NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 371:

  A client who is a breast-feeding mother develops mastitis. The clinical signs and symptoms of mastitis include:

  A. Marked engorgement, elevated temperature, chills, and breast pain with an area that is red and hardened

  B. Marked engorgement and breast pain

  C. Elevated temperature and general malaise

  D. Cracked nipple with complaints of soreness

  Correct Answer: A

  (A) Mastitis is a bacterial inflammation of the breast tissue found primarily in breast-feeding mothers. The bacteria usually enter the breast through a cracked nipple, or the infection results from stasis of milk behind a blocked duct. (B) With breast engorgement during breast-feeding, there may be marked breast pain. This is not necessarily a sign of infection. (C) Women may become ill during breast-feeding with other bacterial or viral infections that are not related to mastitis. (D) Improper care of the nipples or improper positioning of the infant during breastfeeding may result in cracked or sore nipples.

• Question 372:

  A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:

  A. Activity intolerance

  B. Ineffective airway clearance

  C. High risk for infection

  D. Altered oral mucous membrane

  Correct Answer: B

  (A) The laryngectomy client should be able to gradually increase activities without difficulty. (B) The laryngectomy client may have copious amounts of secretions and require suctioning for the first 24?8 hours. The cannula will require cleaning even after the first 24 hours because mucus collects in it. (C) The client does have a potential for infection, but it is not a more importantnursing priority than the ineffective airway clearance. (D) This problem is not a more important nursing priority than ineffective airway clearance. The client's mouth may become dry, but good oral care should take care of the dryness.

• Question 373:

  A 42-year-old client presents with a diagnosis of paranoid schizophrenia. She has become increasingly restless and verbally argumentative, and her speech has become pressured. She is exhibiting signs of:

  A. Depression

  B. Agitation

  C. Psychotic ideation

  D. Anhedonia

  Correct Answer: B

  (A) Signs of depression would include withdrawal, sadness, morbid thoughts, insomnia, early awakening, etc. (B) These clinical features are classic signs of agitation. (C) Psychotic ideation includes delusional thoughts, bizarre behavior, disorganized thinking, etc. (D) Anhedonia is the inability to experience pleasure.

• Question 374:

  The most frequent cause of early postpartum hemorrhage is:

  A. Hematoma

  B. Coagulation disorders

  C. Uterine atony

  D. Retained placental fragments

  Correct Answer: C

  (A) Hematomas, which are the result of damage to a vessel wall without laceration of the tissue, are a cause, though not the most frequent cause. (B) Coagulation disorders are among the causes of postpartal hemorrhage, but they are less common. (C) The most frequent causes of hemorrhage in the postpartal period are related to an interference with involution of the uterus. Uterine atony is the most frequent cause, occurring in the first 24 hours after delivery. (D) Retained placental fragments are also a cause, although these bleeds usually occur 7?4 days after delivery.

• Question 375:

  The nurse is caring for a client who has diabetes insipidus. The nurse would describe this client's urine output pattern as:

  A. Anuria

  B. Oliguria

  C. Dysuria

  D. Polyuria

  Correct Answer: D

  Explanation:

  (A)Anuriais defined as absence of urine output, which is not indicative of the urinary pattern of diabetes insipidus. (B)Oliguriais defined as <500 mL of urine per day, which is not a urinary output pattern associated with diabetes insipidus. (C)

  Dysuriais defined as difficult urination. Clients with diabetes insipidus do not have dysuria as a symptom of their disease. (D) Polyuria is a primary symptom of diabetes insipidus. These clients have decreased or absent vasopressin secretion,

  which causes water loss in the urine and sodium increases.

• Question 376:

  A postoperative prostatectomy client is preparing for discharge from the hospital the next morning. The nurse realizes that additional instructions are necessary when he states:

  A. "If I drink 10 to 12 glasses of fluids each day, that will help to prevent any clot formation in my urine."

  B. "The isometric exercises will help to strengthen my perineal muscles and help me control my urine."

  C. "If I feel as though I have developed a fever, I will take a rectal temperature, which is the most accurate."

  D. "I do not plan to do any heavy lifting until I visit my doctor again."

  Correct Answer: C

  (A) This is correct health teaching. Drinking 10?2 glasses of clear liquid will help increase urine volumes and prevent clot formation. (B) This is correct health teaching. These types of exercises are prescribed by physicians to assist postprostatectomy clients to strengthen their perineal muscles. (C) This action is not recommended post-TURP because of the close proximity of the prostate and rectum. (D) This is correct healthcare teaching. The client should limit walking long distances, lifting heavy objects, or driving a car until these activities are cleared by the physician at the first office visit.

• Question 377:

  The physician prescribes phenytoin (Dilantin) for a client with seizure disorders. Phenytoin can only be mixed with which of the following solutions?

  A. Ringer's lactate

  B. D5 in water

  C. D5 with Ringer's lactate

  D. Normal saline

  Correct Answer: D

  (A) Phenytoin will precipitate if mixed with Ringer's lactate and should not be administered. (B, C) Phenytoin will precipitate if mixed with D5 in Ringer's lactate and should not be administered. (D) Phenytoin is compatible only with normal saline and should be mixed only with normal saline for administration.

• Question 378:

  A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is ototoxic, the nurse would implement which of the following measures?

  A. Instruct the client to report any signs of tinnitus, dizziness or difficulty hearing.

  B. Advise the client to discontinue the drug at the first sign of dizziness.

  C. Order audiometric testing in order to determine if hearing loss is caused by an ototoxic drug or other cause.

  D. Instruct the client in Valsalva's maneuver to equalize middle ear pressure and to prevent hearing loss.

  Correct Answer: A

  (A) The first nursing measure is to instruct the client in which drug side effects to report. (B) Discontinuing the drug is not an independent nursing intervention and may compromise client care. (C) Audiometric testing will detect hearing loss, but it does not indicate a potential cause. (D) Equalizing middle ear pressure will not prevent hearing loss.

• Question 379:

  When caring for a postoperative cholecystectomy client, the nurse assesses patency and documents drainage of the T-tube. The nurse recognizes that the expected amount of drainage during the first 24 hours postoperatively is:

  A. 50

  Correct Answer: C

  (A) During the first 24 hours after surgery, the drainage is normally 300

• Question 380:

  A 5-year-old child was recently diagnosed as having acute lymphoid leukemia. She is hospitalized for additional tests and to begin a course of chemotherapy designed to induce a remission. She is scheduled to have a bone marrow aspiration tomorrow. She has had a bone marrow test previously and is apprehensive about having another. Which of the following interventions will be most effective in relieving her anxiety?

  A. Explain what will take place and what she will see, feel, and hear.

  B. Remind her that she has had this procedure before and that it is nothing to be afraid of.

  C. Tell her not to worry about it, that it will be over soon and she can join her friends in the playroom.

  D. Give her a big hug and tell her that she is a big girl now and that she will do just fine.

  Correct Answer: A

  (A) Even though the child has had the procedure before, she will probably need additional explanations and emotional support. (B) The fact that the child has had the procedure before and possibly found it painful or uncomfortable may increase, not relieve, her stress. (C) This intervention does nothing to reassure the child and may well prevent her from expressing her feelings. (D) This does not prepare the child for the test and burdens her with the expectation that she act bigger and braver than she is.