NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 451:

  A 9-month-old infant was diagnosed with nonorganic failure to thrive. During her hospitalization, primary nurses were assigned to initiate all infant feedings. The infant's parents question why they cannot feed their own child. Which of the following responses would be most appropriate by the nurse?

  A. By assigning the same nurses to the child, the nurses can begin to learn the infant's cues and feeding behaviors.

  B. The same nurses will prevent parental fatigue and frustration.

  C. The same nurses will prevent infant fatigue and frustration.

  D. Primary nurses will ensure privacy.

  Correct Answer: A

  (A) Consistent primary care nurses can better interpret infant cues and note feeding behaviors. (B) In nonorganic failure to thrive the parent-infant dyad has already experienced difficulties in the relationship. These parents may already feel dissatisfied and frustrated. The primary nurse would be unable to prevent this. (C) Assigning a primary nurse does not ensure that infant fatigue and frustration will not occur or can be prevented. (D) Providing privacy does not ensure a change in feeding behavior.

• Question 452:

  A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours' postburn?

  A. Fluid volume deficit secondary to alteration in skin integrity

  B. Alteration in comfort secondary to alteration in skin integrity

  C. Alteration in sensation secondary to third-degree burn

  D. Alteration in airway integrity secondary to edema of neck and face, which in turn is secondary to alteration in skin integrity

  Correct Answer: D

  (A) Fluid deficit is a high priority not only during the first 8 hours postburn, but also during the first 36 hours postburn. (B) Alteration in comfort is a high priority during the entire length of the client's hospitalization and on discharge. (C) Alteration in sensation is a high priority during the first 48?2 hours postburn. Lack of sensation may be indicative of lack of circulation. (D) Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure to continually assess this client's airway status could result in poor ventilation and oxygenation, in addition to an inability to intubate the client secondary to excessive edema formation in the neck.

• Question 453:

  The nurse assesses a client on the second postpartum day and finds a dark red discharge on the peripad. The stain appears to be about 5 inches long. Which of the following correctly describes the character and amount of lochia?

  A. Lochia alba, light

  B. Lochia serosa, heavy

  C. Lochia granulosa, heavy

  D. Lochia rubra, moderate

  Correct Answer: D

  (A) Lochia alba occurs approximately 10 days after birth and is yellow to white. A discharge is classified as light when less than a 4-inch stain exists. (B) Lochia serosa is pink to brown and occurs 3? days after delivery. A stain is classified as heavy when a peripad is saturated in 1 hour. (C) Lochia granulosa is not a proper classification. (D) Lochia rubra is red, consisting mainly of blood, debris, and bacteria, and lasts from the time of delivery to 3? days afterward. A stain is classified as moderate when less than a 6-inch stain exists.

• Question 454:

  A client is a depressed, 48-year-old salesman. A serious concern for the nurse working with depressed clients is the potential of suicide. The time that suicide is most likely to occur is:

  A. In the acutely depressed state

  B. When the depression starts to lift

  C. In the denial phase

  D. During a manic episode

  Correct Answer: B

  (A) The client may be too disorganized in the acute phase to make a workable plan. (B) When the depression starts to lift, the client is able to make a workable plan. (C) There usually is not a significant denial phase related to depression. Suicide occurs in a state of despair and hopelessness. (D) Suicide is uncommon in the manic state. In this state, clients do not feel hopeless, but euphoric and overly confident.

• Question 455:

  A 29-year-old client delivered her fifth child by the Lamaze method and developed a postpartal hemorrhage in the recovery room. What are the initial symptoms of shock that she may experience?

  A. Marked elevation in blood pressure, respirations, and pulse

  B. Decreased systolic pressure, cold skin, and anuria

  C. Rapid pulse; narrowed pulse pressure; cool, moist skin

  D. No urinary output, tachycardia, and restlessness

  Correct Answer: C

  (A) Early shock does not exhibit the symptom of marked elevation in blood pressure. A narrowing of the pulse pressure is indicative of early shock. (B) Anuria is a clinical finding in late shock. (C) All of these clinical findings are congruent with early shock. (D) Absence of urinary output is a clinical finding in the late phase of shock.

• Question 456:

  A 48-year-old client is being seen in her physician's office for complaints of indigestion, heartburn, right upper quadrant pain, and nausea of 4 days' duration, especially after meals. The nurse realizes that these symptoms may be associated with cholecystitis and therefore would check for which specific sign during the abdominal assessment?

  A. Cullen's sign

  B. Rebound tenderness

  C. Murphy's sign

  D. Turner's sign

  Correct Answer: C

  (A) This sign is a faint blue discoloration around the umbilicus found in clients who have hemorrhagic pancreatitis. (B) This sign indicates areas of inflammation within the peritoneum, such as with appendicitis. It is a deep palpation technique used on a nontender area of the abdomen, and when the palpating hand is removed suddenly, the client experiences a sharp, stabbing pain at an area of peritoneal inflammation. (C) This sign is considered positive with acute cholecystitis when the client is unable to take a deep breath while the right upper quadrant is being deeply palpated. The client will elicit a sudden, sharp gasp, which means the gallbladder is acutely inflamed. (D) This is a sign of acute hemorrhagic pancreatitis and manifests as a green or purple discoloration in the flanks.

• Question 457:

  A 22-year-old client who is being seen in the clinic for a possible asthma attack stops wheezing suddenly as the nurse is doing a lung assessment. Which one of the following nursing interventions is most important?

  A. Place the client in a supine position.

  B. Draw a blood sample for arterial blood gases.

  C. Start O2 at 4 L/min.

  D. Establish a patent airway.

  Correct Answer: D

  (A) During impending respiratory failure or asthmatic complications, the client is placed in the high-Fowler position to facilitate comfort and promote optimal gas exchange. (B) Arterial blood gases are monitored in the treatment of respiratory failure during an asthma attack, but it is not an initial intervention. (C) O2 therapy is used during an asthma attack, but it is not the initial intervention. The usual prescribed amount is a cautiously low flow rate of 1? L/min. (D) Wheezing is a characteristic clinical finding during an asthma attack. If wheezing suddenlyceases, it usually indicates a complete airway obstruction and requires immediate treatment for respiratory failure or arrest.

• Question 458:

  A 52-year-old client who underwent an exploratory laparotomy for a bowel obstruction begins to complain of hunger on the third postoperative day. His nasogastric (NG) tube was removed this morning, and he has an IV of D5W with 0.45% normal saline running at 125 mL/hr. He asks when he can get rid of his IV and start eating. The nurse recognizes that he will be able to begin taking oral fluids and nourishment when:

  A. It is determined that he has no signs of wound infection

  B. He is able to eat a full meal without evidence of nausea or vomiting

  C. The nurse can detect bowel sounds in all four quadrants

  D. His blood pressure returns to its preoperative baseline level or greater

  Correct Answer: C

  (A) The absence of wound infection is related to his surgical wound and not to postoperative GI functioning and return of peristalsis. (B) Routine postoperative protocol involves detection of bowel sounds and return of peristalsis before introduction of clear liquids, followed by progression of full liquids and a regular diet versus a full regular meal first. (C) Routine postoperative protocol for bowel obstruction is to assess for the return of bowel sounds within 72 hours after major surgery, because that is when bowel sounds normally return. If unable to detect bowel sounds, the surgeon should be notified immediately and have the client remain NPO. (D) Routine postoperative protocol for bowel obstruction and other major surgeries involves frequent monitoring of vital signs in the immediate postoperative period (in recovery room) and then every 4 hours, or more frequently if the client is unstable, on the nursing unit. This includes assessing for signs of hypovolemic shock. Vital signs usually stabilize within the first 24 hours postoperatively.

• Question 459:

  A client is hyperactive and not sleeping. She will not remain at the table during mealtime. She is getting very limited calories and is using a lot of energy in her hyperactive state. The most therapeutic nursing action is to:

  A. Insist that she remain at the table and eat a balanced diet.

  B. Order a high-calorie diet with supplements.

  C. Provide nutritious finger foods several times a day.

  D. Offer to go to the dining room with her and allow her to open the food and inspect what she eats.

  Correct Answer: C

  (A) The client is not able to sit for long periods. Forcing her to remain at the table will increase her anxiety and cause her to become hostile. (B) This action will not ensure that the client eats what is ordered. Dietary orders are not within the nurse's scope of practice. (C) Providing finger foods increases the likelihood of eating for hyperactive persons. They may be eating "on the run." (D) These clients are not suspicious of the food or insecure in moving about the unit alone.

• Question 460:

  A client was exhibiting signs of mania and was recently started on lithium carbonate. She has no known physical problems. A teaching plan for this client would include which of the following?

  A. Regular foods should be eaten, including those that contain salt, such as bacon, ham, V-8 juice, and tomato juice.

  B. Restrict fluids to 1000 mL/day.

  C. Restrict foods that contain salt or sodium.

  D. Discontinue the medication if nausea occurs.

  Correct Answer: A

  (A) This answer is correct. A balanced diet with adequate salt intake is necessary. (B) This answer is incorrect. The client must drink six to eight full glasses of fluid per day (2000?000 mL/day). (C) This answer is incorrect. The client should be instructed to avoid fluctuations of sodium intake. Diet should be balanced, with an adequate salt intake. (D) This answer is incorrect. Nausea is a frequent side effect that can be minimized with administration of drug with meals or after eating food.