NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 191:

  A client is admitted to the labor room. She is dilated 4 cm. She is placed on electric fetal monitoring. Which of the following observations necessitates notifying the physician?

  A. Contractions every 2 minutes, lasting 100 seconds

  B. Fetal heart decelerations during a contraction

  C. Beat-to-beat variability between contractions

  D. Fetal heart decelerations at the beginning of contractions

  Correct Answer: A

  (A) These are tetanic in nature and can cause rupture of the uterus. (B) The FHR decreases during contractions owing to vasoconstriction and should recover after the contraction. (C) Beat-to-beat variability is a normal finding and demonstrates fetal well- being. (D) The FHR may decrease at the beginning of a contraction owing to head compression.

• Question 192:

  In acute episodes of mania, lithium is effective in 1? weeks, but it may take up to 4 weeks, or even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms. In addition to the lithium, which one of the following medications might the physician prescribe?

  A. Diazepam (Valium)

  B. Haloperidol (Haldol)

  C. Sertraline (Zoloft)

  D. Alprazolam (Xanax)

  Correct Answer: B

  (A) Diazepam is an antianxiety medication and is not designed to reduce psychotic symptoms. (B) Haloperidol is an antipsychotic medication and may be used until the lithium takes effect. (C) Sertraline is an antidepressant and is used primarily to reduce symptoms of depression. (D) Alprazolam is an antianxiety medication and is not designed to reduce psychotic symptoms.

• Question 193:

  A husband and wife and their two children, age 9 and age 5, are requesting family therapy. Which of the following strategies is most therapeutic for the nurse to use during the initial interaction with a family?

  A. Always allow the most vocal person to state the problem first.

  B. Encourage the mother to speak for the children.

  C. Interpret immediately what seems to be going on within the family.

  D. Allow family members to assume the seats as they choose.

  Correct Answer: D

  (A) One will always hear what the most vocal person has to say. It is best to start with the quietest family member to encourage that person to express emotions. (B) All family members are encouraged to speak for themselves. (C) In the initial family assessment, only data collection occurs; interpretations are made later. (D) Allowing family members to choose their own seats will assist the nurse in assessing the family system and in determining who feels closer to whom.

• Question 194:

  A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?

  A. Give fluids if the client requests them.

  B. Assess skin integrity and circulation of extremities before applying restraints and as they are removed.

  C. Measure vital signs at least every 4 hours.

  D. Release restraints every 2 hours for client to exercise.

  Correct Answer: D

  (A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly while the client is restrained, not only before restraints are applied and after they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains agitated in restraints, vital signs should be monitored even more closely, perhaps every 1? hours. (D) Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation.

• Question 195:

  Which of the following blood values would require further nursing action in a newborn who is 4 hours old?

  A. Hemoglobin 17.2 g/dL

  B. Platelets 250,000/mm3

  C. Serum glucose 30 mg/dL

  D. White blood cells 18,000/mm3

  Correct Answer: C

  (A) The normal range for hemoglobin in the newborn is 17?9 g/dL; 17.2 g/dL is within normal limits. (B) A normal value range for platelets in the newborn is 150,000?00,000 mm3; 250,000/mm3 is within normal range. (C) A serum glucose of 30 mg/dL in the first 72 hours of life is indicative of hypoglycemia and warrants further intervention. (D) On the day of birth, a white blood cell count of 18,000?0,000/mm3 is normal in the newborn.

• Question 196:

  While the nurse is taking a male client's blood pressure, he makes flirtatious remarks to her. The nurse will handle this effectively if she:

  A. Politely tells the client, "Keep your hands off "

  B. Ignores the remarks and hopes he will not try it again

  C. Confronts the remarks but attempts not to reject the client

  D. Leaves the room in order to compose herself

  Correct Answer: C

  (A) This response does not recognize normal feelings of attraction and rejects the client. (B) By ignoring the situation, the nurse has not set limits to discourage other remarks or perhaps more sexually aggressive behavior. (C) By confronting the remarks, she can recognize that his feelings of attraction may be normal but are not appropriate within the context of their nurse-client relationship. (D) Leaving the room does not deal with setting limits for future interactions.

• Question 197:

  A client has had amniocentesis. One of the tests performed on the amniotic fluid is a lecithin/sphingomyelin (L/S) ratio. The results show a ratio of 1:1. This is indicative of:

  A. Lung immaturity

  B. Intrauterine growth retardation (IUGR)

  C. Intrauterine infection

  D. Neural tube defect

  Correct Answer: A

  (A) At about 30?2 weeks' gestation, the amounts of the surfactants, lecithin, and sphingomyelin become equal. As the fetal lungs mature, the concentration of lecithin begins to exceed that of sphingomyelin. At 35 weeks, the L/S ratio is 2:1. Respiratory distress syndrome is unlikely if birth occurs at this time. (B) IUGR is associated with compromised uteroplacental perfusion or with viral infections, chromosomal disorders, congenital malformations, and maternal malnutrition. IUGR is not specifically assessed by analysis of the L/S ratio. (C) Analysis of the L/S ratio is not an assessment used to confirm intrauterine infection. (D) Elevated levels of _-fetoprotein in maternal serum or in amniotic fluid have been found to reflect open neural tube defects, such as spina bifida and anencephaly.

• Question 198:

  A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, "The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart." The nurse's best response is:

  A. "I know you're feeling frightened right now, but I want you to know that I don't see anyone in the corner."

  B. "You'll probably see strange things for a while until the PCP wears off."

  C. "Try to sleep. When you wake up, the devil will be gone."

  D. "You're probably feeling guilty because you used illegal drugs tonight."

  Correct Answer: A

  (A) The nurse is the client's link to reality. This response validates the authenticity of the client's experience by casting doubt on his belief and reinforcing reality. (B) Although this statement may be literally correct, it is nontherapeutic because it lacks validation. (C) This response encourages the client to attempt to do something that may be impossible at this time, offers false reassurance, and reinforces delusional content. (D) The nurse is making an incorrect assumption about the client's feelings by offering a nontherapeutic interpretation of the motivation for the client's actions.

• Question 199:

  An 18-year-old girl is admitted to the hospital with a depressed skull fracture as a result of a car accident. If the nurse were to observe a rising pulse rate and lowering blood pressure, the nurse would suspect that the client:

  A. Has a sudden and severe increase in intracranial pressure

  B. Has sustained an internal injury in addition to the head injury

  C. Is beginning to experience a dangerously high level of anxiety

  D. Is having intracranial bleeding

  Correct Answer: B

  (A) Widening pulse pressure (high systolic and low diastolic) with compensatory slowing of pulse rate are late signs of increasing ICP. (B) Rising pulse rate and lowering blood pressure are indicative of hypovolemia due to hemorrhage. (C) High anxiety, in the absence of hemorrhage, would result in a high pulse rate and a high blood pressure. (D) Intracranial bleeding results in increased ICP. A change in level of consciousness is an early sign of increasing ICP, and vital sign changes are late signs of increasing ICP.

• Question 200:

  A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, "Why did this happen to my baby?" is:

  A. "It's God's will. It was probably for the best. There was something probably wrong with your baby."

  B. "You're young. You can have other children later."

  C. "I know your other children will be a great comfort to you."

  D. "I can see you're upset. Would you like to see and hold your baby?"

  Correct Answer: D

  (A) The mother and the father require support; the nurse should not minimize their grief in this situation. (B) Attachment to this infant occurs during the pregnancy for both the mother and father. Another child cannot replace this child. (C) Attachment to this infant occurs during the pregnancy for both the mother and father. Siblings will not replace their feelings or minimize their loss of this infant. (D) Holding and viewing the infant decreases denial and may facilitate the grief process. The nurse should prepare family members for how the infant appears ("she is bruised") and provide support.