NCLEX NCLEX-RN Online Practice Questions and Exam Preparation

NCLEX NCLEX-RN Online Questions & Answers

• Question 151:

  Proper positioning for the child who is in Bryant's traction is:

  A. Both hips flexed at a 90-degree angle with the knees extended and the buttocks elevated off the bed
  B. Both legs extended, and the hips are not flexed
  C. The affected leg extended with slight hip flexion
  D. Both hips and knees maintained at a 90-degree flexion angle, and the back flat on the bed
  A. Both hips flexed at a 90-degree angle with the knees extended and the buttocks elevated off the bed

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  (A) The child's weight supplies the countertraction for Bryant's traction; the buttocks are slightly elevated off the bed, and the hips are flexed at a 90-degree angle. Both legs are suspended by skin traction. (B) The child in Buck's extension traction maintains the legs extended and parallel to the bed. (C) The child in Russell traction maintains hip flexion of the affected leg at the prescribed angle with the leg extended. (D) The child in "90?0" traction maintains both hips and knees at a 90-degree flexion angle and the back is flat on the bed.

• Question 152:

  A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful?

  A. Examine the 4 year old first.
  B. Provide time for play and becoming acquainted.
  C. Have the mother leave the room with one child, and examine the other child privately.
  D. Examine painful areas first to get them "over with."
  B. Provide time for play and becoming acquainted.

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  (A) The 6 month old should be examined first. If several children will be examined, begin with the most cooperative and less anxious child to provide modeling. (B) Providing time for play and getting acquainted minimizes stress and anxiety associated with assessment of body parts. (C) Children generally cooperate best when their mother remains with them. (D) Painful areas are best examined last and will permit maximum accuracy of assessment.

• Question 153:

  A 70-year-old homeless woman is admitted with pneumonia. She is weak, emaciated, and febrile. The physician orders enteral feedings intermittently by nasogastric tube. When inserting the nasogastric tube, once the tube passes through the oropharynx, the nurse will instruct the client to:

  A. Tilt her head backwards
  B. Swallow as tube passes
  C. Hold breath as tube passes
  D. Cough as tube passes
  B. Swallow as tube passes

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  (A) Head should be tilted slightly forward to facilitate insertion. (B) Swallowing assists with insertion of tube and closes off airway. (C) Client should be swallowing as tube passes; holding the breath facilitates nothing. (D) Coughing may expel tube.

• Question 154:

  A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor and delivery are the ischial spines because:

  A. Ischial spines are the narrowest diameter of the pelvis
  B. Ischial spines are the widest diameter of the pelvis
  C. They represent the inlet of birth canal
  D. They measure pelvic floor
  A. Ischial spines are the narrowest diameter of the pelvis

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  (A) The fetal descent, or station, is determined by the relationship of the presenting part to the spine. (B) Ischial spines are the narrowest measurement. (C) Ischial spines measure the pelvic outlet. (D) Pelvic floor measurement is not related to fetal descent.

• Question 155:

  A 30-year-old client is exhibiting auditory hallucinations. In working with this client, the nurse would be most effective if the nurse:

  A. Encourages the client to discuss the voices
  B. Attempts to direct the client's attention to the here and now
  C. Exhibits sincere interest in the delusional voices
  D. Gives the medication as necessary for the acting-out behavior
  B. Attempts to direct the client's attention to the here and now

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  (A) This answer is incorrect. Encouraging discussion of the voices will reinforce the delusion. (B) This answer is correct. The nurse should appropriately present reality. (C) This answer is incorrect. Showing interest would reinforce the delusional system. (D) This answer is incorrect. The statement only indicates that the client is hearing voices. It does not state that the client is acting out.

• Question 156:

  A client who is a breast-feeding mother develops mastitis. The clinical signs and symptoms of mastitis include:

  A. Marked engorgement, elevated temperature, chills, and breast pain with an area that is red and hardened
  B. Marked engorgement and breast pain
  C. Elevated temperature and general malaise
  D. Cracked nipple with complaints of soreness
  A. Marked engorgement, elevated temperature, chills, and breast pain with an area that is red and hardened

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  (A) Mastitis is a bacterial inflammation of the breast tissue found primarily in breast-feeding mothers. The bacteria usually enter the breast through a cracked nipple, or the infection results from stasis of milk behind a blocked duct. (B) With breast engorgement during breast-feeding, there may be marked breast pain. This is not necessarily a sign of infection. (C) Women may become ill during breast-feeding with other bacterial or viral infections that are not related to mastitis. (D) Improper care of the nipples or improper positioning of the infant during breastfeeding may result in cracked or sore nipples.

• Question 157:

  On the first postpartal day, a client tells the nurse that she has been changing her perineal pads every 1/2 hour because they are saturated with bright red vaginal drainage. When palpating the uterus, the nurse assesses that it is somewhat soft, 1 fingerbreadth above the umbilicus, and midline. The nursing action to be taken is to:

  A. Gently massage the uterus until firm, express any clots, and note the amount and character of lochia
  B. Catheterize the client and reassess the uterus
  C. Begin IV fluids and administer oxytocic medication
  D. Administer analgesics as ordered to relieve discomfort
  A. Gently massage the uterus until firm, express any clots, and note the amount and character of lochia

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  (A) Gentle massage and expression of clots will let the fundus return to a state of firmness, allowing the uterus to function as the "living ligature." (B) A distended bladder may promote uterine atony; however, after determining the bladder is distended, the nurse would have the client void. Catheterization is only done if normal bladder function has not returned. (C) Oxytocic medications are ordered and administered if the uterus does not remain contracted after gentle massage and determining if the bladder is empty. (D) The client is not complaining of discomfort or pain; therefore, analgesics are not necessary.

• Question 158:

  A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?

  A. Bulging fontanelles
  B. Seizure
  C. Headache
  D. Ataxia
  C. Headache

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  (A) Bulging fontanelles are a symptom of increased intracranial pressure in infants. (B) Seizure is a late sign of increased intracranial pressure. (C) Headache is a very early symptom of increased intracranial pressure in the child. (D) Ataxia is a late sign of increased intracranial pressure.

• Question 159:

  Which of the following symptoms might the nurse observe in a client with a lithium blood level over 2.0?

  A. Fine hand tremor, headache, mental dullness
  B. Vomiting, impaired consciousness, decreased blood pressure
  C. Polyuria, polydipsia, edema
  D. Gastric irritation, nausea, diarrhea
  B. Vomiting, impaired consciousness, decreased blood pressure

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  (A) These symptoms are acute, common, and usually harmless central nervous system side effects of lithium. (B) These symptoms of lithium toxicity are usually dose related. (C) These symptoms are acute, common, and usually harmless renal side effects of lithium. (D) These symptoms are acute, common, and usually harmless gastrointestinal side effects of lithium.

• Question 160:

  A client is receiving IV morphine 2 days after colorectal surgery. Which of the following observations indicate that he may be becoming drug dependent?

  A. The client requests pain medicine every 4 hours.
  B. He is asleep 30 minutes after receiving the IV morphine.
  C. He asks for pain medication although his blood pressure and pulse rate are normal.
  D. He is euphoric for about an hour after each injection.
  D. He is euphoric for about an hour after each injection.

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  (A) Frequent requests for pain medication do not necessarily indicate drug dependence after complex surgeries such as colorectal surgery. (B) Sleeping after receiving IV morphine is not an unexpected effect because the pain is relieved. (C) A person may be in pain even with normal vital signs. (D) A subtle sign of drug dependency is the tendency for the person to appear more euphoric than relieved of pain.