NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 511:

  Which of the following blood gas parameters primarily reflects respiratory function?

  A. PCO2

  B. CO2 content of the blood

  C. HCO3

  D. Base excess

  Correct Answer: A

  (A) The lungs are responsible for regulation of CO2, and this parameter primarily reflects respiratory function. (B) CO2 content of the blood is an indirect measure of respiratory function. (C) HCO3 is a measure of kidney function only and is important in acid-base balance. (D) Base excess represents the excess of HCO3 and is not reflective of respiratory function.

• Question 512:

  A 5-year-old child cries continually in her bed. Her parents have been unsuccessful in assisting her in expressing her feelings. Which activity should the nurse provide the child to assist her in expressing her feelings?

  A. Books with colorful pictures

  B. Music

  C. Riding toys

  D. Puppets

  Correct Answer: D

  (A) Books increase cognition, assist with fine motor skills, and augment language development. (B) Music provides auditory stimulation and large-muscle activity. (C) Riding toys provide large-muscle activity. (D) Puppets allow expression of feelings and fears that otherwise could not be directly communicated.

• Question 513:

  A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first:

  A. Reinforce the dressing.

  B. Continue to monitor the dressing.

  C. Notify the physician.

  D. Note the time and amount of blood.

  Correct Answer: C

  (A) The dressing should not be reinforced without first notifying the physician. The decision may be made by the physician to reinforce the dressing after assessing the amount of bleeding. (B) Blood on the dressing is unusual and should make the nurse aware that something more than continuing to monitor the dressing should be done. (C) The physician should be notified immediately, because if the bleeding persists, the client may have to be taken back to surgery. (D) The time and amount of blood do need to be recorded after the physician is notified.

• Question 514:

  A 55-year-old client is admitted with a diagnosis of renal calculi. He presented with severe right flank pain, nausea, and vomiting. The most important nursing action for him at this time is:

  A. Intake and output measurement

  B. Daily weights

  C. Straining of all urine

  D. Administration of O2 therapy

  Correct Answer: C

  (A) Intake and output measurements are important but must be accompanied by straining urine. (B) Daily weights would not provide for identification of calculi. (C) Straining urine provides for assessment of calculi and evaluation of calculi descent through ureters and urethra. (D) O2therapy should not be necessary for renal calculi.

• Question 515:

  A client presents to the emergency room with cyanosis, coughing, tachypnea, and tachycardia. She has a history of asthma. Arterial blood gas values are pH 7.28, PaO2 54, PaCO2 60, and HCO3 24. The nursing assessment of arterial blood gases indicate the presence of:

  A. Respiratory alkalosis

  B. Respiratory acidosis

  C. Metabolic alkalosis

  D. Metabolic acidosis

  Correct Answer: B

  (A) Respiratory alkalosis is determined by elevated pH and low PaCO2. (B) Respiratory acidosis is determined by low pH and elevated PaCO2. (C) Metabolic alkalosis is determined by elevated pH and HCO3. (D) Metabolic acidosis is determined by low pH and HCO3.

• Question 516:

  A 45-year-old client has a permanent colostomy. Which of the following foods should he avoid?

  A. Peanut butter and jelly sandwich and milk

  B. Corn beef and cabbage and boiled potatoes

  C. Oatmeal, whole-wheat toast, and milk

  D. Tuna on whole-wheat bread and iced tea

  Correct Answer: B

  (A, C, D) These foods are allowed with a colostomy. (B) Gasforming foods such as cabbage should be avoided.

• Question 517:

  A 22-year-old client presents with a diagnosis of antisocial personality disorder and a history of using drugs, writing numerous checks with insufficient funds, and stealing. He appears charming and intelligent, and the other clients are impressed and want to be liked by him. The greatest problem that may arise from this situation is that:

  A. He will manipulate the other clients for his own benefit

  B. He will cause the other clients to become psychotic

  C. He will become delusional and hallucinate as a result of the excess attention given to him by peers

  D. He may exhibit self-mutilative behavior

  Correct Answer: A

  (A) This answer is correct. Persons with antisocial personality disorder typically are very manipulative. (B) This answer is incorrect. The client's behavior cannot cause another person to become psychotic. (C) This answer is incorrect. Psychosis is not a symptom of antisocial personality. One of the criteria for diagnosis of this disorder is that no psychosis be present. In addition, the client would love the attention. (D) This answer is incorrect. Self-mutilative behavior is characteristic of the borderline personality disorder.

• Question 518:

  Before completing a nursing diagnosis, the nurse must first:

  A. Write goals and objectives

  B. Perform an assessment

  C. Plan interventions

  D. Perform evaluation

  Correct Answer: B

  (A) Goals and objectives are based on a nursing assessment and diagnosis. (B) Assessment is the first step of nursing process. (C) Interventions are nursing actions to meet goals and objectives. (D) Evaluation process follows nursing interventions.

• Question 519:

  A 67-year-old postoperative TURP client has hematuria. The nurse caring for him reviews his postoperative orders and recognizes that which one of the following prescribed medications would best relieve this problem?

  A. Acetaminophen suppository 650 mg

  B. Meperidine 50 mg IM

  C. Promethazine 25 mg IM

  D. Aminocaproic acid (Amicar) 6 g/24 hr

  Correct Answer: D

  (A) Acetaminophen (Tylenol) has analgesic and antipyretic actions approximately equivalent to those of aspirin. It produces analgesia possibly by action on the peripheral nervous system. It reduces fever by direct action on the hypothalamus heat-regulating center with consequent peripheral vasodilation. It is generally used for temporary relief of mild to moderate pain, such as a simple headache, minor joint and muscle pains, and control of fever. (B) Meperidine is a narcotic agonist analgesic with properties similar to morphine except that it has a shorter duration of action and produces less depression of urinary retention and smooth muscle spasm. It is used for moderate to severe pain, for a preoperative medication, for support of anesthesia, and for obstetrical analgesia. In a postoperative TURP client, it would be used in conjunction with other medications for relief of moderate to severe pain, but not specifically for bladder spasms associated with TURP surgery. (C) Promethazine hydrochloride is an antihistamine, antiemetic preparation. It exerts antiserotonin, anticholinergic, and local anesthetic actions. It is used for symptomatic relief of various allergic conditions, motion sickness, nausea, and vomiting. It is used for preoperative, postoperative, and obstetrical sedation and as an adjunct to analgesics for control of pain. (D) This answer is correct because aminocaproic acid is prescribed specifically for hematuria. Aminocaproic acid is excreted in the urine. The nurse should be alert for possible signs of thrombosis, particularly in the extremities.

• Question 520:

  A client is diagnosed with Mycobacterium tuberculosis. He is placed in respiratory isolation, intubated, and receives mechanical ventilation. When performing suctioning, the nurse should:

  A. Suction for a maximum of 20 seconds

  B. Hyperoxygenate before and after suctioning

  C. Suction for a maximum of 30 seconds

  D. Maintain clean technique during suctioning

  Correct Answer: B

  (A) The maximum time for suctioning is 10?5 seconds. (B) Supplemental O2should be administered before and after suctioning to reduce hypoxia. (C) The maximum time for suctioning is 10?5 seconds. (D) Strict sterile technique should be used during suctioning.