NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 551:

  While changing the dressing on a client's central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be appropriate to implement based on this finding?

  A. Discontinue the central line.

  B. Begin a peripheral IV.

  C. Document in the nurse's notes and notify the physician after redressing the site.

  D. Clean the site well and redress.

  Correct Answer: C

  (A) The nurse may never discontinue a central line without a physician's order. (B) The nurse may never initiate a peripheral IV without a physician's order except in an emergency situation. (C) The nurse should always document findings and alert the physician to the findings as well. The physician may then initiate a new central line and order the current central line to be discontinued. (D) Besides cleaning and redressing, the nurse should always document the findings.

• Question 552:

  As a postoperative cholecystectomy client completes tomorrow's dinner menu, the nurse knows that one of the following meal choices will best provide the essential vitamin(s) necessary for proper tissue healing?

  A. Liver, white rice, spinach, tossed salad, custard pudding

  B. Fish fillet, carrots, mashed potatoes, butterscotch pudding

  C. Roast chicken, gelatin with sliced fruit

  D. Chicken breast fillet in tomato sauce, potatoes, mustard greens, orange and strawberry slices

  Correct Answer: D

  (A) This meal choice provides more of the vitamins A, D, and K than of vitamin C. (B) This meal choice provides more of the vitamins A, B12, and D than of vitamin C. (C) This meal choice provides more of the vitamins A, B1 (thiamine), niacin, and microminerals than of vitamin C. (D) This meal choice provides foods rich in vitamin C, which are essential in tissue healing.

• Question 553:

  Decreased pulmonary blood flow, right-to-left shunting, and deoxygenated blood reaching the systemic circulation are characteristic of:

  A. Tetralogy of Fallot

  B. Ventricular septal defect

  C. Patent ductus arteriosus

  D. Transposition of the great arteries

  Correct Answer: A

  (A) Tetralogy of Fallot is the most common cyanotic heart defect, which includes a VSD, pulmonary stenosis, an overriding aorta, and ventricular hypertrophy. The blood flow is obstructed because the pulmonary stenosis decreases the pulmonary blood flow and shunts blood through the VSD, creating a right-to-left shunt that allows deoxygenated blood the reach the systemic circulation. (B) A VSD alone creates a left-to-right shunt. The pressure in the left ventricle is greater than that of the right; therefore, the blood will shunt from the left ventricle to the right ventricle, increasing the blood flow to the lungs. No deoxygenated blood will reach the systemic circulation. (C) In patent ductus arteriosus, the pressure in the aorta is greater than in the pulmonary artery, creating a left-to-right shunt. Oxygenated blood from the aorta flows into the unoxygenated blood of the pulmonary artery. (D) Transposition of the great arteries results in two separate and parallel circulatory systems. The only mixing or shunting of blood is based on the presence of associated lesions.

• Question 554:

  A male client received a heart-lung transplant 1 month ago at a local transplant center. While visiting the nursing center to have his blood pressure taken, he complains of recent weakness and fatigue. He also tells the nurse that he is considering stopping his cyclosporine because it is expensive and is causing his face to become round. He fears he will catch viruses and be more susceptible to infections. The nurse responds to this last statement by explaining that cyclosporine:

  A. Is given to prevent rejection and makes him less susceptible to infection than other oral corticosteroids

  B. Is available at discount pharmacies for a reduced price

  C. Is usually not necessary after the first year following transplantation

  D. May initially cause weakness, dizziness, and fatigue, but these side effects will gradually resolve themselves

  Correct Answer: A

  (A) Cyclosporine is the immunosuppressive drug of choice. It provides immunosuppression but does not lower the white blood cell count; therefore, the client is less susceptible to infection. (B) Cyclosporine is available at discount pharmacies. The cost may be absorbed by health insurance, or Medicare, if the client is eligible. However, this statement does not address the entire problem verbalized by the client. (C) Immunosuppressive agents will be taken for the client's entire life because rejection can occur at any time. (D) These side effects do not necessarily resolve in time; however, the client may adapt.

• Question 555:

  A client has received digoxin 0.25 mg po daily for 2 weeks. Which of the following digoxin levels indicates toxicity?

  A. 0.5 ng/mL

  B. 1.0 ng/mL

  C. 2.0 ng/mL

  D. 3.0 ng/mL

  Correct Answer: D

  (A) 0.5 ng/mL of digoxin is a subtherapeutic level, not a toxic one. (B) 1.0 ng/mL is a therapeutic level. (C) 2.0 ng/mL is a therapeutic level. (D) Digoxin's therapeutic level is 0.8?.0 ng/mL. Digoxin's toxic level is>;2.0 ng/mL.

• Question 556:

  A client is admitted to the hospital with diabetic ketoacidosis.

  The emergency room nurse should anticipate the administration of:

  A. Humulin N

  B. Humulin R

  C. Humulin U

  D. Humulin L

  Correct Answer: B

  (A) Intermediate-acting insulin is not indicated in an emergency. (B) Regular insulin is rapid acting and indicated in an emergency situation. (C) Long-acting insulin is not indicated in an emergency situation. (D) Intermediate-acting insulin is not indicated in an emergency situation.

• Question 557:

  A client returns to the cardiovascular intensive care unit following his coronary artery bypass graft. In planning his care, the most important electrolyte the nurse needs to monitor will be:

  A. Chloride

  B. HCO3

  C. Potassium

  D. Sodium

  Correct Answer: C

  (A) Chloride, HCO3, and sodium will need to be monitored, but monitoring these electrolytes is not as important as potassium monitoring. (B) Chloride, HCO3, and sodium will need to be monitored, but monitoring these electrolytes is not as important as potassium monitoring. (C) Potassium will need to be closely monitored because of its effects on the heart. Hypokalemia could result in supraventricular tachyarrhythmias. (D) Chloride, HCO3, and sodium will need to be monitored, but monitoring these electrolytes is not as important as potassium monitoring.

• Question 558:

  A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse:

  A. Must use the least restrictive measure possible to control the behavior

  B. Should put the client in seclusion until he promises to behave appropriately

  C. Should apply full restraints until the behavior is under control

  D. Should allow other clients to observe the acting out so that they can learn from the experience

  Correct Answer: A

  (A) This answer is correct. Least restrictive measures should always be attempted before a client is placed in seclusion or restraints. The nurse should first try a calm verbal approach, suggest a quiet room, or request that the client take "timeout" before placing the client in seclusion, givingmedication as necessary, or restraining. (B) This answer is incorrect. A calm verbal approach or requesting that a client go to his room should be attempted before restraining. (C) This answer is incorrect. Restraints should be applied only after all other measures fail to control the behavior. (D) This answer is incorrect. Other clients should be removed from the area. It is often very anxiety producing for other clients to see a peer out of control. It could also lead to mass acting- out behaviors.

• Question 559:

  The nurse documents a client's surgical incision as having red granulated tissue. This indicates that the wound is:

  A. Infected

  B. Not healing

  C. Necrotic

  D. Healing

  Correct Answer: D

  (A) The wound is not infected. An infected wound would contain pus, debris, and exudate. (B) The wound is healing properly. (C) A necrotic wound would appear black or brown. (D) The wound is healing properly and is filled with red granulated tissue and fragile capillaries.

• Question 560:

  Because a client is taking an MAO inhibitor, it is necessary to discuss the need for adherence to a low-tyramine diet. Which of the following are foods that she should avoid?

  A. Pickled, aged, smoked, and fermented foods

  B. Fresh vegetables

  C. Broiled fresh fish and fowl

  D. Fresh fruit such as apples and oranges

  Correct Answer: A

  (A) These foods may produce elevation in blood pressure when consumed during MAO inhibition therapy. (B) These foods have not been pickled, fermented, smoked, or aged. They contain very little, if any, tyramine or tryptophan. (C) As long as the meat has not been aged or smoked, it is within the dietary regimen. (D) Fresh fruits can be consumed as desired. However, the consumption of bananas is limited.