NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 581:

  A laboring client presents with a prolapsed cord. The nurse should immediately place the client in what position?

  A. Reverse Trendelenburg

  B. Fowler's

  C. Trendelenburg

  D. Sims'

  Correct Answer: C

  (A) Reverse Trendelenburg position increases pressure on the perineum. This position will not relieve cord pressure. (B) Fowler's position increases perineal pressure. Cord pressure would not be relieved. (C) Trendelenburg position will decrease perineal pressure. Cord compression will be decreased and increase in fetal blood flow occurs. (D) Sims' position does not relieve pressure on cord or perineum.

• Question 582:

  On a mother's 2nd postpartum day after having a vaginal delivery, the RN is preparing to assess her perineum and anus as part of her daily assessment. The best position for the client to be placed in for this assessment is:

  A. Sims'

  B. Fowler's

  C. Prone

  D. Any position that the RN chooses

  Correct Answer: A

  (A) The Sims' position is the best position for assessment of the perineum and anus. The top leg is placed over the bottom leg, and the RN raises the upper buttocks to fully expose the perineum and anus. (B) Fowler's position is a sitting position, and the perineum and anus would not be exposed. (C) The prone position would have the mother on her back, and her perineum and anus would not be exposed. (D) The position of choice should always be the Sims'.

• Question 583:

  A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client's fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process:

  A. Decreases the overall time of the labor process

  B. Prolongs the client's first stage of labor

  C. Decreases the time of the client's first stage of labor

  D. Prolongs the client's third stage of labor

  Correct Answer: B

  (A) Posterior position causes a larger diameter of the fetal head to enter the pelvis than an anterior position. Pressure on the sacral nerves is increased, and it takes the fetus a longer time to enter the pelvic inlet. (B) This position will prolong the first stage of labor. When the larger diameter of the fetal head enters the pelvis first, it will have a more difficult time accommodating to the pelvis; therefore, it will take a longer time for the fetus to move through the pelvis. (C) It will increase the time of labor because the larger diameter of the fetal head will have a more difficult time accommodating to the pelvic inlet and thus will move through the pelvis slower. (D) In the third stage of labor the placenta is delivered; therefore, the infant has been delivered.

• Question 584:

  A 79-year-old client with Alzheimer's disease is exhibiting significant memory impairment, cognitive impairment, extremely impaired judgment in social situations, and agitation when placed in a new situation or around unfamiliar people. The nurse should include the following strategy in the client's care:

  A. Maintain routines and usual structure and adhere to schedules.

  B. Encourage the client to attend all structured activities on the unit, whether she wants to or not.

  C. Ask the client to go to an activity once. If she gives no response right away, change the question around, asking the same thing.

  D. Give the client two or three choices to decide what she wants to do.

  Correct Answer: A

  (A) Alzheimer's clients cope poorly with changes in routine because of memory deficits. Schedule changes cause confusion and frustration, whereas adhering to schedules is helpful and supports orientation. (B) Insisting that the client go to all unit activities may antagonize her and increase her agitation because of cognitive impairments. It may be better to allow the client time for calming down or distraction rather than to insist that she attend every activity. (C) When repeating a question, allow time first for a response; then use the same words the second time to avoid further confusion. (D) The nurse should avoid giving several choices at once. Cognitively impaired clients will become more frustrated with making decisions.

• Question 585:

  At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her contractions are every 5 minutes and last 60 seconds, her cervix is closed, and the suture placed around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is still intact. She is very concerned about delivering prematurely. She asks the RN, "What is the greatest risk to my baby if it is born prematurely?" The RN's answer should be:

  A. Hyperglycemia

  B. Hypoglycemia

  C. Lack of development of the intestines

  D. Lack of development of the lungs

  Correct Answer: D

  (A) Any infant would be at risk for hyperglycemia because the infant's liver is missing the islets of Langerhans, which secrete insulin to break down glucose for cellular use. Prematurity is not an added risk for hyperglycemia. (B) Both premature and mature infants can be at risk for hypoglycemia if their mother had gestational diabetes during pregnancy or entered the pregnancy with diabetes mellitus. These infants are exposed to high levels of maternal glucose while in utero, which causes the islets of Langerhans in the infant's liver to produce insulin. After birth when the umbilical cord is severed, the generous amount of maternal blood glucose is eliminated; however, there is continued islet cell hyperactivity in the infant's liver, which can lead to excessive insulin levels and depleted blood glucose. (C) Mature infants are born with an immature GI system. The nervous control of the stomach is incomplete at birth, salivary glands are immature at birth, and the intestinal tract is sterile. This is not the greatest risk to the premature infant. (D) Infants born before 37 weeks' gestation are at greatest risk for an insufficient amount of surfactant in the alveoli system of the lungs. Surfactant helps to prevent lung collapse and ensures stability of the respiratory system so that the infant can maintain his own respirations once the umbilical cord is severed at birth.

• Question 586:

  A male client has asthma and his physician has prescribed beclomethasone (Vanceril) 3 puffs tid in addition to his other medications. After taking his beclomethasone, the client should be instructed to:

  A. Clean his inhaler with warm water and soak it in a 10% bleach solution

  B. Drink a glass of water

  C. Sit and rest

  D. Use his bronchodilator inhaler

  Correct Answer: B

  (A) Inhalers should be cleaned once a day. They should be taken apart, washed in warm water, and dried according to manufacturer's instructions. Soaking in bleach is inappropriate. (B) A common side effect of inhaled steroid preparations is oral candidal infection. This can be prevented by drinking a glass of water or gargling after using a steroid inhaler. (C) There is nothing wrong with sitting and resting after using a steroid inhaler, but it is not necessary. (D) If a person is using a steroid inhaler as well as a bronchodilator inhaler, the bronchodilator shouldalways be used first. The reason for this is that the bronchodilator opens up the person's airways so that when the steroid inhaler is used next, there will be better distribution of medication.

• Question 587:

  A client was prescribed a major tranquilizer 2 months ago. One month ago she was placed on benztropine (Cogentin). What would indicate that benztropine therapy is effective?

  A. Smooth, coordinated voluntary movement

  B. Tremors

  C. Rigidity

  D. Muscle weakness

  Correct Answer: A

  (A)

  Benztropine is prescribed to decrease or alleviate extrapyramidal side effects of major tranquilizers. Smooth, coordinated voluntary movement indicates minimal extrapyramidal side effects. (B) Tremors are an extrapyramidal side effect.

  (C)

  Rigidity is an extrapyramidal side effect. (D) Muscle weakness is an extrapyramidal side effect.

• Question 588:

  A schizophrenic is admitted to the psychiatric unit. What affect would the nurse expect to observe?

  A. Anger

  B. Apathy and flatness

  C. Smiling

  D. Hostility

  Correct Answer: B

  (A) Anger is an emotion that is not necessarily present in schizophrenia. (B) Lack of response to or involvement with environment and distancing are characteristic of schizophrenia. (C) Euphoria is more characteristic of manic-depressive disorder (bipolar disorder). (D) Hostility is an emotion that is not necessarily present in schizophrenia.

• Question 589:

  A 1000-mL dose of D5W 12 normal saline is to be infused in 8 hours. The drop factor for the tubing is 60 gtt/min. How many drops per minute should the nurse administer?

  A. 75 gtt/min

  B. 100 gtt/min

  C. 125 gtt/min

  D. 150 gtt/min

  Correct Answer: C

  (A) This answer is a miscalculation. (B) This answer is a miscalculation. (C)125 gtt/min. (D) This answer is a miscalculation.

• Question 590:

  A burn victim's immunization history is assessed by the nurse. Which immunization is of priority concern?

  A. Oral poliovirus vaccine

  B. Inactivated poliovirus vaccine

  C. Tetanus toxoid

  D. Hepatitis B vaccine

  Correct Answer: C

  (A) Oral poliovirus vaccine is given to prevent polio. Polio is transmitted by direct contact with an infected person. (B) Inactivated poliovirus vaccine is given to adults and immunosuppressed individuals. Polio is transmitted by direct contact with an infected person. (C) Tetanus toxoid prevents tetanus. Tetanus is transmitted through contaminated wounds. (D) Hepatitis B vaccine prevents hepatitis B infection. Hepatitis B is transmitted through contact with infected blood or body fluids.