NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 681:

  A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful?

  A. Pork chop, baked acorn squash, brussel sprouts

  B. Chicken breast, rice, and green beans

  C. Roast beef, baked potato, and diced carrots D. Tuna casserole, noodles, and spinach

  Correct Answer: A

  (A) Both acorn squash and brussels sprouts are potassium-rich foods. (B) None of these foods is considered potassium rich. (C) Only the baked potato is a potassium-rich food. (D) Spinach is the only potassium-rich food in this option.

• Question 682:

  In assessing the nature of the stool of a client who has cystic fibrosis, what would the nurse expect to see?

  A. Clay-colored stools

  B. Steatorrhea stools

  C. Dark brown stools

  D. Blood-tinged stools

  Correct Answer: B

  (A) Clay-colored stools indicate dysfunction of the liver or biliary tract. (B) In the early stages of cystic fibrosis, fat absorption is primarily affected resulting in fat, foul, frothy, bulky stools. (C) Dark brown stools indicate normal passage through the colon. (D) Blood-tinged stools indicate dysfunction of the gastrointestinal (GI) tract.

• Question 683:

  A 26-year-old client is in a treatment center for aprazolam (Xanax) abuse and continues to manifest moderate levels of anxiety 3 weeks into the rehabilitation program, often requesting medication for "his nerves." Included in the client's plan of care is to identify alternate methods of coping with stress and anxiety other than use of medication. After intervening with assistance in stress reduction techniques, identifying feelings and past coping, the nurse evaluates the outcome as being met if:

  A. Client promises that he will not abuse aprazolam after discharge

  B. Client demonstrates use of exercise or physical activity to handle nervous energy following conflicts of everyday life

  C. Client is able to verbalize effects of substance abuse on the body

  D. Client has remained substance free during hospitalization and is discharged

  Correct Answer: B

  (A) This client response does not address stress reduction techniques. Verbal response focuses only on the problem. (B) Exercise or physical activity is a common strategy or coping technique used to reduce stress and anxiety. (C) Verbalizing effects of substance abuse on the body may help with insight and break through denial, but it is not a strategy to reduce anxiety. (D)Remaining substance-free does indicate motivation to change lifestyle of substance abuse or dependence, and it is not a stress reduction strategy in itself.

• Question 684:

  A client delivered her first-born son 4 hours ago. She asks the nurse what the white cheeselike substance is under the baby's arms. The nurse should respond:

  A. "This is a normal skin variation in newborns. It will go away in a few days."

  B. "Let me have a closer look at it. The baby may have an infection."

  C. "This material, called vernix, covered the baby before it was born. It will disappear in a few days."

  D. "Babies sometimes have sebaceous glands that get plugged at birth. This substance is an example of that condition."

  Correct Answer: C

  (A) This response identifies the fact that vernix is a normal neonatal variation, but it does not teach the client medical terms that may be useful in understanding other healthcare personnel. (B) This response may raise maternal anxiety and incorrectly identifies a normal neonatal variation. (C) This response correctly identifies this neonatal variation and helps the client to understand medical terms as well as the characteristics of her newborn. (D) Blocked sebaceous glands produce milia, particularly present on the nose.

• Question 685:

  With a geriatric client, the nurse should also assess whether he has been obtaining a yearly vaccination against influenza. Why is this assessment important?

  A. Influenza is growing in our society.

  B. Older clients generally are sicker than others when stricken with flu.

  C. Older clients have less effective immune systems.

  D. Older clients have more exposure to the causative agents.

  Correct Answer: C

  (A) Although influenza is common, the elderly are more at risk because of decreased effectiveness of their immune system, not because the incidence is increasing. (B) Older clients have the same degree of illness when stricken as other populations. (C) As people age, their immune system becomes less effective, increasing their risk for influenza. (D) Older clients have no more exposure to the causative agents than do school-age children, for example.

• Question 686:

  The nurse would teach a male client ways to minimize the risk of infection after eye surgery. Which of the following indicates the client needs further teaching?

  A. "I will wash my hands before instilling eye medications."

  B. "I will wear sunglasses when going outside."

  C. "I will wear an eye patch for the first 3 postoperative days."

  D. "I will maintain the sterility of the eye medications."

  Correct Answer: C

  (A) Hand washing would be an important action designed to prevent transmission of pathogens from the hands to the eye. (B) Wearing sunglasses when going outside will prevent airborne pathogens from entering the eye. (C) Eye patches are most frequently ordered to be worn while the client sleeps or naps, not constantly for this length of time. (D) Eye medications are sterile; clients need to be taught how to maintain this sterility.

• Question 687:

  A nurse should carefully monitor a client for the following side effect of MgSO4:

  A. Visual blurring

  B. Tachypnea

  C. Epigastric pain

  D. Respiratory depression

  Correct Answer: D

  (A, C) The nurse should provide good distractors because these symptoms indicate that PIH has become more severe and may precede the convulsive or eclamptic phase. (B) This is the oppositeside effect of this medication. (D) This is a common side effect of this medication and needs to be monitored and recorded frequently.

• Question 688:

  A couple is planning the conception of their first child.

  The wife, whose normal menstrual cycle is 34 days in length, correctly identifies the time that she is most likely to ovulate if she states that ovulation should occur on day:

  A. 14+2 days

  B. 16+2 days

  C. 20+2 days

  D. 22+2 days

  Correct Answer: C

  (A) Ovulation is dependent on average length of menstrual cycle, not standard 14 days. (B) Ovulation occurs 14+2 days before next menses (34 minus 14 does not equal 16). (C) Ovulation occurs 14+2 days before next menses (34 minus 14 equals 20). (D) Ovulation occurs 14+2 days before next menses (34 minus 14 does not equal 22).

• Question 689:

  A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse?

  A. "Keep breathing with your abdominal muscles as long as you can."

  B. "Make sure you take a deep cleansing breath as the contractions start, focus on an object, and breathe about 16?0 times a minute with shallow chest breaths."

  C. "Find a comfortable position before you start a contraction. Once the contraction has started, take slow breaths using your abdominal muscles."

  D. "If a woman in labor listens to her body and takes rapid, deep breaths, she will be able to deal with her contractions quite well."

  Correct Answer: B

  (A) Lamaze childbirth preparation teaches the use of chest, not abdominal, breathing. (B) In Lamaze preparation, every patterned breath is preceded by a cleansing breath; as labor progresses, shallow, paced breathing is found to be effective. (C) It is important to assume a comfortable position in labor, but the Lamazeprepared laboring woman is taught to breathe with her chest, not abdominal, muscles. (D) When deep chest breathing patterns are used in Lamaze preparation, they are slowly paced at a rate of 6? breaths/min.

• Question 690:

  A 26-year-old client is admitted to the labor, delivery, recovery, postpartum unit. The nurse completes her assessment and determines the client is in the first stage of labor. The nurse should instruct her:

  A. To hold her breath during contractions

  B. To be flat on her back

  C. Not to push with her contractions

  D. To push before becoming fully dilated

  Correct Answer: C

  (A) This nursing action may cause hyperventilation. (B) This nursing action could cause inferior vena cava syndrome. (C) The client is allowed to push only after complete dilation during the second stage of labor. The nurse needs to know the stages of labor. (D) If the client pushes before dilation, it could cause cervical edema and/or edema to the fetal scalp; both of these could contribute to increased risk of complications.