NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 401:

  A male client was involved in a motor vehicle accident earlier in the day. The nurse caring for him on evenings notices that on admission to the hospital, he lost a lot of blood and required multiple blood transfusions. The nurse would anticipate which blood product would be ordered when a large blood loss has occurred?

  A. Whole blood

  B. Platelets

  C. Fresh frozen plasma

  D. Packed red blood cells

  Correct Answer: A

  (A) Whole blood is the transfusion component of choice when large volumes of blood need to be replaced. Whole blood contains all blood components that are lost during active bleeding. (B) Platelet therapy is indicated for thrombocytopenia if the client's platelet count is below 15,000/mm3. (C) Infusion of fresh frozen plasma is required when the prothrombin time and partial thromboplastic time are prolonged. (D) Packed red blood cells are transfused in instances of anemia with decreases in hematocrit and hemoglobin.

• Question 402:

  A hyperactive client is experiencing flight of ideas. The most therapeutic activity for him would be:

  A. Doing crafts in occupational therapy

  B. Working a 1000-piece puzzle

  C. Playing bridge with three other clients D. Playing basketball in the gym

  Correct Answer: D

  (A) This activity requires motor skills and therefore would be difficult for a hyperactive client. (B) This activity would take too long, and the client would have difficulty concentrating owing to a limited attention span. (C) This client would not be able to concentrate enough to play card games. He would respond to all the stimuli in the area, become distracted, and leave the table. (D) This activity would allow the client to channel his energy in a positive way.

• Question 403:

  A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony. Which of the following nursing implementations would be most effective in helping him cope with immobility?

  A. Providing him with books, challenging puzzles, and games as diversionary activities

  B. Allowing him to do as much for himself as he is able, including learning to do pin-site care under supervision

  C. Having a volunteer come in to sit with the client and to read him stories

  D. Stimulating rest and relaxation by gentle rubbing with lotion and changing the client's position frequently

  Correct Answer: B

  (A) These activities could be frustrating for the client if he is having difficulty with problem solving and concentration. (B) Selfcare is usually well received by the child, and it is one of the most useful interventions to help the child cope with immobility. (C) This may be helpful to the client if he has no visitors, but it does little to help him develop coping skills. (D) This will helpto prevent skin irritation or breakdown related to immobility but will not help to prevent behavioral changes related to immobility.

• Question 404:

  A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the left side of the chest of a newly intubated client is probably due to:

  A. A left hemothorax

  B. A right hemothorax

  C. Intubation of the right mainstem bronchus

  D. An inadequate mechanical ventilator

  Correct Answer: C

  (A) Although a left hemothorax could cause diminished and distant breath sounds, it is irrelevant to this situation. (B) A right hemothorax will not cause diminished and distant breath sounds on the left side of the chest. (C) The right mainstem bronchus is most frequently intubated in error because the angle of the right mainstem bronchus is very small as compared with that of the left mainstem bronchus. Because ventilation is only occurring on the right side, the nurse would auscultate diminished and distant breath sounds on the left. (D) An inadequate mechanical ventilator has no relationship to this situation.

• Question 405:

  Pin care is a part of the care plan for a client who is in skeletal traction. When assessing the site of pin insertion, which one of the following findings would the nurse know as an indicator of normal wound healing?

  A. Exudate

  B. Crust

  C. Edema

  D. Erythema

  Correct Answer: B

  (A) Exudate (moist, active drainage) is a clinical sign of wound infection. (B) Crust (dry, scaly) is part of the normal stages of wound healing and should not be removed from around the pin site. It usually sloughs off after the underlying tissue has healed. (C) Edema (swelling) is a clinical sign of wound infection. (D) Erythema (redness) is a clinical sign of wound infection.

• Question 406:

  A 25-year-old outpatient presents with a diagnosis of compulsive personality disorder. His coworkers become annoyed with his rigid, perfectionistic manner and preoccupation with trivial details and schedules. A nursing intervention appropriate for this client would include:

  A. Encouraging him to engage in recreational activities

  B. Avoiding discussion of his annoying behavior

  C. Encouraging the client to set a time schedule and deadlines for himself

  D. Contracting with him for the amount of time he will spend on the compulsive behaviors

  Correct Answer: D

  (A) This answer is incorrect. The client will work hard at the activity instead of enjoying it. (B) This answer is incorrect. The nurse should allow the client to discuss these thoughts, within limits, not to avoid discussing them. (C) This answer is incorrect. The compulsive client tends to control time to excess. It should not be encouraged. (D) This answer is correct. A contract with the client regarding the amount of time that will be spent discussing the compulsive activities is appropriate. Time allotted should be gradually decreased.

• Question 407:

  A client is being discharged from the hospital tomorrow following a colon resection with a left colostomy. The nurse knows that the client understands the discharge teaching about care of her colostomy when she says:

  A. "I know that I am not supposed to irrigate my colostomy."

  B. "My stool will be soft like paste."

  C. "My stoma should be red and slightly raised."

  D. "The skin around my stoma may become irritated from the enzymes in my stool."

  Correct Answer: C

  (A) A left colostomy indicates an ascending colon resection. This type of colostomy can be irrigated. (B) The stool from an ascending colon resection should be formed. (C) The healthy stoma should be red and slightly raised. If it begins to turn dark or blue, the client should see the physician immediately. (D) The stool in the ascending colon does not usually have many enzymes in it. Stool from an ileostomy has more enzymes and is more irritating to the skin.

• Question 408:

  A 37-year-old client has been taking antipsychotic medication for the past 10 days. The nurse observes her walking with a shuffling gait and postural rigidity and notes a masklike expression on her face. Which side effect is this client exhibiting?

  A. Dystonia

  B. Parkinsonism

  C. Tardive dyskinesia

  D. Akathesia

  Correct Answer: B

  (A) This answer is incorrect. Dystonia refers to severe, painful muscle contractions. (B) This answer is correct. Parkinsonism commonly occurs approximately 1? weeks after initiation of antipsychotic drug therapy. Traditional signs are masklike facies, postural rigidity, shuffling gait, and resting tremor. (C) This answer is incorrect. Tardive dyskinesia is characterized by involuntary muscle movements of the face, jaw, and tongue. (D) This answer is incorrect. Akathesia is motor restlessness.

• Question 409:

  A client who was started on antipsychotic medication 2 weeks ago is preparing for discharge from the hospital. Compliance with the medication regimen is important despite the mild side effects encountered. In order to increase the likelihood of medication compliance, the nurse would:

  A. Discuss the disease process and the importance of the medication in prevention of symptoms.

  B. Inform the client that additional side effects are to be expected and need not be reported.

  C. Discuss the importance of getting blood drawn weekly to determine medication therapeutics.

  D. Inform the client to cease taking the medication when all psychotic symptoms have cleared.

  Correct Answer: A

  (A) This answer is correct. If the client is well informed about what reactions to expect from her medication, she is more likely to follow the treatment regimen. (B) This answer is incorrect. There are many side effects that are reversible by medication, and these must be reported to the nurse or physician. There are also more severe side effects, such as neuroleptic malignant syndrome, characterized by fever, tachycardia, and diaphoresis, which can be life threatening. (C) This answer is incorrect. There is no need for weekly blood tests if the drug regimen has been followed properly. (D) This answer is incorrect. The client should continue the medicationuntil the physician recommends any change in the drug regimen. Symptoms will usually reappear if medication is discontinued.

• Question 410:

  An expected response to sodium polystyrene sulfonate (Kayexalate) is:

  A. Increase in serum magnesium

  B. Increase in serum HCO3

  C. Decrease in serum potassium

  D. Decrease in serum calcium

  Correct Answer: C

  (A) Sodium polystyrene sulfonate administration will not increase serum magnesium. Hypermagnesemia is virtually unknown except for clients in renal failure. (B) Sodium polystyrene sulfonate administration is not known to increase serum bicarbonate. (C) Decrease in serum potassium, the expected response of sodium polystyrene sulfonate, is secondary to the binding of this drug and potassium in the colon, and potassium is removed through the feces. (D) Serum calcium may actually increase with sodium polystyrene sulfonate administration, especially if calcium chloride is administered concurrently with this drug.