NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 661:

  A client is diagnosed with organic brain disorder. The nursing care should include:

  A. Organized, safe environment

  B. Long, extended family visits

  C. Detailed explanations of procedures

  D. Challenging educational programs

  Correct Answer: A

  (A)

  A priority nursing goal is attending to the client's safety and well-being. Reorient frequently, remove dangerous objects, and maintain consistent environment. (B) Short, frequent visits are recommended to avoid overstimulation and fatigue.

  (C)

  Short, concise, simple explanations are easier to understand. (D) Mental capability and attention span deficits make learning difficult and frustrating.

• Question 662:

  A pregnant client experiences a precipitous delivery. The nursing action during a precipitous delivery is to:

  A. Control the delivery by guiding expulsion of fetus

  B. Leave the room to call the physician

  C. Push against the perineum to stop delivery

  D. Cross client's legs tightly

  Correct Answer: A

  (A) Controlling the rapid delivery will reduce the risk of fetal injury and perineal lacerations. (B) The nurse should always remain with a client experiencing a precipitous delivery. (C) Pushing against the perineum may cause fetal distress. (D) Crossing of legs may cause fetal distress and does not stop the delivery process.

• Question 663:

  A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will:

  A. Drink at least 8 oz of cranberry juice daily

  B. Maintain a fluid intake of at least 2000 mL daily

  C. Wash her hands before and after voiding

  D. Limit her fluid intake after 6 PM so that there is not a great deal of urine in her bladder while she sleeps

  Correct Answer: D

  (A) Cranberry juice helps to maintain urine acidity, thereby retarding bacterial growth. (B) A generous fluid intake will help to irrigate the bladder and to prevent bacterial growth within the bladder. (C) Hand washing is an effective means of preventing pathogen transmission. (D) Restricting fluid intake would contribute to urinary stasis, which in turn would contribute to bacterial growth.

• Question 664:

  A 7-year-old child is brought to the ER at midnight by his mother after symptoms appeared abruptly. The nurse's initial assessment reveals a temperature of 104.5F (40.3C), difficulty swallowing, drooling, absence of a spontaneous cough, and agitation. These symptoms are indicative of which one of the following?

  A. Acute tracheitis

  B. Acute spasmodic croup

  C. Acute epiglottis

  D. Acute laryngotracheobronchitis

  Correct Answer: C

  (A) Clinical manifestations of acute tracheitis include a 2? day history of URI, croupy cough, stridor, purulent secretions, high fever. (B) Clinical manifestations of spasmodic croup include a history of URI, croupy cough, stridor, dyspnea, low-grade fever, and a slow progression. The age group most affected is 3 months to 3 years. (C) Three clinical observations have been found to be predictive of epiglottitis: the presence of drooling, absence of spontaneous cough, and agitation.Epiglottitis has a rapid onset that is accompanied by high fever and dysphagia. (D) Clinical manifestations of acute laryngotracheobronchitis (LTB) include slow onset with a history of URI, low-grade fever, stridor, brassy cough, and irritability.

• Question 665:

  The nurse provides a male client with diet teaching so that he can help prevent constipation in the future. Which food choices indicate that this teaching has been understood?

  A. Omelette and hash browns

  B. Pancakes and syrup

  C. Bagel with cream cheese

  D. Cooked oatmeal and grapefruit half

  Correct Answer: D

  (A) Eggs and hash browns do not provide much fiber and bulk, so they do not effectively prevent constipation. (B) Pancakes and syrup also have little fiber and bulk, so they do not effectively prevent constipation. (C) Bagel and cream cheese do not provide intestinal bulk. (D) A combination of oatmeal and fresh fruit will provide fiber and intestinal bulk.

• Question 666:

  In cleansing the perineal area around the site of catheter insertion, the nurse would:

  A. Wipe the catheter toward the urinary meatus

  B. Wipe the catheter away from the urinary meatus

  C. Apply a small amount of talcum powder after drying the perineal area

  D. Gently insert the catheter another 12 inch after cleansing to prevent irritation from the balloon

  Correct Answer: B

  (A) Wiping toward the urinary meatus would transport microorganisms from the external tubing to the urethra, thereby increasing the risk of bladder infection. (B) Wiping away from the urinary meatus would remove microorganisms from the point of insertion of the catheter, thereby decreasing the risk of bladder infection. (C) Talcum powder should not be applied following catheter care, because powders contribute to moisture retention and infection likelihood. (D) The catheter should never be inserted further into the urethra, because this would serve no useful purpose and would increase the risk of infection.

• Question 667:

  Which of the following would indicate the need for further teaching for the client with COPD? The client verbalizes the need to:

  A. Eat high-calorie, high-protein foods

  B. Take vitamin supplementation

  C. Eliminate intake of milk and milk products

  D. Eat small, frequent meals

  Correct Answer: C

  (A) Protein is vital for the maintenance of muscle to aid in breathing. A high-calorie diet using higher fat than carbohydrate content is given because clients are unable to breathe off the excess CO2that is an end product of carbohydrate metabolism. (B) Inadequate nutritional status, in particular, deficiencies in vitamins A and C, decreases resistance to infection. (C) Milk does not make mucus thicker. It may coat the back of the throat and make it feel thicker. Rinsing the mouth with water after drinking milk will prevent this problem. (D) Small, frequent meals minimize a fullness sensation and reduce pressure on the diaphragm. The work of breathing and SOB are also reduced.

• Question 668:

  A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the gravida and para system to record the client's obstetrical history, the nurse should record:

  A. Gravida 3 para 1

  B. Gravida 3 para 2

  C. Gravida 2 para 1

  D. Gravida 2 para 2

  Correct Answer: B

  (A) This answer is an incorrect application of gravida and para. The client has had two prior deliveries of more than 20 weeks' gestation; therefore, para equals 2, not 1. (B) This answer is the correct application of gravida and para. The client is currently pregnant for the third time (G = 3), regardless of the length of the pregnancy, and has had two prior pregnancies with birth after the 20th week (P = 2), whether infant was alive or dead. (C) This answer is an incorrect application of gravida and para. The client is currently pregnant for the third time (G = 3, not 2); prior pregnancies lasted longer than 20 weeks (therefore, P = 2, not 1). (D) This is an incorrect application of gravida and para. Client is currently pregnant for third time (G = 3, not 2).

• Question 669:

  Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, "Begin oxytocin induction at 1 mU/min." The nurse should:

  A. Begin the oxytocin induction as ordered

  B. Increase the dosage by 2 mU/min increments at 15-minute intervals

  C. Maintain the dosage when duration of contractions is 40

  Correct Answer: D

  (A) Oxytocin stimulates labor but should not be used until CPD (cephalopelvic disproportion) is ruled out in a dysfunctional labor. (B) This answer is the correct protocol for oxytocin administration, but the medication should not be used until CPD is ruled out. (C) This answer is the correct manner to interpret effective stimulation, but oxytocin should not be used until CPD is ruled out. (D) This answer is the appropriate nursing action because the scenario presents adysfunctional labor pattern that may be caused by CPD. Oxytocin administration is contraindicated in CPD.

• Question 670:

  A client with severe PIH receiving MgSO4 is placed in a quiet, darkened room. The nurse bases this action on the following understanding:

  A. The client is restless.

  B. The elevated blood pressure causes photophobia.

  C. Noise or bright lights may precipitate a convulsion.

  D. External stimuli are annoying to the client with PIH.

  Correct Answer: C

  (A) The client may be anxious and hyperresponsive to stimuli but not necessarily restless. (B) This is not a physiological response to an elevated blood pressure in PIH. (C) The nurse must know the nursing measures that decrease the potential for convulsions. A quiet, darkened room decreases stimuli and promotes rest. (D) External stimuli might induce a convulsion but are not annoying to the client with PIH.