NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 601:

  At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her physician orders that an IV be started with 500 mL D5W mixed with 150 mg of ritodrine stat. The RN prepares the IV solution with the medication. The RN knows that clients receiving the medication ritodrine IV should be observed closely for which one of the following side effects:

  A. Hypoglycemia

  B. Hyperkalemia

  C. Tachycardia

  D. Increase in hematocrit and hemoglobin

  Correct Answer: C

  (A) Ritodrine is a sympathomimetic 2-adrenergic agonist that can cause an elevation of blood glucose and plasma insulin in pregnant women. Hyperglycemia can occur in women with abnormal carbohydrate metabolism because of their inability to release more insulin. (B) Hypokalemia can occur resulting from the action of the _-mimetics. It results from a displacement of the extracellular potassium into the intracellular space. (C) Ritodrine causes vasodilation of vessel walls, which can lead to hypotension. The body compensates by increasing heart rate and pulse pressure. (D) There is a lowering of serum iron resulting from the action of _-mimetics to activate hematopoiesis.

• Question 602:

  A client was admitted with rib fractures and a pneumothorax, which were sustained as a result of a motor vehicle accident. A chest tube was placed on the left side to reinflate his lung, and he was transferred to a client unit. Twenty-four hours after admission he continues to have bloody sputum, develops increasing hypoxemia, and his chest x-ray shows patchy infiltrates. The nurse analyzes these symptoms as being consistent with:

  A. Pneumonia

  B. Pulmonary contusions

  C. Pulmonary edema

  D. Tension pneumothorax

  Correct Answer: B

  (A) Pneumonia may be reflected by patchy infiltrates. In addition, fever, an increasing white blood cell count, and copious sputum production would be present. (B) Blunt chest traumacauses a bruising process in which interstitial and alveolar edema and hemorrhage occur. This is manifest by gradual deterioration over 24 hours of arterial blood gases and the continued production of bloody sputum. Patchy infiltrates are evident on chest xray 24 hours postinjury. (C) Pulmonary edema usually results from left heart failure. It is manifest by pink, frothy sputum; increasing dyspnea; tachycardia; and crackles on auscultation. (D) Tension pneumothorax is a potential complication for someone with rib fractures and a chest tube. It is manifest by diminished breath sounds on the affected side, rapidly deteriorating arterial blood gases in the presence of an open airway, and shock that is unexplained by other injuries.

• Question 603:

  A first-trimester primigravida is diagnosed with anemia.

  The nurse should suspect that this anemia is a result of:

  A. Mother's increased blood volume

  B. Mother's decreased blood volume

  C. Fetal blood volume increase

  D. Increase in iron absorption

  Correct Answer: A

  (A) Maternal blood volume increases at the end of the first trimester leading to a dilutional anemia. (B) Maternal blood volume increases. (C) Fetal blood volume is minimal in the first trimester. (D) Increased iron absorption would facilitate the manufacturing of erythrocytes and decrease anemia.

• Question 604:

  A client is 2 hours post ventriculoperitoneal shunt placement. How should the nurse position the client?

  A. Head of bed elevated 30 degrees on nonoperative side

  B. Head of bed elevated 30 degrees on operative side

  C. Bed flat on operative side

  D. Bed flat on nonoperative side

  Correct Answer: D

  (A) Elevation of head on nonoperative side would be the position for the late postoperative period. (B) Positioning on operative side puts pressure on the suture lines and on the shunt valve. Elevation of head in immediate postoperative period may cause rapid reduction of cerebrospinal fluid. (C) Placement on operative side puts pressure on the suture lines and shunt valve. (D) Flat position on nonoperative side in the immediate postoperative period prevents pressure on shunt valve and rapid reduction in cerebrospinal fluid.

• Question 605:

  A male client has been hospitalized with congestive heart failure. Medical management of heart failure focuses on improving myocardial contractility. This can be achieved by administering:

  A. Digoxin (Lanoxin) 0.25 mg po every day

  B. Furosemide (Lasix) 40 mg po every morning

  C. O22 L/min via nasal cannula

  D. Nitroglycerin (Nitrol) 1 inch topically every 4 hours

  Correct Answer: A

  (A) Digoxin is a cardiac glycoside given to clients in heart failure to improve their myocardial contractility. (B) Furosemide is a loop diuretic given to clients in heart failure to promote diuresis. (C) O2is given to clients in heart failure to increase oxygenation and to prevent or treat hypoxemia. (D) Nitroglycerin is a nitrate given to clients in heart failure to increase their cardiac output by decreasing the peripheral resistance that the left ventricle must pump against.

• Question 606:

  An elective saline abortion has been performed on a 3- week primigravida. Following the procedure, the nurse should be alert for which early side effect?

  A. Water satiety

  B. Thirst

  C. Edema

  D. Diabetes insipidus

  Correct Answer: B

  (A) If the client is experiencing water satiety, there is no more desire for water. (B) Absorption of saline into circulation rather than into amniotic sac increases serum sodium and desire for water. (C) Edema can be a late side effect caused by water intoxication. (D) Diabetes insipidus occurs as a result of deficient antidiuretic hormone.

• Question 607:

  A type I diabetic client delivers a male newborn. The newborn is 45 minutes old. What is the primary nursing goal in the nursery during the first hours for this newborn?

  A. Bonding

  B. Maintain normal blood sugar

  C. Maintain normal nutrition

  D. Monitor intake and output

  Correct Answer: B

  (A) Bonding is necessary but would not be the priority with this newborn in the nursery. (B) The infant will be at risk for hypoglycemia because of excess insulin production. (C) Normal nutrition is a goal for all newborns. (D) Monitoring intake and output is necessary but is not the most critical nursing goal.

• Question 608:

  A 67-year-old client will be undergoing a coronary arteriography in the morning. Client teaching about postprocedure nursing care should include that:

  A. Bed rest with bathroom privileges will be ordered

  B. He will be kept NPO for 8-12 hours

  C. Some oozing of blood at the arterial puncture site is normal

  D. The leg used for arterial puncture should be kept straight for 8

  Correct Answer: D

  (A) Bed rest will be ordered for 8-12 hours postprocedure. Flexing of the leg at the arterial puncture site will occur if the client gets out of bed, and this is contraindicated after arteriography. (B) The client will be able to eat as soon as he is alert enough to swallow safely and that will depend on what medications areused for sedation during the procedure. (C) Oozing at the arterial puncture site is not normal and should be closely evaluated. (D) The leg where the arterial puncture occurred must be kept straight for 8-12 hours to minimize the risk of bleeding.

• Question 609:

  The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase?

  A. Mother is concerned about her recovery.

  B. Mother calls infant by name.

  C. Mother lightly touches infant.

  D. Mother is concerned about her weight gain.

  Correct Answer: B

  (A) This observation can be made during the taking-in phase when the mother's needs are more important. (B) This observation can be made during the taking-hold phase when the mother is actively involved with herself and the infant. (C, D) This observation can be made during the taking-in phase.

• Question 610:

  Which type of insulin can be administered by a continuous IV drip?

  A. Humulin N

  B. NPH insulin

  C. Regular insulin

  D. Lente insulin

  Correct Answer: C

  (A) Humulin N cannot be administered IV. (B) NPH insulin cannot be administered IV. (C) Regular insulin is the only insulin that can be administered IV. (D) Lente insulin cannot be administered IV.