NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 351:

  A 48-year-old client presents with a long history of severedepression unrelieved by medication. He is admitted to the hospital for electroconvulsive therapy. Familymembers are very concerned about this therapy and are requesting information about aftereffects of the treatment. The nurse informs the family that he will:

  A. Have transient memory loss, confusion, andheadache

  B. Be alert and oriented immediately after the treatment

  C. Have insomnia for the first few days

  D. Require no special care after the procedure

  Correct Answer: A

  (A) This answer is correct. The client will be confused and have a memory loss, which is usually temporary, after electroconvulsive shock therapy. (B) This answer is incorrect. The client will experience transient memory loss, look bewildered, and be confused initially. (C) This answer is incorrect. The client will sleep immediately following the treatment. (D) This answer is incorrect. Vital signs are taken at least hourly after treatment. The client is monitored for hypotension, tachycardia, respiratory problems, and possible seizure activity.

• Question 352:

  A 72-year-old male client had the Foley catheter that was inserted during the transurethral resection of his prostate removed today. He is concerned about the urinary incontinence he is having since removal of the Foley catheter. The nurse explains that:

  A. He should not be concerned about it because it will resolve quickly

  B. This is usually temporary

  C. The nurse will keep him dry, and he should notify the nurse when this happens

  D. This is related to the bladder spasms and will soon stop

  Correct Answer: B

  (A) This problem is temporary, but it may take some time to resolve, especially in an older man. (B) This problem is usually temporary, but it may take some time to resolve. (C) Keeping the client dry will not relieve his anxiety about his incontinence. (D) The bladder spasms are not the cause of the client's incontinence.

• Question 353:

  A 3-year-old child was hospitalized for acute laryngotracheobronchitis. During her hospitalization, the child was placed under an oxygen mist tent. The nurse's frequent monitoring of the child's temperature frightened her parents. Which response by the nurse would be most appropriate?

  A. Monitoring the temperature prevents undue chilling.

  B. Rapid temperature elevations can occur in children.

  C. Checking the temperature will prevent febrile seizures.

  D. Taking the child's temperature can prevent airway obstruction.

  Correct Answer: A

  (A) The refrigerated cool mist tent creates a cool, moist environment. The child as well as bedding and clothing may become dampened. Monitoring the temperature of the child will ensure warmth and prevent chilling. (B) Only a low-grade fever is expected in laryngotracheobronchitis. (C) Febrile seizures are not expected with the low-grade fever. (D) Inflammation of the mucosal lining in the respiratory tract can cause airway obstruction. However, monitoring the child's temperature would not prevent airway obstruction.

• Question 354:

  An infant with a congenital heart defect is being discharged with an order for the administration of digoxin elixir every 12 hours. The parents need to be taught when administering digoxin to the infant that:

  A. If the infant vomits within 30 minutes of the digoxin administration, repeat the dose

  B. They need to mix it with formula so the infant swallows it easily

  C. If the infant vomits two or more consecutive doses or becomes listless or anorexic, notify the physician

  D. If a dose of digoxin is skipped for more than 6 hours, a new timetable for administration must be developed

  Correct Answer: C

  (A)

  Occasionally the child may vomit. They should not repeat the dose because the amount of digoxin that was absorbed is un-known, and serum levels of digoxin that are too high are more dangerous than those that are temporarily too low.

  (B)

  To ensure that the entire dose of digoxin is received, never mix it with food or formula. (C) Vomiting, anorexia, and listlessness are all signs of digoxin toxicity and should be reported to the physician immediately. (D) If a dose is forgotten for more than 6 hours, the nurse should advise the parents to skip that dose and to continue the next dose as scheduled.

• Question 355:

  The nurse is planning a reality orientation program for a group of clients with organic brain syndrome at the mental health center. Props that could be used for this program are:

  A. Month-old magazines that are provided by volunteers

  B. Large maps and posters depicting area of current residence

  C. A litter of kittens for the clients to pet

  D. A library of biographical books

  Correct Answer: B

  (A) This answer is incorrect. Current magazines would be appropriate. (B) This answer is correct. Maps of the state and town and posters that depict current events in the area are appropriate props. (C) This answer is incorrect. Kittens would be appropriate for pet therapy, not reality therapy. (D) This answer is incorrect. Biographies depict a past, not a present, orientation.

• Question 356:

  A client has been uncomfortable in crowds all her life. After the birth of her child, she has been housebound unless her husband can accompany her to the grocery store and for medical appointments. His schedule will not allow for this, and he has insisted that she must be more independent. Her anxiety has increased to the point of panic. The client has been diagnosed with agoraphobia. Which statement is true about this disorder?

  A. The behavior is not considered disabling.

  B. More men suffer from agoraphobia than women.

  C. The fears are persistent, and avoidance is used as the coping mechanism.

  D. Agoraphobia moves into remission when treated with chlorpromazine.

  Correct Answer: C

  (A) Agoraphobia is the most pervasive and serious phobic disorder. (B) Women compose 70%?5% of agoraphobia sufferers. (C) Agoraphobia is an acute disorder that immobilizes the sufferer with extreme anxiety. (D) Chlorpromazine is not a drug used to treat phobias.

• Question 357:

  In working with mental health clients who are prescribed medication that must be taken on a routine basis, it is important for education to begin when the drug therapy is initiated. One of the first steps in the teaching process is to:

  A. Explain the side effects of the medication

  B. Discuss the danger of overmedication

  C. Distribute written material to supplement verbal instructions

  D. Explore the client's perception regarding medication therapy

  Correct Answer: D

  (A, B, C) The nurse must first obtain information regarding the client's perception of the medication regimen. (D) The first step in the teaching process is to determine the client's perception.

• Question 358:

  A 71-year-old client fell and injured her left leg while cooking in the kitchen. Her husband calls the ambulance, and she is taken to the emergency department at a local hospital. X- ray reports confirm that she has an intertrochanteric fracture of the left femur. Her left leg will require skeletal traction initially and then surgery. The nurse knows that this type of traction will be used:

  A. By inserting pins to provide steady pull on the bone

  B. To suspend the leg in a sling without pull on the extremity

  C. Intermittently to place a pull over the pelvis and lower spine

  D. With weights at both ends of the bed to maintain pull on the upper extremity

  Correct Answer: A

  (A) Skeletal traction is the application of traction directly to bone with the use of pins and wires or tongs for the purpose of providing a strong, steady, continuous longitudinal pull on the bone. It is indicated for preoperative immobilization and positioning of hip and femur fractures. (B) A type of skeletal traction (balanced suspension with a Thomas splint and Pearson attachment) uses a sling to support the extremity, but it also uses weights to provide a strong, steady continuouspull on the extremity. A sling is used instead of pins. (C) Pelvic traction provides an intermittent pull over the pelvis and bone, whereas skeletal traction is continuous. Pelvic traction does not use pins. (D) Skeletal traction uses weights at the end of the bed to provide a continuous pull on long bones. Weights are not applied to both ends of the bed.

• Question 359:

  Primary nursing diagnoses for the antisocial client are:

  A. Alteration in perception and altered self-concept

  B. Impaired social interaction, ineffective individual coping, and altered self-concept

  C. Altered communication processes and altered recreational patterns

  D. Altered body image and altered thought processes

  Correct Answer: B

  (A) This answer is incorrect. Perception is not altered because the client is not psychotic. (B) This answer is correct. The antisocial client lacks responsibility, accountability, and social commitment; has impaired problem-solving ability; tends to overuse defense mechanisms; lies and steals; and is often grandiose concerning self. (C) This answer is incorrect. Altered communication processes do not characterize this client. The antisocial person communicates well and tends to have a charming personality. (D) This answer is incorrect. Altered thought processes refer to delusional thinking, which is bizarre and fixed, and do not characterize this client.

• Question 360:

  Endotracheal tube cuff pressure should never exceed:

  A. 10 mm Hg

  B. 20 mm Hg

  C. 45 mm Hg

  D. 60 mm Hg

  Correct Answer: B

  (A) Pressure<10 mm Hg places the client at risk for aspiration. (B) Pressure in the endotracheal tube cuff should never exceed 20 mm Hg, because higher pressure places the client at risk for tracheal erosion. (C) A pressure of 45 mm Hg is an extremely high pressure in the endotracheal tube cuff. This places the client at great risk for tracheal erosion. (D) A pressure of 60 mm Hg is an extremely high pressure in the endotracheal tube cuff. This places the client at great risk for tracheal erosion.