NCLEX NCLEX-RN Online Practice Questions and Exam Preparation

NCLEX NCLEX-RN Online Questions & Answers

• Question 261:

  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
  C. Test the discharge for sugar

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  (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 262:

  A 6-year-old child is attending a pediatric clinic for a routine examination. What should the nurse assess for while conducting a vision screening?

  A. Hearing test
  B. Gait
  C. Strabismus
  D. Papilledema
  C. Strabismus

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  (A) Hearing should be assessed separately. (B) Gait should be assessed separately. Client usually remains in one place for vision screening. Gait is part of neurological assessment. (C) Strabismus is crossing of eyes or outward deviation, which may cause diplopia or ambylopia. It is easily assessed during vision screening. (D) Papilledema is assessed by an ophthalmoscopic examination, which follows vision screening. It is part of neurological assessment.

• Question 263:

  A 38-year-old pregnant woman visits her nurse practitioner for her regular prenatal checkup. She is 30 weeks' gestation. The nurse should be alert to which condition related to her age?

  A. Iron-deficiency anemia
  B. Sexually transmitted disease (STD)
  C. Intrauterine growth retardation
  D. Pregnancy-induced hypertension (PIH)
  D. Pregnancy-induced hypertension (PIH)

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  (A) Iron-deficiency anemia can occur throughout pregnancy and is not age related. (B) STDs can occur prior to or during pregnancy and are not age related. (C) Intrauterine growth retardation is an abnormal process where fetal development and maturation are delayed. It is not age related. (D) Physical risks for the pregnant client older than 35 include increased risk for PIH, cesarean delivery, fetal and neonatal mortality, and trisomy.

• Question 264:

  Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis?

  A. Urine output 22 mL/hr for 2 hours
  B. Serum potassium level of 3.7
  C. Small T wave of ECG
  D. Serum glucose level of 180
  A. Urine output 22 mL/hr for 2 hours

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  (A) Adequate renal flow of 30 mL/hr is a necessity with potassium infusions because potassium is excreted renally. (B) Because potassium level will decrease during correction of diabetic ketoacidosis, potassium will be infused even if plasma levels of potassium are normal. (C) A small T wave is normal and desired on the electrocardiogram. A tall, peaked T-wave could indicate overinfusion of potassium and hyperkalemia. (D) Glucose levels of <200 are desirable.

• Question 265:

  Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following statements by the client would validate an understanding of his medication?

  A. "I would notify my physician immediately if I experience nausea, vomiting, and double vision."
  B. "I could stop taking this medication when I begin to feel better."
  C. "I should only take the medication if my heart rate is greater than 100 bpm."
  D. "I should always take this medication with an antacid."
  A. "I would notify my physician immediately if I experience nausea, vomiting, and double vision."

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  (A) The first signs of digoxin toxicity include abdominal pain, anorexia, nausea, vomiting, and visual disturbances. The physician should be notified if any of these symptoms are experienced. (B) The positive inotropic effects of digoxin increase cardiac output and result in an enhanced activity tolerance. "Feeling better" indicates the drug is working and medication therapy must be continued. (C) Clients should be taught to take their pulse prior to taking the digoxin. If their pulse rate becomes irregular, slows significantly, or is >100 bpm the physician should be notified. (D) Antacids decrease the effectiveness of digoxin.

• Question 266:

  Forty-eight hours after a thyroidectomy, a female client complains of numbness and tingling of the toes and fingers. The nurse notes upper arm and facial twitching. The nurse needs to:

  A. Report the findings to the physician
  B. Assist the client to do range of motion exercises
  C. Check the client's potassium level
  D. Administer the as-needed dose of phenytoin (Dilantin)
  A. Report the findings to the physician

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  (A) Muscular hyperactivity and parasthesias may indicate hypocalcemic tetany and require immediate administration of calcium gluconate. Tetany can occur if the parathyroid glands were erroneously excised during surgery. (B) Range of motion exercises are not appropriate topresenting symptoms. (C) These characteristics are not usual signs of potassium imbalance, but of calcium imbalance. (D) Phenytoin is indicated for seizure activity mainly of neurological origin.

• Question 267:

  While changing the dressing on a client's central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be appropriate to implement based on this finding?

  A. Discontinue the central line.
  B. Begin a peripheral IV.
  C. Document in the nurse's notes and notify the physician after redressing the site.
  D. Clean the site well and redress.
  C. Document in the nurse's notes and notify the physician after redressing the site.

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  (A) The nurse may never discontinue a central line without a physician's order. (B) The nurse may never initiate a peripheral IV without a physician's order except in an emergency situation. (C) The nurse should always document findings and alert the physician to the findings as well. The physician may then initiate a new central line and order the current central line to be discontinued. (D) Besides cleaning and redressing, the nurse should always document the findings.

• Question 268:

  A client at 9 weeks' gestation comes for an initial prenatal visit. On assessment, the nurse discovers this is her second pregnancy. Her first pregnancy resulted in a spontaneous abortion. She is 28 years old, in good health, and works full-time as an elementary school teacher. This information alerts the nurse to which of the following:

  A. An increased risk in maternal adaptation to pregnancy
  B. The need for anticipatory guidance regarding the pregnancy
  C. The need for teaching regarding family planning
  D. An increased risk for subsequent abortions
  B. The need for anticipatory guidance regarding the pregnancy

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  (A, D) There are no data to support this. (B) Anticipatory guidance and health maintenance is a first-line defense in the promotion of healthy mothers and healthy babies. (C) There are no data to support this at this time. This will be a concern later.

• Question 269:

  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.
  B. Dysfunction in one part affects every other part.

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  (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 270:

  Plans for the care of a client with an ulcer caused by emotional problems need to take into consideration that:

  A. His priority needs are limited to medical management
  B. There is no real psychological basis for his illness
  C. The disorder is a threat to his physical well-being
  D. He is unable to participate in planning his care
  C. The disorder is a threat to his physical well-being

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  (A) There may be a medical emergency that takes top priority; however, the basis of the problem is emotional. (B) The problem is a physical manifestation of an emotional conflict. (C) The bleeding ulcer can be life threatening. (D) For lifestyle change to occur, the client must participate in the planning of his care so that he is committed to changes that will have positive results.