NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 571:

  A 6-year-old child is attending a pediatric clinic for a routine examination. What should the nurse assess for while conducting a vision screening?

  A. Hearing test

  B. Gait

  C. Strabismus

  D. Papilledema

  Correct Answer: C

  (A) Hearing should be assessed separately. (B) Gait should be assessed separately. Client usually remains in one place for vision screening. Gait is part of neurological assessment. (C) Strabismus is crossing of eyes or outward deviation, which may cause diplopia or ambylopia. It is easily assessed during vision screening. (D) Papilledema is assessed by an ophthalmoscopic examination, which follows vision screening. It is part of neurological assessment.

• Question 572:

  In client teaching, the nurse should emphasize that fetal damage occurs more frequently with ingestion of drugs during:

  A. First trimester

  B. Second trimester

  C. Third trimester

  D. Every trimester

  Correct Answer: A

  (A) Organogenesis occurs in the first trimester. Fetus is most susceptible to malformation during this period. (B) Organogenesis has occurred by the second trimester. (C) Fetal development is complete by this time. (D) The dangerous period for fetal damage is the first trimester, not the entire pregnancy.

• Question 573:

  A 1000-mL dose of lactated Ringer's solution is to be infused in 8 hours. The drop factor for the tubing is 10 gtt/mL. How many drops per minute should the nurse administer?

  A. 125 gtt/min

  B. 48 gtt/min

  C. 20 gtt/min

  D. 21 gtt/min

  Correct Answer: D

  (A) This answer is a miscalculation. (B) This answer is a miscalculation. (C) This answer has not been rounded off to an even number. (D) 20.8, or 21 gtt/min.

• Question 574:

  A 45-year-old male client was admitted to a chemical dependency treatment center following legal problems related to alcohol abuse. He states, "I know that alcohol is a problem for some people, but I can stop whenever I want to. I'm never sick or miss work, and no one can complain about me." During the initial assessment, the best response by the nurse would be:

  A. "The fact is you are an alcoholic or you wouldn't be here."

  B. "I understand it took strength to admit yourself to the unit, and I will do my part to help you to stay alcohol- free."

  C. "If you can stop drinking when you want to, why don't you stop?"

  D. "It's good that you can stop drinking when you want to."

  Correct Answer: B

  (A) Direct confrontation initially is nontherapeutic and may result in the client becoming frustrated and wanting to leave. (B) A positive, supportive attitude builds trust, and identifying positive strength raises self-esteem. Offering help allows the client to feel that he is not alone in dealing with problems. (C) Asking the client why or to give an explanation for his behavior puts him in a position of having to justify his behavior to the nurse. (D) Giving approval or placing a value on feelings or a behavior may limit the client's freedom to behave in a way that may displease another. This response may lead to seeking praise instead of progress.

• Question 575:

  A 70-year-old client is almost finished receiving her second unit of packed red blood cells. The client, who weighs 80 lb, has started complaining of being short of breath and now has crackles in the bases of her lungs. After slowing or stopping the transfusion, the most appropriate initial nursing action would be to:

  A. Raise the client's head and place her feet in a dependent position

  B. Notify the physician

  C. Place the client on 2 liters of O2 via nasal cannula

  D. Administer furosemide (Lasix) 20 mg IV push

  Correct Answer: A

  (A)

  Raising the client's head and placing her feet in a dependent position is an independent nursing action that can be taken to decrease venous return and to reduce pulmonary congestion. (B) Notifying the physician is an appropriate action that should be taken after the client is positioned to maximize her respiratory status. (C) Placing the client on O2may be done with a physician's order or according to an institution's standing orders; however, other actions should be taken first.

  (D)

  Furosemide 20 mg IV push is an appropriate medication for the client, but it must be ordered by her physician.

• Question 576:

  A 16-year-old client reports a weight loss of 20% of her previous weight. She has a history of food binges followed by self-induced vomiting (purging). The nurse should suspect a diagnosis of:

  A. Anorexia nervosa

  B. Anorexia hysteria

  C. Bulimia

  D. Conversion reaction

  Correct Answer: C

  (A) Anorexia nervosa is characterized by self-starvation. (B) Anorexia hysteria is not a known disease or disorder. (C) Bulimia is characterized by food binges and self-induced vomiting. (D) Conversion reaction is a defense mechanism.

• Question 577:

  A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor and delivery are the ischial spines because:

  A. Ischial spines are the narrowest diameter of the pelvis

  B. Ischial spines are the widest diameter of the pelvis

  C. They represent the inlet of birth canal

  D. They measure pelvic floor

  Correct Answer: A

  (A) The fetal descent, or station, is determined by the relationship of the presenting part to the spine. (B) Ischial spines are the narrowest measurement. (C) Ischial spines measure the pelvic outlet. (D) Pelvic floor measurement is not related to fetal descent.

• Question 578:

  What is the appropriate nursing action for a child with increased intracranial pressure?

  A. Head of bed elevated 45 degrees with child's head maintained in a neutral position

  B. Child lying flat

  C. Head turned to side

  D. Frequent visitation for stimulation

  Correct Answer: A

  (A) Elevation of head of bed and neutral head position promote drainage of cerebrospinal fluid. (B) Flat position increases intracranial pressure and impedes cerebrospinal fluid drainage. (C) Head turned to either side impedes cerebrospinal fluid drainage. (D) Child should be in a calm, quiet environment with minimal stimulation.

• Question 579:

  A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse anticipates the physician ordering:

  A. Oxytocin

  B. Magnesium sulfate (MgSO4)

  C. Ampicillin

  D. Tetracycline

  Correct Answer: C

  (A) Oxytocin is prescribed to stimulate uterine contractions. (B) MgSO4is a central nervous system depressant prescribed to prevent and control convulsions related to preeclampsia. (C) Ampicillin is a penicillin derivative with no known teratogenic effects. This is the safest antibiotic during pregnancy. (D) Tetracycline stains teeth yellow and is not as safe as ampicillin during pregnancy.

• Question 580:

  After an infant is delivered by cesarean delivery and placed on the warmer, the RN dries and assesses the infant. At 1 and 5 minutes after birth, the RN does the Apgar scoring of the infant. The RN knows that because this infant was delivered by cesarean section, he is at increased risk for having which one of the following:

  A. Cold stress

  B. Cyanosis

  C. Respiratory distress syndrome

  D. Seizures

  Correct Answer: C

  (A) The infant is placed on the warmer and dried after birth. Cold stress occurs when the infant is not dried and kept warm. (B) The fact that this infant was born by cesarean delivery does not place him at a greater risk for cyanosis than an infant delivered vaginally. Cyanosis occurs when infants cannot oxygenate their blood after the umbilical cord is severed. (C) Infants born by cesarean delivery are at a higher risk for developing respiratory distress syndrome because these infants do not pass through the pelvis, where the chest is compressed and fluid is able to escape from the lungs. (D) Cesarean-delivered infants are not at greater risk for seizures than infants delivered vaginally.