NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 641:

  A 4-year-old child has Down syndrome. The community health nurse has coordinated a special preschool program. The nurse's primary goal is to:

  A. Provide respite care for the mother

  B. Facilitate optimal development

  C. Provide a demanding and challenging educational program

  D. Prepare child to enter mainstream education

  Correct Answer: B

  (A) Respite care for the family may be needed, but it is not the primary goal of a preschool program. (B) Facilitation of optimal growth and development is essential for every child. (C) A demanding and challenging educational program may predispose the child to failure. Children with retardation should begin with simple and challenging educational programs. (D) Mental retardation associated with Down syndrome may not permit mainstream education. A preschoolprogram's primary goal is not preparation for mainstream education but continuation of optimal development.

• Question 642:

  A 16-year-old client with anorexia nervosa is on an inpatient psychiatric unit. She has a fear of gaining weight and is refusing to eat sufficient amounts to maintain body weight for her age, height, and stature. To assist with the problem of powerlessness and plan for the client to no longer need to withhold food to feel in control, the nurse uses the following strategy:

  A. Establish a structured environment with routine tasks and activities. Also, serve meals at the same time each day.

  B. Distract the client during meals to get her to eat because she must take in sufficient amounts to keep from starving.

  C. Do frequent room checks to be sure that the client is not hiding food or throwing it away.

  D. Listen attentively and participate in in-depth discussions about food, because these actions may encourage her to eat.

  Correct Answer: A

  (A) Anorexia nervosa clients feel out of control. Providing a structured environment offers safety and comfort and can help them to develop internal control, thus reducing their need to control by self-starvation. (B) Distraction does not focus on the client's need for control. (C) Doing frequent room checks reinforces feelings of powerlessness and the need to continue with the dysfunctional behavior. (D) Participating in long discussions about food does not make the client want to eat, but rather this strategy allows her to indulge in her preoccupation and to continue with the dysfunctional behavior.

• Question 643:

  While the RN is assessing a mother's perineum on her 2nd postpartum day after having a vaginal delivery, the RN notes a large ecchymotic area located to the left of the mother's perineum. Which one of the following interventions should the RN initiate at this time?

  A. Have the client expose the area to air.

  B. Apply ice to the perineum.

  C. Encourage the client to take warm sitz baths.

  D. Inform the physician.

  Correct Answer: C

  (A) The area is bruised and painful. This action would do nothing to help with the healing process of the perineum or to provide comfort. (B) Ice is effective immediately after birth to reduce edema and discomfort, but not on the 2nd postpartum day. (C) Sitz baths are useful if the perineum has been traumatized, because the moist heat increases circulation to the area to promote healing, relaxes tissue, and decreases edema. (D) The physician is not notified of bruising, but if a hematoma is present, then the physician is notified.

• Question 644:

  At 38 weeks' gestation, a client is in active labor. She is using her Lamaze breathing techniques. The RN is coaching her breathing and encouraging her to relax and work with her contractions. Which one of the following complaints by the client will alert the RN that she is beginning to hyperventilate with her breathing?

  A. "I am cold."

  B. "I have a backache."

  C. "I feel dizzy."

  D. "I am nauseous."

  Correct Answer: C

  (A) Cold is not a symptom of hyperventilation. This could be due to the temperature of the room. (B) Backache is not a symptom of hyperventilation. This is probably due to the gravid uterus and its effect on the back muscles, or it may be due to the client's position in bed. (C) Dizziness is the first symptom of hyperventilation. It occurs because the body is eliminating too much CO2. (D) Nausea is not a symptom of hyperventilation. It could be a symptom of pain.

• Question 645:

  A physician's order reads: Administer KCl 10% oral solution 1.5 mL. The KCl bottle reads 20 mEq/15 mL.

  What dosage should the nurse administer to the infant?

  A. 1 mEq

  B. 1.13 mEq

  C. 2 mEq

  D. Not enough information to calculate

  Correct Answer: C

  (A) This answer is a miscalculation. (B) This answer is a miscalculation. (C) 1.33 mEq = 1 mL, then 1.5 mL X=1.99, or 2 mEq. (D) Information is adequate for calculation.

• Question 646:

  A pregnant client during labor is irritable and feels the urge to vomit. The nurse should recognize this as the:

  A. Fourth stage of labor

  B. Third stage of labor

  C. Transition stage of labor

  D. Second stage of labor

  Correct Answer: C

  (A) The fourth stage begins after expulsion of the placenta. Client symptoms are: fatigue; chills; scant, bloody vaginal discharge; and nausea. (B) The third stage is from birth to expulsion of placenta. Client symptoms are uterine contractions, gush of blood, and perineal pain. (C) The transition stage is characterized by strong uterine contractions and cervical dilation. Clientsymptoms are irritability, restlessness, belching, muscle tremors, nausea, and vomiting. (D) The second stage is characterized by full dilation of cervix. Client symptoms are perineal bulge, pushing with contractions, great irritability, and leg cramps.

• Question 647:

  The physician is preparing to induce labor on a 40-week multigravida. The nurse should anticipate the administration of:

  A. Oxytocin (Pitocin)

  B. Progesterone

  C. Vasopressin (Pitressin)

  D. Ergonovine maleate

  Correct Answer: A

  (A) Oxytocin is a hormone secreted by the neurohypophysis during suckling and parturition that produces strong uterine contractions. (B) Progesterone has a quiescence effect on the uterus. (C) Vasopressin is an antidiuretic hormone that promotes water reabsorption by the renal tubules. (D) Ergonovine produces dystocia as a result of sustained uterine contractions.

• Question 648:

  An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action?

  A. Apply ice packs to both legs.

  B. Begin débridement by removing all charred clothing from wound.

  C. Apply Silvadene cream (silver sulfadiazine).

  D. Immerse both legs in cool water.

  Correct Answer: D

  (A)

  Ice creates a dramatic temperature change in the tissue, which can cause further thermal injury. (B) Charred clothing should not be removed from wound first. This creates further tissue damage. Débridement is not the first nursing action.

  (C)

  Applying silver sulfadiazine cream first insulates heat in injured tissue and increases potential for infection. (D) Emergency care of a thermal burn is immersing both legs in cool water. Cool water permits gradual temperature change and prevents further thermal damage.

• Question 649:

  A client was not using his seat belt when involved in a car accident. He fractured ribs 5, 6, and 7 on the left and developed a left pneumothorax. Assessment findings include:

  A. Crackles and paradoxical chest wall movement

  B. Decreased breath sounds on the left and chest pain with movement

  C. Rhonchi and frothy sputum

  D. Wheezing and dry cough

  Correct Answer: B

  (A) Crackles are caused by air moving through moisture in the small airways and occur with pulmonary edema. Paradoxical chest wall movement occurs with flail chest when a segment of the thorax moves outward on inspiration and inward on expiration. (B) Decreased breath sounds occur when a lung is collapsed or partially collapsed. Chest pain with movement occurs with rib fractures. (C) Rhonchi are caused by air moving through large fluid-filled airways. Frothy sputum may occur with pulmonary edema. (D) Wheezing is caused by fluid in large airways already narrowed by mucus or bronchospasm. Dry cough could indicate a cardiac problem.

• Question 650:

  A 30-year-old client has a history of several recent traumatic experiences. She presents at the physician's office with a complaint of blindness. Physical exam and diagnostic testing reveal no organic cause. The nurse recognizes this as:

  A. Delusion

  B. Illusion

  C. Hallucination

  D. Conversion

  Correct Answer: D

  (A) The client's blindness is real. 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.