NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 21:

  The following nursing diagnosis is written for a comatose client with cirrhosis of the liver and secondary splenomegaly--High risk for injury: Increased susceptibility to bleeding related to:

  A. Increased absorption of vitamin K

  B. Thrombocytopenia due to hypersplenism

  C. Diminished function of the Kupffer cells

  D. Increased synthesis of the clotting factors

  Correct Answer: B

  (A) There is a decreased absorption of vitamin K with cirrhosis of the liver. This decrease impairs blood coagulation and the formation of prothrombin. (B) Thrombocytopenia, an increased destruction of platelets, occurs secondary to hypersplenism. (C) A diminished function of the Kupffer cells occurs with cirrhosis of the liver, causing the client to become more susceptible to infections. (D) A decrease in the synthesis of fibrinogen and clotting factors VII, IX, and X occurs with cirrhosis of the liver and increases the susceptibility to bleeding.

• Question 22:

  When planning care for a 9-year-old client, the nurse uses which of the most effective means of helping siblings cope with their feelings about a brother who is terminally ill?

  A. Open discussion and understanding

  B. Play-acting out feelings in different roles

  C. Storytelling

  D. Drawing pictures

  Correct Answer: B

  (A) When dealing with grief, siblings are usually most comfortable initially with open discussion. (B) Assuming different roles allows children to act out their feelings without fear of reprisals and to gain insight and control. (C) This method may be helpful, but having the child take an active part through role playing is more effective. (D) This technique may be helpful, but being an active participant through role playing is more effective.

• Question 23:

  A 9-year-old child was in the garage with his father, who was repairing a lawnmower. Some gasoline ignited and caused an explosion. His father was killed, and the child has split- thickness and full-thickness burns over 40% of his upper body, face, neck, and arms. All of the following nursing diagnoses are included on his care plan. Which of these nursing diagnoses should have top priority during the first 24?8 hours postburn?

  A. Pain related to tissue damage from burns

  B. Potential for infection related to contamination of wounds

  C. Fluid volume deficit related to increased capillary permeability

  D. Potential for impaired gas exchange related to edema of respiratory tract

  Correct Answer: D

  (A, B, C) These answers are all correct; however, maintenance of airway is the top priority. (D) Persons burned about the face and neck during an explosion are also likely to suffer burns of the respiratory tract, which can lead to edema and respiratory arrest.

• Question 24:

  Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. The physician is immediately notified and orders 50 mL of dextrose and 10 U of regular insulin IV push. The nurse administering these drugs knows the Rationale for this therapy is to:

  A. Remove the potassium from the body by renin exchange

  B. Protect the myocardium from the effects of hypokalemia

  C. Promote rapid protein catabolism

  D. Drive potassium from the serum back into the cells

  Correct Answer: D

  (A) Sodium polystyrene sulfonate (Kayexalate), a cation exchange resin, exchanges sodium ions for potassium ions in the large intestine reducing the serum potassium. (B) Calcium is administered to protect the myocardium from the adverse effects of hyperkalemia. Serum levels reflect hyperkalemia. (C) Rapid catabolism releases potassium from the body tissue into the bloodstream. Infection and hyperthermia increase the process of catabolism. (D) The administration of dextrose and regular insulin IV forces potassium back into the cells decreasing the potassium in the serum.

• Question 25:

  The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:

  A. Inspiration is longer than expiration

  B. Breath sounds are high pitched

  C. Breath sounds are slightly muffled

  D. Inspiration and expiration are equal

  Correct Answer: D

  (A) Inspiration is normally longer in vesicular areas. (B) Highpitched sounds are normal in bronchial area. (C) Muffled sounds are considered abnormal. (D) Inspiration and expiration are equal normally in this area, and sounds are medium pitched.

• Question 26:

  A 52-year-old female client is admitted to the hospital in acute renal failure. She has been on hemodialysis for the past 2 years. Stat arterial blood gases are drawn on the client yielding the following results: pH 7.30, PCO2 51 mm Hg, HCO3, 18 mEq/L, PaO2, 84 mm Hg. The nurse would interpret these results as:

  A. Compensated metabolic alkalosis

  B. Respiratory acidosis

  C. Partially compensated metabolic alkalosis

  D. Combined respiratory and metabolic acidosis

  Correct Answer: D

  (A) Compensated metabolic alkalosis would be reflected by the following: pH within normal limit (7.35?.45), PCO2>; 45 mm Hg, HCO3>;26 mEq/L. (B) Respiratory acidosis would be reflected by the following: pH < 7.35, PCO2 > 45 mm Hg,

  HCO3 within normal limits (22?6 mEq/L). (C) Partially compensated metabolic alkalosis would be reflected by the following:

  pH > 7.45, PCO2 > 45 mm Hg, HCO3 > 26 mEq/L. (D) Combined respiratory and metabolicacidosis would be reflected by the following: pH < 7.35, PCO2 > 45 mm Hg, HCO3 < 22 mEq/L.

• Question 27:

  A 33-year-old client is diagnosed with bipolar disorder, acute phase. This is her first psychiatric hospitalization, and she is being evaluated for treatment with lithium. Which of the following diagnostic tests are essential prior to the initiation of lithium therapy with this client?

  A. Hematocrit, hemoglobin, and white blood cell (WBC) count

  B. Blood urea nitrogen, electrolytes, and creatinine

  C. Glucose, glucose tolerance test, and random blood sugar

  D. X-rays, electroencephalogram, and electrocardiogram (ECG)

  Correct Answer: B

  (A) These are general diagnostic blood studies (usually done on admission), but they are not reliable indicators of lithium therapy clearance. (B) These are the primary diagnostic tests to determine kidney functioning. Because lithium is excreted through the kidneys and because it can be very toxic, adequate renal function must be ascertained before therapy begins. (C) These are diagnostic blood tests used to determine the presence of endocrine (not renal) dysfunction. (D) These are other types of diagnostic procedures used to determine musculoskeletal, neural, and cardiac (rather than renal) functioning.

• Question 28:

  During discharge planning, parents of a child with rheumatic fever should be able to identify which of the following as toxic symptoms of sodium salicylate?

  A. Tinnitus and nausea

  B. Dermatitis and blurred vision

  C. Unconsciousness and acetone odor of the breath

  D. Chills and an elevation of temperature

  Correct Answer: A

  (A) These are toxic symptoms of sodium salicylate. (B, C, D) These are not symptoms associated with sodium salicylate.

• Question 29:

  A client is started on prednisone 2.5 mg po bid. Which of the following instructions should be included in her discharge teaching specific to this medication?

  A. Increase your oral intake of fluids to at least 4000 mL every day.

  B. Avoid contact with people who have contagious illnesses.

  C. Brush your teeth at least 4 times a day with a firm toothbrush.

  D. Immediately stop taking the prednisone if you feel depressed.

  Correct Answer: B

  (A) Fluid retention is a side effect of prednisone. The nurse should teach clients to weigh themselves daily and to observe for signs of edema. If these signs of fluid retention occur, they should notify the physician. (B) Prednisone, a glucocorticoid, suppresses the normal immune response making the client more susceptible to infections. (C) An increase in bleeding tendencies is a side effect of prednisone therapy. The nurse should teach clients to use preventive measures (i.e., electric razors and soft toothbrushes). (D) Depression and personality changes are side effects of prednisone therapy. Prednisone should never be discontinued abruptly.

• Question 30:

  A 20-year-old male client is being treated for protein deficiency. If he likes all of the following foods, which one would the nurse recommend to increase in the diet?

  A. Cantaloupe

  B. Rice

  C. Chicken

  D. Green beans

  Correct Answer: C

  (A) Cantaloupe is a good source of carbohydrates, vitamin C, and vitamin A. (B) Rice contains about 4 g of protein per 200 g. (C) Chicken contains 35 g protein per breast. Chicken is a rich source of vitamin B6 (pyridoxine), which is needed for adequate protein synthesis. As protein intake increases, vitamin B6 intake must also be increased. Vitamin B6 is a coenzyme in amino acid metabolism. (D) Green beans only contain 2 g of protein per cup.