NCLEX NCLEX-RN Online Practice Questions and Exam Preparation

NCLEX NCLEX-RN Online Questions & Answers

• Question 531:

  One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:

  A. Blood pressure
  B. Level of consciousness
  C. Skin turgor
  D. Fluid intake
  B. Level of consciousness

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  (A) Blood pressure can remain normotensive in a state of hypovolemia. (B) Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. (C) Skin turgor is not a reliable indicator for assessing hydration in a burn client. (D) Fluid intake does not indicate adequacy of fluid resuscitation in a burn client.

• Question 532:

  A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the gravida and para system to record the client's obstetrical history, the nurse should record:

  A. Gravida 3 para 1
  B. Gravida 3 para 2
  C. Gravida 2 para 1
  D. Gravida 2 para 2
  B. Gravida 3 para 2

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  (A) This answer is an incorrect application of gravida and para. The client has had two prior deliveries of more than 20 weeks' gestation; therefore, para equals 2, not 1. (B) This answer is the correct application of gravida and para. The client is currently pregnant for the third time (G = 3), regardless of the length of the pregnancy, and has had two prior pregnancies with birth after the 20th week (P = 2), whether infant was alive or dead. (C) This answer is an incorrect application of gravida and para. The client is currently pregnant for the third time (G = 3, not 2); prior pregnancies lasted longer than 20 weeks (therefore, P = 2, not 1). (D) This is an incorrect application of gravida and para. Client is currently pregnant for third time (G = 3, not 2).

• Question 533:

  A 22-year-old single woman was admitted to the psychiatric hospital by her mother, who reported bizarre behavior. Except for going to work, she spends all her time in her room and expresses concern over neighbors spying on her. She has fears of the telephone being "bugged." Her diagnosis is schizophrenia. One nurse per shift is assigned to work with the client. The primary reason for this plan would be to:

  A. Protect her from suicide
  B. Enable her to develop trust
  C. Supervise her medication regimen
  D. Involve her in groups for social interaction
  B. Enable her to develop trust

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  (A) Suicide is a greater risk in depression than in schizophrenia. (B) The client is suspicious and needs help to develop trust, which is basic to her improvement. (C) Although she will be taking medication, drug therapy would not necessitate consistency in the nurses assigned. (D) A suspicious client should have limited exposure to groups, because group participation increases discomfort.

• Question 534:

  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
  A. Vitamin C

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  (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 535:

  A 55-year-old man has recently been diagnosed with hypertension. His physician orders a low-sodium diet for him. When he asks, "What does salt have to do with high blood pressure?'' the nurse's initial response would be:

  A. "The reason is not known why hypertension is associated with a high-salt diet."
  B. "Large amounts of salt in your diet can cause you to retain fluid, which increases your blood pressure."
  C. "Salt affects your blood vessels and causes your blood pressure to be high."
  D. "Salt is needed to maintain blood pressure, but too much causes hypertension."
  B. "Large amounts of salt in your diet can cause you to retain fluid, which increases your blood pressure."

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  (A) This response is untrue. (B) Decreasing salt intake reduces fluid retention and decreases blood pressure. (C) Salt does not have an effect on the blood vessels themselves, but on fluid retention, which accompanies salt intake. (D) This response is untrue.

• Question 536:

  Parents of children receiving chemotherapy should be warned that alopecia is a side effect and that:

  A. Children seldom show concern about losing their hair
  B. The hair will come out gradually, and the loss will not be noticeable for some time
  C. It is best for girls to choose a wig similar to their hair style and color before the hair falls out
  D. The parents will soon get used to seeing their children without hair, and it will no longer bother them
  C. It is best for girls to choose a wig similar to their hair style and color before the hair falls out

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  (A) Children may become depressed with a changed appearance and not want to look at themselves or have others see them. (B) The hair will fall out in clumps, causing patchy baldness that is quite noticeable and traumatic to children and their families. (C) Having a wig that looks like a girl's own hair can be a psychological boost to children and is helpful in fostering later adjustments to hair loss. (D) Families may become accustomed to seeing their children without hair, but the loss is traumatic to them and will continue to bother them.

• Question 537:

  The following nursing diagnosis is written for a comatose client with cirrhosis of the liver and secondary splenomegaly--High risk for injury: Increased susceptibility to bleeding related to:

  A. Increased absorption of vitamin K
  B. Thrombocytopenia due to hypersplenism
  C. Diminished function of the Kupffer cells
  D. Increased synthesis of the clotting factors
  B. Thrombocytopenia due to hypersplenism

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  (A) There is a decreased absorption of vitamin K with cirrhosis of the liver. This decrease impairs blood coagulation and the formation of prothrombin. (B) Thrombocytopenia, an increased destruction of platelets, occurs secondary to hypersplenism. (C) A diminished function of the Kupffer cells occurs with cirrhosis of the liver, causing the client to become more susceptible to infections. (D) A decrease in the synthesis of fibrinogen and clotting factors VII, IX, and X occurs with cirrhosis of the liver and increases the susceptibility to bleeding.

• Question 538:

  A client's transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing, anxious, and very restless. The nurse knows these assessment findings are congruent with:

  A. Hemolytic transfusion reaction
  B. Febrile transfusion reaction
  C. Circulatory overload
  D. Allergic transfusion reaction
  D. Allergic transfusion reaction

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  (A) A hemolytic transfusion reaction would be characterized by fever, chills, chest pain, hypotension, and tachypnea. (B) Fever, chills, and headaches are indicative of a febrile transfusion reaction. (C) Circulatory overload is manifest by dyspnea, cough, and pulmonary crackles. (D) Urticaria, pruritus, wheezing, and anxiety are indicative of an allergic transfusion reaction.

• Question 539:

  The physician is preparing to induce labor on a 40-week multigravida. The nurse should anticipate the administration of:

  A. Oxytocin (Pitocin)
  B. Progesterone
  C. Vasopressin (Pitressin)
  D. Ergonovine maleate
  A. Oxytocin (Pitocin)

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  (A) Oxytocin is a hormone secreted by the neurohypophysis during suckling and parturition that produces strong uterine contractions. (B) Progesterone has a quiescence effect on the uterus. (C) Vasopressin is an antidiuretic hormone that promotes water reabsorption by the renal tubules. (D) Ergonovine produces dystocia as a result of sustained uterine contractions.

• Question 540:

  A 68-year-old woman is admitted to the hospital with chronic obstructive pulmonary disease (COPD). She is started on an aminophylline infusion. Three days later she is breathing easier. A serum theophylline level is drawn. Which of the following values represents a therapeutic level?

  A. 14 μ g/mL
  B. 25 μ g/mL
  C. 4 μ g/mL
  D. 30 μ g/mL
  A. 14 μ g/mL

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  (A) The therapeutic blood level range of theophylline is 100 mg/mL. Therapeutic drug monitoring determines effective drug dosages and prevents toxicity. (B, D) This value is a toxic level of the drug. (C) This value is a nontherapeutic level of the drug.