NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 241:

  An infant weighing 15 lb has just been treated for severe diarrhea in the hospital. Discharge instructions by the nurse will include maintenance fluid requirements for the pediatric client. Which of the following values best indicates the nurse's understanding of normal fluid requirements for this infant?

  A. 240 mL/day

  B. 680 mL/day

  C. 330 mL/day

  D. 960 mL/day

  Correct Answer: B

  (A, C, D) These answers are incorrect. (B) Normal fluid requirement for this pediatric client is based on the fact that 0?0 kg of weight equals 100 mL/kg per day. This infant weighs 15 pounds (6.8 kg). Thus, 100 mL X 6.8 = 680 mL/day.

• Question 242:

  A female client comes for her second prenatal visit. The nurse-midwife tells her, "Your blood tests reveal that you do not show immunity to the German measles." Which notation will the nurse include in her plan of care for the client? "Will need . . .

  A. Rh-immune globulin at the next visit"

  B. Rh-immune globulin within 3 days of delivery"

  C. Rubella vaccine at the next visit"

  D. Rubella vaccine after delivery on the day of discharge"

  Correct Answer: D

  (A) Rh immune globulin is given to Rh-negative mothers to prevent the maternal Rh immune response. (B) Rh immune globulin is given to Rh-negative mothers to prevent the maternal Rh immune response. (C) The rubella vaccine is not given during pregnancy because of its teratogenicity. (D) Nonimmune mothers are vaccinated early in the postpartum period to prevent future infection with the rubella virus.

• Question 243:

  A client is receiving peritoneal dialysis. He has been taught to warm the dialyzing fluid prior to instilling it because:

  A. Warmed solution helps keep the body temperature maintained within a normal range during instillation

  B. Warmed solution helps dilate the peritoneal blood vessels

  C. Warmed solution decreases the risk of peritoneal infection

  D. Warmed solution promotes a relaxed abdominal muscle

  Correct Answer: B

  (A) Instilling a cool solution does not significantly lower the body temperature during peritoneal dialysis. (B) Warmed solution does help dilate the peritoneal blood vessels, facilitating the exchange of fluids. (C) Warming the dialysate does not decrease the risk of peritoneal infection. Sterile technique decreases this risk. (D) Relaxing the abdominal muscles does not facilitate peritoneal dialysis.

• Question 244:

  For the past several months, an elderly female client with Alzheimer's disease has experienced paranoia; hallucinations; and aggressive, disruptive behavior. The family is utilizing haloperidol as needed to control her behavior. On nursing assessment, you note that the client demonstrates involuntary movements of the tongue and fingers. This may most likely indicate:

  A. Tardive dyskinesia, which may be a side effect of antipsychotic medication

  B. Early symptoms of Parkinson's disease

  C. A more advanced stage of Alzheimer's disease than previously experienced by the client

  D. The need to change her medication from haloperidol to another antipsychotic drug to lessen symptoms

  Correct Answer: A

  (A) Tardive dyskinesia is a common side effect of antipsychotic medications such as haloperidol. Discontinuing the medication can alleviate symptoms. (B) Although mild tremors are an early sign of Parkinson's disease, haloperidol must be discontinued first and the client further evaluated. (C) These symptoms do not necessarily indicate a more advanced stage of Alzheimer's disease. (D) Most antipsychotic drugs are chemically similar and will produce the same side effects.

• Question 245:

  A female client plans to bottle-feed her newborn. Her physician has ordered bromocriptine (Parlodel) to suppress lactation. Which of the following instructions about bromocriptine should be given by the nurse?

  A. Bromocriptine stimulates the production of prolactin.

  B. Hypertension is a primary side effect.

  C. Bromocriptine is generally taken for 5 days.

  D. Her blood pressure must be stable before starting bromocriptine.

  Correct Answer: D

  (A) Bromocriptine inhibits the secretion of prolactin. (B) Hypotension is a side effect of this drug; hypertension is not. (C) Bromocriptine is generally taken for 14 days. (D) The administration of bromocriptine is delayed at least 4 hours postpartum and given only when the client's blood pressure is stable, because it can cause hypotension and syncope.

• Question 246:

  Newborns are routinely screened for phenylketonuria. The nursery nurse ensures that this screening test is performed:

  A. Immediately after birth, because the most accurate result is obtained at this time

  B. After 2

  Correct Answer: B

  (A) The infant has not ingested any protein immediately after birth, which is necessary to detect excessive serum phenylalanine. (B) It is important that the infant take in 2

• Question 247:

  A young child has been placed in a spica cast. The chief concern of the nurse during the first few hours is:

  A. Prevention of neurovascular complications

  B. Prevention of loss of muscle tone

  C. Immobilization of the affected limb

  D. Using heated fans to dry the cast

  Correct Answer: A

  (A) Because the extremity may continue to swell and the cast could constrict circulation, the nurse should elevate the limb and observe for capillary refill, warmth, mobility of toes and circulation. (B) Although muscle tone may diminish over time in the affected limb, this is not the immediate concern. (C) The limb has been immobilized already by the cast, and therefore immobilization is not a concern. (D) Heated fans and dryers are discouraged because the outside cast will dry quickly, yet the area beneath the cast remains wet and could cause burns.

• Question 248:

  A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?

  A. "I did not get the raise because my boss does not like me."

  B. "I felt a lump in my breast 2 weeks ago. I put off getting it checked until after my sister's wedding."

  C. "My son died 3 years ago. I still cannot bring myself to clean out his room."

  D. "My husband told me this morning that he wants a divorce. I am upset, but I cannot discuss the matter with him until after my company's board meeting today."

  Correct Answer: D

  (A) This statement is an example of adaptive rationalization. She is coping with her disappointment by rationalizing. This is adaptive because no harm is done to self or others. It is used to protect her ego. (B) This is an example of maladaptive suppression. She is suppressing the seriousness of the lump. It is maladaptive because delaying treatment will cause harm to her. (C) The client's actions are an example of maladaptive denial. She is denying her son's death by not facing his possessions. Until she faces his death, she cannot face reality. (D) This is an example of adaptive suppression. She realizes the impact of her husband's statement but delays discussion until she can devote her full attention to the matter.

• Question 249:

  A 1-year-old child is to receive an IM injection ordered by his pediatrician. He has fallen asleep in his mother's arms when the nurse approaches. Which approach is most appropriate at this time?

  A. Give the injection in the vastus lateralis site before the child awakens.

  B. Awaken the child first and give the injection in the ventrogluteal site.

  C. Awaken the child first and give the injection in the dorsogluteal site.

  D. Ask the mother to place the child on the examination table and leave the room, and then give the injection in an appropriate site.

  Correct Answer: B

  (A) If awakened first, the child will know that nothing painful will be done without the child being alerted. (B) The ventrogluteal site is a safe site for children because it is a large muscle free of major nerves and blood vessels. (C) The dorsogluteal site is not recommended in children who have not been walking for at least 1 year because the muscle is not fully developed. (D) The parent will be able to offer support and comfort during and after the injection.

• Question 250:

  A male client is experiencing extreme distress. He begins to pace up and down the corridor. What nursing intervention is appropriate when communicating with the pacing client?

  A. Ask him to sit down. Speak slowly and use short, simple sentences.

  B. Help him to recognize his anxiety.

  C. Walk with him as he paces.

  D. Increase the level of his supervision.

  Correct Answer: C

  (A) The nurse should not ask him to sit down. Pacing is the activity he has chosen to deal with his anxiety. The nurse dealing with this client should speak slowly and with short, simplesentences. (B) The client may already recognize the anxiety and is attempting to deal with it. (C) Walk with the client as he paces. This gives support while he uses anxiety- generated energy. (D) Increasing the level of supervision may be appropriate after he stops pacing. It would minimize self-injury and/or loss of control.