NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 541:

  A 19-year-old male client arrived via ambulance to the emergency room following a motorcycle accident. He is comatose. His face has evidence of dried blood. On assessment, the nurse notes an obvious injury to his left eye. The preferred positioning for a client with an obvious eye injury is:

  A. Reclining to control bleeding

  B. Any position in which the client is comfortable

  C. Side-lying, either left or right

  D. Sitting with head support

  Correct Answer: D

  (A) A reclining position can cause a penetrating object to advance further into the eye. (B) Prevention of further injury is the priority, not comfort. (C) A side-lying position may increase intraocular and intracranial pressure if an accompanying head injury is suspected. (D) A sitting position with the head supported will prevent further injury while allowing injury care to take place.

• Question 542:

  In working with a manipulative client, which of the following nursing interventions would be most appropriate?

  A. Bargaining with the client as a strategy to control the behavior

  B. Redirecting the client

  C. Providing a consistent set of guidelines and rules

  D. Assigning the client to different staff persons each day

  Correct Answer: C

  (A) This answer is incorrect. Bargaining is a manipulative act, which the nurse could expect from the client. (B) This answer is incorrect. Confrontation is an effective nursing strategy with manipulative behavior. Redirection is appropriate for the client who is out of touch with reality. (C) This answer is correct. Manipulative clients must abide by consistent rules. (D) This answer is incorrect. Manipulation is kept at a minimum if the same staff person is assigned to the client. Often the client will attempt to play staff persons against each other.

• Question 543:

  Following a fracture of the left femur, a client develops symptoms of osteomyelitis. During the acute phase of osteomyelitis, nursing care is directed toward:

  A. Moving or turning the client's left leg carefully to minimize pain and discomfort

  B. Allowing the client out of bed only in a wheelchair or gurney to minimize weight bearing on the left leg

  C. Providing the client with a high-protein, high-fiber diet to promote healing

  D. Instituting physical therapy to ensure restoration of optimal functioning of the leg

  Correct Answer: A

  (A) Any movement of his affected limb will cause discomfort to the child. (B) No weight bearing will be allowed until healing is well underway to avoid pathological fractures. (C) The child will be anorexic and may experience vomiting. Diet should be simple and high caloric until appetite returns and symptoms subside. (D) Physical therapy is instituted only after infection subsides.

• Question 544:

  The nurse recognizes that a client with the diagnosis of cholecystitis and cholelithiasis would expect to have stools that are:

  A. Clay or gray colored

  B. Watery and loose

  C. Bright-red streaked

  D. Black

  Correct Answer: A

  (A) Clients who have obstruction in the biliary tract so that bile is not released into the duodenum experience a change in stools from brown to gray or clay colored. (B) This type of stool can occur with other GI problems, such as bacterial or viral infections, and other disease problems, and is not a common finding with biliary obstructions such as cholecystitis and cholelithiasis. (C) This type of stool is usually associated with a GI or bowel problem, such as lower GI bleeding, rather than with biliary obstructions. (D) This type of stool is usually associated with a GI or bowel problem, such as upper GI bleeding, rather than with biliary obstructions.

• Question 545:

  A client is having a pneumonectomy done today, and the nurse is planning her postoperative care. Nursing interventions for a postoperative left pneumonectomy would include:

  A. Monitoring the chest tubes

  B. Positioning the client on the right side

  C. Positioning the client in semi-Fowler position with a pillow under the shoulder and back

  D. Monitoring the right lung for an increase in rales

  Correct Answer: D

  (A) Chest tubes are usually not necessary in a pneumonectomy because there is no lung to re-expand on the operative side. (B) The pneumonectomy client should be positioned on the back or operated side because the sutured bronchial stump may open, allowing fluid to drain into the unoperated side and drown the client. (C) The client should not have a pillow under the shoulder and back because of the subscapular incision. (D) Rales are commonly heard over the base of the remaining lung, but an increase could indicate circulatory overload and therefore should be closely monitored.

• Question 546:

  In admitting a client to the psychiatric unit, the nurse must explain the rules and regulations of the unit. A client with antisocial personality disorder makes the following remark, "Forget all those rules. I always get along well with the nurses." Which nursing response to him would be most effective?

  A. "OK, don't listen to the rules. See where you end up."

  B. "I'm pleased that you get along so well with the staff. You must still know and abide by the rules."

  C. "It is irrelevant whether you get along with the nurses."

  D. "I'm not the other nurses. You better read the rules yourself."

  Correct Answer: B

  (A) This answer is incorrect. A nurse should be an appropriate role model. Threats are not appropriate. No limit setting was stated. (B) This answer is correct. The nurse made a positive statement followed by a simple, clear, concise setting of limits. (C) This answer is incorrect. It appears to have a negative connotation. There was no limit setting. (D) This answer is incorrect. The nurse obviously responded in a negative manner. Learning takes place more readily when one is accepted, not rejected. No limits were set.

• Question 547:

  A child receiving chemotherapeutic drugs experiences a loss of appetite directly related to the therapy. Which of the following strategies should be most effective in encouraging the child to eat?

  A. Provide a well-balanced diet at usual times, and restrict dessert if the child fails to eat well.

  B. Schedule procedures immediately after eating so that the child will not be tired or in pain at mealtime.

  C. Offer the child a diet with a wider variety of foods and with more seasoning than her usual diet.

  D. Offer the child smaller meals more frequently than usual, and include as many of her favorite foods as possible.

  Correct Answer: D

  (A) Because the child's appetite is capricious at best, regular servings may be overwhelming. Praise the child for what is eaten. (B) The child will soon learn that procedures follow meals and may play with food rather than eat it to avoid or delay the procedure. (C) Young children usually do not like highly seasoned foods and may need the security of usual foods. Such a change may actually increase anorexia. (D) Small servings appear more achievable to the child, and the inclusion of favorite foods can add a sense of security.

• Question 548:

  The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this finding?

  A. Palpate these pulses again in 15 minutes.

  B. Use a Doppler to determine presence and strength of these pulses.

  C. Document the finding that the pulses are not palpable.

  D. Call the physician and notify the physician of this finding.

  Correct Answer: B

  (A)

  Palpating these pulses again in 15 minutes may only result in the same findings. (B) Any time during an assessment that the nurse is unable to palpate pulses, the nurse should then obtain a Doppler and assess for presence or absence of the pulse and pulse strength, if a pulse is present. (C) Pulses may be present and assessed through use of a Doppler. Absence of palpable pulses does not indicate absence of blood flow unless pulses cannot be located with a Doppler.

  (D)

  The nurse would only call the physician after determining that the pulses are absent by both palpation and Doppler.

• Question 549:

  When assessing residual volume in tube feeding, the feeding should be delayed if the amount of gastric contents (residual) exceeds:

  A. 20 mL

  B. 25 mL

  C. 30 mL

  D. 50 mL

  Correct Answer: D

  (A) A residual volume of 20 mL is not excessive. (B) A residual volume of 25 mL is not excessive. (C) A residual volume of 30 mL is not excessive. (D) Tube feedings should be withheld and physician notified for residual volumes of 50?00 mL.

• Question 550:

  The nurse has been assigned a client who delivered a 6- lb, 12-oz baby boy vaginally 40 minutes ago. The initial assessment of greatest importance for this client would be:

  A. Length of her labor

  B. Type of episiotomy

  C. Amount of IV fluid to be infused

  D. Character of the fundus

  Correct Answer: D

  The length of labor has little bearing on the fourth stage of labor. The type of labor and delivery is significant. (B) The type of episiotomy will affect the client's comfort level. However, the nurse's assessment and implementations center on prevention of hemorrhage during the fourthstage of labor. The amount of bleeding from the episiotomy or hematoma formation is of higher priority than the type of episiotomy. (C) The amount of IV fluid to be infused is a nursing function to be attended to; however, it is lower in priority than determining if hemorrhaging is occurring. (D) Character of the fundus would be the priority nursing assessment because changes in uterine tone may identify possible postpartum hemorrhage.