NCLEX NCLEX-RN Online Practice Questions and Exam Preparation

NCLEX NCLEX-RN Online Questions & Answers

• Question 561:

  A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:

  A. Deflating the cuff for 10 minutes every other hour instead of 5 minutes every hour
  B. Avoiding manipulation of the tracheostomy including cuff deflation
  C. Reporting any signs of crepitus immediately to the physician
  D. Changing tracheostomy dressing only as necessary using one-half strength hydrogen peroxide to cleanse the site
  B. Avoiding manipulation of the tracheostomy including cuff deflation

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  (A) The tracheal cuff should not be deflated within the first 24 hours following surgery. (B) To minimize bleeding, any manipulation, including cuff deflation, should be avoided. (C) Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician. (D) The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.

• Question 562:

  A 27-year-old male client is admitted to the acute care mental health unit for observation. He has recently lost his job, and his wife told him yesterday that she wants a divorce. The client is placed on suicide precautions. In assessing suicide potential, the nurse should pay close attention to the client's:

  A. Level of insight
  B. Thought processes
  C. Mood and affect
  D. Abstracting abilities
  C. Mood and affect

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  (A) Assessing the client's level of insight is an important part of the mental status exam (MSE), but it does not reflect suicide potential. (B) Assessing the client's thought processes is an important part of the MSE, but it does not reflect suicide potential. (C) Assessing the client's mood and affect is an important part of the MSE, and it can be a very valuable indicator of suicide potential. Frequently a client who has decided to proceed with suicide plans will exhibit a suddenly improved mood and affect. (D) Assessing a client's abstracting abilities is an important part of the MSE, but it does not reflect suicide potential.

• Question 563:

  A client had a vaginal delivery 3 days ago and is discharged from the hospital on the 2nd day postpartum. She told the RN, "I need to start exercising so that I can get back into shape. Could you suggest an exercise I could begin with?'' The RN could suggest which one of the following?

  A. Push-ups
  B. Jumping jacks
  C. Leg lifts
  D. Kegel exercises
  D. Kegel exercises

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  (A, B, C) This exercise is too strenuous at this time. (D) This exercise is recommended for the first few days after delivery. It helps to stimulate muscle tonus in the area of the perineum and the area around the urinary meatus and vagina.

• Question 564:

  A client was admitted to the hospital for a TURP. Within 48 hours of admission and 12 hours postoperatively, both the blood pressure and pulse increased. He became agitated, thought snakes were crawling on his arms and legs, and generally became unmanageable. He pulled out his IV and urinary catheter in attempt to rid himself of the snakes. He was sweating profusely. The admission nurse's notes indicated that the client admitted to "having a few drinks now and then." He is probably experiencing which of the following?

  A. Major psychotic depression
  B. Delirium tremens
  C. Generalized anxiety disorder
  D. Adjustment disorder with mixed features
  B. Delirium tremens

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  (A) Symptoms of psychotic depression must exist for at least 2 weeks, and the symptoms must represent a change from previous functioning. (B) Delirium tremens occur approximately on the second or third day following cessation or reduction of alcohol intake. Symptoms would be all those described in the situation. (C) Symptoms exhibited by this client are not exhibited in clients with anxiety disorders, who manifest excessive or unrealistic worry about life circumstances for at least 6 months. (D) Symptoms for adjustment disorders with mixed emotional features (e.g., depression and anxiety) are different from those exhibited by the client in this situation.

• Question 565:

  The nurse is trying to help a mother understand what is happening with her son who has recently been diagnosed with paranoid schizophrenia. At present, he is experiencing hallucinations and delusions of persecution and suffers from poor hygiene. The nurse can best help her understand her son's condition by which of the following statements?

  A. "Sometimes these symptoms are caused by an overstimulation of a chemical called dopamine in the brain."
  B. "Has anyone in your family ever had schizophrenia?"
  C. "If your son has a twin, he probably will eventually develop schizophrenia, too."
  D. "Some of his symptoms may be a result of his lack of a strong mother-child bonding relationship."
  A. "Sometimes these symptoms are caused by an overstimulation of a chemical called dopamine in the brain."

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  (A) The most plausible theory to date is that dopamine causes an overstimulation in the brain, which results in the psychotic symptoms. (B) This statement will only create anxiety in the mother, and the genetic theory is only one of the etiological factors. (C) This statement will cause the mother much alarm, and nothing was mentioned about any other child. (D) The motherchild relationship is one of the previous theories examined, but it is not one to be emphasized, thereby causing a lot of anxiety for the mother.

• Question 566:

  The nurse would be sure to instruct a client on the signs and symptoms of an eye infection and hemorrhage. These signs and symptoms would include:

  A. Blurred vision and dizziness
  B. Eye pain and itching
  C. Feeling of eye pressure and headache
  D. Eye discharge and hemoptysis
  B. Eye pain and itching

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  (A) Although blurred vision may occur, dizziness would not be associated with an infection or hemorrhage. (B) Eye pain is a symptom of hemorrhage within the eye, and itching is associated with infection. (C) Nausea and headache would not be usual symptoms of eye hemorrhage or infection. (D) Some eye discharge might be anticipated if an infection is present; hemoptysis would not.

• Question 567:

  The nurse enters the room of a client on which a "do not resuscitate" order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, "please save her!" The nurse's action would be:

  A. Call the physician and inform him that the client has expired.
  B. Remind the husband that the physician wrote an order not to resuscitate.
  C. Discuss with the husband that these orders are written only on clients who are not likely to recover with resuscitative efforts.
  D. Call a code and proceed with cardiopulmonary resuscitation.
  D. Call a code and proceed with cardiopulmonary resuscitation.

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  (A, B, C) The last request from the husband overrides the decision not to initiate resuscitation efforts. (D) The nurse should begin cardiopulmonary resuscitation unless a living will and durable power of attorney are in force. In the meantime, the nurse should talk with the husband and notify the doctor.

• Question 568:

  A 23-year-old male client is admitted to the chemical dependency unit with a medical diagnosis of alcoholism. He reports that the last time he drank was 3 days ago, and that now he is starting to "feel kind of shaky." Based on the information given above, nursing care goals for this client will initially focus on:

  A. Self-concept problems
  B. Interpersonal issues
  C. Ineffective coping skills
  D. Physiological stabilization
  D. Physiological stabilization

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  (A) Self-concept and self-esteem problems may emerge during the client's treatment, but these are not immediate concerns. (B) Interpersonal issues may become evident during the course of the client's treatment, but these are also not immediate areas of concern. (C) Improving individual coping skills is generally a primary focus in the treatment and nursing care of persons with substance abuse problems. However, this is still not the immediate concern in this client situation. (D) Correction of fluid and electrolyte status and vitamin deficiencies, as well as prevention of delirium, is the immediate concern in the care of this client.

• Question 569:

  A client was exhibiting signs of mania and was recently started on lithium carbonate. She has no known physical problems. A teaching plan for this client would include which of the following?

  A. Regular foods should be eaten, including those that contain salt, such as bacon, ham, V-8 juice, and tomato juice.
  B. Restrict fluids to 1000 mL/day.
  C. Restrict foods that contain salt or sodium.
  D. Discontinue the medication if nausea occurs.
  A. Regular foods should be eaten, including those that contain salt, such as bacon, ham, V-8 juice, and tomato juice.

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  (A) This answer is correct. A balanced diet with adequate salt intake is necessary. (B) This answer is incorrect. The client must drink six to eight full glasses of fluid per day (2000?000 mL/day). (C) This answer is incorrect. The client should be instructed to avoid fluctuations of sodium intake. Diet should be balanced, with an adequate salt intake. (D) This answer is incorrect. Nausea is a frequent side effect that can be minimized with administration of drug with meals or after eating food.

• Question 570:

  An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction?

  A. Boardlike, rigid abdomen
  B. Loss of the urge to defecate
  C. Liquid stool
  D. Abdominal pain
  C. Liquid stool

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  (A) A boardlike, rigid abdomen would point to a perforated bowel, not a fecal impaction. (B) When a client is fecally impacted, a common symptom is the urge to defecate but the inability to do so. (C) When an impaction is present, only liquid stool will be able to pass around the impacted site. (D) Abdominal pain without distention is not a sign of a fecal impaction.