NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 591:

  A 55-year-old man has recently been diagnosed with hypertension. His physician orders a low-sodium diet for him. When he asks, "What does salt have to do with high blood pressure?'' the nurse's initial response would be:

  A. "The reason is not known why hypertension is associated with a high-salt diet."

  B. "Large amounts of salt in your diet can cause you to retain fluid, which increases your blood pressure."

  C. "Salt affects your blood vessels and causes your blood pressure to be high."

  D. "Salt is needed to maintain blood pressure, but too much causes hypertension."

  Correct Answer: B

  (A) This response is untrue. (B) Decreasing salt intake reduces fluid retention and decreases blood pressure. (C) Salt does not have an effect on the blood vessels themselves, but on fluid retention, which accompanies salt intake. (D) This response is untrue.

• Question 592:

  At 16 weeks' gestation, a pregnant client is admitted to the maternity unit to have a McDonald procedure (cerclage) done. She tells the RN who is admitting her to the unit that her physician had explained what this procedure was, but that she did not understand. The RN explains to the client that the purpose for this procedure is to:

  A. Reinforce an incompetent cervix

  B. Repair the amniotic sac

  C. Evaluate cephalopelvic disproportion

  D. Dilate the cervix

  Correct Answer: A

  (A) The treatment most commonly uses the Shirodkar-Barter procedure (McDonald procedure) or cerclage to enforce the weakened cervix by encircling it with a suture at the level of the internal os. (B) There is no known procedure that is used to repair the amniotic sac. (C) Cephalopelvic disproportion is evaluated later in pregnancy. It is not related to this procedure. (D) No procedure is done to dilate the cervix at 16 weeks' gestation unless the pregnancy is to be terminated.

• Question 593:

  A client is in active labor and has been admitted to the labor and delivery unit. The RN has just done a sterile vaginal exam and determines that the client is dilated 5 cm, effaced 85%, and the fetus's head is at 0 station. She asks if she could have a lumbar epidural now. The epidural is started, and the anesthetic agent used is bupivacaine (Marcaine). After the client has received her lumbar epidural, it is important for the RN to monitor her for which of the following side effects:

  A. Hypertension

  B. Hypotension

  C. Hypoglycemia

  D. Hyperglycemia

  Correct Answer: B

  (A) The medication bupivacaine will cause vasodilation in the vascular system, and this does not result in elevation of the ma-ternal blood pressure. (B) The medication bupivacaine will cause vasodilation in the vascular system, and this will result in lowering the maternal blood pressure. (C) Bupivacaine does not interfere with the functioning of the endocrine system. (D) Bupivacaine does not interfere with the functioning of the endocrine system.

• Question 594:

  A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?

  A. Bulging fontanelles

  B. Seizure

  C. Headache

  D. Ataxia

  Correct Answer: C

  (A) Bulging fontanelles are a symptom of increased intracranial pressure in infants. (B) Seizure is a late sign of increased intracranial pressure. (C) Headache is a very early symptom of increased intracranial pressure in the child. (D) Ataxia is a late sign of increased intracranial pressure.

• Question 595:

  A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:

  A. Prevent air from entering the pleural space

  B. Prevent fluid from entering the pleural space

  C. Provide a means to measure chest drainage

  D. Provide an indicator of respiratory effort

  Correct Answer: A

  (A) A chest tube extends from the pleural space to a collection device. The tube is placed below the surface of the saline so that air cannot enter the pleural space. (B) Fluid may enter the pleural space as a result of injury or disease. A chest tube may drain fluid from the pleural space, but the water seal is not involved in this. (C) Chest drainage should be measured, but the water seal is not involved in this. (D) Fluctuations in the tube in the water-sealed bottle will give an indication of respiratory effort, but that is not the purpose of the water seal.

• Question 596:

  A client has consented to have a central venous catheter placed. The best position in which to place the client is the Trendelenburg position. The reason is that the Trendelenburg position:

  A. Allows the physician to visualize the subclavian vein

  B. Reduces the possibility of air embolism

  C. Reduces the possibility of hematoma formation

  D. Makes the procedure more comfortable for the client

  Correct Answer: B

  (A) The subclavian vein is not visible during central line insertion regardless of the client's position. (B) The Trendelenburg position reduces the possibility of air embolism because it places slight positive pressure on the central veins. It also distends the veins, and distention facilitates insertion. (C) This response is untrue; it has no effect on hematoma formation. (D) This position is not necessarily more comfortable for the client, and many clients, especially those who may be short of breath, may find the position uncomfortable and difficult to maintain.

• Question 597:

  Nursing care of the infant prior to surgical closure of a meningomyelocele would include:

  A. Cover sac with dry sterile dressing

  B. Cover sac with saline-soaked sterile dressing

  C. Do not apply dressing; keep sac open to air

  D. Aspirate any fluid from sac

  Correct Answer: B

  (A) A dry, sterile dressing would adhere to the sac, causing tissue damage. (B) A saline- soaked sterile dressing protects the sac from contamination by air and prevents drying. (C) A sac open to air causes drying and potential for contamination. (D) This intervention is not an independent nursing action.

• Question 598:

  A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician?

  A. pH 7.39

  B. White blood cell (WBC) count 10,000 WBCs/mm3

  C. Hematocrit 60%

  D. Bleeding time of 4 minutes

  Correct Answer: C

  (A) Normal pH of arterial blood gases for an infant is 7.35?.45. (B) Normal white blood cell count in an infant is 6,000?7,500 WBCs/mm3. (C) Normal hematocrit in infant is 28%?2%. A 60% hematocrit may indicate polycythemia, a common complication of cyanotic heart disease. (D) Normal bleeding time is 2? minutes.

• Question 599:

  A physician's order reads: Administer furosemide oral solution 0.5 mL stat. The furosemide bottle dosage is 10 mg/mL. What dosage of furosemide should the nurse give to this infant?

  A. 5 mg

  B. 0.5 mg

  C. 0.05 mg

  D. 20 mg

  Correct Answer: A

  (A) 1 mg = 0.1 mL, then 0.5 mL X= 55 mg. (B) Thisanswer is a miscalculation. (C) This answer is a miscalculation. (D) This answer is a miscalculation.

• Question 600:

  Following a vaginal delivery, the postpartum nurse should observe for:

  A. Dystocia, kraurosis

  B. Chadwick's sign

  C. Fatigue, hemorrhoids

  D. Hemorrhage and infection

  Correct Answer: D

  (A) Dystocia is difficult labor. The delivery has occurred. Kraurosis is atrophy and dryness of skin and any mucous membrane (vulva). (B) Chadwick's sign is a bluish color of vaginal mucosa suggestive of pregnancy. (C) Fatigue is a common symptom in the postpartal period. Hemorrhoids may occur with pregnancy. (D) Hemorrhage and infection are potential complications of vaginal delivery. Hemorrhage may result from retained placental fragments or soft uterus. Infection may occur from the introduction of organisms into the uterus during the delivery.