NCLEX NCLEX-RN Online Practice Questions and Exam Preparation

NCLEX NCLEX-RN Online Questions & Answers

• Question 611:

  The nurse writes the following nursing diagnosis for a client in acute renal failure--Impaired gas exchange related to:

  A. Decreased red blood cell production
  B. Increased levels of vitamin D
  C. Increased red blood cell production
  D. Decreased production of renin
  A. Decreased red blood cell production

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  (A) Red blood cell production is impaired in renal failure owing to impaired erythropoietin production. This causes a decrease in the delivery of oxygen to the tissue and impairs gas exchange. (B) The conversion of vitamin D to its physiologically active form is impaired in renal failure. (C) In renal failure, a decrease in red blood cell production occurs owing to an impaired production of erythropoietin, leading to impaired gas exchange at the cellular level. (D) The decreased production of renin in renal failure causes an increased production of aldosterone causing sodium and water retention.

• Question 612:

  A client with a head injury asks why he cannot have something for his headache. The nurse's response is based on the understanding that analgesics could:

  A. Counteract the effects of antibiotics
  B. Elevate the blood pressure
  C. Mask symptoms of increasing intracranial pressure
  D. Stimulate the central nervous system
  C. Mask symptoms of increasing intracranial pressure

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  (A) Analgesic medication does not counteract the effects of antibiotics. (B) Analgesic medication may lower blood pressure elevated due to anxiety. (C) Analgesic medication, especially CNS depressants, is not given if there is danger of increasing ICP, because neurological changes may not be apparent. Also, further depression of the CNS is contraindicated. (D) Analgesics do not stimulate the CNS.

• Question 613:

  The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?

  A. Pulse rate of 50?0 bpm by her third postpartum day
  B. Diuresis by her second or third postpartum day
  C. Vaginal discharge or rubra, serosa, then rubra
  D. Diaphoresis by her third postpartum day
  C. Vaginal discharge or rubra, serosa, then rubra

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  (A) Bradycardia is an expected assessment during the postpartum period. (B) Diuresis can occur during labor and the postpartum period and is an expected physiological adaptation. (C) A return of rubra after the serosa period may indicate a postpartal complication. (D) Diaphoresis, especially at night, is an expected physiological change and does not indicate an infectious process. Bradycardia, diuresis, and diaphoresis are normal postpartum physiological responses to adjust

  the cardiac output and blood volume to the nonpregnant state.

• Question 614:

  A 35-year-old client is receiving psychopharmacological treatment of his major depression with tranylcypromine sulfate (Parnate), a monoamine oxidase (MAO) inhibitor. The nurse teaches the client that while he is taking this type of antidepressant, he needs to restrict his dietary intake of:

  A. Potassium-rich foods
  B. Tryptophan
  C. Tyramine
  D. Saturated fats
  C. Tyramine

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  (A) The client may need to avoid some potassium-rich foods (such as bananas, raisins, etc.). However, this is not because of the potassium content of these foods. (B) Tryptophan is an essential amino acid that is present in high concentrations in animal and fish protein. (C) The client will need to watch his dietary intake of tyramine. Tyramine is a by-product of the conversion of tyrosine to epinephrine. Tyramine is found in a variety of foods and beverages, ranging from aged cheese to caffeine drinks. Ingestion of tyramine-rich foods while taking a MAO inhibitor may lead to an increase in blood pressure and/or a life- threatening hypertensive crisis. (D) To maintain a healthy lifestyle, restriction of dietary saturated fats is advisable.

• Question 615:

  A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy:

  A. Prevents the development of ophthalmia neonatorum
  B. Assists the baby's clotting mechanism
  C. Breaks down bilirubin in the skin into substances that can be excreted in stool or urine
  D. Increases levels of unconjugated bilirubin, thereby preventing kernicterus (brain damage)
  C. Breaks down bilirubin in the skin into substances that can be excreted in stool or urine

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  (A) The instillation of erythromycin ophthalmic preparation, not phototherapy, prevents ophthalmia neonatorum. (B) The administration of vitamin K (AquaMEPHYTON) assists the infant's clotting mechanism. (C) Excessive bilirubin accumulates when the infant's liver cannothandle the increased load caused by the breakdown of red blood cells postnatally. This excessive bilirubin seeps out of the blood and into the tissues, staining them yellow. Phototherapy accelerates the removal of bilirubin from the skin by breaking it down into substances that can be excreted in stool or urine. (D) Phototherapy decreases levels of unconjugated bilirubin, thereby preventing kernicterus.

• Question 616:

  A primigravida is at term. The nurse can recognize the second stage of labor by the client's desire to:

  A. Push during contractions
  B. Hyperventilate during contractions
  C. Walk between contractions
  D. Relax during contractions
  A. Push during contractions

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  (A) The second stage of labor is characterized by uterine contractions, which cause the client to bear down. (B) Slow, deep, rhythmic breathing facilitates the laboring process. Hyperventilation is abnormal breathing resulting from loss of pain control. (C) The client should remain on bed rest during labor. (D) Contractions result in discomfort.

• Question 617:

  A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is being given digoxin. Prior to administering the medication, the nurse should:

  A. Not give the digoxin if the pulse is_60
  B. Not give the digoxin if the pulse is_100
  C. Take the apical pulse for a full minute
  D. Monitor for visual disturbances, a side effect of digoxin
  C. Take the apical pulse for a full minute

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  (A) Digoxin should not be given to adults with an apical pulse < 60 bpm. (B) Digoxin should be given to children with an apical pulse > 100 bpm. With a pulse < 100 bpm, the medication should be withheld and the physician notified. (C) Prior to digoxin administration in both children and adults, an apical pulse should be taken for 1 full minute. Aside from the rate per minute, the nurse should note any sudden increase or decrease in heart rate, irregular rhythm, or regularization of a chronic irregular heart rhythm. (D) Early indications of digoxin toxicity, such as visual disturbances, occur rarely as initial signs in children.

• Question 618:

  The parents of a 9-year-old child with acute lymphocytic leukemia expressed concern about his alopecia from cranial irradiation. The nurse explains that: A. Alopecia is an unavoidable side effect.

  B. There are several wig makers for children.
  C. Most children select a favorite hat to protect their heads.
  D. His hair will grow back in a few months.
  D. His hair will grow back in a few months.

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  (A) Alopecia has occurred, and knowing it is a side effect does not address their concern. (B) Although true, it does not give them hope for the future. (C) Although true, it does not provide them with information of the temporary nature of the situation. (D) Knowing the hair will grow back provides comfort that the alopecia is temporary.

• Question 619:

  A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?

  A. Ineffective airway clearance related to immobility, ineffective cough, and decreased level of consciousness
  B. Altered cerebral tissue perfusion related to pathophysiological changes that decrease blood flow
  C. Potential for injury related to impaired mobility and seizures
  D. Impaired verbal communication related to aphasia
  A. Ineffective airway clearance related to immobility, ineffective cough, and decreased level of consciousness

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  (A) An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. (B) Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is secondary to maintenance of an effective airway. (C) While prevention of injury is important, it is secondary to maintaining an effective airway and cerebral tissue perfusion. (D) Impaired verbal communication is not life threatening in the acute phase of recovery. It is the lowest priority of the nursing diagnoses listed.

• Question 620:

  A client is pregnant for the fourth time and has had three normal vaginal deliveries. She is in active labor and fully dilated. Suddenly she calls, "Nurse, the baby is coming." As the nurse responds to her call, which one of the following observations should the nurse make first?

  A. Inspect the perineum.
  B. Time the contractions.
  C. Prepare a sterile area for delivery.
  D. Auscultate for fetal heart rate (FHR).
  A. Inspect the perineum.

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  (A) The nurse must assess the labor status to determine if birth is imminent. The nurse may note perineal bulging, crowning, or birth of the head to ascertain labor status. (B) Assessing uterine contractions is one intervention to ascertain labor status. Based on the client's cry, it is not the intervention of choice. (C) If delivery of the infant is imminent, preparing a clean or sterile area for delivery is appropriate, but labor status must be established, whether delivery is imminent, by perineal assessment. (D) Assessing FHR is one intervention to ascertain fetal well-being. Based on the client's cry, this is not the intervention of choice.