NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 11:

  The nurse is in the hallway and one of the visitors faints. The nurse should:

  A. Sit the victim up and lightly slap his face

  B. Elevate the victim's legs

  C. Apply a cool cloth to the victim's neck and forehead until he recovers

  D. Sit the victim up and place the head between the knees

  Correct Answer: B

  (A) Sitting the client up defeats the goal of re-establishing cerebral blood flow. (B) Elevating the legs anatomically redirects blood flow to the cerebral area. (C) This strategy is a nice general comfort measure after the victim has regained consciousness. (D) This strategy is not as effective a strategy in helping the client to regain consciousness as elevating the legs.

• Question 12:

  A client states to his nurse that "I was told by the doctor not to take one of my drugs because it seems to have caused decreasing blood cells." Based on this information, which drug might the nurse expect to be discontinued?

  A. Prednisone

  B. Timolol maleate (Blocadren)

  C. Garamycin (Gentamicin)

  D. Phenytoin (Dilantin)

  Correct Answer: D

  (A) Prednisone is not linked with hematological side effects. (B) Timolol, a -adrenergic blocker is metabolized by the liver. It has not been linked to blood dyscrasia. (C) Gentamicin is ototoxic and nephrotoxic. (D) Phenytoin usage has been linked to blood dyscrasias such as aplastic anemia. The drug most commonly linked to aplastic anemia is chloramphenicol (Chlormycetin).

• Question 13:

  A female baby was born with talipes equinovarus. Her mother has requested that the nurse assigned to the baby come to her room to discuss the baby's condition. The nurse knows that the pediatrician has discussed the baby's condition with her mother and that an orthopedist has been consulted but has not yet seen the baby. What should the nurse do first?

  A. Call the orthopedist and request that he come to see the baby now.

  B. Question the mother and find out what the pediatrician has told her about the baby's condition.

  C. Tell the mother that this is not a serious condition.

  D. Tell the mother that this condition has been successfully treated with exercises, casts, and/or braces.

  Correct Answer: B

  (A) The nurse should call the orthopedist after assessing the mother's knowledge. (B) The nurse must first assess the knowledge of the parent before attempting any explanation. (C) The nurse should assess the mother's knowledge of the baby's condition as the first priority. (D) This answer is correct, but the priority is B.

• Question 14:

  Morphine sulfate 4 mg IV push q2h prn for chest pain was ordered for a client in the emergency room with severe chest pain. The nurse administering the morphine sulfate knows which of the following therapeutic actions is related to the morphine sulfate?

  A. Increased level of consciousness

  B. Increased rate and depth of respirations

  C. Increased peripheral vasodilation

  D. Increased perception of pain

  Correct Answer: C

  (A) Morphine sulfate, a narcotic analgesic, causes sedation and a decrease in level of consciousness. (B) The side effects of morphine sulfate include respiratory depression. (C) Morphine sulfate causes peripheral vasodilation, which decreases afterload, producing a decrease in the myocardial workload. (D) Morphine sulfate alters the perception of pain through an unclear mechanism. This alteration promotes pain relief.

• Question 15:

  A child is to receive atropine 0.15 mg (1/400 g) as part of his preoperative medication. A vial containing atropine 0.4 mg (1/150 g)/mL is on hand. How much atropine should be given?

  A. 0.06 mL

  B. 0.38 mL

  C. 2.7 mL

  D. Information given insufficient to determine the amount of atropine to be administered

  Correct Answer: B

  (A, C) Information was incorrectly placed in the formula, resulting in an incorrect answer.

  (B) The answer is correct.

  0.4 mg = 1 mL:0.15 mg 5 = mL

  0.4 x = 0.15 x = 0.15/0.4 x = 0.375 or 0.38 mL

  (D) Sufficient information is provided to determine the amount of atropine to administer. The amount of atropine available and the amount of atropine ordered is required to determine the amount of atropine to be given.

• Question 16:

  A 14-year-old boy has had diabetes for 7 years. He takes 30 U of NPH insulin and 10 U of regular insulin every morning at 7 AM. He eats breakfast at 7:30 AM and lunch at noon. What time should he expect the greatest risk for hypoglycemia?

  A. 9 AM

  B. 1 PM

  C. 11 AM

  D. 3 PM

  Correct Answer: C

  (A) This time is incorrect because regular insulin would peak after the teenager has eaten breakfast. (B) This time is incorrect because it is after lunch when the NPH peaks. (C) Regular insulin peaks in 2? hours and has a duration of 4? hours. NPH insulin's onset is 4? hours and peaks in 8?6 hours. Blood sugar would peak after meals and be lowest before meals and during the night. (D) This time is incorrect because it is before the NPH and after the regular insulin peak times.

• Question 17:

  A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will teach her to:

  A. Limit activities which require focusing (close vision)

  B. Take more frequent naps

  C. Use artificial tears

  D. Wear a patch over one eye

  Correct Answer: D

  (A) Limiting activities requiring close vision will not alleviate the discomfort of double vision. (B) Frequent naps may be comforting, but they will not prevent double vision. (C) Artificial tears are necessary in the absence of a corneal reflex, but they have no effect on diplopia. (D) An eye patch over either eye will eliminate the effects of double vision during the time the eye patch is worn. An eye patch is safe for a person with an intact corneal reflex.

• Question 18:

  An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his left leg that started approximately 20 minutes ago. When performing the admission assessment, the nurse would expect to observe which of the following:

  A. Both lower extremities warm to touch with 2_pedal pulses

  B. Both lower extremities cyanotic when placed in a dependent position

  C. Decreased or absent pedal pulse in the left leg

  D. The left leg warmer to touch than the right leg

  Correct Answer: C

  (A) This statement describes a normal assessment finding of the lower extremities. (B) This assessment finding reflects problems caused by venous insufficiency. (C) Decreased or absentpedal pulses reflect a problem caused by arterial insufficiency. (D) The leg that is experiencing arterial insufficiency would be cool to touch due to the decreased circulation.

• Question 19:

  A 35-year-old client has returned to her room following surgery on her right femur. She has an IV of D5 in onehalf normal saline infusing at 125 mL/hr and is receiving morphine sulfate 10?5 mg IM q4h prn for pain. She last voided 51/2 hours ago when she was given her preoperative medication. In monitoring and promoting return of urinary function after surgery, the nurse would:

  A. Provide food and fluids at the client's request

  B. Maintain IV, increasing the rate hourly until the client voids

  C. Report to the surgeon if the client is unable to void within 8 hours of surgery

  D. Hold morphine sulfate injections for pain until the client voids, explaining to her that morphine sulfate can cause urinary retention

  Correct Answer: C

  (A) Provision of food and fluid promotes bowel elimination. Nutritional needs postoperatively are determined by the physician, not the client. (B) Increasing IV fluids postoperatively will not cause a client to void. Any change in rate of administration of IV fluids should be determined by the physician. (C) The postoperative client with normal kidney function who cannot void 8 hours after surgery is retaining urine. The client may need catheterization or medication. The physician must provide orders for both as necessary. (D) Although morphine sulfate can cause urinary retention, withholding pain medication will not ensure that the client will void. The client with uncontrolled pain will probably not be able to void.

• Question 20:

  A 27-year-old male client is admitted to the acute care mental health unit for observation. He has recently lost his job, and his wife told him yesterday that she wants a divorce. The client is placed on suicide precautions. In assessing suicide potential, the nurse should pay close attention to the client's:

  A. Level of insight

  B. Thought processes

  C. Mood and affect

  D. Abstracting abilities

  Correct Answer: C

  (A) Assessing the client's level of insight is an important part of the mental status exam (MSE), but it does not reflect suicide potential. (B) Assessing the client's thought processes is an important part of the MSE, but it does not reflect suicide potential. (C) Assessing the client's mood and affect is an important part of the MSE, and it can be a very valuable indicator of suicide potential. Frequently a client who has decided to proceed with suicide plans will exhibit a suddenly improved mood and affect. (D) Assessing a client's abstracting abilities is an important part of the MSE, but it does not reflect suicide potential.