NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 201:

  Two weeks after a client's admission for depression, the physician orders a consult for electroconvulsive therapy (ECT). Which of the following conditions, if present, would be a contraindication for ECT?

  A. Brain tumor or other space-occupying lesion

  B. History of mitral valve prolapse

  C. Surgically repaired herniated lumbar disk

  D. History of frequent urinary tract infections

  Correct Answer: A

  (A) A contraindication for ECT is a space-occupying lesion such as a brain tumor. During ECT, intracranial pressure increases. Therefore, ECT would not be prescribed for a client whose intracranial pressure is already elevated. (B) Any cardiac dysrhythmias or complications that arise during ECT are usually attributed to the IV anesthetics used, not to preexisting cardiac structural conditions. (C) Musculoskeletal injuries during ECT are extremely rare because of the IV use of centrally acting muscle relaxers. (D) A history of any kind of infection would not contraindicate the use of ECT. In fact, concurrent treatment of infections with ECT is not uncommon.

• Question 202:

  The nurse in the mental health center is instructing a depressed client about the dietary restrictions necessary in taking her medication, which is a monoamine oxidase (MAO) inhibitor. Which of the following is she restricting from the client's diet?

  A. Cream cheese

  B. Fresh fruits

  C. Aged cheese

  D. Yeast bread

  Correct Answer: C

  (A) Cream cheese does not contain tyramine, which might cause a hypertensive crisis. (B) Fresh fruits do not contain tyramine, which might cause a hypertensive crisis. (C) Aged or matured cheese combined with a monoamine oxidase predisposes the client to a hypertensive crisis. (D) Bread products raised with yeast do not contain tyramine.

• Question 203:

  When assessing the client 6 hours postpartum, the fundus is found to be U +3, displaced to the right of midline, and slightly boggy. The nurse would first:

  A. Increase the IV oxytocin drip rate

  B. Give methergine IM

  C. Assess for a full bladder

  D. Grasp the uterus and massage vigorously

  Correct Answer: C

  (A) Oxytocin may not be necessary if the bladder is emptied and if the uterus remains firm, midline, and at about U11 after massage. (B) The same rationale as for answer "A" applies. (C) A full bladder is the most common cause of uterine atony. If the bladder is full, it should be emptied and the uterus reassessed before further intervention. (D) If the bladder is full, the uteruswill not stay contracted or return to a normal position. Overly vigorous massage also encourages uterine atony.

• Question 204:

  A client's prenatal screening indicated that she has no immunity to rubella. She is now 10 weeks pregnant. The best time to immunize her is:

  A. In the immediate postpartum period

  B. After the first trimester

  C. At 28 weeks' gestation

  D. Within 72 hours postpartum

  Correct Answer: A

  (A) The rubella vaccine is made with attenuated virus and is given in the immediate postpartal period to prevent infection during pregnancy and subsequent adverse fetal and neonatal sequelae. Mothers are advised to prevent pregnancy for 3 months following immunization. (B) Rubella infection during the second trimester may result in permanent hearing loss for the fetus. (C) RhoGam is the drug generally administered at 28 weeks' gestation to Rh-negative women. It is contraindicated to administer rubella vaccine during pregnancy. (D) RhoGam is the drug administered within 72 hours postpartum to Rh- negative women to prevent the development of antibodies to fetal cells.

• Question 205:

  In healthcare settings, nurses must be familiar with primary, secondary, and tertiary levels of care. As a nurse in the community, which of the following interventions might be a primary prevention strategy?

  A. Crisis intervention with an intoxicated teenager whose mother just committed suicide

  B. Referring a client who has been on a detoxification unit to a rehabilitation center

  C. Teaching fifth-grade children the harmful effects of substance abuse

  D. Counseling a client with post-traumatic stress disorder

  Correct Answer: C

  (A) The teenager is already coping ineffectively and requires early detection and treatment, which is secondary prevention. (B) The client must be sent to a rehabilitation unit, which requires tertiary prevention. (C) Reducing the incidence of disease through education supports primary prevention. (D) A client with identified symptoms of post-traumatic stress disorder requires intervention by treatment.

• Question 206:

  A family is experiencing changes in their lifestyle in many ways. The invalid grandmother has moved in with them. The couple have a 2-year-old son by their marriage, and the wife has two children by her previous marriage. The older children are in high school. In applying systems theory to this family, it is important for the nurse to remember which of the following principles?

  A. The parts of a system are only minimally related.

  B. Dysfunction in one part affects every other part.

  C. A family system has no boundaries.

  D. Healthy families are enmeshed.

  Correct Answer: B

  (A) The parts of a system are interrelated. (B) Any change in any part of the system affects all other parts. (C) A family system, like any other system, has boundaries. (D) Healthy families are neither enmeshed nor disengaged.

• Question 207:

  A 35-year-old primigravida comes to the clinic for her first prenatal visit. The midwife, on examining the client, suspects that she is approximately 11 weeks pregnant. The pregnancy is positively confirmed by finding:

  A. Chadwick's sign

  B. FHR by ultrasound

  C. Enlargement of the uterus

  D. Breast tenderness and enlargement

  Correct Answer: B

  (A) Chadwick's sign is a presumptive sign of pregnancy. The coloration may not subside from past pregnancy or could be caused by other situations that create vasocongestion. (B) FHR (movement) observed on ultrasound is a positive diagnosis of pregnancy. (C) Enlargement of the uterus may be due to fibroids or infection. It is considered a probable sign. (D) Breast tenderness and enlargement is a presumptive sign because it may be due to other conditions, such as premenstrual changes.

• Question 208:

  A female client with major depression stated that "life is hopeless and not worth living." The nurse should place highest priority on which of the following questions?

  A. "How has your appetite been recently?"

  B. "Have you thought about hurting yourself?"

  C. "How is your relationship with your husband?"

  D. "How has your depression affected your daily livingactivities?"

  Correct Answer: B

  (A) Although eating habits are important to assess, they are less important than suicidal intent. (B) Maintenance of the client's life is the priority; assessment of suicidal intent is imperative. (C) Relationships and support systems are an important part of assessment, but they are less important than suicidal intent. (D) Daily living activities will give additional information about the level of depression, and are less significant than suicidal intent, although this information may give additional information about the actual plan for a suicidal attempt.

• Question 209:

  In counseling a client, the nurse emphasizes the danger signals during pregnancy. On the next visit, the client identifies which of the following as a danger signal that should be reported immediately?

  A. Backache

  B. Leaking of clear yellow fluid from breasts

  C. Constipation with hemorrhoids

  D. Visual changes

  Correct Answer: D

  (A) Backache is a common complaint during pregnancy. Proper body mechanics, pelvic rock, back rubs, and other comfort measures should relieve the discomfort. In the presence of uterine contractions, the backache would radiate to the lower abdomen. (B) Colostrum is normal and can be present anytime in the second half of pregnancy. (C) Constipation and hemorrhoids are common and do need attention, but they do not constitute a dangerous situation. (D) Visual changes are possibly related to PIH. The client should be assessed immediately to rule out or prevent worsening of PIH.

• Question 210:

  The client will be more comfortable and the results more accurate when the nurse prepares the client for Leopold's maneuvers by having her:

  A. Empty her bladder

  B. Lie on her left side

  C. Place her arms over her head

  D. Force fluids 1 hour prior to procedure

  Correct Answer: A

  (A) A full bladder would cause discomfort and possible urinary incontinence during the exam. (B) The left side-lying position would not accommodate the exam. The head of the exam table or bed can be slightly elevated to prevent supine hypotension. (C) Arms extended over the head would cause the abdomen to be tighter and less easily palpable. (D) Forcing fluids would encourage a full bladder, which is not desired for the exam.