NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 321:

  A 32-year-old male client is a marketing representative. His job requires him to have a tremendous amount of energy during the day. He frequently uses cocaine to sustain his energy level. Lately he has increased his use of cocaine and even experimented with crack cocaine. Realizing he can no longer continue this destructive behavior, he is seeking treatment for cocaine addiction. In planning nursing care for the client's inpatient stay, which expected outcome is most appropriate?

  A. He will attend four consecutive group educational sessions on substance abuse.

  B. He will name activities that he would most likely be involved in posttreatment.

  C. He will meet with his family in counseling sessions and discuss his feelings.

  D. He will be able to deal with his feelings through participation in group therapy sessions.

  Correct Answer: D

  (A) This expected outcome is specific as related to attendance, but not specific as related to outcome criteria. (B) Stating activities does not guarantee involvement. (C) This goal may help the recovery process, but postcounseling behavior is not addressed. (D) This statement best describes the expected outcome. The client will be attending group therapy sessions and through them he will deal with his feelings.

• Question 322:

  A 10-year-old boy has been diagnosed with Legg-Calv?Perthes disease. Which of the client's responses would indicate compliance during initial therapy?

  A. Drinking large amounts of milk

  B. Not bearing weight on affected extremity

  C. Walking short distances 3 times/day

  D. Putting self on weight reduction diet

  Correct Answer: B

  (A) This condition causes aseptic necrosis of the head of the femur in the acetabulum. Drinking large quantities of milk at this time cannot hasten recovery. (B) The aim of treatment is to keep the head of the femur in the acetabulum. Non瓀 eight-bearing is essential. Activity causes microfractures of the epiphysis. (C) In addition to non瓀eight- bearing, clients are often placed on bedrest, which helps to reduce inflammation. Later, active motion is encouraged. (D) Weight is not generally an issue with this disease. Slipped femoral capital epiphysis, which is most frequently observed in obese pubescent children, usually requires a weight reduction diet.

• Question 323:

  A 19-year-old primigravida is admitted to the labor and delivery suite of the hospital. Her husband is accompanying her. The couple tells the nurse that this is the first hospital admission for her. The client's vaginal exam indicates she is 3 cm dilated, 80% effaced, and at _0 station. Based on the vaginal exam, she is in:

  A. Stage 2, latent phase

  B. Stage 1, active phase

  C. Stage 3, transition phase

  D. Stage 1, latent phase

  Correct Answer: D

  (A) The second stage of labor is from full cervical dilation through birth of the baby. The three phases of this stage include latency or resting, descent, and final transition. The client is less than fully dilated so she is not in stage 2. (B) The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0? cm), the active phase (4? cm), and the transitional phase (7?0 cm). The client is<;4 cm dilated so she is in the latent phase of the first stage of labor. (C) The third stage of labor is from the birth of the baby until the delivery of the placenta. The client is less than fully dilated. (D) The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early orlatent phase (0? cm), the active phase (4? cm), and the transitional phase (7?0 cm). The client i

• Question 324:

  A primipara is assessed on arrival to the postpartum unit. The nurse finds her uterus to be boggy. The nurse's first action should be to:

  A. Call the physician

  B. Assess her vital signs

  C. Give the prescribed oxytocic drug

  D. Massage her fundus

  Correct Answer: D

  (A) The nurse should first implement independent and dependent measures to achieve uterine tone before calling the physician. (B) Assessment of vital signs will not help to restore uterine atony, which is the priority need. (C) Giving a prescribed oxytocic drug would be necessary ifthe uterus did not maintain tone with massage. (D) Fundal massage generally restores uterine tone within a few moments and should be attempted first.

• Question 325:

  A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures should be included in the postoperative care?

  A. Encourage the child to cough up blood if present.

  B. Give warm clear liquids when fully alert.

  C. Have child gargle and do toothbrushing to remove old blood.

  D. Observe for evidence of bleeding.

  Correct Answer: D

  (A) The nurse should discourage the child from coughing, clearing the throat, or putting objects in his mouth. These may induce bleeding. (B) Cool, clear liquids may be given when child is fully alert. Warm liquids may dislodge a blood clot. The nurse should avoid red- or brown-colored liquids to distinguish fresh or old blood from ingested liquid should the child vomit. (C) Gargles and vigorous toothbrushing could initiate bleeding. (D) Postoperative hemorrhage, though unusual, may occur. The nurse should observe for bleeding by looking directly into the throat and for vomiting of bright red blood, continuous swallowing, and changes in vital signs.

• Question 326:

  A client is dilated 8 cm and entering the transition phase of labor. Common behaviors of the laboring woman during transition are:

  A. Frustration, vague in communication

  B. Seriousness, some difficulty following directions

  C. Calmness, follows directions easily

  D. Excitement, openness to instructions

  Correct Answer: A

  (A) During the transition phase, the mother may become frustrated and unclear in her communication owing to severe pain and fear of loss of control. (B) These behaviors are common in the active phase of labor. (C) These behavioral clues are seen in the latent phase of labor. (D) These characteristics are observed in the latent phase of labor.

• Question 327:

  The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at nine weeks' gestation. An appropriate response by the nurse would be:

  A. "It must be God's will and probably is for the best."

  B. "This must be a difficult time for you. Would you like to talk about it?"

  C. "I'm sure your other children will be a comfort for you."

  D. "Don't worry, you're still young. If I were you I'd just try again."

  Correct Answer: B

  (A) This response is nontherapeutic because it belittles the client's response and gives a meaningless rationalization. (B) This response acknowledges the client's feelings and demonstrates the therapeutic offering of self by the nurse. (C) This response is nontherapeutic because it does not focus on the client's feelings and offers false reassurance. (D) This response is nontherapeutic because it belittles the client's feelings and offers her advice.

• Question 328:

  A female client has a chest tube placed. It is accidentally pulled out of the intrapleural space when she is ambulating. The first action the nurse should take is to:

  A. Instruct the client to cough deeply to re-expand her lung

  B. Put on sterile gloves and replace the tube

  C. Apply a petrolatum dressing over the site

  D. Auscultate the lung to determine if she needs the tube replaced

  Correct Answer: C

  (A) This action is inappropriate. Coughing will not re-expand the lung and could result in further harm. (B) This action is a medical procedure, not a nursing procedure. (C) An occlusive dressing will prevent further air leak until the physician institutes further treatment. (D) The decision to reinsert the tube is a medical decision, not a nursing one.

• Question 329:

  A female client presents to the obstetric-gynecology clinic for a pregnancy test, the result which turns out to be positive. Her last menstrual period began December 10, 1993. Using N鋑ele's rule, the nurse estimates her date of delivery to be:

  A. September 17, 1994

  B. September 10, 1994

  C. September 3, 1994

  D. August 17, 1994

  Correct Answer: A

  (A) According to N鋑ele's rule, the estimated date of delivery is calculated by adding 7 days to the date of the first day of the normal menstrual period (December 10 + 7 days = December 17), and then by counting back 3 months (December 17 -3 mo = September 17). (B, C, D) These answers are incorrect.

• Question 330:

  A 30-year-old female client is receiving antineoplastic chemotherapy. Which of the following symptoms should especially concern the nurse when caring for her?

  A. Respiratory rate of 16 breaths/min

  B. Pulse rate of 80 bpm

  C. Complaints of muscle aches

  D. A sore throat

  Correct Answer: D

  (A) A respiratory rate of 16 breaths/min is normal and is not a cause for alarm. (B) A pulse rate of 80 bpm is normal and is not a cause for alarm. (C) Complaints of muscle aches are unrelated to her receiving chemotherapy. There may be other causes related to her hospital stay or the disease process. (D) A sore throat is an indication of a possible infection. A client receiving chemotherapy is at risk of neutropenia. An infection in the presence of neutropenia can result in a life-threatening situation.