NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 121:

  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

  Correct Answer: C

  (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 122:

  Two hours after the second injection of haloperidol, a client complains to the nurse of a stiff neck and inability to sit still. He is experiencing symptoms consistent with:

  A. Parkinsonism and dystonia

  B. Dystonia and akathisia

  C. Akathisia and parkinsonism

  D. Neuroleptic malignant syndrome

  Correct Answer: B

  (A) Stiff neck is consistent with a dystonic reaction, but the client has no symptoms of drooling, shuffling gait, or pill-rolling movements characteristic of parkinsonism. (B) Stiff neck is consistent with a dystonic reaction, and inability to sit still with varying degrees of psychomotor agitation is characteristic of akathisia. (C) The client has symptoms of dystonia but not of parkinsonism. (D) The client has none of the characteristic symptoms of neuroleptic malignant syndrome: hyperpyrexia, generalized muscle rigidity, mutism, obtundation, agitation, sweating, increased blood pressure and pulse.

• Question 123:

  A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is being given digoxin. Prior to administering the medication, the nurse should:

  A. Not give the digoxin if the pulse is_60

  B. Not give the digoxin if the pulse is_100

  C. Take the apical pulse for a full minute

  D. Monitor for visual disturbances, a side effect of digoxin

  Correct Answer: C

  (A) Digoxin should not be given to adults with an apical pulse < 60 bpm. (B) Digoxin should be given to children with an apical pulse > 100 bpm. With a pulse < 100 bpm, the medication should be withheld and the physician notified. (C) Prior to digoxin administration in both children and adults, an apical pulse should be taken for 1 full minute. Aside from the rate per minute, the nurse should note any sudden increase or decrease in heart rate, irregular rhythm, or regularization of a chronic irregular heart rhythm. (D) Early indications of digoxin toxicity, such as visual disturbances, occur rarely as initial signs in children.

• Question 124:

  A 35-year-old client is receiving psychopharmacological treatment of his major depression with tranylcypromine sulfate (Parnate), a monoamine oxidase (MAO) inhibitor. The nurse teaches the client that while he is taking this type of antidepressant, he needs to restrict his dietary intake of:

  A. Potassium-rich foods

  B. Tryptophan

  C. Tyramine

  D. Saturated fats

  Correct Answer: C

  (A) The client may need to avoid some potassium-rich foods (such as bananas, raisins, etc.). However, this is not because of the potassium content of these foods. (B) Tryptophan is an essential amino acid that is present in high concentrations in animal and fish protein. (C) The client will need to watch his dietary intake of tyramine. Tyramine is a by-product of the conversion of tyrosine to epinephrine. Tyramine is found in a variety of foods and beverages, ranging from aged cheese to caffeine drinks. Ingestion of tyramine-rich foods while taking a MAO inhibitor may lead to an increase in blood pressure and/or a life- threatening hypertensive crisis. (D) To maintain a healthy lifestyle, restriction of dietary saturated fats is advisable.

• Question 125:

  One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:

  A. Blood pressure

  B. Level of consciousness

  C. Skin turgor

  D. Fluid intake

  Correct Answer: B

  (A) Blood pressure can remain normotensive in a state of hypovolemia. (B) Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. (C) Skin turgor is not a reliable indicator for assessing hydration in a burn client. (D) Fluid intake does not indicate adequacy of fluid resuscitation in a burn client.

• Question 126:

  A 6-month-old infant who was diagnosed at 4 weeks of age with a ventricular septal defect, was admitted today with a diagnosis of failure to thrive. His mother stated that he had not been eating well for the past month. A cardiac catheterization reveals congestive heart failure. All of the following nursing diagnoses are appropriate. Which nursing diagnosis should have priority?

  A. Altered nutrition: less than body requirements related to inability to take in adequate calories

  B. Altered growth and development related to decreased intake of food

  C. Activity intolerance related to imbalance between oxygen supply and demand

  D. Decreased cardiac output related to ineffective pumping action of the heart

  Correct Answer: D

  (A) Altered nutrition occurs owing to the fatigue from decreased cardiac output associated with congestive heart failure. (B) The decreased intake occurs due to fatigue from the altered cardiac output. (C) Fatigue occurs due to the decreased cardiac output. (D) The ineffective action of the myocardium leads to inadequate O2 to the tissues, which produces activity intolerance, altered nutrition, and altered growth and development.

• Question 127:

  A client hospitalized with a medical diagnosis of adjustment disorder versus personality disorder states, "Nobody cares about the clients." The nurse's most effective response would be:

  A. "How can you say that I don't care? We just met."

  B. "What makes you think the nurses don't care?"

  C. "You will feel differently about us in a few days."

  D. "You seem angry. Tell me more about how you feel."

  Correct Answer: D

  (A) This statement is a defensive response that places the nurse in a vulnerable countertransference position, and at the same time, fails to challenge the client's "splitting" behavior. (B) This statement is a defensive response by the nurse. In addition, this type of nontherapeutic statement requests that the client explain the reasons for her behavior, a difficult task for an individual with limited insight. (C) This statement is a nontherapeutic response that both ignores the intensity of the client's emotions and the dynamics underlying "splitting" behavior. (D) By simultaneously acknowledging the client's emotional intensity and gently challenging her "splitting" behavior, the nurse addresses the client's current distortions and prepares for further interventions with angry or ambivalent feelings.

• Question 128:

  In caring at home for a child who just ingested a caustic alkali, the nurse would immediately tell the mother to:

  A. Give vinegar, lemon juice, or orange juice

  B. Phone the doctor

  C. Take the child to the emergency room

  D. Induce vomiting

  Correct Answer: A

  (A) The immediate action is to neutralize the action of the chemical before further damage takes place. (B) This action should be done after neutralizing the chemical. (C) This action should be done after neutralizing the chemical. (D) Never induce vomiting with a strong alkali or acid. Additional damage will be done when the child vomits the chemical.

• Question 129:

  The nurse writes the following nursing diagnosis for a client in acute renal failure--Impaired gas exchange related to:

  A. Decreased red blood cell production

  B. Increased levels of vitamin D

  C. Increased red blood cell production

  D. Decreased production of renin

  Correct Answer: A

  (A) Red blood cell production is impaired in renal failure owing to impaired erythropoietin production. This causes a decrease in the delivery of oxygen to the tissue and impairs gas exchange. (B) The conversion of vitamin D to its physiologically active form is impaired in renal failure. (C) In renal failure, a decrease in red blood cell production occurs owing to an impaired production of erythropoietin, leading to impaired gas exchange at the cellular level. (D) The decreased production of renin in renal failure causes an increased production of aldosterone causing sodium and water retention.

• Question 130:

  Often children are monitored with pulse oximeter. The pulse oximeter measures the:

  A. O2 content of the blood

  B. Oxygen saturation of arterial blood

  C. PO2

  D. Affinity of hemoglobin for O2

  Correct Answer: B

  (A) The O2 content of whole blood is determined by the partial pressure of oxygen (PO2) and the oxygen saturation. The pulse oximeter does not measure the PO2. (B) The pulse oximeter is a noninvasive method of measuring the arterial oxygen saturation. (C) The PO2 is the amount of O2 dissolved in plasma, which the pulse oximeter does not measure. (D) The affinity of hemoglobin for O2 is the relationship between oxygen saturation and PO2 and is not measured by the pulse oximeter.