NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 301:

  A male client has heart failure. He has been instructed to gradually increase his activities. Which signs and symptoms of worsening heart failure should the nurse tell him to watch for that would indicate a need for him to lower his activity level?

  A. Pain in his legs when he walks

  B. Thirst, weight loss, and polyuria

  C. Drowsiness and lethargy after his activities

  D. Weight gain, edema in his lower extremities, and shortness of breath

  Correct Answer: D

  (A) Pain in the legs could be indicative of doing too much too quickly, but not of worsening heart failure. The client should be cautioned to increase his activities slowly. (B) Thirst, weight loss, and frequent urination are not indicative of heart failure. The client should report these symptoms to his physician. (C) Drowsiness and lethargy are not indicative of worsening heart failure. The client should report these symptoms to his physician. (D) All of these symptoms indicate a worsening cardiac condition possibly associated with too much activity. The client's activity level should be evaluated.

• Question 302:

  A male infant is to be discharged home this morning. Which instruction related to his cord care should be included in his mother's discharge teaching plan?

  A. Keep the umbilical area moist with Vaseline until the stump falls off.

  B. Keep the umbilical area covered at all times with the diaper.

  C. Clean the umbilical cord with alcohol at each diaper change.

  D. Clean the umbilical cord daily with soap and water during the bath.

  Correct Answer: C

  (A) The umbilical area should be kept dry for healing to occur. Moisture is conducive to bacterial growth and therefore could lead to infection at the site. (B) The diaper should be folded below the cord to allow the cord stump to be exposed to the air for healing. (C) The umbilical cord should be swabbed with alcohol at each diaper change to remove urine and stool and to facilitate the desiccation process through drying. (D) Soap and water should not be used to clean the umbilical area because the area could retain moisture, thus making it susceptible to bacterial growth and infection.

• Question 303:

  A female client at 10 weeks' gestation complains to her physician of slight vaginal bleeding and mild cramps. On examination, her physician determines that her cervix is closed. The client is exhibiting signs of:

  A. An inevitable abortion

  B. A threatened abortion

  C. An incomplete abortion

  D. A missed abortion

  Correct Answer: B

  (A) An inevitable abortion includes the signs of cervical dilation and effacement as well as pain and bleeding. (B) A threatened abortion is a condition in which intrauterine bleeding occurs early in pregnancy, the cervix remains undilated, and the uterine contents are not necessarily expelled. (C) An incomplete abortion occurs when some portions of the products of conception are expelled from the uterus. (D) A missed abortion occurs when the embryo dies in utero and is retained in the uterus.

• Question 304:

  The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on oral griseofulvin. The nurse should emphasize which of these instructions to the mother and/or child?

  A. Administer oral griseofulvin on an empty stomach for best results.

  B. Discontinue drug therapy if food tastes funny.

  C. May discontinue medication when the child experiences symptomatic relief.

  D. Observe for headaches, dizziness, and anorexia.

  Correct Answer: D

  (A) Giving the drug with or after meals may allay gastrointestinal discomfort. Giving the drug with a fatty meal (ice cream or milk) increases absorption rate. (B) Griseofulvin may alter taste sensations and thereby decrease the appetite. Monitoring of food intake is important, and inadequate nutrient intake should be reported to the physician. (C) The child may experience symptomatic relief after 48?6 hours of therapy. It is important to stress continuing the drug therapy to prevent relapse (usually about 6 weeks). (D) The incidence of side effects is low; however, headaches are common. Nausea, vomiting, diarrhea, and anorexia may occur. Dizziness, although uncommon, should be reported to the physician.

• Question 305:

  A 50-year-old male client is to receive chemotherapy. The physician's orders include antiemetics. When planning his care, the nurse should take into consideration that antiemetics are best administered in the following way:

  A. Give antiemetics when nausea is experienced and continue on a regular schedule for 12

  Correct Answer: B

  (A)

  Nausea is more difficult to control if antiemetics are withheld until nausea is experienced. (B) Antiemetics should be given prophylactically at the beginning of chemotherapy and continued on an around-the-clock basis to prevent nausea.

  (C)

  Combinations of antiemetics give the best control for nausea by blocking various causes of nausea induced by chemotherapy. (D) Antiemetics should be given around the clock during the course of chemotherapy. This prevents nausea from developing and prevents anticipatory nausea during subsequent chemotherapy administrations.

• Question 306:

  A 10-year-old has been diagnosed with acute poststreptococcal glomerulonephritis. The clinical findings were proteinuria, moderately elevated blood pressure, and periorbital edema. Which dietary plan is most appropriate for this client?

  A. Low-protein diet

  B. Low-sodium diet

  C. Increased fluid intake

  D. High-cholesterol diet

  Correct Answer: B

  (A) A high-protein diet is usually indicated because protein is excreted in urine. Protein restriction is usually prescribed with severe azotemia. (B) The kidneys usually enlarge in these children, and sodium and water are retained. (C) Fluid restriction may be ordered to help reduce edema; however, monitoring for dehydration is indicated. (D) A high- cholesterol diet would not be indicated for any child, especially one with elevated blood pressure.

• Question 307:

  A male client has been an insulin-dependent diabetic for approximately 30 years. He frequently indulges in highsugar foods and forgets to take his insulin. He has not experienced acute diabetic emergencies over the years but is now beginning to demonstrate symptoms of diabetic peripheral neuropathy. This distresses him because dancing is one of his favorite pastimes. He decides to question his wife's home health nurse about diabetic peripheral neuropathy. The nurse points out his noncompliance to his diabetic diet and insulin regimen. The client answers the nurse, "It has been my experience that the diabetic diet is very difficult to follow. As far as the insulin, isn't a fellow allowed to forget now and then?" The client's actions and response best demonstrate:

  A. Depression

  B. Anger

  C. Denial

  D. Bargaining

  Correct Answer: C

  (A) Depression may be an underlying feature, but it is not evident from limited data presented here. (B) Anger is not exhibited in his response. (C) Denial is evident in the client's actions; through the years, he has had a casual approach to his illness. He only becomes concerned when bodily changes affect his present lifestyle, when in fact he should have been concerned all along. His verbal response also reflects denial. (D) There is no evidence of bargaining in the client's actions or verbal response.

• Question 308:

  A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately:

  A. 10 weeks

  B. 16 weeks

  C. 20 weeks

  D. 30 weeks

  Correct Answer: C

  (A) At 10 weeks, the fundus is located slightly above the symphysis pubis. (B) At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus. (C) At 20 weeks, the fundus is located approximately at the umbilicus. (D) At 30 weeks, the fundal height is about 30 cm, or 10 cm above the umbilicus.

• Question 309:

  A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is NPO with IV fluids infusing at 100 mL/hour. He is experiencing excruciating abdominal pain. Based on an analysis of these data, which nursing diagnosis would receive the highest priority?

  A. Pain related to stimulation of nerve endings associated with obstruction of the pancreatic tract

  B. Fluid volume deficit related to vomiting and nasogastric tube drainage

  C. Knowledge deficit related to treatment regimen

  D. Altered nutrition: less than body requirements, related to inadequate intake associated with current anorexia, nausea, vomiting, and digestive enzyme loss

  Correct Answer: A

  (A) Relief of pain is the primary goal of nursing intervention because this client is experiencing acute pain. (B) Fluid volume deficit is being treated with IV fluid replacement. (C) Knowledge deficit will not be addressed at this time because a client in acute pain is not ready to learn. (D) Alteration in nutrition is the third priority after relief of pain and fluid volume deficit.

• Question 310:

  A 15-year-old female adolescent is frequently breaking the rules of the unit. She has left the unit and was found smoking in the bathroom and spending a large amount of time in the male ward. Which statement by the nurse would best explain to the teenager why she must follow the rules of the unit?

  A. "It is not easy, but the rules must be followed so that everyone can get a fair chance."

  B. "If you do not follow the rules, you will be transferred to the closed, locked unit."

  C. "You are not being fair to the other clients by getting them involved in your deviant behavior."

  D. "Break the rules, all you want, but don't get caught again!"

  Correct Answer: A

  (A) This statement acknowledges that it is difficult but is not threatening or punitive. (B) This statement is threatening and describes specific punishment for further deviant behavior. (C) This response elicits shame by blaming her for involving others. (D) This response gives her permission to break the rules but indicates that getting caught is wrong.