NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 31:

  A 40-year-old client has been admitted to the hospital with severe substernal chest pain radiating down his left arm. The nurse caring for the client establishes the following priority nursing diagnosis--Alteration in comfort, pain related to:

  A. Increased excretion of lactic acid due to myocardial hypoxia

  B. Increased blood flow through the coronary arteries

  C. Decreased stimulation of the sympathetic nervous system

  D. Decreased secretion of catecholamines secondary to anxiety

  Correct Answer: A

  (A) Anaerobic metabolism results because the decreased blood supply to the myocardium causes a release of lactic acid. Lactic acid is an irritant to the myocardial neural receptors, producing chest pain. (B) Chest pain is caused by a decrease in the O2 supply to the myocardial cells. Treatment modalities for chest pain are aimed toward increasing the blood flow through coronary arteries. (C) Chest pain causes an increase in the stimulation of the sympathetic nervous system. This stimulation increases the heart rate and blood pressure, causing an increase in myocardial workload aggravating the chest pain. (D) Chest pain and anxiety cause increased secretion of catecholamines by stimulating the sympathetic nervous system. This stimulation increases chest pain by increasing the workload of the heart.

• Question 32:

  Goal setting for a client with Meniere's disease should include which of the following?

  A. Frequent ambulation

  B. Prevention of a fall injury

  C. Consumption of three meals per day

  D. Prevention of infection

  Correct Answer: B

  (A) Although not contraindicated, initially ambulation may be difficult because of vertigo and is recommended only with assistance. (B) Vertigo resulting in balance problems is one of the most common manifestations of Meniere's disease. (C) Adequate nutrition is important, but the emphasis in Meniere's disease is not the number of meals per day but a decrease in intake of sodium. (D) Infection is not an anticipated problem.

• Question 33:

  The nurse enters the room of a client on which a "do not resuscitate" order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, "please save her!" The nurse's action would be:

  A. Call the physician and inform him that the client has expired.

  B. Remind the husband that the physician wrote an order not to resuscitate.

  C. Discuss with the husband that these orders are written only on clients who are not likely to recover with resuscitative efforts.

  D. Call a code and proceed with cardiopulmonary resuscitation.

  Correct Answer: D

  (A, B, C) The last request from the husband overrides the decision not to initiate resuscitation efforts. (D) The nurse should begin cardiopulmonary resuscitation unless a living will and durable power of attorney are in force. In the meantime, the nurse should talk with the husband and notify the doctor.

• Question 34:

  A client is admitted to the hospital with a diagnosis of aplastic anemia and placed on isolation. The nurse notices a family member entering the room without applying the appropriate apparel. The nurse will approach the family member using the following information as a basis for discussion:

  A. The risks of exposure of the visitor to infectious organisms is great.

  B. Hospital regulations mandate that everyone in the facility adhere to appropriate codes.

  C. The client is at extreme risk of acquiring infections.

  D. Adherence to the guidelines are the latest Centers for Disease Control and Prevention recommendations on use of protective apparel.

  Correct Answer: C

  (A) Although clients with a compromised immune system may acquire infections, the primary emphasis is on protecting the client. (B, D) Most people are aware of the guidelines once they see posted signs, so quoting regulations is not likely to result in consistent adherence to regulations. (C) Clients with aplastic anemia have white cell counts of 2000 or lower, making them more vulnerable to infections from others.

• Question 35:

  The nurse notes scattered crackles in both lungs and 1+ pitting edema when assessing a cardiac client. The physician is notified and orders furosemide (Lasix) 80 mg IV push stat. Which of the following diagnostic studies is monitored to assess for a major complication of this therapy?

  A. Serum electrolytes

  B. Arterial blood gases

  C. Complete blood count

  D. 12-Lead ECG

  Correct Answer: A

  (A)

  Furosemide, a potassium-depleting diuretic, inhibits the reabsorption of sodium and chloride from the loop of Henle and the distal renal tubules. Serum electrolytes are monitored for hypokalemia. (B) Severe acid-base imbalances influence the movement of potassium into and out of the cells, but arterial blood gases to not measure the serum potassium level. (C) Furosemide is a potassium-depleting diuretic. A complete blood count does not reflect potassium levels.

  (D)

  Abnormalities in potassium (both hyperkalemia and hypokalemia) are reflected in ECG changes, but these changes do not occur until the abnormality is severe.

• Question 36:

  The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years. Which of the following data is most likely significant in relation to the cause of the low blood pressure?

  A. Pedal pulses 11 (weak)

  B. Twenty-four-hour intake 1000 mL/day for past 2 days

  C. Serum potassium 3.3

  D. Pulse rate 150 bpm

  Correct Answer: B

  (A, D) Decreased pulse volume and increased pulse rate are signs of an acute hypotensive episode. (B) Inadequate fluid volume when taking vasodilators can result in a drop in blood pressure when vasodilation starts to physiologically occur as an action of the drug. (C) A potassium level of 3.3 would not be associated with a significant drop in blood pressure.

• Question 37:

  The nurse is developing a plan of care for a client with an electrolyte imbalance and identifies a nursing diagnosis of decreased physical mobility. Which alteration is most the etiology?

  A. Hypernatremia

  B. Hypocalcemia

  C. Hypokalemia

  D. Hypomagnesemia

  Correct Answer: C

  (A) A deficit in sodium concentration results in muscular weakness and lethargy. (B) Muscle fatigue and hypotonia are caused by hypercalcemia. (C) Muscle weakness and fatigue are classic signs of hypokalemia. (D) Hypermagnesemia can cause muscle weakness, paralysis, and coma.

• Question 38:

  A client admitted with a diagnosis of possible myocardial infarction is admitted to the unit from the emergency room. The nurse's first action when admitting the client will be to:

  A. Obtain vital signs

  B. Connect the client to the cardiac monitor

  C. Ask the client if he is still having chest pain

  D. Complete the history profile

  Correct Answer: B

  (A) Obtaining vital signs is important after connecting the client to the monitor because vital signs should be stable before the client is discharged from the emergency room. (B) All are important, but the first priority is to monitor the client's rhythm. (C) If the client is in severe pain, pain medication should be given after connecting him to the monitor and obtaining vital signs. (D) Completion of the history profile is the least important of the nursing actions.

• Question 39:

  A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should:

  A. Notify the physician immediately

  B. Hold the morning lithium dose and continue to observe the client

  C. Administer the morning lithium dose as scheduled

  D. Obtain an order for benztropine (Cogentin)

  Correct Answer: C

  (A) There is no need to phone the physician because the lithium level is within therapeutic range and because there are no indications of toxicity present. (B) There is no reason to withhold the lithium because the blood level is within therapeutic range. Also, it is necessary to give the medication as scheduled to maintain adequate blood levels. (C) The lab results indicate that the client's lithium level is within therapeutic range (0.2?.4 mEq/L), so the medication should be given as ordered. (D) Benztropine is an antiparkinsonism drug frequently given to counteractextrapyramidal symptoms associated with the administration of antipsychotic drugs (not lithium).

• Question 40:

  The mother of a child taking phenytoin will need to plan appropriate mouth care and gingival stimulation. When tooth-brushing is contraindicated, the next most effective cleansing and gingival stimulation technique would be:

  A. Using a water pik

  B. Rinsing with water

  C. Rinsing with hydrogen peroxide

  D. Rinsing with baking soda

  Correct Answer: A

  (A) This technique provides effective rinsing and gingival stimulation. (B) This technique does not provide gingival stimulation. (C) This technique provides effective rinsing but not gingival stimulation. Using peroxide is not pleasant for the child. (D) This technique provides effective rinsing but not gingival stimulation.