NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 391:

  A 32-year-old mother of two was brought to the hospital by her husband. He reported that his wife could no longer manage the house and children. She does not sleep and talks day and night. She has purchased some very expensive clothes. The nurse noted that the client speaks rapidly and changes the subject irrationally. This is an example of:

  A. Flight of ideas

  B. Delusions

  C. Hallucinations

  D. Echolalia

  Correct Answer: A

  (A) Rapidly moving from one topic to another without following any logical sequence is called flight of ideas. (B) False beliefs are delusions. (C) False sensory perceptions are hallucinations ("hearing voices"). (D) Repeating words is called echolalia.

• Question 392:

  A 10-month-old infant's mother says that he takes fresh whole milk eagerly, but that when she offered him baby foods at 6 months of age, he pushed them out of his mouth. Because he has gained weight appropriately, she has quit trying to get him to eat other foods. The nurse's response is based on the knowledge that:

  A. Milk intake should be limited to no more than four 8-oz bottles per day and should be followed by iron-enriched cereal or other solid foods or juices

  B. Milk is an excellent food and will meet his nutritional needs adequately until he is ready to eat solid foods

  C. It is acceptable to continue to give him whole milk and to delay giving solid foods as long as he takes a vitamin supplement daily

  D. He should be started on iron-enriched cereal, meat, vegetables, fruits, and juices prior to bottle feeds. Milk intake should be limited to 1 qt/day

  Correct Answer: D

  (A) If the infant is given the bottle first, he will be less likely to be hungry enough to eat the solid foods. (B) Milk is deficient in iron, vitamin C, zinc, and fluoride. It does not provide an adequate diet. (C) The vitamin supplement will help, but the infant needs an iron supplement. (D) Giving the solid food when the infant is hungriest will increase the likelihood that he will eat. The more solid food he takes, the less milk he will desire.

• Question 393:

  The client tells the nurse, "I have pain in my left shoulder."

  This is considered:

  A. Evaluation process

  B. Objective information

  C. Subjective information

  D. Complaining

  Correct Answer: C

  (A) Evaluation process follows a nursing intervention. (B) Objective information can be measured. (C) Subjective information is provided by a person. (D) Client is reporting a symptom that needs to be assessed.

• Question 394:

  A 52-year-old client is scheduled for a small-bowel resection in the morning. In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises. She will teach the client to:

  A. Inhale slowly and deeply through the nose until the lungs are fully expanded, hold the breath a couple of seconds, and then exhale slowly through the mouth. Repeat 2? more times to complete the series every 1? hours while awake

  B. Purse the lips and take quick, short breaths approximately 18?0 times/min

  C. Take a large gulp of air into the mouth, hold it for 10?5 seconds, and then expel it through the nose. Repeat 4? times to complete the series

  D. Inhale as deeply as possible and then immediately exhale as deeply as possible at a rate of approximately 20?4 times/min

  Correct Answer: A

  (A) This is the correct method of teaching diaphragmatic breathing, which allows full lung expansion to increase oxygenation, prevent atelectasis, and move secretions up and out of the lungs to decrease risk of pneumonia. (B) Quick, short breaths do not allow for full lung expansion and movement of secretions up and out of the lungs. Quick, short breaths may lead to O2 depletion, hyperventilation, and hypoxia. (C) Expelling breaths through the nose does not allow for full lung expansion and the use of diaphragmatic muscles to assist in moving secretions up and out of the lungs. (D) Inhaling and exhaling at a rate of 20?4 times/min does not allow time for full lung expansion to increase oxygenation. This would most likely lead to O2 depletion and hypoxia.

• Question 395:

  When providing dietary teaching to an individual who has diabetes mellitus, type II, the nurse discusses the importance of consuming the recommended daily allowance of which of the following electrolytes?

  A. Potassium

  B. Magnesium

  C. Sodium

  D. HCO3

  Correct Answer: B

  (A) Potassium intake that meets the recommended daily allowance is important, especially in clients who have a history of cardiac disease. (B) Low levels of magnesium can cause an increase in resistance to insulin and can lead to carbohydrate intolerance. (C) Sodium is an important electrolyte for all clients but has no direct effect on diabetes mellitus. (D) Bicarbonate plays an important role in acid-base balance. It is equally necessary for maintenance of all body functions.

• Question 396:

  On the first postpartal day, a client tells the nurse that she has been changing her perineal pads every 1/2 hour because they are saturated with bright red vaginal drainage. When palpating the uterus, the nurse assesses that it is somewhat soft, 1 fingerbreadth above the umbilicus, and midline. The nursing action to be taken is to:

  A. Gently massage the uterus until firm, express any clots, and note the amount and character of lochia

  B. Catheterize the client and reassess the uterus

  C. Begin IV fluids and administer oxytocic medication

  D. Administer analgesics as ordered to relieve discomfort

  Correct Answer: A

  (A) Gentle massage and expression of clots will let the fundus return to a state of firmness, allowing the uterus to function as the "living ligature." (B) A distended bladder may promote uterine atony; however, after determining the bladder is distended, the nurse would have the client void. Catheterization is only done if normal bladder function has not returned. (C) Oxytocic medications are ordered and administered if the uterus does not remain contracted after gentle massage and determining if the bladder is empty. (D) The client is not complaining of discomfort or pain; therefore, analgesics are not necessary.

• Question 397:

  In the coronary care unit, a client has developed multifocal premature ventricular contractions. The nurse should anticipate the administration of:

  A. Furosemide

  B. Nitroglycerin

  C. Lidocaine

  D. Digoxin

  Correct Answer: C

  (A) Furosemide is a loop diuretic. (B) Nitroglycerin is a vasodilator. (C) Lidocaine is the drug of choice to treat ectopic ventricular beats. (D) Digoxin slows down the electrical impulses and increases ventricular contractions, but it does not rapidly correct ventricular ectopy.

• Question 398:

  A client is being discharged from the hospital today. The discharge teaching for care of her colostomy included which of the following basic principles for protecting the skin around her stoma:

  A. Taping a pouch that is leaking

  B. Cutting the skin barrier 112 inches larger than the stoma

  C. Changing the pouch only when leakage occurs

  D. Using a skin sealant under pouch adhesives

  Correct Answer: D

  (A) When a pouch seal leaks, the pouch should be immediately changed, not taped. Stool held against the skin can quickly result in severe irritation. (B) The skin barrier should be cut only slightly larger than the stoma (one-half inch). (C) The client should be taught to change pouches whenever possible before leakage occurs. (D) When skin sealant is used under the tape, the outermost layer of the epidermis remains intact. When no skin sealant is used, this layer is removed when the tape is removed.

• Question 399:

  The physician prescribes a medical regimen of isoniazid, rifampin, and vitamin B6 for a tuberculosis client. The nurse instructs the client that B6 is given because it:

  A. Increases activity of isoniazid

  B. Increases activity of rifampin

  C. Improves nutritional status

  D. Reduces peripheral neuropathy

  Correct Answer: D

  (A) Vitamin B6does not enhance the activity of isoniazid. (B) Vitamin B6does not enhance the activity of rifampin. (C) A vitamin alone does not improve nutritional status. (D) Isoniazid leads to Vitamin B6deficiency, which is manifested as peripheral neuropathy.

• Question 400:

  A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that he has had no significant illnesses or injuries. Which of the following signs would lead the nurse to believe that he has had a cerebral injury?

  A. Hyperextension of the neck with evidence of pain on flexion

  B. Holding the head to one side and pointing the chin toward the other side

  C. Holding the head erect and in the midline when in a vertical position

  D. Significant head lag when raised to a sitting position

  Correct Answer: D

  (A) This position is indicative of a possible meningeal irritation or infection such as meningitis. (B) This position is seen most frequently in infants who have had an injury to the sternocleidomastoid muscle. (C) Most infants aged 4 months and older are able to maintain this position. (D) Infants older than 6 months of age should not have significant head lag. This is a sign of cerebral injury and should be referred for further evaluation.