NCLEX NCLEX-RN Online Practice Questions and Exam Preparation

NCLEX NCLEX-RN Online Questions & Answers

• Question 111:

  The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:

  A. Immediate treatment of mild PIH includes the administration of a variety of medications
  B. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation
  C. Self-discipline is required to control caloric intake throughout the pregnancy
  D. The client may not recognize the early symptoms of PIH
  D. The client may not recognize the early symptoms of PIH

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  (A) Mild PIH is not treated with medications. (B) Emotional stress is not the cause of blood pressure elevation in PIH. (C) Excessive caloric intake is not the cause of weight gain in PIH. (D) The client most frequently is not aware of the signs and symptoms in mild PIH.

• Question 112:

  A male client has a history of diverticulosis. He has questions about the foods that he should eat. His nurse gives him the following information:

  A. He should be on a high-fiber diet.
  B. He should eat a low-residue diet.
  C. He should drink minimal amounts of fluids.
  D. He does not need to make any modifications.
  A. He should be on a high-fiber diet.

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  (A) Clients with diverticulosis should maintain a high-fiber diet and prevent constipation with bran or bulk laxatives. (B) Lowresidue diets lead to constipation and are contraindicated in clients with diverticulosis. (C) Clients with diverticulosis should drink at least eight glasses of water each day to prevent constipation. (D) Clients with diverticulosis should modify their diet to include high-fiber foods and bulk laxatives.

• Question 113:

  A client was not using his seat belt when involved in a car accident. He fractured ribs 5, 6, and 7 on the left and developed a left pneumothorax. Assessment findings include:

  A. Crackles and paradoxical chest wall movement
  B. Decreased breath sounds on the left and chest pain with movement
  C. Rhonchi and frothy sputum
  D. Wheezing and dry cough
  B. Decreased breath sounds on the left and chest pain with movement

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  (A) Crackles are caused by air moving through moisture in the small airways and occur with pulmonary edema. Paradoxical chest wall movement occurs with flail chest when a segment of the thorax moves outward on inspiration and inward on expiration. (B) Decreased breath sounds occur when a lung is collapsed or partially collapsed. Chest pain with movement occurs with rib fractures. (C) Rhonchi are caused by air moving through large fluid-filled airways. Frothy sputum may occur with pulmonary edema. (D) Wheezing is caused by fluid in large airways already narrowed by mucus or bronchospasm. Dry cough could indicate a cardiac problem.

• Question 114:

  Three hours postoperatively, a 27-year-old client complains of right leg pain after knee reduction. The first action by the nurse will be to:

  A. Assess vital signs
  B. Elevate the extremity
  C. Perform a lower extremity neurovascular check
  D. Remind the client that he has a client-controlled analgesic pump, and reinstruct him on its use
  C. Perform a lower extremity neurovascular check

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  (A) Vital signs may be altered if there is acute pain or complications related to bleeding or swelling, but they should not be assessed before checking the affected extremity. (B) The extremity will be elevated if ordered by the doctor. (C) Assessment of the postoperative area is important to determine if bleeding, swelling, or decreased circulation is occurring. (D) Reinforcement of teaching on use of the client-controlled analgesic pump is important, but not the first action.

• Question 115:

  After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis?

  A. One centimeter below the ischial spines
  B. One centimeter above the ischial spines
  C. Has not entered the pelvic inlet yet
  D. Located in the pelvic outlet
  B. One centimeter above the ischial spines

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  (A) The ischial spines are located on both sides of the midpelvis. These spines mark the diameter of the narrowest part of the pelvis that the fetus will encounter. They are not sharp protrusions that will harm the fetus. Station refers to the relationship between the ischial spines in the pelvis and the fetus. The ischial spines are designated at 0 station. If the presenting part of the fetus is located above the ischial spines, a negative number is assigned, noting the number of centimeters above the ischial spines. Therefore, 1 centimeter below the ischial spines is designated as +1 station. (B) See explanation in A. One centimeter above the ischial spines is designated as +1 station. (C) The pelvic inlet is the first part of the pelvis that the fetus enters in routine delivery. The midpelvis is the second part of the pelvis to be entered by the fetus. The ischial spines are located on both sides of the midpelvis. (D) The pelvic outlet is the last part of the pelvis that the fetus will enter. When the fetus reaches this part of the pelvis, birth is near.

• Question 116:

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

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  (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 117:

  A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child?

  A. Blood pressure
  B. Serum potassium level
  C. Urine output
  D. Pulse rate
  C. Urine output

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  (A) Blood pressure can remain normotensive even in a state of hypovolemia. (B) Serum potassium is not reliable for determining adequacy of fluid resuscitation. (C) Urine output, alteration in sensorium, and capillary refill are the most reliable indicators for assessing adequacy of fluid resuscitation. (D) Pulse rate may vary for many reasons and is not a reliable indicator for assessing adequacy of fluid resuscitation.

• Question 118:

  The nurse is teaching a 10-year-old insulin-dependent diabetic how to administer insulin. Which one of the following steps must be taught for insulin administration?

  A. Never use abdominal site for a rotation site.
  B. Pinch the skin up to form a subcutaneous pocket.
  C. Avoid applying pressure after injection.
  D. Change needles after injection.
  B. Pinch the skin up to form a subcutaneous pocket.

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  (A)

  Sites for injection need to be rotated, including abdominal sites, to enhance insulin absorption. (B) The pinch technique is the most effective method for obtaining skin tightness to allow easy entrance of the needle to subcutaneous tissues.

  (C)

  Massaging the site of injection facilitates absorption of the insulin. (D) Changing the needle will break the sterility of the system. It has become acceptable practice to reuse disposable needles and syringes for 3? days.

• Question 119:

  When caring for a postoperative cholecystectomy client, the nurse assesses patency and documents drainage of the T-tube. The nurse recognizes that the expected amount of drainage during the first 24 hours postoperatively is:

  A. 5000 mL
  B. 20000 mL
  C. 30000 mL
  D. 1000200 mL
  C. 30000 mL

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  (A) During the first 24 hours after surgery, the drainage is normally 30000 mL and then decreases to about 200 mL in 24 hours during the next 3 days. (B) This range is the amount of drainage after the first 24 hours postoperatively. During the first 24 hours, it is 300-500 mL. (C) During the first 24 hours after surgery, this range is the expected amount of drainage. (D) The expected amount of drainage during the first 24 hours is 30000 mL. An output of >500 mLshould be reported to the physician, because an occlusion of some type, caused by a retained gallstone or an inflammatory process within the biliary drainage system, is evident.

• Question 120:

  Which type of insulin can be administered by a continuous IV drip?

  A. Humulin N
  B. NPH insulin
  C. Regular insulin
  D. Lente insulin
  C. Regular insulin

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  (A) Humulin N cannot be administered IV. (B) NPH insulin cannot be administered IV. (C) Regular insulin is the only insulin that can be administered IV. (D) Lente insulin cannot be administered IV.