NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 161:

  Assessment of a client reveals a 30% loss of preillness weight, lanugo, and cessation of menses for 3 months. Her vital signs are BP 90/50, P 96 bpm, respirations 30, and temperature 97 F. She admits to the nurse that she has induced vomiting 3 times this morning, but she had to continue exercising to lose "just 5 more lb." Her symptoms are consistent with:

  A. Pregnancy

  B. Bulimia

  C. Gastritis

  D. Anorexia nervosa

  Correct Answer: D

  (A)

  Presenting behaviors collectively are inconsistent with depression. (B) A preillness weight loss of 30%, lanugo, and cessation of menses are inconsistent with bulimia. (C) Symptoms and vital signs do not indicate the presence of infection.

  (D)

  All symptoms and vital signs are consistent with anorexia nervosa.

• Question 162:

  In evaluating the effectiveness of magnesium sulfate (MgSO4), which of the following might indicate that the client was developing MgSO4 toxicity?

  A. A 31 patellar tendon reflex

  B. Respirations of 12 breaths/min

  C. Urine output of 40 mL/hr

  D. A 21 proteinuria value

  Correct Answer: B

  (A) Diminished (not accentuated) patellar tendon reflex is a sign of developing MgSO4 toxicity. A value of 21 is considered a normal tendon reflex; 3+ is considered brisker than normal. (B) MgSO4 is a central nervous system (CNS) depressant. It also relaxes smooth muscle. If the respiratory rate is <16 bpm magnesium toxicity may be developing. (C) Urine output of 40mL/hr is enough to allow elimination of toxic levels of magnesium. Urinary output of <100 mL in a 4hour period may result in toxic levels of magnesium. (D) Presence of protein in the urine is a symptom of pregnancy-induced hypertension (PIH), a clinical syndrome for which magnesium sulfate is frequently used in medical management. Protein in the urine is not induced by magnesium sulfate intake.

• Question 163:

  The physician of an alcoholic client places him on a low-protein, high-carbohydrate diet. When choosing his menu, the client's best choice from the items below would be:

  A. Liver and onions, macaroni and cheese, tea with sugar

  B. Baked chicken, baked potato with bacon bits, milk

  C. Waffles with butter and honey, orange juice

  D. Cheese omelette with ham and mushrooms, milk

  Correct Answer: C

  (A, B, D) These foods are high in protein, which needs to be restricted. (C) Serum ammonia levels can be decreased by restricting dietary protein intake. Waffles, honey, and orange juice are high in carbohydrate and low or completely lacking in protein. Butter, a concentrated fat, will provide extra calories.

• Question 164:

  A 24-year-old woman who is gravida 1 reports, "I can't take iron pills because they make me sick." She continues, "My bowels aren't moving either." In counseling her based on these complaints, the nurse's most appropriate response would be, "It would be beneficial for you to eat . . .

  A. prunes."

  B. green leafy vegetables."

  C. red meat."

  D. eggs."

  Correct Answer: A

  (A) Prunes provide fiber to decrease constipation and are an excellent source of dietary iron, as the prenatal client is not taking her supplemental iron and iron-deficiency anemia is common during pregnancy. (B) Green leafy vegetables provide a source of fiber and iron; however, prunes are a better source of both. (C) Red meat is a good iron source but will not address the constipation problem. (D) Eggs are a good iron source but do not address the constipation problem.

• Question 165:

  The nurse has been caring for a 16-year-old female who recently experienced date rape. After having had crisis intervention and been hospitalized for 2 weeks, the nurse knows that the client is effectively coping with the rape when she tells the nurse:

  A. "I know it was my fault that it happened, because I shouldn't have been out so late."

  B. "If I had not worn that sexy dress that night, he wouldn't have raped me."

  C. "I know my date just had so much passion he couldn't handle me saying `no.' "

  D. "I know now that it was not my fault, but I want to continue counseling after my discharge."

  Correct Answer: D

  (A) This response does not show any insight; the client falsely assumes that she is responsible for the rape. (B) The client continues to falsely assume responsibility for the rapist's behavior. (C) The client believes falsely that rape is an act of passion, rather than one of violence, control, and domination. (D) The client has insight into the rape; she does not believe it was her fault and shows good judgment in deciding to continue with counseling after discharge.

• Question 166:

  A client who has been diagnosed with anorexia nervosa reluctantly agrees to eat all prescribed meals. The most important intervention in monitoring her dietary compliance would be to:

  A. Allow her privacy at mealtimes

  B. Praise her for eating everything

  C. Observe behavior for 1? hours after meals to prevent vomiting

  D. Encourage her to eat in moderation, choose foods that she likes, and avoid foods that she dislikes

  Correct Answer: C

  (A) Eating alone is not recommended for anorexic clients because they tend to hoard food instead of eating it. (B) The client should be praised for whatever she eats, which is usually a small portion or percentage of what is served. Praise should not be withheld until she eats everything. (C) The client should be observed eyeto- eye for at least 1 hour following meals to prevent discarding food stashed in her clothing at mealtime or engaging in selfinduced vomiting. (D) If offered these choices, the client would choose low-caloric foods, not a nutritious diet.

• Question 167:

  A baby is circumcised. Immediate postoperative care should include:

  A. Applying a loose diaper

  B. Keeping the baby NPO for 4 hours to avoid vomiting

  C. Changing the dressing frequently using dry, sterile gauze

  D. Taking the baby to his mother for cuddling

  Correct Answer: D

  (A) A pressure diaper should be applied to discourage hemorrhage. (B) The baby can be fed by his mother soon after the procedure, once it is assessed that he is not in any distress and is stable. (C) Dressing changes should not be dry. Dry dressing will stick. (D) Cuddling after the procedure will hopefully quiet the baby. Feeding is also important if his feeding was withheld prior to the procedure or it is time for a feeding.

• Question 168:

  A client at 6 months' gestation complains of tiredness and dizziness. Her hemoglobin level is 10 g/dL, and her hematocrit value is 32%. Her nutritional intake is assessed as sufficient. The most likely diagnosis is:

  A. Iron-deficiency anemia

  B. Physiological anemia

  C. Fatigue due to stress

  D. No problem indicated

  Correct Answer: A

  (A) This clinical situation is indicative of iron-deficiency anemia because the client has inadequate nutritional intake. Her blood volume is increasing faster than her red blood cell volume. Anemia is present in the second trimester when the hemoglobin level is <10.5 and the hematocrit value falls below 35%. She needs increased iron supplements with follow- up. (B) The client's values are below levels for physiological anemia. (C) The client is fatigued because of a low hemoglobin level. (D) Her hemoglobin level is low and will probably decrease even more when the blood volume peaks at 28 weeks.

• Question 169:

  A 14-year-old boy fell off his bike while "popping a wheelie" on the dirt trails. He has sustained a head injury with laceration of his scalp over his temporal lobe. If he were to complain of headache during the first 24 hours of his hospitalization, the nurse would:

  A. Ask the physician to order a sedative

  B. Have the client describe his headache every 15 minutes

  C. Increase his fluid intake to 3000 mL/24 hr

  D. Offer diversionary activities

  Correct Answer: D

  (A) CNS depressants are not given for headache due to head injury because they would mask changes in neurological status and because they could further depress the CNS. (B) The client should not be asked to think about his headache every 15 minutes. (C) Fluid intake should be normal or restricted for a client with a head injury. Normal fluid intake for a 14 year old is about 2000?400 mL daily. (D) Diversion may help the child to focus on a pleasant activity instead of on his headache.

• Question 170:

  The nurse assesses a client's monitor strip and finds the following: uterine contractions every 3? minutes, lasting 60?0 seconds; FHR baseline 134?46 bpm, with accelerations to 158 bpm with fetal movement. Which nursing intervention is appropriate?

  A. Notify physician of nonreassuring FHR pattern.

  B. Turn the client to her left side.

  C. Start IV for fetal distress and administer O2 at 6? liters by mask.

  D. Evaluate to see if the monitor strip is reassuring.

  Correct Answer: D

  (A) These indices are within normal parameters; therefore, the nurse does not need to contact the physician. (B) The purpose of turning a client to her left side is to maximize uteroplacental blood flow. Based on the above assessment, there is no indication that blood flow is compromised. (C) These interventions are appropriate nursing interventions for late and prolonged decelerations. Following these interventions, the nurse should notify the physician. These indices are within normal parameters; therefore, the nurse does not need to start an IV and administer O2. (D) Variations of 20 bpm above or below the baseline FHR is considered normal. Normal FHRs range from 120?60 bpm. As the fetus moves, the FHR increases, and accelerations often occur in concert with contractions. During the active phase of labor, the frequency of uterine contractions is every 2? minutes, with an appropriate duration of 60 sec.