NCLEX NCLEX-RN Online Practice Questions and Exam Preparation

NCLEX NCLEX-RN Online Questions & Answers

• Question 671:

  The initial focus when providing nursing care for a child with rheumatic fever during the acute phase of the illness should be to:

  A. Maintain contact with her parents
  B. Provide for physical and psychological rest
  C. Provide a nutritious diet
  D. Maintain her interest in school
  B. Provide for physical and psychological rest

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  (A) This goal is helpful, but rest is essential during the acute phase. (B) Rest is essential for healing to occur and for pain to be relieved. (C) This goal is important, but rest is essential. (D) This goal should be part of the plan of care, but it is not the priority during the acute phase.

• Question 672:

  A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?

  A. "I did not get the raise because my boss does not like me."
  B. "I felt a lump in my breast 2 weeks ago. I put off getting it checked until after my sister's wedding."
  C. "My son died 3 years ago. I still cannot bring myself to clean out his room."
  D. "My husband told me this morning that he wants a divorce. I am upset, but I cannot discuss the matter with him until after my company's board meeting today."
  D. "My husband told me this morning that he wants a divorce. I am upset, but I cannot discuss the matter with him until after my company's board meeting today."

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  (A) This statement is an example of adaptive rationalization. She is coping with her disappointment by rationalizing. This is adaptive because no harm is done to self or others. It is used to protect her ego. (B) This is an example of maladaptive suppression. She is suppressing the seriousness of the lump. It is maladaptive because delaying treatment will cause harm to her. (C) The client's actions are an example of maladaptive denial. She is denying her son's death by not facing his possessions. Until she faces his death, she cannot face reality. (D) This is an example of adaptive suppression. She realizes the impact of her husband's statement but delays discussion until she can devote her full attention to the matter.

• Question 673:

  In caring at home for a child who just ingested a caustic alkali, the nurse would immediately tell the mother to:

  A. Give vinegar, lemon juice, or orange juice
  B. Phone the doctor
  C. Take the child to the emergency room
  D. Induce vomiting
  A. Give vinegar, lemon juice, or orange juice

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  (A) The immediate action is to neutralize the action of the chemical before further damage takes place. (B) This action should be done after neutralizing the chemical. (C) This action should be done after neutralizing the chemical. (D) Never induce vomiting with a strong alkali or acid. Additional damage will be done when the child vomits the chemical.

• Question 674:

  At 16 weeks' gestation, a pregnant client is admitted to the maternity unit to have a McDonald procedure (cerclage) done. She tells the RN who is admitting her to the unit that her physician had explained what this procedure was, but that she did not understand. The RN explains to the client that the purpose for this procedure is to:

  A. Reinforce an incompetent cervix
  B. Repair the amniotic sac
  C. Evaluate cephalopelvic disproportion
  D. Dilate the cervix
  A. Reinforce an incompetent cervix

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  (A) The treatment most commonly uses the Shirodkar-Barter procedure (McDonald procedure) or cerclage to enforce the weakened cervix by encircling it with a suture at the level of the internal os. (B) There is no known procedure that is used to repair the amniotic sac. (C) Cephalopelvic disproportion is evaluated later in pregnancy. It is not related to this procedure. (D) No procedure is done to dilate the cervix at 16 weeks' gestation unless the pregnancy is to be terminated.

• Question 675:

  On morning rounds, the nurse found a manic-depressive client who is taking lithium in a confused mental state, vomiting, twitching, and exhibiting a coarse hand tremor. Which one of the following nursing actions is essential at this time?

  A. Administer her next dosage of lithium, and then call the physician.
  B. Withhold her lithium, and report her symptoms to the physician.
  C. Place her on NPO to decrease the excretion of lithium from her body, and call the physician.
  D. Contact the lab and request a lithium level in 30 minutes, and call the physician.
  B. Withhold her lithium, and report her symptoms to the physician.

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  (A) The client has lithium toxicity, and the nurse must withhold further dosages. (B) Because of her level of toxicity, further lithium could cause coma and death. The nurse needs further orders from the physician to stabilize the client's lithium level. (C) Ensuring adequate intake of sodium chloride will promote excretion of lithium and will assist in managing the client's lithiumtoxicity. (D) A lithium blood level must be drawn immediately to determine the seriousness of the toxicity and to provide the physician with data for medical orders.

• Question 676:

  A 2-year-old child is recovering from surgery. Considering growth and development according to Erikson, the nurse identifies which of the following play activities as most appropriate?

  A. Assembling a puzzle with large pieces
  B. Being taken for a wheelchair ride
  C. Listening to a story about the Muppets
  D. Watching Sesame Street on television
  A. Assembling a puzzle with large pieces

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  (A) A 2-year-old child is in the stage of autonomy, according to Erikson. Assembling a puzzle with large pieces enables her to "do it herself." (B) A wheelchair ride would probably be fun, but it is not directed toward helping the child to achieve autonomy. (C) Listening to a story may be fun and educational, but it is not directed toward helping the child to achieve autonomy. (D) Watching television may be a favorite activity, but it does not foster autonomy.

• Question 677:

  A client had a hemicolectomy performed 2 days ago. Today, when the nurse assesses the incision, a small part of the abdominal viscera is seen protruding through the incision. This complication of wound healing is known as:

  A. Excoriation
  B. Dehiscence
  C. Decortication
  D. Evisceration
  D. Evisceration

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  (A) Excoriation is abrasion of the epidermis or of the coating of any organ of the body by trauma, chemicals, burns, or other causes. (B) Dehiscence is a partial or complete separation of the wound edges with no protrusion of abdominal tissue. (C) Decortication is removal of the surface layer of an organ or structure. It is a type of surgery, such as removing the fibrinous peel from the visceral pleura in thoracic surgery. (D) Evisceration occurs when the incision separates and the contents of the cavity spill out.

• Question 678:

  The nurse is teaching a child's parents how to protect the child from lead poisoning. The nurse knows that a common source of lead poisoning in children is:

  A. Dandelion leaves
  B. Pencils
  C. Old paint
  D. Stuffing from toy animals
  C. Old paint

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  (A) Dandelion leaves are not a source of lead. (B) Pencils are not a source of lead poisoning. (C) Chewing on objects painted before 1960 is a common source of lead poisoning in children. Gasoline is another source. (D) Stuffed animals are not a source of lead.

• Question 679:

  A 42-year-old client presents with a diagnosis of paranoid schizophrenia. She has become increasingly restless and verbally argumentative, and her speech has become pressured. She is exhibiting signs of:

  A. Depression
  B. Agitation
  C. Psychotic ideation
  D. Anhedonia
  B. Agitation

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  (A) Signs of depression would include withdrawal, sadness, morbid thoughts, insomnia, early awakening, etc. (B) These clinical features are classic signs of agitation. (C) Psychotic ideation includes delusional thoughts, bizarre behavior, disorganized thinking, etc. (D) Anhedonia is the inability to experience pleasure.

• Question 680:

  Prior to an amniocentesis, a fetal ultrasound is done in order to:

  A. Evaluate fetal lung maturity
  B. Evaluate the amount of amniotic fluid
  C. Locate the position of the placenta and fetus
  D. Ensure that the fetus is mature enough to perform the amniocentesis
  C. Locate the position of the placenta and fetus

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  (A) Amniocentesis can be performed to assess for lung maturity. Fetal ultrasound can be used for gestational dating, although it does not separately determine lung maturity. (B) Ultrasound can evaluate amniotic fluid volume, which may be used to determine congenital anomalies. (C) Amniocentesis involves removal of amniotic fluid for evaluation. The needle, inserted through the abdomen, is guided by ultrasound to avoid needle injuries, and the test evaluates the position of the placenta and the fetus. (D) Amniocentesis can be performed as early as the 15th?7th week of pregnancy.