NCLEX NCLEX-RN Online Practice Questions and Exam Preparation

NCLEX NCLEX-RN Online Questions & Answers

• Question 601:

  A term neonate has experienced no distress at birth and has an Apgar score of 9. Her mother has asked to breastfeed her following delivery. Immediately after birth, the neonate was most susceptible to heat loss. The most appropriate intervention to conserve heat loss and promote bonding is to:

  A. Place her under the radiant warmer
  B. Dry her with blankets
  C. Place her to her mother's breast
  D. Place her on a heated pad
  C. Place her to her mother's breast

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  (A) A radiant warmer maintains an optimal thermal environment by use of a thermal skin sensor taped to the infant. The warmer limits parental attachment, so, although appropriate, it is not an intervention that promotes infant attachment. (B) Warmed blankets prevent heat loss in the neonate by conduction. In addition, tactile stimuli promote crying and lung expansion. This intervention does not promote attachment, however. (C) Skin-to- skin contact is an effective way to conserve heat after delivery and promotes parental attachment following birth in the healthy term infant. The first period of reactivity lasts approximately 30 minutes following birth. A strong sucking reflex and an active, awake newborn characterize this period. (D) Surfaces of objects warmer than the infant promote overheating by conduction, and neonatal hyperthermia may result.

• Question 602:

  In working with mental health clients who are prescribed medication that must be taken on a routine basis, it is important for education to begin when the drug therapy is initiated. One of the first steps in the teaching process is to:

  A. Explain the side effects of the medication
  B. Discuss the danger of overmedication
  C. Distribute written material to supplement verbal instructions
  D. Explore the client's perception regarding medication therapy
  D. Explore the client's perception regarding medication therapy

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  (A, B, C) The nurse must first obtain information regarding the client's perception of the medication regimen. (D) The first step in the teaching process is to determine the client's perception.

• Question 603:

  Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who suffered partial- and fullthickness burns to 25% of her body?

  A. Urine output
  B. Edema
  C. Hypertension
  D. Bulging fontanelle
  A. Urine output

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  (A) Urinary output is a reliable indicator of renal perfusion, which in turn indicates that fluid resuscitation is adequate. IV fluids are adjusted based on the urinary output of the child during fluid resuscitation. (B) Edema is an indication of increased capillary permeability following a burn injury. (C) Hypertension is an indicator of fluid volume excess. (D) Fontanelles close by 18 months of age.

• Question 604:

  The nurse is in the hallway and one of the visitors faints. The nurse should:

  A. Sit the victim up and lightly slap his face
  B. Elevate the victim's legs
  C. Apply a cool cloth to the victim's neck and forehead until he recovers
  D. Sit the victim up and place the head between the knees
  B. Elevate the victim's legs

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  (A) Sitting the client up defeats the goal of re-establishing cerebral blood flow. (B) Elevating the legs anatomically redirects blood flow to the cerebral area. (C) This strategy is a nice general comfort measure after the victim has regained consciousness. (D) This strategy is not as effective a strategy in helping the client to regain consciousness as elevating the legs.

• Question 605:

  The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 1? hours if needed. The most likely rationale for this order is:

  A. The client will settle down more quickly if he thinks the staff is medicating him
  B. The medication will sedate the client until the physician arrives
  C. Haloperidol is a minor tranquilizer and will not oversedate the client
  D. Rapid neuroleptization is the most effective approach to care for the violent or potentially violent client
  D. Rapid neuroleptization is the most effective approach to care for the violent or potentially violent client

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  (A) If the client could think logically, he would not be paranoid. In fact, he is probably suspicious of the staff, too. Newly admitted clients frequently experience high levels of anxiety, which can contribute to delusions. (B) The goal of pharmacological intervention is to calm the client and assist with reality-based thinking, not to sedate him. (C) Haloperidol is a neuroleptic and antipsychotic drug, not a minor tranquilizer. (D) Haloperidol is a high- potency neuroleptic and first-line choice for rapid neuroleptization, with low potential for sedation.

• Question 606:

  Morphine sulfate 4 mg IV push q2h prn for chest pain was ordered for a client in the emergency room with severe chest pain. The nurse administering the morphine sulfate knows which of the following therapeutic actions is related to the morphine sulfate?

  A. Increased level of consciousness
  B. Increased rate and depth of respirations
  C. Increased peripheral vasodilation
  D. Increased perception of pain
  C. Increased peripheral vasodilation

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  (A) Morphine sulfate, a narcotic analgesic, causes sedation and a decrease in level of consciousness. (B) The side effects of morphine sulfate include respiratory depression. (C) Morphine sulfate causes peripheral vasodilation, which decreases afterload, producing a decrease in the myocardial workload. (D) Morphine sulfate alters the perception of pain through an unclear mechanism. This alteration promotes pain relief.

• Question 607:

  Which of the following blood values would require further nursing action in a newborn who is 4 hours old?

  A. Hemoglobin 17.2 g/dL
  B. Platelets 250,000/mm3
  C. Serum glucose 30 mg/dL
  D. White blood cells 18,000/mm3
  C. Serum glucose 30 mg/dL

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  (A) The normal range for hemoglobin in the newborn is 17?9 g/dL; 17.2 g/dL is within normal limits. (B) A normal value range for platelets in the newborn is 150,000?00,000 mm3; 250,000/mm3 is within normal range. (C) A serum glucose of 30 mg/dL in the first 72 hours of life is indicative of hypoglycemia and warrants further intervention. (D) On the day of birth, a white blood cell count of 18,000?0,000/mm3 is normal in the newborn.

• Question 608:

  A client with cystic fibrosis exhibits activity intolerance related to the pulmonary problems associated with his disease. However, he needs to be encouraged to participate in daily physical exercise. The ultimate aim of exercise is to:

  A. Create a sense of well-being and self-worth
  B. Help him overcome respiratory infections
  C. Establish an effective, habitual breathing pattern
  D. Promote normal growth and development
  C. Establish an effective, habitual breathing pattern

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  (A) Regular exercise does promote a sense of well-being and selfworth, but this is not the ultimate goal of exercise for this client. (B) Regular chest physiotherapy, not exercise per se, helps to prevent respiratory infections. (C) Physical exercise is an important adjunct to chest physiotherapy. It stimulates mucus secretion, promotes a feeling of well-being, and helps to establish a habitual breathing pattern. (D) Along with adequate nutrition and minimization of pulmonary complications, exercise does help promote normal growth and development. However, exercise is promoted primarily to help establish a habitual breathing pattern.

• Question 609:

  A 26-year-old client is in a treatment center for aprazolam (Xanax) abuse and continues to manifest moderate levels of anxiety 3 weeks into the rehabilitation program, often requesting medication for "his nerves." Included in the client's plan of care is to identify alternate methods of coping with stress and anxiety other than use of medication. After intervening with assistance in stress reduction techniques, identifying feelings and past coping, the nurse evaluates the outcome as being met if:

  A. Client promises that he will not abuse aprazolam after discharge
  B. Client demonstrates use of exercise or physical activity to handle nervous energy following conflicts of everyday life
  C. Client is able to verbalize effects of substance abuse on the body
  D. Client has remained substance free during hospitalization and is discharged
  B. Client demonstrates use of exercise or physical activity to handle nervous energy following conflicts of everyday life

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  (A) This client response does not address stress reduction techniques. Verbal response focuses only on the problem. (B) Exercise or physical activity is a common strategy or coping technique used to reduce stress and anxiety. (C) Verbalizing effects of substance abuse on the body may help with insight and break through denial, but it is not a strategy to reduce anxiety. (D)Remaining substance-free does indicate motivation to change lifestyle of substance abuse or dependence, and it is not a stress reduction strategy in itself.

• Question 610:

  To facilitate maximum air exchange, the nurse should position the client in:

  A. High Fowler
  B. Orthopneic
  C. Prone
  D. Flat-supine
  B. Orthopneic

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  (A) The high Fowler position does increase air exchange, but not to the extent of orthopneic position. (B) The orthopneic position is a sitting position that allows maximum lung expansion. (C) The prone position places pressure on diaphragm and does not promote maximum air exchange. (D) The flat-supine position places pressure on diaphragm by abdominal organs and does not promote maximum air exchange.