NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 291:

  A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful?

  A. Examine the 4 year old first.

  B. Provide time for play and becoming acquainted.

  C. Have the mother leave the room with one child, and examine the other child privately.

  D. Examine painful areas first to get them "over with."

  Correct Answer: B

  (A) The 6 month old should be examined first. If several children will be examined, begin with the most cooperative and less anxious child to provide modeling. (B) Providing time for play and getting acquainted minimizes stress and anxiety associated with assessment of body parts. (C) Children generally cooperate best when their mother remains with them. (D) Painful areas are best examined last and will permit maximum accuracy of assessment.

• Question 292:

  A female client has just died. Her family is requesting that all nursing staff leave the room. The family's religious leader has arrived and is ready to conduct a ceremony for the deceased in the room, requesting that only family members be present. The nurse assigned to the client should perform the appropriate nursing action, which might include:

  A. Inform the family that it is the hospital's policy not to conduct religious ceremonies in client rooms.

  B. Refuse to leave the room because the client's body is entrusted in the nurse's care until it can be brought to the morgue.

  C. Tell the family that they may conduct their ceremony in the client's room; however, the nurse must attend.

  D. Respect the client's family's wishes.

  Correct Answer: D

  (A) It is rare that a hospital has a specific policy addressing this particular issue. If the statement is true, the nurse should show evidence of the policy to the family and suggest alternatives, such as the hospital chapel. (B) Refusal to leave the room demonstrates a lack of understanding related to the family's need to grieve in their own manner. (C) The nurse should leave the room and allow the family privacy in their grief. (D) The family's wish to conduct a religious ceremony in the client's room is part of the grief process. The request is based on specific cultural and religious differences dictating social customs.

• Question 293:

  As soon as a child has been diagnosed as "hearing impaired," special education should begin. Which of the following special education tasks is the most difficult for a severely hearing-impaired child?

  A. Auditory training

  B. Speech

  C. Lip reading

  D. Signing

  Correct Answer: B

  (A) With the slight and mild hard of hearing, auditory training is beneficial. (B) Speech is the most difficult task because it is learned by visual and auditory stimulation, imitation, and reinforcement. (C, D) Lip reading and signing are aimed at establishing communicative skills, but they are learned more easily by visual stimulation.

• Question 294:

  An alcoholic client who is completing the inpatient segment of a substance abuse program was placed on disulfiram (Antabuse) drug therapy. What should the nurse include in the discharge instructions?

  A. If disulfiram is taken and alcohol ingested, the client experiences nausea, vomiting and elevated blood pressure.

  B. Disulfiram is most effective when prescribed as late as possible in a recovery program.

  C. Disulfiram works on the desensitization principle.

  D. The effects of disulfiram can be triggered by alcohol 5 days to 2 weeks after the drug is discontinued.

  Correct Answer: D

  (A) When alcohol is ingested with disulfiram therapy, the client experiences nausea, vomiting, and a potentially serious drop in blood pressure. (B) Disulfiram is most successful when used early in the recovery process while the individual makes major lifestyle changes necessary for long-term recovery. (C) Disulfiram works on the classical conditioning principle. (D) The effects of disulfiram can be felt when alcohol is ingested 1? weeks after disulfiram is discontinued.

• Question 295:

  A 24-year-old male client is admitted with a diagnosis of sickle cell anemia. The nurse discusses his disease with him and emphasizes the following information:

  A. He should monitor his sputum, stools, and urine for signs of bleeding.

  B. His daily diet should include a large amount of fluid.

  C. He should not be concerned about having to fly on a commuter airplane on a weekly basis.

  D. He should not worry about having children because this disease is passed on only by female carriers.

  Correct Answer: B

  (A) Bleeding is not a symptom of sickle cell anemia or sickle cell crisis. (B) Decreased blood viscosity leads to sickling of red blood cells. Increased fluid intake maintains adequate circulating blood volume and decreases the chance of sickling. (C) Hypoxia leads to sickling of cells. Flying in nonpressurized planes places the client in a situation of low O2 tension, which can lead to sickling. (D) Male and female clients with sickle cell disease can pass the trait on to their offspring. Therefore, this client should receive genetic counseling prior to having children.

• Question 296:

  A term neonate has experienced no distress at birth and has an Apgar score of 9. Her mother has asked to breastfeed her following delivery. Immediately after birth, the neonate was most susceptible to heat loss. The most appropriate intervention to conserve heat loss and promote bonding is to:

  A. Place her under the radiant warmer

  B. Dry her with blankets

  C. Place her to her mother's breast

  D. Place her on a heated pad

  Correct Answer: C

  (A) A radiant warmer maintains an optimal thermal environment by use of a thermal skin sensor taped to the infant. The warmer limits parental attachment, so, although appropriate, it is not an intervention that promotes infant attachment. (B) Warmed blankets prevent heat loss in the neonate by conduction. In addition, tactile stimuli promote crying and lung expansion. This intervention does not promote attachment, however. (C) Skin-to- skin contact is an effective way to conserve heat after delivery and promotes parental attachment following birth in the healthy term infant. The first period of reactivity lasts approximately 30 minutes following birth. A strong sucking reflex and an active, awake newborn characterize this period. (D) Surfaces of objects warmer than the infant promote overheating by conduction, and neonatal hyperthermia may result.

• Question 297:

  A male client is admitted to the psychiatric unit after experiencing severe depression. He states that he intends to kill himself, but he asks the nurse not to repeat his intentions to other staff members. Which response demonstrates understanding and appropriate action on the part of the nurse?

  A. "I understand you're depressed, but killing yourself is not a reasonable option."

  B. "We need to discuss this further, but right now let's complete these forms."

  C. "Don't do that, you have so much to live for. You have a wonderful wife and children. The client in the next room has no one."

  D. "This is very serious. I do not want any harm to come to you. I will have to report this to the rest of the staff."

  Correct Answer: D

  (A) To the client, suicide may be a reasonable action and the only one he can cope with at this time. (B) This response indicates to the client that his intention to commit suicide is not important to the nurse at this time. (C) The client is so depressed that he is not able to see the positive aspects of his life. At no time should the nurse discuss another client's problems in conversation. (D) This statement tells the client that the nurse recognizes his problem is of a serious nature and will take all steps necessary to help him.

• Question 298:

  A male client has a history of diverticulosis. He has questions about the foods that he should eat. His nurse gives him the following information:

  A. He should be on a high-fiber diet.

  B. He should eat a low-residue diet.

  C. He should drink minimal amounts of fluids.

  D. He does not need to make any modifications.

  Correct Answer: A

  (A) Clients with diverticulosis should maintain a high-fiber diet and prevent constipation with bran or bulk laxatives. (B) Lowresidue diets lead to constipation and are contraindicated in clients with diverticulosis. (C) Clients with diverticulosis should drink at least eight glasses of water each day to prevent constipation. (D) Clients with diverticulosis should modify their diet to include high-fiber foods and bulk laxatives.

• Question 299:

  A 26-year-old client has no children. She has had an abdominal hysterectomy. In the first 24 hours postoperatively, the nurse would be concerned if the client:

  A. Cries easily and says she is having abdominal pain

  B. Develops a temperature of 102_F

  C. Has no bowel sounds

  D. Has a urine output of 200 mL for 4 hours

  Correct Answer: B

  (A) The client may be more tearful than normal due to the stress of the surgery and its implications for her future life. She would be expected to have pain following surgery. (B) A temperature of 102_F indicates an infectious process. This is not a normal sequence to surgery and indicates a need for further assessment. (C) The client is expected to have no bowel soundsfor 24?8 hours after surgery because of the trauma to the bowel. (D) Normal urine output is 30 mL/hr. This represents an output of 50 mL/hr, which is greater than normal.

• Question 300:

  The physician has ordered that ampicillin 250 mg IV be given over 30 minutes. The medication is diluted as recommended in 10 mL in the volume control chamber of a set that has a tubing of 12 mL. Which nursing measure is most accurate considering these facts?

  A. Infuse volume at 44 mL/hr.

  B. Infuse volume at 22 mL/hr.

  C. Infuse volume at 10 mL/hr.

  D. Infuse volume at 30 mL/hr.

  Correct Answer: A

  (A) The volume to be infused should be diluted medication volume added to the volume control chamber (10 mL) plus the tubing volume (12 mL). The general formula for calculating IV medications for children is: Rate = Volume to Be Infused

  X Administration Set Drop Factor (microdrop: 60 gtts/min)Desired Time to Infuse in Minutes Rate = (10 +

  12)22 X 60 30 = 44 mL/hr. (B, C, D) These values are incorrect.