NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 561:

  A 47-year-old client has been admitted to the general surgery unit for bowel obstruction. The doctor has ordered that an NG tube be inserted to aid in bowel de-compression. When preparing to insert a NG tube, the nurse measures from the:

  A. Lower lip to the shoulder to the upper sternum

  B. Tip of the nose to the lower lip to the umbilicus

  C. End of the tube to the first measurement line on the tube

  D. Tip of the nose to the ear lobe to the xiphoid process or midepigastric area

  Correct Answer: D

  (A) This measurement is _50 cm (48?9 cm). Fifty centimeters is considered the length necessary for the distal end of the tube to be in place in the stomach. This measurement is too short. (B) This measurement is _50 cm (47?8 cm). Fifty centimeters is considered the lengthnecessary for the distal end of the tube to be in place in the stomach. This measurement is too short. (C) This measurement gives an approximate indication of the length necessary for the distal end of the tube to be in place in the stomach, but it is not as accurate as actually measuring the client (nose-earxiphoid). (D) This is the correct measurement of 50 cm from the tip of the client's nose to the tip of the earlobe to the xiphoid process (called the NEX [nose-ear-xiphoid] measurement). It is approximately equal to the distance necessary for the distal end of the tube to be located in the correct position in the stomach.

• Question 562:

  Cheyne-Stokes respiratory pattern can be associated with which of the following conditions?

  A. Diabetic ketoacidosis

  B. Fever

  C. Increased intracranial pressure

  D. Spinal meningitis

  Correct Answer: C

  Explanation:

  (A) Kussmaul's respirations are associated with diabetic ketoacidosis, severe hemorrhage, peritonitis, renal failure, and uremia. (B) Tachypnea (respiratory rate >25 breaths/min) is often associated with fever. (C) Cheyne-Stokes respiratory pattern is most often associated with increased intracranial pressure secondary to changes in pressure in the cerebral and cerebellar areas. (D) Biot's breathing is most frequently associated with spinal meningitis.

• Question 563:

  After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis?

  A. One centimeter below the ischial spines

  B. One centimeter above the ischial spines

  C. Has not entered the pelvic inlet yet

  D. Located in the pelvic outlet

  Correct Answer: B

  (A) The ischial spines are located on both sides of the midpelvis. These spines mark the diameter of the narrowest part of the pelvis that the fetus will encounter. They are not sharp protrusions that will harm the fetus. Station refers to the relationship between the ischial spines in the pelvis and the fetus. The ischial spines are designated at 0 station. If the presenting part of the fetus is located above the ischial spines, a negative number is assigned, noting the number of centimeters above the ischial spines. Therefore, 1 centimeter below the ischial spines is designated as +1 station. (B) See explanation in A. One centimeter above the ischial spines is designated as +1 station. (C) The pelvic inlet is the first part of the pelvis that the fetus enters in routine delivery. The midpelvis is the second part of the pelvis to be entered by the fetus. The ischial spines are located on both sides of the midpelvis. (D) The pelvic outlet is the last part of the pelvis that the fetus will enter. When the fetus reaches this part of the pelvis, birth is near.

• Question 564:

  A 70-year-old client has pneumonia and has just had a respiratory arrest. He has just been intubated with an 8- mm endotracheal tube. During auscultation of his chest, breath sounds were found to be absent on the left side. The nurse identifies the most likely cause of this as:

  A. Inappropriate endotracheal tube size

  B. Left-sided pneumothorax

  C. Right mainstem bronchus intubation

  D. Pneumonia

  Correct Answer: C

  (A) Appropriate endotracheal tube sizes for adults range from 7.0?.5 mm. (B) Pneumothorax could be indicated by an absence of breath sounds on the affected side. However, in a recently intubated client, the first priority would be to consider tube malposition. (C) During intubation, the right mainstem bronchus can be inadvertently entered if the endotracheal tube is inserted too far. Left mainstem bronchus intubation almost never occurs because of the angle of the left mainstem bronchus. (D) Breath sounds for someone with pneumonia may be decreased over the areas of consolidation. However, in a recently intubated client, the first priority would be to consider tube malposition.

• Question 565:

  After the fetal activity test (nonstress test) is completed, the RN is looking at the test results on the monitor strip. The RN observes that the fetal heart accelerated 5 beats/min with each fetal movement. The accelerations lasted 15 seconds and occurred 3 times during the 20- minute test. The RN knows that these test results will be interpreted as:

  A. A reactive test

  B. A nonreactive test

  C. An unsatisfactory test

  D. A negative test

  Correct Answer: A

  (A) A nonstress test that shows at least two accelerations of the fetal heart rate of 15 bpm with fetal activity, lasting 15 seconds over a 20-minute period. (B) Reactive criteria are not met. The accelerations of the fetal heart rate are not at least 15 bpm and do not last 15 seconds. This could mean fetal well-being is compromised. Usually a contraction stress test is ordered if the nonstress test results are negative. (C) An unsatisfactory test means the data cannot be interpreted, or there was inadequate fetal activity. If this happens, usually the test is ordered to be done at a later date. (D) A negative test is a term used to describe the results of a contraction stress test.

• Question 566:

  The nurse instructs a client on the difference between true labor and false labor. The nurse explains, "In true labor:

  A. Uterine contractions will weaken with walking."

  B. Uterine contractions will strengthen with walking."

  C. The cervix does not dilate."

  D. The fetus does not descend."

  Correct Answer: B

  (A) Uterine contractions increase with activity. (B) Walking will increase the strength and regularity of uterine contractions in true labor. (C) Uterine contractions that are strong and regular facilitate cervical dilation. (D) Regular, strong uterine contractions, as in true labor, result in fetal descent.

• Question 567:

  At 32 weeks' gestation, a client is scheduled for a fetal activity test (nonstress test). She calls the clinic and asks the RN, "How do I prepare for the test I am scheduled for?" The RN will most likely inform her of the following instructions to help prepare her for the test:

  A. "You need to know that an IV is always started before the test."

  B. "You will need to drink 6 to 8 glasses of water to fill your bladder."

  C. "Do not eat any food or drink any liquids before the test is started."

  D. "You will have to remain as still as you possibly can."

  Correct Answer: D

  (A) An IV line is not started in a nonstress test, because this test is used as an indicator of fetal well-being. This test measures fetal activity and heart rate acceleration. (B) The bladder does not have to be full prior to this test. It is not a sonogram test where a full bladder enables other structures to be scanned. (C) It has been proved that eating or drinking liquids prior to the test can assist in increasing fetal activity. (D) Any maternal activity will interfere with the results of the test.

• Question 568:

  A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurse instructs the client to:

  A. Clean the sutured laceration twice a day with povidone- iodine (Betadine)

  B. Remove his scalp sutures after 5 days

  C. Return to the hospital immediately if he develops confusion, nausea, or vomiting

  D. Take meperidine 50 mg po q4?h prn for headache

  Correct Answer: C

  (A) Povidone-iodine is very irritating to skin and should not be routinely used. (B) Sutures should not be removed by the client. (C) Confusion, nausea, vomiting, and behavioral changes may indicate increasing intracranial pressure as a result of intracerebral bleeding. (D) Use of a narcotic opiate such as meperidine is not recommended in clients with a possible head injury because it may produce sedation, pupil changes, euphoria, and respiratory depression, which may mask the signs of increasing intracranial pressure.

• Question 569:

  A young boy tells the nurse, "I don't like my Dad to kiss or hug my Mom. I love my Mom and want to marry her." The nurse recognizes this stage of growth and development as:

  A. Electra complex

  B. Oedipus complex

  C. Superego

  D. Ego

  Correct Answer: B

  (A) The Electra complex is the erotic attachment of the female child to the father. (B) The Oedipus complex is characterized by jealousy toward the parent of the same sex and erotic attachment to the parent of the opposite sex. (C) The superego as described by Freud is the part of personality that is associated with internalized parental and societal control. (D) The ego as described by Freud is the part of personality that is associated with reality assessment.

• Question 570:

  A 52-year-old client's abdominal aortic aneurysm ruptured. She received rapid massive blood transfusions for bleeding. One potential complication of blood administration for which she is especially at risk is:

  A. Air embolus

  B. Circulatory overload

  C. Hypocalcemia

  D. Hypokalemia

  Correct Answer: C

  (A) Air embolism is a potential complication of blood administration, but it is fairly rare and can be prevented by using good IV technique. (B) Circulatory overload is a potential complication of blood administration, but because this client is actively bleeding, she is not at high risk for overload. (C) Hypocalcemia is a potential complication of blood administration that occurs in situations where massive transfusion has occurred over a short period of time. It occurs because the citrate in stored blood binds with the client's calcium. Another potential complication for which this client is especially at risk is hypothermia, which can be prevented by using a blood warmer to administer the blood. (D) Hypokalemia is not a complication of blood administration.