NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 261:

  A 44-year-old female client is receiving external radiation to her scapula for metastasis of breast cancer.

  Teaching related to skin care for the client would include which of the following?

  A. Teach her to completely clean the skin to remove all ointments and markings after each treatment.

  B. Teach her to cover broken skin in the treated area with a medicated ointment.

  C. Encourage her to wear a tight-fitting vest to support her scapula.

  D. Encourage her to avoid direct sunlight on the area being treated.

  Correct Answer: D

  (A) The skin in a treatment area should be rinsed with water and patted dry. Markings should be left intact, and the skin should not be scrubbed. (B) Clients should avoid putting any creams or lotions on the treated area. This could interfere with treatment. (C) Radiation therapy clients should wear loose-fitting clothes and avoid tight, irritating fabrics. (D) The area of skin being treated is sensitive to sunlight, and the client should take care to prevent sun damage by avoiding direct sunlight and covering the area when she is in the sun.

• Question 262:

  An 8-year-old boy has been diagnosed with hemophilia. Which of the following diagnostic blood studies is characteristically abnormal in this disorder?

  A. Partial thromboplastin time

  B. Platelet count

  C. Complete blood count

  D. Bleeding time

  Correct Answer: A

  (A) Partial thromboplastic time measures activity of thromboplastin, which depends on the intrinsic clotting factors deficient in children who are hemophiliacs. (B) Platelet counts are normal in hemophilia. (C) Hemophilia does not affect the complete blood count. (D) Bleeding times are normal in hemophiliacs. They measure the time interval for the bleeding from small superficial wounds to cease.

• Question 263:

  A female client was recently diagnosed with gastric cancer. She entered the hospital and had a total gastrectomy with esophagojejunostomy. Her postoperative recovery was uneventful. On conducting discharge teaching, the nurse discusses changes in bodily function and lifestyle changes with the client. In order to prevent pernicious anemia, the nurse stresses that the client must:

  A. Receive monthly blood transfusions

  B. Increase the amount of iron in her diet

  C. Eat small quantities several times daily until she is able to tolerate food in moderate portions

  D. Understand the need for Vitamin B12 replacement therapy

  Correct Answer: D

  (A) Monthly blood transfusions are not indicated postgastrectomy. (B) Increasing iron in the client's diet may cause irritation and will not alleviate pernicious anemia. (C) It may be necessary that the client eat small meals several times per day, but this measure has no relevance to prevention of pernicious anemia. (D) Pernicious anemia is caused by lack of Vitamin B12, and replacement therapy will be necessary because the client's stomach has been removed.

• Question 264:

  A 15-year-old child is admitted to the pediatric unit with a diagnosis of thalassemia. Which of the following would be included in educating the mother and child as part of discharge planning?

  A. Give oral iron medication every day.

  B. Have the child's blood pressure monitored every week.

  C. Know the signs and symptoms of iron overload.

  D. Keep exercise at a minimum to reduce stress.

  Correct Answer: C

  (A) Oral iron supplements are contraindicated in thalassemia. (B) Although heart failure may be an end result of this disease, this action is unnecessary. (C) Iron overload is a potential complication of frequent blood transfusions of children with thalassemia. (D) Children should be encouraged to pursue activities related to their exercise tolerance.

• Question 265:

  As a nurse in the emergency room, you receive an outside call from an elderly woman who states she has just been raped. She states, "I know I must come to the hospital, but what do I do next?" You advise her to call the police, then come to the hospital emergency room. What action by the nurse would indicate an understanding of the examination process once the victim enters the emergency room?

  A. Inform the victim not to wash, change clothes, douche, brush teeth, or eat or drink anything.

  B. Inform the victim to bring insurance information with her to the hospital so she can be properly cared for.

  C. Phone a rape counselor to begin working with the victim as soon as she enters the hospital.

  D. Do not leave the victim alone to collect her thoughts.

  Correct Answer: A

  (A) Providing the victim with these instructions will aid in the determination of physical evidence of rape. Victims frequently feel "dirty" after rape, and their first instinct is to take care of personal hygiene before facing anyone. (B) This action is of lesser importance at this time. (C) Although this is a nursing measure appropriate in this situation, contacting a counselor can be done once the victim enters the hospital. Frequently victims call but do not follow up with the visit. (D) Once the victim enters the emergency room, it is important not to leave her alone.

• Question 266:

  A 14-year-old teenager is demonstrating behavior indicative of an obsessive-compulsive disorder. She is obsessed with her appearance. She will not leave her room until her hair, clothes, and makeup are perfect. She always dresses

  immaculately. Recently, she expressed disgust over her appearance after she gained 5 lb. After observing a marked weight loss over a 2-week period, her mother suspects that she is experiencing bulimia. She eats everything on her plate,

  then runs to the bathroom. In interviewing the teenager, she discusses in great detail all of the events leading to her bulimia, but not her feelings.

  What defense mechanism is she using?

  A. Dissociation

  B. Intellectualization

  C. Rationalization

  D. Displacement

  Correct Answer: B

  (A) Dissociation is separating a group of mental processes from consciousness or identity, such as multiple personalities. That is not evident in this situation. (B) Intellectualization is excessive use of reasoning, logic, or words usually without experiencing associated feelings. This is the defense mechanism that this client is using. (C) Rationalization is giving a socially acceptable reason for behavior rather than the actual reason. She is discussing events, not reasons. (D) Displacement is a shift of emotion associated with an anxiety-producing person, object, or situation to a less threatening object.

• Question 267:

  At her monthly prenatal visit, a client reports experiencing heartburn. Which nursing measure should be included in her plan of care to help alleviate it?

  A. Restrict fluid intake.

  B. Use Alka-Seltzer as necessary.

  C. Eat small, frequent bland meals.

  D. Lie down after eating.

  Correct Answer: C

  (A) At least eight glasses of fluid per day are encouraged to help dilute stomach contents, thereby decreasing irritation. (B) Alka Seltzer contains aspirin, which is irritating to gastric mucosa, and therefore should be avoided. (C) Small, frequent bland meals help to decrease gastric pressure and to prevent reflux. (D) Lying down after meals may cause gastric reflux and prevents optimal gastric emptying.

• Question 268:

  A client has been instructed in how to take her nitroglycerin tablets. The nurse giving her instructions knows the client understands the information when she tells her:

  A. "I should contact my physician if I have headaches after I take this medicine."

  B. "I should keep the tablets in the refrigerator."

  C. "I should call the doctor if three doses of the medicine do not relieve my pain."

  D. "I should take these with water but not with milk."

  Correct Answer: C

  (A) Headaches may occur after taking nitroglycerin because of vasodilation. (B) The tablets do not need to be refrigerated. The client should carry them with her. (C) The client should contact the physician if repeated doses of nitroglycerin do not relieve the discomfort. (D) Nitroglycerin tablets should be dissolved under the tongue, not swallowed.

• Question 269:

  A primigravida with a blood type A negative is at 28 weeks' gestation. Today her physician has ordered a RhoGAM injection. Which statement by the client demonstrates that more teaching is needed related to this therapy?

  A. "I'm getting this shot so that my baby won't develop antibodies against my blood, right?"

  B. "I understand that if my baby is Rh positive I'll be getting another one of these injections."

  C. "This shot should help to protect me in future pregnancies if this baby is Rh positive, like my husband."

  D. "This shot will prevent me from becoming sensitized to Rh-positive blood."

  Correct Answer: A

  (A) RhoGAM is given to Rh-negative mothers to prevent the maternal Rh immune response to fetal Rh-positive antigens. (B) If the infant is Rh positive, the mother will receive another dose postdelivery to prevent maternal sensitization. (C) Prevention of maternal sensitization will protect future pregnancies because the mother's blood will be free of antibodies against her fetus. (D) RhoGAM prevents maternal sensitization to Rh-positive blood.

• Question 270:

  The postpartum nurse should include which of the following instructions to breast-feeding mothers?

  A. Limit feeding times for several days to avoid nipple soreness.

  B. Wash the nipples with soap and water before and after each feeding.

  C. Daily caloric intake should be increased by 500 cal.

  D. Breast milk is totally digestible by the baby because it contains lactose.

  Correct Answer: C

  (A) Limiting initial feeding times will only delay nipple soreness as well as the establishment of the letdown reflex, thus encouraging engorgement from clogged ducts and ductules. (B) Soap should be avoided because it may be excessively drying, predisposing nipples to cracking. (C) For optimal milk production, an additional 500 kcal over maintenance levels are needed daily. (D) Lipase, not lactose, emulsifies the fat in breast milk, making it almost totally digestible by infants.