NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 431:

  A child becomes neutropenic and is placed on protective isolation. The purpose of protective isolation is to:

  A. Protect the child from infection

  B. Provide the child with privacy

  C. Protect the family from curious visitors

  D. Isolate the child from other clients and the nursing staff

  Correct Answer: A

  (A) The child no longer has normal white blood cells and is extremely susceptible to infection. (B) There are more appropriate ways to provide privacy, and there is no need to protect the child from healthy visitors. (C) Visitors and visiting hours may be at the client's and/or family's request without regard to the isolation precaution. (D) The child may have strong positive relationships with other clients or staff. As long as proper precautions are observed, there is no reason to isolate her from them.

• Question 432:

  A client is now pregnant for the second time. Her first child weighed 4536 g at delivery. The client's glucose tolerance test shows elevated blood sugar levels. Because she only shows signs of diabetes when she is pregnant, she is classified as having:

  A. Insulin-dependent diabetes

  B. Type II diabetes mellitus

  C. Type I diabetes mellitus

  D. Gestational diabetes mellitus

  Correct Answer: D

  (A) Insulin-dependent diabetes mellitus, also known as type I diabetes, usually appears before the age of 30 years with an abrupt onset of symptoms requiring insulin for management. It is not related to onset during pregnancy. (B) Non-insulin璬ependent diabetes (type II diabetes) usually appears in older adults. It has a slow onset and progression of symptoms. (C) This type of diabetes is the same as insulin-dependent diabetes. (D) Gestational diabetes mellitus has its onset of symptoms during pregnancy and usually disappears after delivery. These symptoms are usually mild and not life threatening, although they are associated with increased fetal morbidity and other fetal complications.

• Question 433:

  A behavioral modification program is recommended by the multidisciplinary team working with a 15-year-old client with anorexia nervosa. A nursing plan of care based on this modality would include:

  A. Role playing the client's eating behaviors

  B. Restriction to the unit until she has gained 2 lb

  C. Encouraging her to verbalize her feelings concerning food and food intake

  D. Provision for a high-calorie, high-protein snack between meals

  Correct Answer: B

  (A) This answer is incorrect. Role playing is based on learning but is not based on the behavioral modification model. (B) This answer is correct. The behavioral modification model is based on negative and positive reinforcers to change behavior. (C) This answer is incorrect. Verbal catharsis is not an intervention based on behavioral modification. (D) This answer is incorrect. Although an acceptable nursing intervention, it is not based on behavioral modification.

• Question 434:

  A post-lung surgery client is placed on a chest tube drainage system. When explaining to the family how the system works, the nurse states that the water-seal bottle of a three- bottle chest drainage system serves which of the following purposes?

  A. Collection bottle for drainage

  B. Pressure regulator

  C. Preventing accumulation of blood around the heart

  D. Preventing air from entering the chest upon inspiration

  Correct Answer: D

  (A) There is a separate collection bottle for drainage as part of a chest drainage system. (B) In a three-bottle chest drainage system, one bottle serves only as a pressure regulator. (C) Mediastinal chest tubes prevent accumulation of blood around the heart immediately following heart surgery. (D) The purpose of the water-seal bottle in any chest drainage setup is to allow air out of the chest, but not back in. This negative pressure promotes lung expansion.

• Question 435:

  The physician prescribes amitriptyline (Elavil) for a client. What does the patient need to know about this medication?

  A. Prolonged use of this medication will result in extrapyramidal side effects.

  B. When the medication is effective, he will experience no anxiety.

  C. The medication should relieve his symptoms of depression.

  D. Blood must be drawn weekly to test for toxicity.

  Correct Answer: C

  (A) Phenothiazines cause extrapyramidal symptoms. (B) No amount of medication can relieve all anxiety in all cases. (C) The purpose of amitriptyline is to relieve the symptoms of depression because it is an antidepressant. It increases the action of norepinephrine and serotonin on nerve cells. (D) Periodic blood tests are done when lithium is prescribed.

• Question 436:

  When a client arrives on the labor and delivery unit, she informs the nurse that she has been having contractions for the last 5 hours. Now the pain is constant and not cyclical as it was earlier. The nurse considers the possibility of uterine rupture. Which of the following symptoms would be consistent with a uterine rupture?

  A. A large gush of clear fluid from the vagina

  B. Systolic hypertension

  C. Abdominal rigidity

  D. Increased fetal movements

  Correct Answer: C

  (A) This symptom would indicate a rupture of the membranes, which would be expected during labor. There would be no cause for alarm if the fluid were clear. (B) With uterine rupture and the risk of maternal shock secondary to blood loss, the most likely sign would be hypotension indicating hypovolemic shock. (C) In the event of a uterine rupture, an abdominal examination would likely reveal rigidity or tenderness. (D) The most likely finding would be a decrease in fetal movement related to fetal distress due to impaired uteroplacental blood flow. Maintaining the client on her left side would help to maximize uterine blood flow.

• Question 437:

  An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to:

  A. A tension pneumothorax

  B. An asthma attack

  C. Pneumonia

  D. Pulmonary embolus

  Correct Answer: B

  (A) A tension pneumothorax is an accumulation of air in the pleural space. Important physical assessment findings to confirm this condition include cyanosis, jugular vein distention, absent breath sounds on the affected side, distant heart sounds, and lowered blood pressure. (B) Asthma is a disorder in which there is an airflow obstruction in the bronchioles and smaller bronchi secondary to bronchospasm, swelling of mucous membranes, and increased mucus production.Physical assessment reveals some important findings: agitation, nasal flaring, tachypnea, and expiratory wheezing. (C) Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung in the alveolar and interstitial tissue and results in consolidation. Specific assessment findings to confirm this condition include decreased chest expansion caused by pleuritic pain, dullness on percussion over consolidated areas, decreased breath sounds, and increased vocal fremitus. (D) A pulmonary embolus is the passage of a foreign substance (blood clot, fat, air, or amniotic fluid) into the pulmonary artery or its branches, with subsequent obstruction of blood supply to lung tissue. Specific assessment findings that confirm this condition include tachypnea, tachycardia, crackles (rales), transient friction rub, diaphoresis, edema, and cyanosis.

• Question 438:

  A client has received preoperative teaching for the vertical partial laryngectomy that he is scheduled to have in the morning. The nurse determines that the teaching has been effective when the client states:

  A. "I know I will need special swallowing training after my surgery."

  B. "The quality of my voice will be excellent after surgery."

  C. "I will have very little difficulty swallowing after surgery."

  D. "I may also have to have a radical neck dissection done."

  Correct Answer: C

  (A) A client with a supraglottic (horizontal partial) laryngectomy would require special swallowing training, not a vertical partial laryngectomy. (B) The quality of the client's voice will be altered but adequate for communication. (C) The client will have minimal difficulty swallowing. (D) A radical neck dissection may be done with a total laryngectomy, but not with a partial laryngectomy.

• Question 439:

  The physician has prescribed metoclopramide (Reglan). When assessing the client, the nurse would expect to find which of the following responses?

  A. Increase in gastric secretions

  B. Increase in peristalsis

  C. Disorientation

  D. Drowsiness

  Correct Answer: B

  (A) Metoclopramide does not stimulate gastric secretions. (B) This response is expected with metoclopramide, in addition to increasing gastric emptying. (C) Disorientation is a symptom of metoclopramide overdose. The drug should be discontinued. (D) Drowsiness is a symptom of metoclopramide overdose and the drug should be discontinued.

• Question 440:

  A client has been admitted to the nursing unit with the diagnosis of severe anemia. She is slightly short of breath, has episodes of dizziness, and complains her heart sometimes feels like it will "beat out of her chest." The physician has ordered her to receive 2 U of packed red blood cells. The most important nursing action to be taken is:

  A. Starting an 18-gauge IV infusion

  B. Having the consent form on the chart

  C. Administering the correct blood product to the correctclient

  D. Transfusing the blood in a 2-hour time frame

  Correct Answer: C

  (A) An 18-gauge IV is an appropriate size for administering blood; however, client safety demands that the right blood product must be administered. (B) The consent form is legally necessary to be on the chart, but client safety is maintained by giving the correct blood component to the correct client. (C) Administering the correct blood product to the correct client will maintain physiological safety and minimize transfusion reactions. (D) The blood administration should take place over the ordered time frame designated by the physician.