NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 41:

  On assessment, the nurse learns that a chronic paranoid schizophrenic has been taking "the blue pill" (haloperidol) in the morning and evening, and "the white pill" (benztropine) right before bedtime. The nurse might suggest to the client that she try:

  A. Doubling the daily dose of benztropine

  B. Decreasing the haloperidol dosage for a few days

  C. Taking the benztropine in the morning

  D. Taking her medication with food or milk

  Correct Answer: C

  (A) Suggesting that a client increase a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order. (B) To suggest that a client decrease a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order. (C) This response is an appropriate independent nursing action. Because motorrestlessness can also be a side effect of cogentin, the nurse may suggest that the client try taking the drug early in the day rather than at bedtime. (D) Certain medications can cause gastric irritation and may be taken with food or milk to prevent this side effect.

• Question 42:

  A 29-year-old client is admitted for a hysterectomy. She has repeatedly told the nurses that she is worried about having this surgery, has not slept well lately, and is afraid that her husband will not find her desirable after the surgery. Shortly into the preoperative teaching, she complains of a tightness in her chest, a feeling of suffocation, lightheadedness, and tingling in her hands. Her respirations are rapid and deep. Assessment reveals that the client is:

  A. Having a heart attack

  B. Wanting attention from the nurses

  C. Suffering from complete upper airway obstruction

  D. Hyperventilating

  Correct Answer: D

  (A) Classic symptoms of a heart attack include heaviness or squeezing pain in the chest, pain spreading to the jaw, neck, and arm. Nausea and vomiting, sweating, and shortness of breath may be present. The client does not exhibit these symptoms. (B) Clients suffering from anxiety or fear prior to surgical procedures may develop hyperventilation. This client is not seeking attention. (C) Symptoms of complete airway obstruction include not being able to speak, and no airflow between the nose and mouth. Breath sounds are absent. (D) Tightness in the chest; a feeling of suffocation; lightheadedness; tingling in the hands; and rapid, deep respirations are signs and symptoms of hyperventilation. This is almost always a manifestation of anxiety.

• Question 43:

  A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low, intermittent suction with orders to "Irrigate NG tube with sterile saline q1h and prn." The rationale for using sterile saline, as opposed to using sterile water to irrigate the NG tube is:

  A. Water will deplete electrolytes resulting in metabolic acidosis.

  B. Saline will reduce the risk of severe, colicky abdominal pain during NG irrigation.

  C. Water is not isotonic and will increase restlessness and insomnia in the immediate postoperative period.

  D. Saline will increase peristalsis in the bowel.

  Correct Answer: A

  (A) Water is a hypotonic solution and will deplete electrolytes and cause metabolic acidosis when used for nasogastric irrigation. (B) Irrigating with saline does not cause abdominal discomfort. Severe, colicky abdominal pain is a symptom of intestinal obstruction. (C) Irrigating with water will not cause restlessness or insomnia in the postoperative client. Restlessness and insomnia can be emotional complications of surgery. (D) A nasogastric tube placed in the stomach is used to decompress the bowel. Irrigating with saline ensures a patent, well-functioning tube. Irrigating with saline will not increase peristalsis.

• Question 44:

  A client delivered a stillborn male at term. An appropriate action of the nurse would be to:

  A. State, "You have an angel in heaven."

  B. Discourage the parents from seeing the baby.

  C. Provide an opportunity for the parents to see and hold the baby for an undetermined amount of time.

  D. Reassure the parents that they can have other children.

  Correct Answer: C

  (A) This is not a supportive statement. There are also no data to indicate the family's religious beliefs. (B) Seeing their baby assists the parents in the grieving process. This gives them the opportunity to say "good-bye." (C) Parents need time to get to know their baby. (D) This is not a comforting statement when a baby has died. There are also no guarantees that the couple will be able to have another child.

• Question 45:

  The nurse knows that children are more susceptible to respiratory tract infections owing to physiological differences. These childhood differences, when compared to an adult, include:

  A. Fewer alveoli, slower respiratory rate

  B. Diaphragmatic breathing, larger volume of air

  C. Larger number of alveoli, diaphragmatic breathing

  D. Rounded shape of chest, smaller volume of air

  Correct Answer: D

  (A) Although a child has fewer alveoli than an adult, the child's respiratory rate is faster. (B) Although a child may use diaphragmatic breathing, the adult exchanges a larger volume of air. (C) The adult has a larger number of alveoli than a child. (D) The child's chest is rounded whereas the adult chest is more of an oval shape, and the child does exchange a smaller volume of air than an adult.

• Question 46:

  The nurse is collecting a nutritional history on a 28- year-old female client with iron- deficiency anemia and learns that the client likes to eat white chalk. When implementing a teaching plan, the nurse should explain that this practice:

  A. Will bind calcium and therefore interfere with its metabolism

  B. Will cause more premenstrual cramping

  C. Interferes with iron absorption because the iron precipitates as an insoluble substance

  D. Causes competition at iron-receptor sites between iron and vitamin B1

  Correct Answer: C

  (A) Eating chalk is not related to calcium and its absorption. (B) Poor nutritional habits may result in increased discomfort during premenstrual days, but this is not a primary reason for the client to stop eating chalk. Premenstrual discomfort has not been mentioned. (C) Iron is rendered insoluble and is excreted through the gastrointestinal tract. (D) There is no competition between the two nutrients.

• Question 47:

  Discharge teaching for the client who has a total gastrectomy should include which of the following?

  A. Need for the client to increase fluid intake to 3000 mL/day

  B. Follow-up visits every 3 weeks for the first 6 months

  C. B12 injections needed for the rest of the client's life

  D. Need to eat three full meals with plenty of fiber per day

  Correct Answer: C

  (A) There will be no need to increase fluid intake excessively, because dumping syndrome could present a problem. (B) Followup visits every 3 weeks are not a standard recommendation. Follow-up visits will be highly individualized. (C) With removal of the stomach, intrinsic factor will no longer be produced. Intrinsic factor is necessary for vitamin B12 absorption. Parenteral injections of B12 will be needed on a monthly basis for the rest of the person's life. (D) Smaller, more frequent meals, rather than large, bulky meals, are recommended to prevent problems with dumping syndrome.

• Question 48:

  A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and kill her. The best verbal response to the client by the nurse at this time is:

  A. "I understand that the voices are real to you, but I want you to know I don't hear them. They are a symptom of your illness."

  B. "Just don't pay attention to the voices. They'll go away after some medication."

  C. "You can't leave here. This unit is locked and the doctor has not ordered your discharge."

  D. "We will have to put you in seclusion and restraints for a while. You could hurt someone with thoughts like that."

  Correct Answer: A

  (A) This response validates the client's experience and presents reality to him. (B) This nontherapeutic response minimizes and dismisses the client's verbalized experience. (C) This response can be interpreted by a paranoid client as a threat, thereby increasing the client's potential for violence and loss of control. (D) This response is also threatening. The client's behavior does not call for restraints because he has not lost control or hurt anyone. If seclusion or restraints were indicated, the nurse should never confront the client alone.

• Question 49:

  The nurse will be alert to the most potentially lifethreatening side effect associated with the administration of monoamine oxidase (MAO) inhibitor. This is:

  A. Oculogyric crisis

  B. Hypertensive crisis

  C. Orthostatic hypotension

  D. Tardive dyskinesia

  Correct Answer: B

  (A) Oculogyric crisis, involuntary upward deviation and fixation of the eyeballs, is usually associated with either postencephalitic parkinsonian or drug-induced extrapyramidal symptoms (EPS). (B) Hypertensive crisis is a potentially life-threatening side effect. This may occur if the client ingests foods, beverages, or medications containing tyramine. (C) Orthostatic hypotension, a drop in blood pressure resulting from a rapid change of body position, can occur with the administration of antidepressants. (D) Tardive dyskinesia, characterized by slow, rhythmical, automatic or stereotyped muscular movements, usually is associated with the administration of certain antipsychotic medications.

• Question 50:

  A male client is scheduled to have angiography of his left leg. The nurse needs to include which of the following when preparing the client for this procedure?

  A. Validate that he is not allergic to iodine or shellfish.

  B. Instruct him to start active range of motion of his left leg immediately following the procedure.

  C. Inform him that he will not be able to eat or drink anything for 4 hours after the procedure.

  D. Inform him that vital signs will be taken every hour for 4 hours after the procedure.

  Correct Answer: A

  (A) Angiography, an invasive radiographic examination, involves the injection of a contrast solution (iodine) through a catheter that has been inserted into an artery. (B) The client is kept on complete bed rest for 6?2 hours after the procedure. The extremity in which the catheter was inserted must be immobilized and kept straight during this time. (C) The contrast dye, iodine, is nephrotoxic. The client must be instructed to drink a large quantity of fluids to assist the kidneys in excreting this contrast media. (D) The major complication of this procedure is hemorrhage. Vital signs are assessed every 15 minutes initially for signs of bleeding.