NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 171:

  Medication is administered to a client who has been placed in restraints after a sudden violent episode, and his EPSs subside. Restraints can be removed when:

  A. The physician orders it

  B. A therapeutic alliance has been established, and violent behavior subsides

  C. The violent behavior subsides, and the client agrees to behave

  D. The nurse deems that removal of restraints is necessary

  Correct Answer: B

  (A) The physicianmayorder release of restraints, but prior to that, the client must meet criteria for release. (B) While the client is still restrained, but after violent behavior has subsided, a therapeutic bridge is built. This alliance encourages dialogue between nurse and client, allowing the client to determine causative factors, feelings prior to loss of control, and adaptive alternatives to violence. (C) If the client only "agrees to behave" after violent behavior subsides, he has developed no insight into cause and effect of violence or his response to stress. (D)Removal of restraints occurs only when the client meets the criteria for release, not just because the nurse says it is necessary.

• Question 172:

  A female client admitted to the labor and delivery unit thinks her bag of water "broke" approximately 2 hours ago. She is having mild contractions 5 minutes apart. The most immediate nursing intervention would be to:

  A. Note the color and amount of fluid on her clothes.

  B. Assess the FHR.

  C. Notify the physician.

  D. Place the nitrazine test paper at the cervical os and note the color change.

  Correct Answer: B

  (A)

  Amniotic fluid is generally pale and straw colored. Meconium- stained amniotic fluid would indicate a previous hypoxic episode. This intervention, though appropriate, is not the immediate priority. (B) With rupture of the membranes, the umbilical cord may prolapse if the presenting part does not fill the pelvis. Assessing FHR ascertains fetal well-being. (C) More information regarding fetal status and assessing for membrane rupture is needed prior to contacting the physician.

  (D)

  Nitrazine test paper differentiates amniotic fluid from urine. Amniotic fluid is normally alkaline in contrast to urine, which is acidic. This intervention, though appropriate, is not the immediate priority.

• Question 173:

  A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse's best response is:

  A. "You'll have to get permission from the physician to visit. Clients are pretty sick after the first treatment."

  B. "Visitors are not allowed. We will telephone you to inform you of her progress."

  C. "There's really no need to stay with her. She's going to sleep for several hours after the treatment."

  D. "Yes, you may visit. She may experience temporary drowsiness, confusion, or memory loss after each treatment."

  Correct Answer: D

  (A) It is within the nurse's realm of practice to grant visiting privileges according to hospital policy. ECT treatments do not make clients sick. (B) Visitors are allowed and encouraged, particularly family members. (C) Clients are usually awake within 1 hour posttreatment. Drowsiness wanes as the anesthetic wears off. (D) A family member is encouraged to stay with the client after return to the unit. The nurse has used an opportunity to do family teaching and allay fears by explaining temporary side effects of the treatment.

• Question 174:

  An IDDM client's condition stabilizes. He begins to receive a daily injection of NPH insulin at 6:30 AM. The nurse can most likely expect a hypoglycemic reaction to occur that same day at:

  A. 8:30 AM

  Correct Answer: B

  (A) This time describes the time of onset of NPH insulin's action, rather than its peak effect. (B) NPH insulin, an intermediateacting insulin, usually begins to lower serum glucose levels about 2 hours after administration. The action of NPH insulin peaks 8

• Question 175:

  After several days, an IDDM client's serum glucose stabilizes, and the registered nurse continues client teaching in preparation for his discharge. The nurse helps him plan an American Diabetes Association diet and explains how foods can

  be substituted on the exchange list. He can substitute 1 oz of poultry for:

  A. One frankfurter

  B. One ounce of ham

  C. Two slices of bacon

  D. One-fourth cup dry cottage cheese

  Correct Answer: D

  (A) A frankfurter is a high-fat meat on the diabetic exchange list. (B) Ham is a medium-fat meat on the diabetic exchange list, unless it is a center-cut slice. (C) One strip of bacon equals onefatexchange rather than ameatexchange. Dietary substitutions should occur within exchange lists and not between exchange lists. (D) Diabetic meat-exchange lists are categorized into leanmeat foods, medium-fat meats, and high-fat meats. Cottage cheese (dry, 2% butterfat), one-fourth cup, can substitute for one lean-meat exchange.

• Question 176:

  A client's membranes have just ruptured spontaneously. Which of the following nursing actions should take priority?

  A. Assess quantity of fluid.

  B. Assess color and odor of fluid.

  C. Document on fetal monitor strip and chart.

  D. Assess fetal heart rate (FHR).

  Correct Answer: D

  (A) Assessing the quantity of amniotic fluid is important as an indication of maternal fetal well-being, but it does not take priority over assessment of FHR. (B) Greenish-brown discoloration of amniotic fluid indicates presence of meconium.

  Foul odor may indicate presence of infection. Both of these are important assessment data, but they do not take priority over possible lifethreatening compression of the umbilical cord. (C) Documentation is important, but it does not take priority over the possible life-threatening compression of the umbilical cord. (D) If changes in the FHR are noted, the nurse should check for umbilical cord prolapse. This intervention has priority over the other actions. The danger of a prolapsed cord is increased once membranes have ruptured, especially if the presenting part of the fetus does not fit firmly against the cervix.

• Question 177:

  A 26-year-old female client presents at 10 weeks' gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her grandmother also has insulin- dependent diabetes. The client's previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches tall and her current weight is 130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following factors places her at risk for gestational diabetes?

  A. Age>25 years

  B. Maternal weight

  C. Previous birth of an infant weighing>9 lb

  D. Family history of heart disease

  Correct Answer: C

  (A) Maternal age older than 30 years is an identified risk factor for diabetes. Age younger than 30 years is insignificant for diabetes unless there is a familial history of diabetes. (B) The client's weight is appropriate for her height. Obesity or pregnancy weight >20% of the ideal weight is a contributing factor to the development of gestational diabetes. (C) The birth of an infant weighing >9 lb (4000 g) is an identified risk factor for gestational diabetes. (D) A familial history of heart disease is insignificant in the development of diabetes. However, a familial history of type II diabetes mellitus is identified as a risk factor in the development of diabetes during pregnancy.

• Question 178:

  A registered nurse is trying to determine the appropriate care that she should provide for her obstetrical clients. Which of the following documents is considered the legal standard of practice?

  A. State nursing practice act

  B. AWHONN Standards for the Nursing Care of Women and Newborns

  C. American Nurses' Association Standards of Maternal- Child Health Nursing

  D. International Council of Nurses' Code

  Correct Answer: A

  (A) The state nursing practice act determines the standard of care for the professional nurse. (B) AWHONN Standards are published as recommendations and guidelines for maternal-newborn nursing. (C) American Nurses' Association Standards are published as recommendations and guidelines for maternalchild health nursing. (D) The International Council of Nurses' Code emphasizes the nurse's obligations to the client rather than to the physician. It is published as recommendations and guidelines by the international organization for professional nursing.

• Question 179:

  On morning rounds, the nurse found a manic-depressive client who is taking lithium in a confused mental state, vomiting, twitching, and exhibiting a coarse hand tremor. Which one of the following nursing actions is essential at this time?

  A. Administer her next dosage of lithium, and then call the physician.

  B. Withhold her lithium, and report her symptoms to the physician.

  C. Place her on NPO to decrease the excretion of lithium from her body, and call the physician.

  D. Contact the lab and request a lithium level in 30 minutes, and call the physician.

  Correct Answer: B

  (A) The client has lithium toxicity, and the nurse must withhold further dosages. (B) Because of her level of toxicity, further lithium could cause coma and death. The nurse needs further orders from the physician to stabilize the client's lithium level. (C) Ensuring adequate intake of sodium chloride will promote excretion of lithium and will assist in managing the client's lithiumtoxicity. (D) A lithium blood level must be drawn immediately to determine the seriousness of the toxicity and to provide the physician with data for medical orders.

• Question 180:

  The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to:

  A. Wear gloves for the procedure

  B. Place and adjust the pad from back to front

  C. Cleanse and wipe the perineum from front to back

  D. Protect the outer surface of the pad from contamination

  Correct Answer: C

  (A) Perineal hygiene is a clean procedure and does not require the client to wear gloves. A care provider should wear gloves to adhere to universal precautions. (B) The pad should be applied from front to back to prevent contamination of the birth canal or urinary tract from rectal bacteria. (C) Wiping from front to back and discarding the wipe prevents contamination of the urinary tract and birth canal from rectal bacteria. (D) The inner surface of the pad should not be touched to maintain asepsis.