NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 151:

  A 24-hours' postpartum client complains of discomfort at the episiotomy site. On assessment, the nurse notes the episiotomy is without signs of infection. To relieve the discomfort, the nurse should first:

  A. Assist her with a sitz bath

  B. Administer the prescribed medication for pain

  C. Teach her Kegel exercises

  D. Apply an ice pack

  Correct Answer: A

  (A) Warm, moist heat will promote circulation and provide comfort. A sitz bath should be tried before medication is given. (B) Pain medication can be given when other comfort measures such as a sitz bath and topical applications are ineffective. (C) Kegel exercises facilitate sitting by decreasing tension on the episiotomy. They will not be effective for pain control or sustained comfort level. (D) Ice packs are appropriate to apply in the first 12 hours postdelivery to produce vasoconstriction and to reduce edema to the area.

• Question 152:

  In teaching the client about proper umbilical cord care, the nurse recommends that:

  A. Petrolatum be placed around the cord after the sponge bath

  B. A belly binder be applied to prevent umbilical hernia

  C. The area be cleansed at diaper changes with alcohol and inspected for redness or drainage

  D. The cord clamp be left on until the cord stump separates

  Correct Answer: C

  (A) Petrolatum does not allow the cord to dry and will encourage infection. (B) Belly binders do not facilitate drying of the cord and will encourage abdominal relaxation. (C) Frequent applications of alcohol will facilitate drying and discourage infection. (D) The cord clamp can be removed in 24 hours. Leaving it on is cumbersome and could pull on the cord unnecessarily.

• Question 153:

  A 26-year-old male client is brought by his wife to the emergency department (ED) unconscious. Blood is drawn for a stat blood count (CBC), fasting blood sugar level, and electrolytes. An indwelling urinary catheter is inserted. He has a history of type 1 diabetes (insulindependent diabetes mellitus [IDDM]). A diagnosis of ketoacidosis is made. Stat lab values reveal a blood sugar level of 520 mg/dL. Which of the following should the nurse expect to administer in the ER?

  A. D50W by IV push

  B. NPH insulin SC

  C. Regular insulin by IV infusion

  D. Sweetened grape juice by mouth

  Correct Answer: C

  (A) This action would further increase the client's blood sugar. (B) NPH insulin is an intermediate-acting insulin, with an average of 4? hours before onset of action. The client needs insulin that will act immediately. During a ketoacidotic state, the client is dehydrated, so any insulin administered SC will be poorly absorbed. (C) Regular insulin is the fastest acting-insulin; when given IV, it will immediately act to decrease blood sugar. Regular insulin is given to decrease blood glucose levels by promoting metabolism of glucose, inhibiting lipolysis and formation of ketone bodies. (D) This action would further increase the client's blood sugar.

• Question 154:

  The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have:

  A. A low birth weight

  B. A birth defect

  C. Anemia

  D. Nicotine withdrawal

  Correct Answer: A

  (A) Women who smoke during pregnancy are at increased risk for miscarriage, preterm labor, and IUGR in the fetus. (B) Although smoking produces harmful effects on the maternal vascular system and the developing fetus, it has not been directly linked to fetal anomalies. (C) Smoking during pregnancy has not been directly linked to anemia in the fetus. (D) Smoking during pregnancy has not been linked to nicotine withdrawal symptoms in the newborn.

• Question 155:

  A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life- threatening complications may occur initially, so the nurse will monitor him closely for serum:

  A. Chloride level of 99 mEq/L

  B. Sodium level of 136 mEq/L

  C. Potassium level of 3.1 mEq/L

  D. Potassium level of 6.3 mEq/L

  Correct Answer: D

  (A) The chloride level is within acceptable limits. (B) The sodium level is within acceptable limits. (C) This value indicates hypokalemia, rather than the hyperkalemia that occurs during diabetic ketoacidosis. (D) When diabetic ketoacidosis exists, intracellular dehydration occurs and potassium leaves the cells and enters the vascular system, thus increasing the serum level beyond an acceptable range. When insulin and fluids are administered, cell walls are repaired and potassium is transported back into the cells. Normal serum potassium levels range from 3.5?.0 mEq/L.

• Question 156:

  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

  Correct Answer: B

  (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 157:

  A client's record from the ED indicates that she overdosed on phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor. Which diet would be the most appropriate at this time?

  A. High carbohydrate, low cholesterol

  B. High protein, high carbohydrate

  C. 1 g sodium

  D. Tyramine-free

  Correct Answer: D

  (A) There are no data to support the need for increased carbohydrates or decreased cholesterol in the diet. (B) There is no data to support the need for increased protein or increased carbohydrates in the diet. (C) There is no assessment or laboratory data indicating that sodium should be restricted in the diet. (D) Tyramine is an amino acid activated by MAO in the liver and intestinal wall. It is released as proteins are hydrolyzed through aging, pickling, smoking, or spoilage of foods. When MAO is inhibited, tyramine levels rise, stimulating the adrenergic system to release large amounts of norepinephrine, which can produce a hypertensive crisis.

• Question 158:

  A client presented herself to the mental health center, describing the following symptoms: a weight loss of 20 lb in the past 2 months, difficulty concentrating, repeated absences from work due to "fatigue," and not wanting to get dressed in the morning. She leaves her recorded message on her telephone and has lost interest in answering the phone or doorbell. The nurse's assessment of her behavior would most likely be:

  A. Deep depression

  B. Psychotic depression

  C. Severe anxiety

  D. Severe depression

  Correct Answer: D

  (A) A client in deep depression would have been brought to the mental health center and would not be physically able to seek help for herself. (B) She is not manifesting psychotic symptoms in her behaviors. (C) The client's symptoms are more indicative of depression than anxiety. (D) Although the client was able to bring herself to the mental health center, the extent of her weight loss and the interference of symptoms with activities of daily living indicate that she is severely depressed.

• Question 159:

  A new mother experiences strong uterine contractions while breast-feeding her baby. She excitedly rings for the nurse. When the nurse arrives the mother tells her, "Something is wrong. This is like my labor." Which reply by the nurse identifies the physiological response of the client?

  A. "Your breasts are secreting a hormone that enters your bloodstream and causes your abdominal muscles to contract."

  B. "Prolactin increases the blood supply to your uterus, and you are feeling the effects of this blood vessel engorgement."

  C. "The same hormone that is released in response to the baby's sucking, causing milk to flow, also causes the uterus to contract."

  D. "There is probably a small blood clot or placental fragment in your uterus, and your uterus is contracting to expel it."

  Correct Answer: C

  (A) Mammary growth as well as milk production and maintenance in the breast occur in response to hormones produced primarily by the hypothalamus and the pituitary gland. (B) Prolactin stimulates the alveolar cells of the breast to produce milk. It is important in the initiation of breast-feeding. (C) Oxytocin, which is released by the posterior pituitary, stimulates the let-down reflex by contraction of the myoepithelial cells surrounding the alveoli. In addition, it causes contractions of the uterus and uterine involution. (D) Afterpains may occur with retained placental fragments. A boggy uterus and continued bleeding are other symptoms that occur in response to retained placental fragments.

• Question 160:

  A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5'4" and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:

  A. Obtain an accurate weight

  B. Search the client's purse for pills

  C. Assess vital signs

  D. Assign her to a room with someone her own age

  Correct Answer: C

  (A)

  On admission, vital signs are the highest priority. Weight is not a vital sign. (B) Belongings are routinely searched on admission to a psychiatric unit, but this search is not a high priority. (C) Vital signs are a high priority when working with selfdestructive clients.

  (D)

  Room assignment is of low priority.