NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 221:

  A 64-year-old client is admitted to the hospital with benign prostatic hypertrophy (BPH). He has a history of adult-onset diabetes and hypertension and is scheduled to undergo a resection of the prostate. When recording his health history, the nurse asks about his chief complaint. The most serious symptom that may accompany BPH is:

  A. Acute urinary retention

  B. Hesitancy in starting urination

  C. Increased frequency of urination

  D. Decreased force of the urinary stream

  Correct Answer: A

  (A) Acute urinary retention requires urgent medical attention. If measures such as a warm tub bath or warm tea do not occur after 6 hours, the client should go to the ED for catheterization. (B, C, D) This choice is a symptom of BPH, but it is not serious or life threatening.

• Question 222:

  A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U +1 in contrast to the previous assessment of U _2. The immediate nursing response is to:

  A. Administer methergine IM

  B. Remove the retained placental fragments

  C. Assist the client to the bathroom and provide cues to stimulate urination

  D. Massage the fundus until firm

  Correct Answer: D

  (A) Methergine is given following placental delivery to promote uterine contractions and prevent hemorrhage. Methergine may be administered in this clinical situation, but fundal massage would be the first response. (B) Removal of retained placental fragments is done by the physician and is not the first response. (C) If the fundus rises and is deviated, particularly to theright, the nurse should suspect bladder distention secondary to bladder and urethral trauma associated with birth and decreased bladder tone following delivery. Therefore, women have a diminished sensation to void. (D) A boggy fundus rises and is indicative of blood pooling, predisposing the woman to clot formation. Massage the uterus until firm. Too vigorous massage will result in atonia. Clots may be expelled by a kneading motion of the uterus by the nurse.

• Question 223:

  The nurse is caring for a 2-year-old girl with a subdural hematoma of the temporal area as a result of falling out of bed and notices that she has a runny nose. The nurse should:

  A. Call the doctor immediately

  B. Help her to blow her nose carefully

  C. Test the discharge for sugar

  D. Turn her to her side

  Correct Answer: C

  (A) The nasal discharge could be due to a cold. It is necessary to gather additional assessment data to identify a possible cerebrospinal fluid leak. (B) If the discharge is cerebrospinal fluid, it would not be safe to encourage the girl to blow her nose. (C) Cerebrospinal fluid is positive for sugar; mucus is not. (D) Turning her to her side will have no effect on her "runny nose." It is necessary to gather further assessment data.

• Question 224:

  A client is resting comfortably after delivering her first child. When assessing her pulse rate, the nurse would recognize the following finding to be typical:

  A. Thready pulse

  B. Irregular pulse

  C. Tachycardia

  D. Bradycardia

  Correct Answer: D

  (A) A thready pulse is indicative of hypotension and excessive blood loss and is often rapid. (B) Pulse irregularities or dysrhythmias do not occur in the normal postpartal woman. (C) Tachycardia occurs less frequently than bradycardia and is related to increased blood loss or prolonged difficult labor and/or birth. (D) Puerperal bradycardia with rates of 50?0 bpm commonly occurs during the first 6?0 days of the postpartal period. It may be related to decreased cardiac strain, decreased blood volume, contraction of the uterus, and increased stroke volume.

• Question 225:

  A client who has been diagnosed with anorexia nervosa refuses to eat lunch. The most therapeutic response by the nurse to her refusal is:

  A. "Okay, missing one meal won't hurt."

  B. "You'll have to eat lunch, or we'll force-feed you."

  C. "It's not appropriate for you to try to manipulate the staff into granting your wishes."

  D. "We will not allow you to starve yourself. You may choose to eat voluntarily or be fed."

  Correct Answer: D

  (A) This response reinforces the client's maladaptive behavior, thereby contributing to the client's risk. (B) Ultimatums are not therapeutic. (C) This comment invites an argument because it puts the client on the defensive and stabs at her self-esteem, which is already compromised. (D) Setting limits assures the client that staff has genuine concern for her safety and well-being. Giving her an actual choice will give the client an increased sense of control over her life and avoid an argument or power struggle.

• Question 226:

  A chronic alcoholic client's condition deteriorates, and he begins to exhibit signs of hepatic coma. Which of the following is an early sign of impending hepatic coma?

  A. Hiccups

  B. Anorexia

  C. Mental confusion

  D. Fetor hepaticus

  Correct Answer: C

  (A)

  Hiccups are not a sign of impending hepatic coma. (B) Anorexia is not a sign of impending hepatic coma. (C) One of the earliest symptoms of hepatic coma is mental confusion. Asterixis, a flapping tremor of the hand, may also be seen.

  (D)

  This sign is associated with the later stages of hepatic coma. Fetor hepaticus, a characteristic odor on the breath that smells like acetone, may sometimes be noted when the liver fails.

• Question 227:

  After 7 hours in restraints and a total of 30-mg haloperidol in divided doses, a client complains of stiffness in his neck and his tongue "pulling to one side." These extrapyramidal symptoms (EPS) will most likely be relieved by the administration of:

  A. Lorazepam (Ativan)

  B. Benztropine (Cogentin)

  C. Thiothixene (Navane)

  D. Flurazepan (Dalmane)

  Correct Answer: B

  (A) Lorazepam is an antianxiety agent that produces muscle relaxation and inhibits cortical and limbic arousal. It has no action in the basal ganglia of the brain. (B) Benztropine acts to reduce EPS by blocking excess CNS cholinergic activity associated with dopamine deficiency in the basal ganglia by displacing acetylcholine at the receptor site. (C) Thiothixene is an antipsychotic known to block dopamine in the limbic system, thereby causing EPS. (D) Flurazepan is a hypnotic that acts in the limbic system, thalamus, and hypothalamus of the CNS to produce sleep. It has no known action in the vasal ganglia.

• Question 228:

  A 48-year-old male client is hospitalized with mild ascites, bruising, and jaundice. He has a 20-year history of alcohol abuse. The client is diagnosed with cirrhosis. His serum ammonia level is high, indicating hepatic encephalopathy. He has esophageal varices. Which of the following may cause the varices to rupture?

  A. Lifting heavy objects

  B. Walking briskly

  C. Ingestion of barbiturates

  D. Ingestion of antacids

  Correct Answer: A

  (A) Lifting heavy objects will increase intrathoracic pressure, thus placing the client at risk for rupturing esophageal varices. (B, C, D) This activity will not cause an increase in intrathoracic pressure.

• Question 229:

  The healthcare team determines that an elderly client has had progressive changes in memory over the last 2 years that have interfered with her personal, social, or occupational functioning. Her memory, learning, attention, and judgment have all been affected in some way. These symptoms describe which of the following conditions?

  A. Dementia

  B. Parkinsonism

  C. Delirium

  D. Mania

  Correct Answer: A

  (A) These changes are common characteristics of dementia. (B) Parkinson's disease affects the muscular system. Progressive memory changes are not presenting symptoms. (C) Delirium includes an altered level of consciousness, which is not found in dementia. (D) Mania includes symptoms of hyperactivity, flight of ideas, and delusions of grandeur.

• Question 230:

  A 6-year-old girl is visiting the outpatient clinic because she has a fever and a rash. The doctor diagnoses chickenpox. Her mother asks the nurse how many baby aspirins her daughter can have for fever. The nurse should:

  A. Advise the mother not to give her aspirin

  B. Ask if the client is allergic to aspirin before giving further information

  C. Assess the function of the client's cranial nerve VIII

  D. Check the aspirin bottle label to determine milligrams per tablet

  Correct Answer: A

  (A) Aspirin taken during a viral infection has been implicated as a predisposing factor to Reye's syndrome in children and adolescents. Children and adolescents should not be given aspirin. (B) Allergy to aspirin is not related to Reye's syndrome. (C) Tinnitus, caused by damage to the acoustic nerve, occurs with aspirin toxicity, but this is not related to Reye's syndrome. (D) A 6-year-old child should not be given any baby aspirin.