NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 461:

  A 27-year-old primigravida at 32 weeks' gestation has been diagnosed with complete placenta previa. Conservative management including bed rest is the proper medical management. The goal for fetal survival is based on fetal lung maturity. The test used to determine fetal lung maturity is:

  A. Dinitrophenylhydrazine

  B. Metachromatic stain

  C. Blood serum phenylalanine test

  D. Lecithin-sphingomyelin ratio

  Correct Answer: D

  (A) Dinitrophenylhydrazine is a laboratory test used to detect phenylketonuria, maple syrup urine disease, and Lowe's syndrome. (B) Metachromatic stain is a laboratory test that may be used to diagnose Tay-Sachs and other lipid diseases of the central nervous system. (C) The blood serum phenylalanine test is diagnostic of phenylketonuria and can be used for wide-scale screening. (D) A lecithin-sphingomyelin ratio of at least 2:1 is indicative of fetal lung maturity, and survival of the fetus is likely.

• Question 462:

  What specific hormone must be present in serum or urine laboratory tests used to diagnose pregnancy?

  A. Human chorionic gonadotropin

  B. Estrogen

  C. -fetoprotein

  D. Sphingomyelin

  Correct Answer: A

  (A) Human chorionic gonadotropin is the biochemical basis for pregnancy tests. It is produced by the placenta to help maintain the corpus luteum. Its levels climb rapidly following conception, peaking at about 8 weeks and then gradually decreasing to low levels after 16 weeks. (B) Estrogen does steadily rise throughout pregnancy, increasing to 30 times that of prepregnancy levels. Although estrogen levels do change during pregnancy, it is not used as the main hormone of evaluation in pregnancy tests. (C) -Fetoprotein is the major protein in the serum of theembryo. It is initially produced by the yolk sac. (D) Lecithin and sphingomyelin are two phospholipids of which fetal lung surfactant is composed. Levels are evaluated to determine fetal lung maturity.

• Question 463:

  A 58-year-old client on a general surgery unit is scheduled for transurethral resection of the prostate (TURP) in 2 hours. The nurse explains to the client that this procedure means:

  A. Removal of the prostate tissue by way of a lower abdominal midline incision through the bladder and into the prostate gland

  B. Removal of prostate tissue by a resectoscope that is inserted through the penile urethra

  C. Removal of the prostate tissue by an open surgical approach through an incision between the ischial tuberosities, the scrotum, and the rectum

  D. Removal of prostate tissue by an open surgical approach through a low horizontal incision, bypassing the bladder, to the prostate gland

  Correct Answer: B

  (A) This describes a suprapubic (transvesical) prostatectomy procedure. (B) This is the correct description of a TURP procedure. (C) This describes a perineal prostatectomy procedure. (D) This describes a retropubic (extravesical) prostatectomy procedure.

• Question 464:

  A mother called the physician's office to ask if it would help relieve her small daughter's abdominal pain if she gave an enema and placed a heating pad on the abdomen. Her daughter has a fever and has vomited twice.

  The nurse's response is based on the knowledge that:

  A. The symptoms could easily have been caused by constipation, which an enema would relieve

  B. Heat would help to relax the abdominal muscles and relieve her pain

  C. Both heat and enemas stimulate intestinal motility and could increase the risk of perforation

  D. Complaints of stomach ache are common in young children and are generally best ignored

  Correct Answer: C

  (A) Constipation does not cause fever or vomiting but may cause anorexia. Risk of perforation outweighs the possible benefits of an enema. (B) Heat will not relieve her symptoms but will increase intestinal motility and increase the risk of perforation. (C) Heat and enemas are contraindicated where severe abdominal pain is suspected because they increase intestinal motility and the risk of perforation. (D) Complaints accompanied by physical symptoms such as pain, anorexia, and fever should never be ignored.

• Question 465:

  The serial sevens test is often used to determine delirium and dementia. This test aids in assessing which of the following?

  A. Abstract thinking

  B. Ability to focus and concentrate thoughts

  C. Judgment

  D. Memory

  Correct Answer: B

  (A) This answer is incorrect. The test measures the abilities to concentrate and calculate. The use of proverbs is the most common way to test abstraction. (B) This answer is correct. The serial sevens test is a common test of calculation ability. It is difficult for the demented or delirious client to perform. (C) This answer is incorrect. The test for judgment should predict whether the individual will behave in a socially accepted manner. (D) This answer is incorrect. In testingmemory, the nurse would attempt to get the client either to recall recent events or to think about past events.

• Question 466:

  A 22-year-old single woman was admitted to the psychiatric hospital by her mother, who reported bizarre behavior. Except for going to work, she spends all her time in her room and expresses concern over neighbors spying on her. She has fears of the telephone being "bugged." Her diagnosis is schizophrenia. One nurse per shift is assigned to work with the client. The primary reason for this plan would be to:

  A. Protect her from suicide

  B. Enable her to develop trust

  C. Supervise her medication regimen

  D. Involve her in groups for social interaction

  Correct Answer: B

  (A) Suicide is a greater risk in depression than in schizophrenia. (B) The client is suspicious and needs help to develop trust, which is basic to her improvement. (C) Although she will be taking medication, drug therapy would not necessitate consistency in the nurses assigned. (D) A suspicious client should have limited exposure to groups, because group participation increases discomfort.

• Question 467:

  A 60-year-old woman exhibits forgetfulness, emotional lability, confusion, and decreased concentration. She has been unable to perform activities of daily living without assistance. After a thorough medical evaluation, a diagnosis of Alzheimer's disease was made. An appropriate nursing intervention to decrease the anxiety of this client would include:

  A. Allowing the client to perform activities of daily living as much as possible unassisted

  B. Confronting confabulations

  C. Reality testing

  D. Providing a highly stimulating environment

  Correct Answer: A

  (A) This answer is correct. The more the client is able to control her daily routine, the less anxiety she will experience. (B) This answer is incorrect. Confrontation tends to increase anxiety. (C) This answer is incorrect. Reality testing is an assessment tool. It does not decrease anxiety. (D) This answer is incorrect. A highly stimulating environment increases distractibility and anxiety.

• Question 468:

  A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:

  A. Deflating the cuff for 10 minutes every other hour instead of 5 minutes every hour

  B. Avoiding manipulation of the tracheostomy including cuff deflation

  C. Reporting any signs of crepitus immediately to the physician

  D. Changing tracheostomy dressing only as necessary using one-half strength hydrogen peroxide to cleanse the site

  Correct Answer: B

  (A) The tracheal cuff should not be deflated within the first 24 hours following surgery. (B) To minimize bleeding, any manipulation, including cuff deflation, should be avoided. (C) Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician. (D) The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.

• Question 469:

  The mother of a 7-year-old mental health center client reports that the client has refused to attend gymnastics for the past 2 weeks. Prior to that time, the child liked going to this class and was attending 3 times a week. In talking with the client, the nurse would:

  A. Ask her why she doesn't like gymnastics anymore

  B. Ask her to describe how things were at gymnastics before she started refusing to go

  C. Tell her that it is OK to be afraid of this activity

  D. Reassure her that things will get better once she begins the classes again

  Correct Answer: B

  (A) The child has not said that she dislikes gymnastics. (B) The nurse will be able to obtain information on what events occurred at gymnastics prior to her refusal to attend. The nurse will also gain information about the child's perception of the problem. (C) The child has not said she is afraid to go to gymnastics. (D) False reassurance is inappropriate.

• Question 470:

  A client was admitted to the hospital for a TURP. Within 48 hours of admission and 12 hours postoperatively, both the blood pressure and pulse increased. He became agitated, thought snakes were crawling on his arms and legs, and generally became unmanageable. He pulled out his IV and urinary catheter in attempt to rid himself of the snakes. He was sweating profusely. The admission nurse's notes indicated that the client admitted to "having a few drinks now and then." He is probably experiencing which of the following?

  A. Major psychotic depression

  B. Delirium tremens

  C. Generalized anxiety disorder

  D. Adjustment disorder with mixed features

  Correct Answer: B

  (A) Symptoms of psychotic depression must exist for at least 2 weeks, and the symptoms must represent a change from previous functioning. (B) Delirium tremens occur approximately on the second or third day following cessation or reduction of alcohol intake. Symptoms would be all those described in the situation. (C) Symptoms exhibited by this client are not exhibited in clients with anxiety disorders, who manifest excessive or unrealistic worry about life circumstances for at least 6 months. (D) Symptoms for adjustment disorders with mixed emotional features (e.g., depression and anxiety) are different from those exhibited by the client in this situation.