NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 491:

  A 72-year-old client with a new colostomy is being evaluated at the clinic today for constipation. When discussing diet with the client, the nurse recognizes that which one of the following foods most likely caused this problem?

  A. Fried chicken

  B. Eggs

  C. Tapioca

  D. Cabbage

  Correct Answer: C

  (A) Fried, greasy food, such as fried chicken, will produce diarrhealike stools in individuals with all types of GI ostomies. (B) Eggs will cause odor-producing stools in individuals with all types of GI ostomies. (C) Tapioca and rice products will cause constipation in individuals with all types of GI ostomies. (D) Cabbage will cause odor-producing and flatus-producing stools in individuals with all types of GI ostomies.

• Question 492:

  Except for initial explosiveness on admission, a client diagnosed with schizophrenia stays in her room. She continues to believe other people are out to get her. A nursing intervention basic to improving withdrawn behavior is:

  A. Assigning her to occupational therapy

  B. Having her sit with the nurses while they chart

  C. Helping her to make friends

  D. Facilitating communication

  Correct Answer: D

  (A) The nurse does not make this assignment. (B) One-to-one observation is not appropriate. It does not focus on the client or encourage communication. (C) The client is too suspicious to accomplish this goal. (D) The withdrawn individual must learn to communicate on a one-to-one level before moving on to more threatening situations.

• Question 493:

  A client has just been transferred to the floor from the labor and delivery unit following delivery of a stillborn term infant. She is very despondent. When the nurse attempts to take her vital signs, she responds in anger, stating, "You leave me alone. You don't care anything about me. It's people like you who let my baby die." The nurse's best course of action is to:

  A. Quietly leave her room, allowing her more private time to deal with her loss.

  B. Tell her that what happened was for the best and that she is still young and can have other children.

  C. Tell her how sorry you are, and let her know that her child is now a little angel in heaven.

  D. Tell her how sorry you are about the loss of her baby, and acknowledge her anger as being a normal stage of grief. Assure her that you are there to help her in any way you can.

  Correct Answer: D

  (A)

  Parents do need their privacy following a loss, but the nurse still has a responsibility to provide postpartum physical care. (B) This is a negative statement, which is not therapeutic. The client is not concerned about future children but is in the first stages of grief, denial, and anger. (C) This is a negative statement, which is not therapeutic. The client does not want to hear about her baby in heaven. She cannot believe that God could love or want her child more than she could.

  (D)

  Acknowledging that anger is normal and beneficial will help the client to understand the normal stages of grief. Expressing sorrow over her loss and assuring her that the support is there to take care of her physical and emotional needs will help to promote a trusting relationship.

• Question 494:

  Plans for the care of a client with an ulcer caused by emotional problems need to take into consideration that:

  A. His priority needs are limited to medical management

  B. There is no real psychological basis for his illness

  C. The disorder is a threat to his physical well-being

  D. He is unable to participate in planning his care

  Correct Answer: C

  (A) There may be a medical emergency that takes top priority; however, the basis of the problem is emotional. (B) The problem is a physical manifestation of an emotional conflict. (C) The bleeding ulcer can be life threatening. (D) For lifestyle change to occur, the client must participate in the planning of his care so that he is committed to changes that will have positive results.

• Question 495:

  Succinylcholine chloride (Anectine) is ordered prior to electroconvulsive therapy treatment for depressed clients. The nurse explains that the purpose of the drug is to:

  A. Relax muscles

  B. Relieve anxiety

  C. Reduce secretions

  D. Act as an anesthetic

  Correct Answer: A

  (A) Succinylcholine chloride relaxes muscles and decreases the intensity of the seizure. (B) Succinylcholine chloride does not relieve anxiety. (C) Atropine is given to reduce secretions. (D) Thiamylal sodium (Surital) or other phenobarbital preparations are used as brief anesthetics.

• Question 496:

  A 27-year-old healthy primigravida is brought to the labor and birthing room by her husband at 32 weeks' gestation. She experienced a sudden onset of painless vaginal bleeding. Following an ultrasound examination, the diagnosis of bleeding secondary to complete placenta previa is made. Expected assessment findings concerning the abdomen would include:

  A. A rigid, boardlike abdomen

  B. Uterine atony

  C. A soft relaxed abdomen

  D. Hypertonicity of the uterus

  Correct Answer: C

  (A) A rigid, boardlike abdomen is an assessment finding indicative of placenta abruptio. (B) A cause of postbirth hemorrhage is uterine atony. With placenta previa, uterine tone is within normal range. (C) The placenta is located directly over the cervical os in complete previa. Blood will escape through the os, resulting in the uterus and abdomen remaining soft and relaxed. (D) In placenta abruptio, hypertonicity of the uterus is caused by the entrapment of blood between the placenta and uterine wall, a retroplacental bleed. This does not exist in placenta previa.

• Question 497:

  A client had a right below-the-knee amputation 4 days ago. He is complaining of pain in his right lower leg. The nurse should:

  A. Remind the client that he no longer has that part of his leg and assure him he will be OK

  B. Call the physician to request a psychological consultation for the client

  C. Turn on the television to distract the client's attention from his amputated leg

  D. Give the client his order of Demerol 50 mg IM prn

  Correct Answer: D

  (A) The nurse is ignoring the client's pain. Telling the client that he will be OK will not relieve his phantom pain. (B) The client does not need a psychological consultation. Phantom pain is a normal sensation experienced by clients with amputations. (C) Using the television as a distractor will not relieve the client's phantom pain. (D) Phantom pain is a normal, very real experience for an amputee and should be treated with pain medication.

• Question 498:

  The most appropriate method of evaluating whether the diet of a child with cystic fibrosis is meeting his caloric needs is:

  A. Careful monitoring of weight loss or gain

  B. Carefully recording amounts and types of foods ingested

  C. Keeping a strict account of the number of calories ingested

  D. Keeping a careful account of the amount of pancreatic enzymes ingested

  Correct Answer: A

  (A)

  Consistent weight gain, even if it is slow, is an indication that the child is eating and digesting sufficient calories. (B) Recording how much the child eats is useful, but it is not an indicator of how well his body is using the foods consumed.

  (C)

  Counting calories will indicate how much he is eating, but it will not reflect whether or not the foods are properly digested. (D) Keeping track of the enzyme intake will indicate compliance with medication but not whether the child is getting sufficient calories.

• Question 499:

  A client has ascites, which is caused by:

  A. Decreased plasma proteins

  B. Electrolyte imbalance

  C. Decreased renal function

  D. Portal hypertension

  Correct Answer: A

  (A) A decrease in plasma proteins causes a decrease in intravascular osmotic pressure resulting in leakage of fluid into peritoneal cavity. (B) Fluid and electrolyte imbalance may occur as a result of the ascites. (C) Ascites is a result of hepatic malfunction, not renal malfunction. (D) Portal hypertension causes esophageal varices, not ascites.

• Question 500:

  A client is to have a coronary artery bypass graft performed in the morning using a saphenous vein. He wants to know why the physician does not use the internal mammary artery for his bypass graft because his friend's physician uses this artery. The nurse tells the client that the internal mammary artery:

  A. Takes more time to remove

  B. Has a greater risk of becoming reoccluded

  C. Is smaller in diameter

  D. Has too many valves

  Correct Answer: A

  (A) It does take more time to remove the internal mammary artery, and this is one reason why some physicians do not use it. (B) There is not a greater risk of reocclusion. In fact, it may actually stay patent longer. (C) The internal mammary artery is actually larger in diameter than the saphenous vein. (D) The internal mammary artery does not have too many valves.