NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 341:

  An obstructing stone in the renal pelvis or upper ureter causes:

  A. Radiating pain into the urethra with labia pain experienced in females or testicular pain in males

  B. Urinary frequency and dysuria

  C. Severe flank and abdominal pain with nausea, vomiting, diaphoresis, and pallor

  D. Dull, aching, back pain

  Correct Answer: C

  (A) Radiating pain in the urethra in both sexes, extending into the labia in females and into the testicle or penis in the male, indicates a stone in the middle or lower segment of the ureter. (B) Urinary frequency and dysuria are caused by a stone in the terminal segment of the ureter withinthe bladder wall. (C) An obstructing stone in the renal pelvis or upper ureter causes severe flank and abdominal pain with nausea, vomiting, diaphoresis, and pallor. (D) Dull and aching pain may indicate early stages of hydronephrosis. Also, a stone in the renal pelvis or upper ureter causes severe flank and abdominal pain.

• Question 342:

  Following the delivery of a healthy newborn, a client has developed thrombophlebitis and is receiving heparin IV. What are the signs and symptoms of a heparin overdose for which the nurse would need to observe during postpartum care of the client?

  A. Dysuria

  B. Epistaxis, hematuria, dysuria

  C. Vertigo, hematuria, ecchymosis

  D. Hematuria, ecchymosis, and epistaxis

  Correct Answer: D

  (A) Dysuria is not a common symptom of heparin overdose. (B) Although epistaxis and hematuria are common symptoms of heparin overdose, dysuria is not. (C) Vertigo is not a common symptom of heparin overdose. (D) Hematuria, ecchymosis, and epistaxis are the most common signs and symptoms of a heparin overdose. Others are thrombocytopenia, elevated liver enzymes, and local injection site complications.

• Question 343:

  A 32-year-old female client is being treated for Guillain- Barr?syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation?

  A. Complaints of a headache

  B. Loss of superficial and deep tendon reflexes

  C. Complaints of shortness of breath

  D. Facial paralysis

  Correct Answer: C

  (A) Headaches are not associated with Guillain-Barr?syndrome. (B) Loss of superficial and deep tendon reflexes is expected with this diagnosis. (C) Complaints of shortness of breath must be further evaluated. Forty percent of all clients have some detectable respiratory weakness and should be prepared for a possible tracheostomy. Pneumonia is also a common complication of this syndrome. (D) Facial paralysis is expected and is not considered abnormal.

• Question 344:

  A 40-year-old client is admitted to the coronary care unit with chest pain and shortness of breath. The physician diagnosed an anterior wall myocardial infarction.

  What tests should the nurse anticipate?

  A. Reticulocyte count, creatinine phosphokinase (CPK)

  B. Aspartate transaminase, alanine transaminase

  C. Sedimentation rate, WBC count

  D. Lactic dehydrogenase, CPK

  Correct Answer: D

  (A) Reticulocyte count measures the number of immature erythrocytes. CPK is an enzyme released from injured myocardial tissue. (B) Aspartate transaminase is an enzyme released from injured myocardial tissue. Alanine transaminase is an enzyme released for general tissue destruction, which is specific for liver injury. (C) Sedimentation rate is a nonspecific test for inflammation. (D) Lactic dehydrogenase and CPK are enzymes released from injured myocardial tissue.

• Question 345:

  A common complication of cirrhosis of the liver is prolonged bleeding. The nurse should be prepared to administer?

  A. Vitamin C

  B. Vitamin K

  C. Vitamin E

  D. Vitamin A

  Correct Answer: B

  (A) Vitamin C does not directly affect clotting. (B) Vitamin K is a fat-soluble vitamin that depends on liver function for absorption. Vitamin K is essential for clotting. (C) Vitamin E does not directly affect clotting. (D) Vitamin A does not directly affect clotting.

• Question 346:

  A nurse is taking a maternal history for a client at her first prenatal visit. Her pregnancy test was positive, she has two living children, she had one spontaneous abortion, and one infant died at the age of 3 months. Which of the following best describes the client at the present?

  A. Gravida 4, para 2, ab 1

  B. Gravida 5, para 3, ab 1

  C. Gravida 5, para 4, ab 0

  D. Gravida 4, para 3, ab 0

  Correct Answer: B

  (A) This individual has been pregnant four times, delivered two children, and had one abortion. (B) Your client has been pregnant five times, delivered three children, and had one abortion. (C) This individual has been pregnant five times, delivered four children, and has not had an abortion. (D) This individual has been pregnant four times, delivered three children, and has not had an abortion.

• Question 347:

  A 28-year-old woman was admitted to the hospital for a thyroidectomy. Postoperatively she is taken to the postanesthesia care unit for several hours. In preparing for the client's return to her room, which nursing measure best demonstrates the nurse's thorough understanding of possible postthyroidectomy complications?

  A. Dressings are placed at the bedside for dressing changes, which are to be done every 2 hours to best detect postoperative bleeding.

  B. Narcotics are readily available and administered when the client returns to her room to prevent excruciating pain.

  C. A tracheostomy set, O2, and suction are available at the bedside.

  D. The nurse should instruct the client as soon as possible on alternative means of communication.

  Correct Answer: C

  (A) Dressing changes are done as necessary for bleeding. However, frequently, post- thyroidectomy bleeding may not be visible on the dressing, but blood may drain down the back of the neck by gravity. (B) Narcotics are administered for acute pain as necessary. They are not necessarily given on return of the client to her room. (C) The most serious postthyroidectomy complication is ineffective airway and breathing pattern related to tracheal compression and edema. A tracheostomy set, O2, and suction should be available at bedside for at least the first 24 hours postoperatively. (D) Impaired verbal communication may occur due to laryngeal edema or nerve damage, but most commonly, it occurs due to endotracheal intubation. The client is usually able to communicate but is hoarse.

• Question 348:

  On an assessment of a client's mouth, the nurse notices white patches on the buccal mucosa. The nurse tries to obtain a sample for a culture, but the lesion cannot be rubbed off. The nurse would suspect that this lesion is:

  A. Xerosteromia

  B. Candidiasis

  C. Leukoplakia

  D. Stomatitis

  Correct Answer: C

  (A) Xerostomia is dry mouth. (B) Candidiasis can be rubbed off, but it will bleed. (C) Leukoplakia cannot be rubbed off. (D) Stomatitis is caused by candidiasis and gram- negative bacteria.

• Question 349:

  A postoperative TURP client returns from the recovery room to the general surgery unit and is in stable condition. One hour later the nurse assesses him and finds him to be confused and disoriented. She recognizes that this is most likely caused by:

  A. Hypovolemic shock

  B. Hypokalemia

  C. Hypernatremia

  D. Hyponatremia

  Correct Answer: D

  (A) Early signs of hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, and diaphoresis. (B) Early signs of potassium depletion include muscular weakness or paralysis, tetany, postural hypotension, weak pulse, shallow respirations, apathy, weak voice, and electrocardiographic changes. (C) Early signs of an elevated sodium level include dry oral mucous membranes, marked thirst, hypertension, tachycardia, oliguria or anuria, anxiety, and agitation. (D) This answer is correct. Important early clinical findings of a decreased sodium concentration include confusion and disorientation. Hyponatremia can occur after a TURP because absorption during surgery through the prostate veins can increase circulating blood volume and decrease sodium concentration.

• Question 350:

  The nurse who is caring for a client with pneumonia assesses that the client has become increasingly irritable and restless. The nurse realizes that this is a result of:

  A. Prolonged bed rest

  B. The client's maintaining a semi-Fowler position

  C. Cerebral hypoxia

  D. IV fluids of 2.5? liters in 24 hours

  Correct Answer: C

  (A) Maintaining bed rest helps to decrease the O2 needs of the tissues, which decreases dyspnea and workload on the respiratory system. (B) The semi-Fowler or high-Fowler position is necessary to aid in lessening pressure on the diaphragm from the abdominal organs, which facilitates comfort and easier breathing patterns. (C) Cerebral hypoxia causes the client with pneumonia to be increasingly irritable and restless and results from the client not obtaining enough O2 to meet metabolic needs. (D) Proper hydration facilitates liquefaction of mucus trapped in the bronchioles and alveoli and enhances expectoration. Unless contraindicated, a reasonable amount of IV fluids to be administered is at least 2.5? liters in a 24-hour period.