NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 531:

  The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue healing?

  A. Vitamin C

  B. Vitamin B1

  C. Vitamin D

  D. Vitamin A

  Correct Answer: A

  (A) Vitamin C (ascorbic acid) is essential in promoting wound healing and collagen formation. (B) Vitamin B1 (thiamine) maintains normal gastrointestinal (GI) functioning, oxidizes carbohydrates, and is essential for normal functioning of nervous tissue. (C) Vitamin D regulates absorption of calcium and phosphorus from the GI tract and helps prevent rickets. (D) Vitamin A is necessary for the formation and maintenance of skin and mucous membranes. It is also essential for normal growth and development of bones and teeth.

• Question 532:

  A 29-year-old client is diagnosed with borderline personality disorder. He has aroused the nurse's anger by using a condescending tone of voice with other clients and staff persons. Which of the following statements from the nurse would be most appropriate in acknowledging feelings regarding the client's behavior?

  A. "I feel angry when I hear that tone of voice."

  B. "You make me angry when you talk to me that way."

  C. "Are you trying to get me angry?"

  D. "Why do you treat me that way?"

  Correct Answer: A

  The nurse appropriately states how he or she feels when the client speaks in a condescending manner. (B) This statement indicates that the client has control over the nurse. No one makes another person angry; each individual has a choice.

  (C) "Why" questions usually put a person on the defensive. In addition, the client cannot "make" the nurse angry. The client does not have that control. (D) Again, a "why" statement places the client on the defensive.

• Question 533:

  A 70-year-old homeless woman is admitted with pneumonia. She is weak, emaciated, and febrile. The physician orders enteral feedings intermittently by nasogastric tube. When inserting the nasogastric tube, once the tube passes through the oropharynx, the nurse will instruct the client to:

  A. Tilt her head backwards

  B. Swallow as tube passes

  C. Hold breath as tube passes

  D. Cough as tube passes

  Correct Answer: B

  (A) Head should be tilted slightly forward to facilitate insertion. (B) Swallowing assists with insertion of tube and closes off airway. (C) Client should be swallowing as tube passes; holding the breath facilitates nothing. (D) Coughing may expel tube.

• Question 534:

  A 9-month-old infant visits her pediatrician for a routine visit. A developmental assessment was initiated by the nurse. Which skill would cause the nurse to be concerned about the infant's developmental progression?

  A. She sits briefly alone with assistance.

  B. She creeps and crawls.

  C. She pulls herself to her feet with help.

  D. She stands while holding onto furniture.

  Correct Answer: A

  (A) The 9-month-old infant can sit alone for long periods. By the age of 6 months, many infants can pull themselves to a sitting position. (B, C, D) This skill represents normal development.

• Question 535:

  A male client had a right below-the-knee amputation 4 days ago. His incision is healing well. He has gotten out of bed several times and sat at the side of the bed. Each time after returning to bed, he has experienced pain as if it were located in his right foot. Which nursing measure indicates the nurse has a thorough understanding of phantom pain and its management?

  A. Phantom pain is entirely in the client's mind. The client should be instructed that the pain is psychological and should not be treated.

  B. The basis for phantom pain may occur because the nerves still carry pain sensation to the brain even though the limb has been amputated. The pain is real, intense, and should be treated.

  C. The cause of phantom pain is unknown. The nurse should provide the client with support, promote sleep, and handle the injured limb smoothly and gently.

  D. Phantom pain is caused by trauma, spasms, and edema at the incisional site. It will decrease when postoperative edema decreases. It should be treated with nonnarcotic medication whenever possible.

  Correct Answer: B

  (A) This statement is entirely false. (B) Phantom pain may be caused by nerves continuing to carry sensation to the brain even though the limb is removed. It is real, intense, and should be treated as ordinary pain would. (C) Although the cause of phantom pain is still unknown, thesemeasures may promote the relief of any type of pain, not just phantom pain. (D) Phantom pain is not caused by trauma, spasms, and edema and will not be relieved by decreasing edema.

• Question 536:

  Chorioamnionitis is a maternal infection that is usually associated with:

  A. Prolonged rupture of membranes

  B. Postterm deliveries

  C. Maternal pyelonephritis

  D. Maternal dehydration

  Correct Answer: A

  (A) Chorioamnionitis is an inflammation of the chorion and amnion that is generally associated with premature or prolonged rupture of membranes. (B) Postterm deliveries have not been shown to increase the risk of chorioamnionitis unless there has been prolonged rupture of membranes. (C) Pyelonephritis is a kidney infection that develops in 20%?0% of untreated maternal UTIs. (D) Maternal dehydration, though of great concern, is not related to chorioamnionitis.

• Question 537:

  One week ago, a 21-year-old client with a diagnosis of bipolar disorder was started on lithium 300 mg po qid. A lithium level is ordered. The client's level is 1.3 mEq/L. The nurse recognizes that this level is considered to be:

  A. Within therapeutic range

  B. Below therapeutic range

  C. Above therapeutic range

  D. At a level of toxic poisoning

  Correct Answer: A

  (A) This answer is correct. The therapeutic range is 1.0?.5 mEq/L in the acute phase. Maintenance control levels are 0.6?.2 mEq/L. (B, C) This answer is incorrect. A level of 1.3 mEq/L is within therapeutic range. (D) This answer is incorrect. Toxic poisoning is usually at the 2.0 level or higher.

• Question 538:

  A 68-year-old man was recently diagnosed with endstage renal disease. He has not yet begun dialysis but is experiencing severe anemia with associated symptoms of dyspnea on exertion and chest pain. Which statement best describes the management of anemia in renal failure?

  A. Hematocrit levels usually remain slightly below normalin clients with renal failure.

  B. Transfusion is often begun as early as possible to prevent complications of anemia such as dyspnea and angina.

  C. Anemia in renal failure is frequently caused by low serum iron and ferritin and corrected by oral iron and ferritin replacement therapy.

  D. The renal secretion of erythropoiesis is decreased. The bone marrow requires erythropoietin to mature red blood cells.

  Correct Answer: D

  (A) Clients in renal failure typically have very low hematocrits, often in the range of 16?2%. (B) Transfusion is avoided unless the client exhibits acute symptoms such as dyspnea, chest pain, tachycardia, and extreme fatigue. When the client is given a transfusion, the bone marrow adjusts by producing less red blood cells. (C) Anemia in renal failure is caused primarily by decreased erythropoietin. Low serum iron and ferritin may aggravate the anemia and require treatment. (D) Decreased secretion of erythropoietin by the kidney is the primary cause of anemia. The bone marrow requires this hormone to mature red blood cells. Treatment is with replacement therapy.

• Question 539:

  A 15-year-old client was diagnosed as having cystic fibrosis at 8 months of age. He is in the hospital for a course of IV antibiotic therapy and vigorous chest physiotherapy. He has a poor appetite. The nurse can best help him to meet the desired outcome of consuming a prescribed number of calories by:

  A. Including the client in planning sessions to select the type of meal plan and foods for his diet

  B. Working with the nutritionist to devise a diet with significantly increased calories

  C. Selecting foods for the client's diet that are high in calories and instituting a strict calorie count

  D. Constantly providing him with chips, dips, and candies, because the number of calories consumed is more important than the quality of foods

  Correct Answer: A

  (A) The adolescent knows what he likes and will be more likely to eat if he has some control over his diet. (B) The nurses and nutritionist can plan an excellent diet, but it will not help the adolescent unless he eats it. (C) Eating is already a chore for this client. Adding a strict calorie count could make it even more burdensome. (D) Fats are particularly difficult for the cystic fibrosis client to digest. He does need a healthful diet, not just more calories.

• Question 540:

  A 50-year-old depressed client has recently lost his job. He has been reluctant to leave his hospital room. Nursing care would include:

  A. Forcing the client to attend all unit activities

  B. Encouraging the client to discuss why he is so sad

  C. Monitoring elimination patterns

  D. Providing sensory stimulation

  Correct Answer: C

  (A) The client should be encouraged to attend the unit activities. The nurse and client should choose a few activities for the client to attend that will be positive experiences for him. (B) The nurse should encourage the client to discuss his feelings and to begin to deal with the depression. (C) Depressed persons often have little appetite and poor fluid intake. Constipation is common. (D) A calm, consistent level of stimuli is most effective. Sensory deprivation and overstimulation should be avoided.