NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 621:

  A newborn infant is exhibiting signs of respiratory distress. Which of the following would the nurse recognize as the earliest clinical sign of respiratory distress?

  A. Cyanosis

  B. Increased respirations

  C. Sternal and subcostal retractions

  D. Decreased respirations

  Correct Answer: C

  (A) Cyanosis is a late clinical sign of respiratory distress. (B) Rapid respirations are normal in a newborn. (C) The newborn has to exert an extra effort for ventilation, which is accomplished by using the accessory muscles of ventilation. The diaphragm and abdominal muscles are immature and weak in the newborn. (D) Decreased respirations are a late clinical sign. In the newborn, decreased respirations precede respiratory failure.

• Question 622:

  A schizophrenic client who is experiencing thoughts of having special powers states that "I am a messenger from another planet and can rule the earth." The nurse assesses this behavior as:

  A. Ideas of reference

  B. Delusions of persecution

  C. Thought broadcasting

  D. Delusions of grandeur

  Correct Answer: D

  (A) Clients experiencing ideas of reference believe that information from the environment (e.g., the television) is referring to them. (B) Clients experiencing delusions of persecution believe that others in the environment are plotting against them. (C) Clients experiencing thought broadcasting perceive that others can hear their thoughts. (D) Clients experiencing delusions of grandeur think that they are omnipotent and have superhuman powers.

• Question 623:

  A newborn is admitted to the newborn nursery with tremors, apnea periods, and poor sucking reflex. The nurse should suspect:

  A. Central nervous system damage

  B. Hypoglycemia

  C. Hyperglycemia

  D. These are normal newborn responses to extrauterine life

  Correct Answer: B

  (A) Central nervous system damage presents as seizures, decreased arousal, and absence of newborn reflexes. (B) In a diabetic mother, the infant is exposed to high serum glucose. The fetal pancreas produces large amounts of insulin, which causes hypoglycemia after birth. (C) Hypoglycemia is a common newborn problem. Increased insulin production causes hypoglycemia, not hyperglycemia. (D) These are not normal adaptive behaviors to extrauterine life.

• Question 624:

  When planning care for the passive-aggressive client, the nurse includes the following goal:

  A. Allow the client to use humor, because this may be the only way this client can express self.

  B. Allow the client to express anger by using "I" messages, such as "I was angry when . . .," etc.

  C. Allow the client to have time away from therapeutic responsibilities.

  D. Allow the client to give excuses if he forgets to give staff information.

  Correct Answer: B

  (A) Ceasing to use humor and sarcasm is a more appropriate goal, because this client uses these behaviors covertly to express aggression instead of being open with anger. (B) Use of "I" messages demonstrates proper use of assertive behavior to express anger instead of passive-aggressive behavior. (C) Client is expected to complete share of work in therapeutic community because he has often obstructed other's efforts by failing to do his share. (D) Client has used conveniently forgetting or withholding information as a passive- aggressive behavior, which is not acceptable.

• Question 625:

  The nurse is assessing and getting a history from a client treated for depression with a monoamine oxidase (MAO) antidepressant. The most serious side effect associated with this antidepressant and the ingestion of tyramine in aged foods may be:

  A. Hypertensive crisis

  B. Severe rash

  C. Severe hypotension

  D. Severe diarrhea

  Correct Answer: A

  (A) The most serious adverse reactions of MAO inhibitors involve blood pressure and ingestion of tyramine-containing foods, which may provoke a hypertensive crisis. (B) MAO inhibitors cause adverse reactions affecting the central nervous system and serious adverse reactions involving blood pressure. (C) MAO inhibits false neurotransmitters (phenylalanines) and may produce hypotensive reactions from gradual accumulation of these neurotransmitters. (D) The most serious adverse reactions of MAO inhibitors involve blood pressure.

• Question 626:

  A client's congestive heart failure has been treated, and he will soon be discharged. Discharge teaching should include instruction to call the physician if he notices a 2-lb weight gain in a 24-hour period. Increased weight gain may indicate:

  A. A diet too high in calories and saturated fat

  B. Decreasing cardiac output

  C. Decreasing renal function

  D. Development of diabetes insipidus

  Correct Answer: B

  (A) Increased calories may result in weight gain, but there is no indication in this question that this man's diet has changed in a way that would result in increased calories. (B) Decreasing cardiac output stimulates the renin-angiotensinaldosterone cycle and results in fluid retention, which is reflected by weight gain. (C) Decreasing renal function may result in fluid retention, but this question gives no indication that this man has any renal problems. (D) Profound diuresis occurs with diabetes insipidus, which results in weight loss.

• Question 627:

  A physician's order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a microdrip tubing set. How many drops per minute should the nurse administer?

  A. 1 gtt/min

  B. 5 gtt/min

  C. 50 gtt/min

  D. 100 gtt/min

  Correct Answer: C

  (A) This answer is a miscalculation. (B) This answer is a miscalculation. (C)50 gtt/min. (D) This answer is a miscalculation.

• Question 628:

  A 24-year-old client presents to the emergency department protesting "I am God." The nurse identifies this as a:

  A. Delusion

  B. Illusion

  C. Hallucination

  D. Conversion

  Correct Answer: A

  (A) Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion is the expression of intrapsychic conflict through sensory or motor manifestations.

• Question 629:

  A 19-year-old client has sustained a C-7 fracture, which resulted in his spinal cord being partially transected. By 2 weeks' postinjury, his neck has been surgically stabilized, and he has been transferred from the intensive care unit. A potential life-threatening complication the nurse monitors the client for is:

  A. Autonomic dysreflexia

  B. Bradycardia

  C. Central cord syndrome

  D. Spinal shock

  Correct Answer: A

  (A) Autonomic dysreflexia is the exaggerated sympathetic nervous system response to various stimuli in the anesthetized area. Sympathetic stimulation results in severe, uncontrolled hypertension, which may result in myocardial infarction or cerebral hemorrhage. (B) Bradycardia occurs as a result of sympathetic blockade in the immediate postinjury period. After spinal shock recedes, cardiovascular stability returns, but the client will be bradycardiac for life. (C) Central cord syndrome is a specific type of spinal cord injury that occurs as a result of either hyperextension injuries or disrupted blood flow to the spinal cord. (D) Spinal shock occurs in the immediate postinjury phase and usually resolves in approximately 72 hours.

• Question 630:

  A 13-year-old hemophiliac is hospitalized for hemarthrosis of his right knee. To relieve the pain, the nurse should: A. Place on bed rest; elevate and splint the right knee

  B. Apply moist heat to the right knee

  C. Administer aspirin for pain

  D. Encourage active range of motion to right knee

  Correct Answer: A

  (A) Immobilization, splinting, and bed rest will reduce the bleeding. Once bleeding is reduced or stopped, the pain will subside. (B) Moist heat causes vasodilation and bleeding. Ice or cold compresses should be applied. (C) Aspirin decreases platelet aggregation, which causes bleeding. (D) Active range of motion aggravates bleeding and damages the synovial sac during bleeding episodes.