NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 231:

  The physician of a client diagnosed with alcoholism orders neomycin 0.5 g q6h to prevent hepatic coma. Neomycin decreases serum ammonia levels by:

  A. Decreasing nitrogen-forming bacteria in the intestines

  B. Acidifying colon contents by causing ammonia retention in the colon

  C. Decreasing the uptake of vitamin D, thereby drawing more water into the colon

  D. Irritating the bowel and promoting evacuation of stool

  Correct Answer: A

  (A) Neomycin interferes with protein synthesis in the bacterial cell, causing bacterial death. Neomycin reduces the growth of the ammonia-producing bacteria in the intestines and is used for the treatment of hepatic coma. (B) This choice describes the action of lactulose, another drug commonly used to decrease systemic ammonia levels. (C) Neomycin's action doesnotdecrease uptake of vitamin D to reduce serum ammonia levels. (D) Bowel irritation with diarrhea is more likely to occur with administration of lactulose rather than of neomycin. Besides, diarrhea is a side effect of a drug, not the action of the drug.

• Question 232:

  A client is a victim of domestic violence. She is now receiving assistance at a shelter for battered women. She tells the nurse about the cycle of violence that she has been experiencing in her relationship with her husband of 5 years. In the "tension-building phase," the nurse might expect the client to describe which of the following?

  A. Promises of gifts that her husband made to her

  B. Acute battering of the client, characterized by his volatile discharge of tension

  C. Minor battering incidents, such as the throwing of food or dishes at her

  D. A period of tenderness between the couple

  Correct Answer: C

  (A) This description is characteristic of the "honeymoon" or "respite" phase. (B) This description is characteristic of the "battering" phase. (C) This description is characteristic of the "tension- building" phase prior to the volatile discharge of tension found in the battering phase. (D) This description is characteristic of the "honeymoon" or "respite" phase.

• Question 233:

  A client who is gravida 1 para 1 vaginally delivered a 7- lb girl. She received a midline episiotomy at delivery. When assessing the level of her uterus immediately following delivery, the nurse would expect the fundus to be located:

  A. At the umbilicus

  B. At the symphysis pubis

  C. Midway between the umbilicus and the xiphoid process

  D. Midway between the umbilicus and the symphysis pubis

  Correct Answer: D

  (A) Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. (B) The uterus descends into the pelvic cavity at approximately 10?2 postpartal days and can no longer be palpated abdominally. (C) Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. An enlarged uterus may indicate subinvolution or postpartal hemorrhage. (D) Immediately following delivery, the uterus lies midline, about midway between the umbilicus and the symphysis pubis.

• Question 234:

  A female client at 37 weeks' gestation has just undergone a nonstress test. The results were two fetal movements with a corresponding increase in fetal heart rate (FHR) of 15 bpm lasting 15 seconds within a 20-minute period. Her results would be classified as:

  A. Reactive; needs follow-up contraction stress test

  B. Reactive; no contraction stress test required

  C. Non-reactive; needs follow-up contraction stress test

  D. Non-reactive; no contraction stress test required

  Correct Answer: B

  (A) A contraction stress test is unnecessary following a reactive (normal) nonstress test. (B) The results are considered reactive, indicating that the fetus is not showing distress. Therefore, a contraction stress test, which is a more in-depth test for fetal distress, is unnecessary. (C) A nonreactive test would show fewer than two fetal movements or a failure of the FHR to increase at least 15 bpm with the movements in a 20-minute period. (D) A contraction stress test should follow a nonreactive nonstress test to validate fetal distress.

• Question 235:

  A client has chronic obstructive pulmonary disease. She is slowly losing weight, and her daughter is very concerned about increasing her nutrition. The nurse helps the daughter devise a plan of care for her mother. The plan of care should include which of the following interventions to promote nutrition?

  A. Offer her oral hygiene before and after meals.

  B. Encourage her to consume milk products.

  C. Encourage her to engage in an activity before a meal to stimulate her appetite.

  D. Restrict her fluid intake to three glasses of water a day.

  Correct Answer: A

  (A) Clients with respiratory diseases are generally mouth breathers. Cleaning the oral cavity may improve the client's appetite, increase her feelings of well-being, and remove the taste and odor of sputum. (B) Milk causes thick sputum; therefore, milk products would not be beneficial for this client. (C) Exercise prior to a meal would require increased O2 consumption and most likely would decrease the client's ability to eat. (D) Clients with respiratory diseases need increased fluid to liquefy secretions.

• Question 236:

  A 4-week-old infant is admitted to the emergency room in respiratory distress. Which of the following statements indicates the nurse's knowledge of the anatomy of the respiratory system in pediatric clients?

  A. The diameter of the trachea is much smaller in children than in adults.

  B. The tongue is proportionally smaller in children than in adults.

  C. The pediatric airway is more rigid than that of the adults.

  D. The length of the pediatric airway is longer in children than in adults.

  Correct Answer: A

  (A)

  The airway in children is much smaller than it is in adults. The diameter of the trachea in the newborn is 4 mm and that of the adult is 20 mm. A small change in the diameter of the airway can make a major difference in the pediatric client.

  (B)

  The tongue is proportionally larger in children and fills most of the oral cavity, thereby decreasing air space. (C) The entire pediatric airway is elastic. Elasticity diminishes with age, however. (D) The distances between respiratory structures are shorter than that of adults, and therefore organisms are able to move more rapidly down the throat, leading to more extensive respiratory involvement.

• Question 237:

  A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy:

  A. Prevents the development of ophthalmia neonatorum

  B. Assists the baby's clotting mechanism

  C. Breaks down bilirubin in the skin into substances that can be excreted in stool or urine

  D. Increases levels of unconjugated bilirubin, thereby preventing kernicterus (brain damage)

  Correct Answer: C

  (A) The instillation of erythromycin ophthalmic preparation, not phototherapy, prevents ophthalmia neonatorum. (B) The administration of vitamin K (AquaMEPHYTON) assists the infant's clotting mechanism. (C) Excessive bilirubin accumulates when the infant's liver cannothandle the increased load caused by the breakdown of red blood cells postnatally. This excessive bilirubin seeps out of the blood and into the tissues, staining them yellow. Phototherapy accelerates the removal of bilirubin from the skin by breaking it down into substances that can be excreted in stool or urine. (D) Phototherapy decreases levels of unconjugated bilirubin, thereby preventing kernicterus.

• Question 238:

  A female client has been recently diagnosed as bipolar. She has taken lithium for the past several weeks to control mania. What must be included in client education regarding lithium toxicity?

  A. Maintain a normal diet; however, limit salt intake to no more than 3 g/day.

  B. Take lithium between meals to increase absorption.

  C. Withhold lithium if experiencing diarrhea, vomiting, or diaphoresis.

  D. For pain or fever, avoid aspirin or acetaminophen (Tylenol). Nonsteroidal anti- inflammatory drugs are preferred.

  Correct Answer: C

  (A) The client should maintain a normal diet including normal salt intake. A low-sodium diet can cause lithium retention, leading to toxicity. (B) Lithium must be taken with meals because it is irritating to the gastric mucosa. (C) Diarrhea, vomiting, or diaphoresis can cause dehydration, which will increase lithium blood levels. If these symptoms occur, the nurse should instruct the client to withhold lithium. (D) Lithium is not to be taken with over- the-counter drugs without specific instruction. Some drugs raise lithium levels, whereas others lower lithium levels.

• Question 239:

  A 78-year-old female client has a total hip arthroplasty. Her nurse should know that which of the following is contraindicated?

  A. Encourage exercises in the unaffected extremities.

  B. Encourage her to cross and uncross her legs.

  C. Check neurological and circulatory status of the affected leg hourly.

  D. Place a trochanter roll along the upper thigh of the affected leg.

  Correct Answer: B

  (A) Exercising the unaffected extremities will prevent contractures and emboli. (B) Crossing and uncrossing the affected leg after surgery can dislocate the joint. (C) Neurological and circulatory status of the affected leg has been compromised by surgery. Hourly checks are needed to monitor the status of the leg. (D) A trochanter roll will prevent the upper thigh from rolling outward, increasing the chances of dislocation.

• Question 240:

  A male client tells his nurse that he has had an ulcer in the past and is afraid it is "flaring up again." The nurse begins to ask him specific questions about his symptoms. The nurse knows that a symptom that might indicate a serious complication of an ulcer is:

  A. Pain in the middle of the night

  B. A bowel movement every 3? days

  C. Melena

  D. Episodes of nausea and vomiting

  Correct Answer: C

  (A) Clients with ulcers generally experience abdominal pain. It is common to have pain in the early morning hours with an ulcer. (B) Constipation is not a symptom associated with ulcers and would indicate a need to look at other factors. (C) Melena is blood in the stools. This could indicate a slow bleeding ulcer, which could result in significant amounts of blood loss over time.(D) Nausea and vomiting may be present as a result of the ulcer, especially if it is a gastric ulcer. This does not indicate an immediate life-threatening complication.