NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 521:

  A 28-year-old client performs a long, involved ritual in getting up and preparing for the day. He became unable to get to his job before noon. His family, in desperation, has admitted him to the hospital's psychiatric unit. On the unit, he is always late for breakfast, which is served at 8 am. The nurse identifies that the best approach to this problem is to:

  A. Allow him to eat late

  B. Suggest that he do the rituals after breakfast

  C. Get him up early so that he can complete the ritual before breakfast

  D. Ask him to get all the other clients up so that he will forget about his ritual

  Correct Answer: C

  (A) Allowing him to eat late is not a solution to the problem because the ritual affects more than just this meal. (B) He is helpless to change this behavior because the rituals occur as a result of an irrational effort to control his anxiety. (C) To interfere with the ritual will increase anxiety. Until the basic problem is resolved, and in turn his need for the ritual relieved, arrange the schedule so that essential activities may be included (such as meals with the group). (D) This approach would be very disruptive to the other clients and would not serve to relieve the anxiety of the client.

• Question 522:

  A client had a transurethral resection of the prostate yesterday. He is concerned about the small amount of blood that is still in his urine. The nurse explains that the blood in his urine:

  A. Should not be there on the second day

  B. Will stop when the Foley catheter is removed

  C. Is normal and he need not be concerned about it

  D. Can be removed by irrigating the bladder

  Correct Answer: C

  (A) Some hematuria is usual for several days after surgery. (B) The client will continue to have a small amount of hematuria even after the Foley catheter is removed. (C) Some hematuria is usual for several days after surgery. The client should not be concerned about it unless it increases. (D) Irrigating the bladder will not remove the hematuria. Irrigation is done to remove blood clots and facilitate urinary drainage.

• Question 523:

  A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?

  A. Ineffective airway clearance related to immobility, ineffective cough, and decreased level of consciousness

  B. Altered cerebral tissue perfusion related to pathophysiological changes that decrease blood flow

  C. Potential for injury related to impaired mobility and seizures

  D. Impaired verbal communication related to aphasia

  Correct Answer: A

  (A) An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. (B) Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is secondary to maintenance of an effective airway. (C) While prevention of injury is important, it is secondary to maintaining an effective airway and cerebral tissue perfusion. (D) Impaired verbal communication is not life threatening in the acute phase of recovery. It is the lowest priority of the nursing diagnoses listed.

• Question 524:

  A client on the infectious disease unit is discussing transmission of human immunodeficiency virus (HIV).

  The nurse would need to provide more client education based on which client statement?

  A. "HIV is a virus transmitted by sexual contact."

  B. "Condoms reduce the transmission of HIV."

  C. "HIV is a virus that is easily transmitted by casual contact."

  D. "HIV can be transmitted to an unborn infant."

  Correct Answer: C

  (A) HIV is transmitted through unprotected sexual contact. (B) Condoms are an effective barrier to prevent HIV transmission. (C) HIV is not easily transmitted by casual contact. (D) HIV can be transmitted intrauterinely at the time of delivery, and by breast-feeding.

• Question 525:

  A 25-year-old lawyer who is married with three young children works long hours in an effort to become a partner in the law firm. Following a recent hospitalization for a bleeding ulcer, he was referred for therapy to treat this psychophysiological disorder. On meeting with the therapist, he informed him or her that he was a busy man and did not have much time for this "psych stuff." When guiding the client to ventilate his feelings, the therapist can expect him to express feelings of:

  A. Guilt

  B. Shame

  C. Despair

  D. Anger

  Correct Answer: D

  (A) Guilt relates to depression. (B) Shame is not associated with psychophysiological disorders. (C) Despair relates to depression. (D) Repressed anger is associated with psychophysiological disorders.

• Question 526:

  At her first prenatal visit, a 21-year-old woman who is gravida 2, para 0, ab 1, is currently at 32 weeks' gestation and has a history of drug abuse, smoking, and occasional ethyl alcohol use. Fetal ultrasound tests indicate poor fetal growth. The most likely reason for the infant's intrauterine growth retardation is:

  A. The client's young age

  B. The client's previous abortion

  C. The client's history of drug, ethyl alcohol, and tobacco use

  D. The client's late prenatal care

  Correct Answer: C

  (A) Although adolescents frequently have a higher incidence of low-birth-weight infants, this client is 21 years old. (B) Uncomplicated induced abortions have not been proved to influence the growth of infants of subsequent pregnancies. (C) Compounds in cigarettes and some illicit drugs cause maternal vasoconstriction and a subsequent reduction in O2 availability for the fetus owing to the resulting reduction in uteroplacental blood flow. As few as one or two drinks of alcohol per day will decrease birth weight. (D) Although early prenatal care has been shown to improve pregnancy outcomes, not seeking care until the second week of gestation does not, in and of itself, cause intrauterine growth retardation.

• Question 527:

  The nurse is caring for a client with pancreatitis. Which of the following IV medications would the nurse expect the physician to prescribe for control of pain in this client?

  A. Morphine sulfate

  B. Kerolac tromethamine (Toradol)

  C. Promethazine (Phenergan)

  D. Meperidine (Demerol)

  Correct Answer: D

  (A) Morphine sulfate is contraindicated in clients with pancreatitis because it may cause spasms of the sphincter of Oddi and increase pancreatic pain. (B) Ketorolac tromethamine is currently not approved by the Food and Drug Administration for IV use. (C) Promethazine is a medication that has no analgesic properties. (D) Meperidine is the drug of choice for clients with pancreatitis. It will not cause spasms at the sphincter of Oddi, which can lead to increased pancreatic pain.

• Question 528:

  A client with cystic fibrosis exhibits activity intolerance related to the pulmonary problems associated with his disease. However, he needs to be encouraged to participate in daily physical exercise. The ultimate aim of exercise is to:

  A. Create a sense of well-being and self-worth

  B. Help him overcome respiratory infections

  C. Establish an effective, habitual breathing pattern

  D. Promote normal growth and development

  Correct Answer: C

  (A) Regular exercise does promote a sense of well-being and selfworth, but this is not the ultimate goal of exercise for this client. (B) Regular chest physiotherapy, not exercise per se, helps to prevent respiratory infections. (C) Physical exercise is an important adjunct to chest physiotherapy. It stimulates mucus secretion, promotes a feeling of well-being, and helps to establish a habitual breathing pattern. (D) Along with adequate nutrition and minimization of pulmonary complications, exercise does help promote normal growth and development. However, exercise is promoted primarily to help establish a habitual breathing pattern.

• Question 529:

  A baby who was diagnosed with pyloric stenosis has continued to have projectile vomiting. With prolonged vomiting, the infant is prone to:

  A. Respiratory acidosis

  B. Respiratory alkalosis

  C. Metabolic acidosis

  D. Metabolic alkalosis

  Correct Answer: D

  (A) Respiratory acidosis is the result of problematic ventilation. Plasma pH decreases, while plasma PCO2 and plasma HCO3 increase. (B) Respiratory alkalosis results from increased respiratory rate and depth. Plasma pH increases, while plasma PCO2 and plasma HCO3 decrease. (C) Metabolic acidosis occurs when there is strong acid gain in the body. Plasma pH, PCO2, and HCO3 decrease. (D) Increased risk for metabolic alkalosis is due to a loss of hydrogen ions; depletion of potassium, sodium, and chloride when vomiting occurs. Plasma pH and plasma PCO2 increase; plasma HCO3 may decrease and then increase to compensate.

• Question 530:

  On admission to the inpatient unit, a 34-year-old client is able to follow simple directions, but with great difficulty.

  He is worried about how he can keep clean in such a public place and repeatedly dusts his bureau, straightens his bed, and adjusts the clothes in his closet. The client is experiencing a severe level of anxiety. Which response by the nurse would be most therapeutic in initially attempting to reduce his anxiety?

  A. "You will not be allowed to remain in your room if you continue to bother things."

  B. "I can see how uncomfortable you are, but I would like you to walk with me so I can show you around the unit."

  C. "Tell me why your room needs to be so clean."

  D. "I've inspected this room and it is perfectly clean."

  Correct Answer: B

  (A) This statement is punitive. (B) Acknowledging the anxiety and channeling it into some positive activity is therapeutic. (C) The client cannot say "why"; this statement puts the client on the defensive. (D) A rational approach, especially a judgmental one, is nontherapeutic.