NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 311:

  An 11-month-old infant is admitted with a possible diagnosis of pyloric stenosis. Which of the following best describes the characteristic clinical manifestations of pyloric stenosis?

  A. Pain, especially when eating

  B. Poor appetite and sucking reflex

  C. Increased frequency and quantity of stools

  D. Palpable olive-shaped mass in the epigastrium just right of the umbilical cord

  Correct Answer: D

  (A) There is no evidence of pain in infants with pyloric stenosis whether eating or not. (B) There are both good appetite and feeding habits in these children. (C) Because of regurgitation, there is usually decreased frequency and quantity of stools and also signs of dehydration and weight loss. (D) Along with upper abdominal distention, there is a characteristic palpable olive-shaped mass located to the right of the umbilicus.

• Question 312:

  After instructing a female client on circumcision care, the nursery nurse asks her to restate some of the key points covered. Which statement shows that the client will properly care for her son's circumcision?

  A. "I'll make sure I soak the gauze with warm water first, before I take it off each time."

  B. "I'll make sure that I report any drainage around where they operated."

  C. "I'll apply alcohol to the area daily to clean it and prevent any infection."

  D. "I'll keep a close watch on it for a day or two."

  Correct Answer: A

  (A) Before petrolatum gauze is removed, it should be soaked with warm water to prevent trauma to adherent tissues. (B) A yellow exudate often forms normally over the surgical site. Only if it becomes foul-smelling and purulent would it need to be reported. (C) Alcohol should never be used on the site; this would be extremely painful to the infant. (D) Special care and observance should continue until the site is completely covered with clean, pink granulation tissue, which could take 7?0 days.

• Question 313:

  A female client is exhibiting signs of respiratory distress. Which of the following signs indicate a possible pneumothorax?

  A. Crackles or rales on the affected side

  B. Bradypnea and bradycardia

  C. Shortness of breath and sharp pain on the affected side

  D. Increased breath sounds on the affected side

  Correct Answer: C

  (A) With a pneumothorax, air occupies the pleural space. Crackles or rales are heard with increased fluid or secretions and would not be present with air in the space. (B) With a pneumothorax, the client would experience tachypnea and tachycardia to compensate for the decrease in oxygenation. (C) Symptoms of pneumothorax include shortness of breath, sharp pain on the affected side with movement or coughing, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. (D) With a pneumothorax, breath sounds would be decreased on the affected side (indicates air in the pleural space).

• Question 314:

  A 24-year-old graduate student recognizes that he has a phobia. He suffers severe anxiety when he is in darkness. It has altered his lifestyle because he is unable to go to a movie theater, concert, and other events that may require absence of light. The client is seeking assistance because he is no longer able to socialize with friends due to his phobia. The psychologist working with him is using desensitization. He has asked the nursing staff to assist the client in muscle relaxation techniques. What result would indicate client education has been successful?

  A. He enters a movie theater, sits in his chair, and replaces anxiety with relaxation as the theater darkens.

  B. He enters a concert, but as the lights dim, he does not experience anxiety.

  C. He states that he no longer fears dark places.

  D. He takes a part-time job as a photographic assistant. His job necessitates his working in a darkroom.

  Correct Answer: A

  (A) This situation provides specific evidence that the client is able to integrate muscle relaxation technique into his lifestyle to alleviate anxiety. (B) The client may not experience anxiety at the concert, but there is no evidence regarding the technique that he used to alleviate anxiety. (C) The client may state he no longer experiences anxiety, but there is no evidence demonstrating this. He may be denying anxiety to discontinue therapy prematurely. (D) Does he experience anxiety in the darkroom? He may have taken this job to force himself to deal with the phobia directly.

• Question 315:

  A female client has been diagnosed with chronic renal failure. She is a candidate for either peritoneal dialysis or hemodialysis and must make a choice between the two. Which information should the nurse give her to help her decide?

  A. Hemodialysis involves less time to filter the blood; but the client must consider travel time, distance, and inconvenience.

  B. Hemodialysis involves more time to filter the blood than does peritoneal dialysis.

  C. Peritoneal dialysis has almost no complications and is less time consuming than hemodialysis. Therefore it is preferred.

  D. Peritoneal dialysis requires that a home health nurse prepare and administer the treatments.

  Correct Answer: A

  (A) Hemodialysis is faster in clearing the blood of toxins than peritoneal dialysis. However, clients must consider the time that they spend traveling to the dialysis center and the disruption in their daily lives. (B) Peritoneal dialysis requires several exchanges with dwelling time for the dialysate and therefore takes longer than hemodialysis. (C) Several serious complications of peritoneal dialysis include peritonitis, catheter displacement and/or plugging, or pain during dialysis. (D) A client can be taught to self-administer peritoneal dialysis without the aid of a professional.

• Question 316:

  An 82-year-old former restaurant owner walks to the nursing station and states, "I have to go. The restaurant opens at 11 am." Which response by the nurse is the most appropriate?

  A. "Go back to your room. You do not own a restaurant."

  B. "You are in the hospital now. Calm down."

  C. "You once owned a restaurant. Tell me about it."

  D. "It is snowing outside. The restaurant is closed."

  Correct Answer: C

  (A) This response cuts off communication with the client. It does not address her feelings. (B) Reality orientation frequently does not work alone. Feelings must be addressed. Telling a client to calm down is frequently ineffective. (C) Reminiscence is used here to reorient and recall past pleasant events. Talking about the restaurant will allay anxiety. (D) This response may confirm to the client that she indeed does still own a restaurant, buying into her confusion. Her feelings and anxiety require nursing intervention.

• Question 317:

  When interviewing parents who are suspected of child abuse, the nurse would use which of the following interview techniques?

  A. Be direct, honest, and attentive.

  B. Approach them in the emergency room as soon as you suspect abuse to "clear the air" right away.

  C. Ask the parents what they could have done differently to prevent this from happening to the child.

  D. After the interview, call child protective services.

  Correct Answer: A

  (A) The nurse must be honest, direct, professional, and attentive in her interview to gain the parent's trust. (B) The nurse should approach the parents in private, away from the child. (C) Asking them to relive and evaluate the situation may be looked at as placing blame on the parents for the child's "accident." At this point, the parents may get defensive and stop communicating. (D) Although you may call child protective services, the nurse should inform the parents of their responsibility to do this and explain the process to them.

• Question 318:

  A client is pregnant for the fourth time and has had three normal vaginal deliveries. She is in active labor and fully dilated. Suddenly she calls, "Nurse, the baby is coming." As the nurse responds to her call, which one of the following observations should the nurse make first?

  A. Inspect the perineum.

  B. Time the contractions.

  C. Prepare a sterile area for delivery.

  D. Auscultate for fetal heart rate (FHR).

  Correct Answer: A

  (A) The nurse must assess the labor status to determine if birth is imminent. The nurse may note perineal bulging, crowning, or birth of the head to ascertain labor status. (B) Assessing uterine contractions is one intervention to ascertain labor status. Based on the client's cry, it is not the intervention of choice. (C) If delivery of the infant is imminent, preparing a clean or sterile area for delivery is appropriate, but labor status must be established, whether delivery is imminent, by perineal assessment. (D) Assessing FHR is one intervention to ascertain fetal well-being. Based on the client's cry, this is not the intervention of choice.

• Question 319:

  A female client at 36 weeks' gestation is experiencing preterm labor. Her physician has prescribed two doses of betamethasone 12 mg IM q24h. The nurse explains that she is receiving this drug to:

  A. Treat fetal respiratory distress syndrome

  B. Prevent uterine infection

  C. Promote fetal lung maturation

  D. Increase uteroplacental circulation

  Correct Answer: C

  (A) Respiratory distress syndrome occurs in the newborn, not the fetus. It may be treated postnatally with surfactant therapy. (B) Betamethasone is a corticosteroid, not an anti- infective drug; therefore, its use would not prevent uterine infection. (C) Betamethasone binds with glucocorticoid receptors in alveolar cells to increase production of surfactant, thus increasing lung maturity in the preterm fetus. (D) Betamethasone does not affect uteroplacental circulatory exchange.

• Question 320:

  A 12-year-old girl has been diagnosed with insulindependent diabetes mellitus. Which of these principles would best guide her nutritional management?

  A. Concentrated sweets are taken during increased activity.

  B. Food restriction is imposed to reduce weight.

  C. Caloric distribution should be calculated to fit activity patterns.

  D. Fat requirements are increased owing to the possibility of ketoacidosis.

  Correct Answer: C

  (A) Concentrated sweets are eliminated from diet planning. Complex carbohydrates may be taken at the time of increased activity. (B) Food restriction is not used for diabetic control of growing children. Caloric restriction may be imposed for weight control if necessary. (C) Total caloric intake and proportions of basic nutrients should be consistent from day to day. Distribution of these calories should fit the activity pattern. Extra food is needed for increased activity. A balance of food, exercise, and insulin should be maintained. (D) Because of the increased risk of atherosclerosis, the fat percentage of the total caloric intake is reduced.