardiac output and result in an enhanced activity tolerance. "Feeling better" indicates the drug is working and medication therapy must be continued. (C) Clients should be taught to take their pulse prior to taking the digoxin. If their pulse rate becomes irregular, slows significantly, or is >100 bpm the physician should be notified. (D) Antacids decrease the effectiveness of digoxin.

• Question 104:

  A 6-year-old child returned to the surgical floor 20 hours ago after an appendectomy for a gangrenous appendix. His mother tells the nurse that he is becoming more restless and is anxious. Assessment findings indicate that the child has atelectasis. Appropriate nursing actions would include:

  A. Allowing the child to remain in the position of comfort, preferably semi-or high-Fowler position

  B. Administering analgesics as ordered

  C. Having the child turn, cough, and deep breathe every 1

  Correct Answer: C

  (A) Allowing the client to remain in the position of comfort will not resolve the atelectasis. This position, if left unchanged, over time may actually increase the atelectasis. (B) Analgesics will not resolve the atelectasis and may contribute to it if proper nursing actions are not taken to help resolve the atelectasis. (C) Having the client turn, cough, and deep breathe every 1

• Question 105:

  The nurse assesses a postoperative mastectomy client and notes that breath sounds are diminished in both posterior bases. The nurse's action should be to:

  A. Encourage coughing and deep breathing each hour

  B. Obtain arterial blood gases

  C. Increase O2 from 2? L/min

  D. Remove the postoperative dressing to check for bleeding

  Correct Answer: A

  (A) Decreased or absent breath sounds are frequently indicators of postoperative atelectasis. (B) Arterial blood gases are not indicated because there is no other information indicating impendingdanger. (C) Increasing O2 rate is not indicated without additional information. (D) Removing the dressing is not indicated without additional information.

• Question 106:

  In planning daily care for a client with multiple sclerosis, the nurse would take into consideration that multiple sclerosis:

  A. Becomes progressively debilitating without remission

  B. Has unpredictable remissions and exacerbations

  C. Is rapidly fatal

  D. Responds quickly to antimicrobial therapy

  Correct Answer: B

  (A) Multiple sclerosis eventually becomes debilitating, but it is characterized by remission of symptoms. (B) Remissions and exacerbations are unpredictable with multiple sclerosis. The client experiences progressive dysfunction after each exacerbation episode. (C) Multiple sclerosis is usually slowly progressive. (D) Multiple sclerosis is an autoimmune disease. Antimicrobial therapy has no effect on its course.

• Question 107:

  Which of the following physician's orders would the nurse question on a client with chronic arterial insufficiency?

  A. Neurovascular checks every 2 hours

  B. Elevate legs on pillows

  C. Arteriogram in the morning

  D. No smoking

  Correct Answer: B

  (A) Neurovascular checks are a routine part of assessment with clients having this diagnosis. (B) Elevation of the legs is contraindicated because it reduces blood flow to areas already compromised. (C) Arteriogram is a routine diagnostic order. (D) Smoking is highly correlated with this disorder.

• Question 108:

  Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?

  A. Fresh fruit

  B. A milkshake

  C. Saltine crackers and peanut butter

  D. A ham and cheese sandwich

  Correct Answer: B

  (A) Albumin, a blood volume expander, increases the circulating blood volume by exerting an osmotic pull on tissue fluids, pulling them into the vascular system. This fluid shift causes an increase in the heart rate and blood pressure. (B) Albumin, a blood volume expander, exerts an osmotic pull on fluids in the interstitial spaces, pulling the fluid back into the circulatory system. This fluid shift causes an increase in the urinary output. (C) Adventitious breath sounds and dyspnea can occur due to circulatory overload if the albumin is infused too rapidly. (D) Chills, fever, itching, and rashes are signs of a hypersensitivity reaction to albumin.

• Question 109:

  Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?

  A. Fresh fruit

  B. A milkshake

  C. Saltine crackers and peanut butter

  D. A ham and cheese sandwich

  Correct Answer: A

  (A) High levels of ammonia, a by-product of protein metabolism, can precipitate metabolic encephalopathy. These clients need a diet high in carbohydrates and bulk. (B) Metabolic encephalopathy of the brain associated with liver failure is precipitated by elevated ammonia levels. Ammonia is a by-product of protein metabolism. (C, D) Metabolic encephalopathy in liver failure is precipitated by elevated ammonia levels. Ammonia is a by-product of protein metabolism.

• Question 110:

  Which of the following nursing orders has the highest priority for a child with epiglottitis?

  A. Vital signs every shift

  B. Tracheostomy set at bedside

  C. Intake and output

  D. Specific gravity every shift

  Correct Answer: B

  (A) Because of the possibility of fever or respiratory failure, vital signs should be done more often than every eight hours. (B) If the epiglottitis worsens, the edema and laryngospasm may close the airway and an emergency tracheostomy may be necessary. (C) Although intake and output are a part of the nursing care of a child with epiglottitis, it is not as important as the safety measure of keeping the tracheostomy set at the bedside. (D) Specific gravity will indicate hydration status, but it is not as important as keeping the tracheostomy set at the bedside.