NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 271:

  A female client at 36 weeks' gestation has been treated successfully for premature labor for 4 weeks. She has begun having uterine contractions today and has been admitted to the labor and delivery suite. Her amniocentesis results reveal a lecithin/sphingomyelin (L/S) ratio of 2 and positive phosphatidylglycerol (PG). These lab values indicate:

  A. Placental maturity

  B. Suspected chronic asphyxia

  C. Cord compression

  D. Fetal lung maturity

  Correct Answer: D

  (A) Placental maturity is assessed by a biophysical profile. (B) L/S ratio and presence of phosphatidylglycerol are not used to determine fetal asphyxia. A biophysical profile score of6 may indicate this condition. (C) Cord compression is not reflected by the L/S ratio or presence of phosphatidylglycerol. Variable decelerations observed through electronic fetal monitoring could reflect umbilical cord compression. (D) An L/S ratio>2 and the presence of phosphatidylglycerol in amniotic fluid indicate fetal lung maturity.

• Question 272:

  A client has just received an epidural block. She is laboring on her right side. The nurse notes that her blood pressure has dropped from 132/68 to 78/42 mm Hg. The nurse's first action would be to:

  A. Call the physician immediately and give dopamine IM

  B. Turn her on her left side and recheck her blood pressure in 5 minutes

  C. Administer oxytocin (Pitocin) immediately and increase the rate of IV fluids

  D. Increase the rate of IV fluids and start O2 by mask

  Correct Answer: D

  (A) Nursing measures to support fetal oxygenation and promote maternal blood pressure would precede calling the physician. (B) Systolic pressures below 100 mm Hg or a reduction in the systolic pressure of>30% necessitate treatment. Assessing the blood pressure in 5 minutes may allow for further fetal and/or maternal compromise. Turning the client on her left side will promote uteroplacental perfusion and is appropriate. (C) Oxytocin (Pitocin) increases the strength of uterine contractions and may cause maternal hypotension; thus it is an inappropriate drug for use in this clinical situation. IV fluids would be increased to expand the circulating blood volume and promote increased blood pressure. (D) Turning the mother to her left lateral side promotes uteroplacental perfusion. IV fluids are administered to increase the circulating blood volume, and O2 is administered to promote fetal oxygenation and decrease the nausea accompanying the hypotension.

• Question 273:

  A female client at 30 weeks' gestation is brought into the emergency department after falling down a flight of stairs. On examination, the physician notes a rigid, boardlike abdomen; FHR in the 160s; and stable vital signs. Considering possible abdominal trauma, which obstetric emergency must be anticipated?

  A. Abruptio placentae

  B. Ectopic pregnancy

  C. Massive uterine rupture

  D. Placenta previa

  Correct Answer: A

  (A) Abruptio placentae, the complete or partial separation of the placenta from the uterine wall, can be caused by external trauma. When hemorrhage is concealed, one sign is a rapid increase in uterine size with rigidity. (B) Ectopic pregnancy occurs when the embryo implants itself outside the uterine cavity. (C) Massive uterine rupture occurs during labor when the uterine contents are extruded through the uterine wall. It is usually due to weakness from a pre-existing uterine scar and trauma from instruments or an obstetrical intervention. (D) Placenta previa is the condition in which the placenta is implanted in the lower uterine segment and either completely or partially covers the cervical os.

• Question 274:

  A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must:

  A. Assess the site for leakage of blood or fluids

  B. Auscultate the site for a bruit

  C. Assess the site for bruising or hematoma

  D. Inspect the site for color, warmth, and sensation

  Correct Answer: B

  (A) This is an internal device. Assessment of the site should include assessing for swelling, pain, warmth, and discoloration. This measure does not assess patency. (B) The presence of a bruit indicates good blood flow through the device. (C) The nurse should inspect the site for bruising or hematoma; however, this measure does not assure patency of the device. (D) The nurse should inspect the vascular access site frequently for signs of infection. However, this does not assure patency.

• Question 275:

  A male client has burns over 90% of his body after an automobile accident resulting in a fire. He was trapped inside the auto and pulled out by a bystander. After several months in the hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization the nursing staff has been aware of psychological changes the client faces after burns over a large portion of his body resulting in disfigurement. The nursing staff can best foster the client's self-esteem by:

  A. Adhering to a strict schedule of diet, exercise, and wound care

  B. Allowing him to go to physical therapy for whirlpool treatment when other clients were not in physical therapy

  C. Following a standardized plan of care for burn clients formulated by a world-renowned burn center

  D. Allowing him to plan, assist in, and perform his own care whenever possible

  Correct Answer: D

  (A) A regimented schedule, allowing no flexibility, will not foster the client's self-esteem. (B) Isolating the client may only enhance his feelings of social isolation due to his disfigurement. (C) Standardized care plans must be personalized and adapted to each client's situation. (D) Allowing the client control over his care will foster his self-esteem and prepare him for life outside of the hospital.

• Question 276:

  A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea, vomiting, and sore throat for the past several days. In caring for a young child with symptoms of influenza, the mother must be cautioned about:

  A. Giving aspirin and bismuth subsalicylate (Pepto-Bismol) to treat the symptoms

  B. Giving clear liquids too soon

  C. Allowing the child to come in contact with other children for 3 days

  D. The possibility of pneumonia as a complication

  Correct Answer: A

  (A) Aspirin should never be given to children with influenza because of the possibility of causing Reye's syndrome. Pepto- Bismol is also classified as a salicylate and should be avoided. (B) Depending on the severity of symptoms, the child may be receiving IV therapy or clear liquids. (C) The disease has a 1? day incubation period and affected children are most infectious 24 hours before and after the onset of symptoms. (D) Although viral pneumonia can be a complication of influenza, this would not be an initial priority.

• Question 277:

  A male client is undergoing cardiac tests. He has been instructed to wear a Holter monitor. The nurse knows she has included the appropriate information in her teaching when the client tells her:

  A. "He should remove the electrodes for bathing."

  B. "Damage to his heart muscle will be recorded by the monitor."

  C. "He is to keep a record of everything he does during the day."

  D. "He is to refrain from activities that cause chest pain."

  Correct Answer: C

  (A) The client should leave the electrodes in place during the entire time the test is ordered. He should not even remove the electrodes for bathing. (B) The Holter monitor will record cardiac electrical activity but will not record damage to his myocardium. (C) The client should keep a record of all of his activities so the physician can correlate the ECG findings with his activities. (D) The client should continue doing his regular activities. The purpose of the Holter monitor is to record heart activity during routine activities.

• Question 278:

  A male client is being treated in the burn unit for thirddegree burns on his head, neck, and upper chest received in the last 24 hours. The nurse is evaluating the effectiveness of fluid resuscitation. Which of the following indicates effective fluid balance?

  A. His weight increases from 165 to 175 lb.

  B. His urine output is equal to his total fluid intake.

  C. His urine output has been>35 mL/hr for the past 12 hours.

  D. His blood pressure is 94/62.

  Correct Answer: C

  (A) A weight gain of 10 lb represents a state of overhydration. (B) He is losing fluids through insensible losses; a urine output equal to his intake indicates that he is receiving too little fluids. (C) A urine output greater than his intake indicates that he is receiving adequate fluid resuscitation to account for urinary and insensible losses. (D) A blood pressure of 94/62 indicates a state of underhydration and inadequate circulatory volume.

• Question 279:

  In an interview for suspected child abuse, the child's mother openly discusses her feelings. She feels her husband is too aggressive in disciplining their child. The child's father states, "Being a school custodian, I see kids every day that are bad because they did not get enough discipline at home. That will not happen to our child." Based on this remark, the nurse would make the following nursing diagnosis:

  A. Fear related to retaliation by the father

  B. Actual injury related to poor impulse control by the father

  C. Ineffective coping

  D. Altered family process related to physical abuse

  Correct Answer: D

  (A) There is no evidence of fear as the child is unable to communicate. (B) There is actual injury, but the parents have not yet admitted causing the child's injuries. (C) This diagnosis is incomplete. There is no specific ineffective coping behavior identified in this nursing diagnosis. (D) Altered family process best describes the family dynamics in this situation. The parents have admitted severe disciplinary action.

• Question 280:

  A 40-year-old client has lived for 8 years with an abusive spouse. She married her husband in her senior year of high school after becoming pregnant. Shortly after the baby was born, he began to physically abuse her. She has attempted to leave him several times, but she has always returned. She is unable to support herself financially, and her husband threatens to kill her if she leaves him. This time, her husband has beaten her so badly she cannot stop the bleeding from the gash above her eye. She admits her husband caused her injury. In assessing a person after experiencing spousal abuse, which need has the highest priority?

  A. Assess the level of anxiety, coping responses, and support systems.

  B. Assess the history of physical abuse.

  C. Assess suicide potential.

  D. Assess drug and alcohol use.

  Correct Answer: C

  (A) Assessing the level of anxiety, coping responses, and support systems is very important, but not of highest priority at this time. (B) A history of physical abuse is an important part of assessment. The nurses must also always ask if there is abuse of the children. (C) Although all of these answers are very important in assessment, the highest priority is assessment of suicide potential, because this could cause the greatest harm to the client. Feeling there is no other way out, abused spouses may consider suicide. (D) The spouse may be self-medicating herself with alcohol or drugs to escape an awful situation. The abuser may also be abusing drugs or alcohol. If this is so, the nurse should encourage the spouse to seek counseling and not to return to the home.