NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 481:

  A neonate was admitted to the hospital with projectile vomiting. According to the parents, the baby had experienced vomiting episodes after feeding for the last 2 days. A medical diagnosis of hypertrophic pyloric stenosis was made. On assessment, the infant had poor skin turgor, sunken eyeballs, dry skin, and weight loss. Identify the number-one priority nursing diagnosis.

  A. Fluid volume deficit

  B. Altered nutrition

  C. Altered bowel elimination

  D. Anxiety

  Correct Answer: A

  (A) Fluid volume deficit is the major problem. Symptoms of dehydration are evident. The effects of fluid and electrolyte balance may be life threatening. Rehydration can be accomplished effectively through IV fluids and electrolytes. (B) Vomiting may also signal a nutritional problem. However, the nutritional problem would be secondary to fluid and electrolyte disturbances. The infant may also be placed on NPO status. (C) With vomiting, a decrease in the size and number of stools is expected. (D) The infant cannot verbalize feelings of anxiety. Anxiety would not be an appropriate diagnosis.

• Question 482:

  A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody drainage on his surgical dressing. The nurse would document this as what type of drainage?

  A. Serosanguinous

  B. Purulent

  C. Sanguinous

  D. Catarrhal

  Correct Answer: C

  (A) Drainage from a surgical incision usually proceeds from sanguinous to serosanguinous. (B) Purulent drainage usually indicates infection and should not be seen initially from a surgical incision. (C) Drainage from a surgical incision is initially sanguinous, proceeding to serosanguinous, and then to serous. (D) Catarrhal is a type of exudate seen in upper respiratory infections, not in surgical incisions.

• Question 483:

  Parents of children receiving chemotherapy should be warned that alopecia is a side effect and that:

  A. Children seldom show concern about losing their hair

  B. The hair will come out gradually, and the loss will not be noticeable for some time

  C. It is best for girls to choose a wig similar to their hair style and color before the hair falls out

  D. The parents will soon get used to seeing their children without hair, and it will no longer bother them

  Correct Answer: C

  (A) Children may become depressed with a changed appearance and not want to look at themselves or have others see them. (B) The hair will fall out in clumps, causing patchy baldness that is quite noticeable and traumatic to children and their families. (C) Having a wig that looks like a girl's own hair can be a psychological boost to children and is helpful in fostering later adjustments to hair loss. (D) Families may become accustomed to seeing their children without hair, but the loss is traumatic to them and will continue to bother them.

• Question 484:

  The 4th of July holiday comes while a client is in the hospital being treated for schizophrenia. She is taking chlorpromazine and has improved to the point of being allowed to go with a group to the park for a picnic. The side effect of chlorpromazine that the nurse needs to keep in mind during this outing is:

  A. Hypotension

  B. Photosensitivity

  C. Excessive appetite

  D. Dryness of the mouth

  Correct Answer: B

  (A) A decrease in blood pressure sometimes occurs with chlorpromazine. It would not be a factor influenced by a picnic in the park. (B) Protection from the sun is important in clients taking phenothiazines because they burn easily and severely. (C) An appetite increase sometimes occurs with chlorpromazine. It would not be affected by a picnic. (D) Dryness of the mouth may occur at any time and is not affected by the picnic outing.

• Question 485:

  The parents of a 2-year-old child are ready to begin toilet training activities with him. His parents feel he is ready to train because he is now 2 years old. What would the nurse identify as readiness in this child?

  A. Patience by the child when wearing soiled diapers

  B. Communicating the urge to defecate or urinate

  C. The child awakening wet from his naps

  D. The age at which the child's siblings were trained

  Correct Answer: B

  (A) Children experience impatience with soiled diapers when readiness for training is apparent. They often desire to be changed immediately. (B) A child must be able to use verbal or nonverbal skills to communicate needs. (C) A readiness indicator would be awaking dry from naps. (D) The age at which a sibling was toilet trained has no implications for training this child.

• Question 486:

  The nurse is notified that a 27-year-old primigravida diagnosed with complete placenta previa is to be admitted to the hospital for a cesarean section. The client is now at 36 weeks' gestation and is presently having bright red bleeding of moderate amount. On admission, the nursing intervention that the nurse should give the highest priority to is:

  A. Shave the client's abdomen and arrange her lab work

  B. Determine the status of the fetus by fetal heart tones

  C. Start an IV infusion in the client's arm

  D. Insert an indwelling catheter into her bladder

  Correct Answer: B

  (A) These nursing actions are necessary prior to the cesarean section, but not immediately necessary to maintain physiological equilibrium. (B) Determining the physiological status of the fetus would constitute the highest priority in evaluating and maintaining fetal life. (C) These nursing actions are necessary prior to the cesarean section, but not immediately necessary to maintain physiological equilibrium. (D) These nursing actions are necessary prior to the cesarean section, but not immediately necessary to maintain physiological equilibrium.

• Question 487:

  Several months after antibiotic therapy, a child is readmitted to the hospital with an exacerbation of osteomyelitis, which is now in the chronic stage. The mother appears anxious and asks what she could have done to prevent the exacerbation. The nurse's response is based on the knowledge that chronic osteomyelitis:

  A. Is caused by poor physical conditions or poor nutrition

  B. Often results from unhygienic conditions or an unclean environment

  C. Is directly related to sluggish circulation in the affected limb

  D. May develop from sinuses in the involved bone that retain infectious material

  Correct Answer: D

  (A) Poor nutrition and/or poor physical conditions are factors that predispose to the development of osteomyelitis but do not cause it. (B) An unclean or unhygienic environment may predispose to the development of chronic osteomyelitis, but it does not cause an exacerbation of the previous infection. (C) Sluggish circulation through the medullary cavity during acute osteomyelitis may delay healing, but it does not cause the disease to become chronic. (D) Areas of sequestrum may be surrounded by dense bone, become honeycombed with sinuses, and retain infectious organisms for a long time.

• Question 488:

  The nurse needs to be aware that the most common early complication of a myocardial infarction is:

  A. Diabetes mellitus

  B. Anaphylactic shock

  C. Cardiac hypertrophy

  D. Cardiac dysrhythmia

  Correct Answer: D

  (A) Diabetes mellitus is not a common complication of myocardial infarction. (B) Anaphylactic shock is an allergic reaction. (C) Cardiac hypertrophy is a late potential complication. It is a common complication of congestive heart failure. (D) Myocardial infarction causes tissue damage, which may interrupt electrical impulses. Myocardial irritability results from lack of oxygenated tissue.

• Question 489:

  A successful executive left her job and became a housewife after her marriage to a plastic surgeon. She started doing volunteer work for a charity organization. She developed pain in her legs that advanced to the point of paralysis. Her physicians can find no organic basis for the paralysis. The client's behavior can be described as:

  A. Housework phobia

  B. Malingering

  C. Conversion reaction

  D. Agoraphobia

  Correct Answer: C

  (A) A typical phobia does not result in physical symptoms (i.e., paralysis). (B) Malingering is pretending to be ill. This person has a true paralysis. (C) A conversion reaction is a physical expression of an emotional conflict. It has no organic basis. (D) Agoraphobia is fear of public places.

• Question 490:

  Which of the following nursing actions is essential to prevent drug-resistant tuberculosis?

  A. Monitor liver function.

  B. Monitor renal function.

  C. Assess knowledge of respiratory isolation.

  D. Monitor compliance with drug therapy.

  Correct Answer: D

  (A) Monitoring liver function will not prevent the development of drug-resistant organisms. (B) Monitoring renal function will not prevent the development of drug-resistant organisms. (C) Knowledge of respiratory isolation will reduce

  transmission of tuberculosis but will not prevent development of drug-resistant organisms. (D) Noncompliance with prescribed antituberculosis drug regimen is the primary cause of drug-resistant organisms.

  Noncompliance permits the mutation of organisms.