NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 61:

  A 45-year-old client diagnosed with major depression is scheduled for electroconvulsive therapy (ECT) in the morning. Which of the following medications are routinely administered either before or during ECT?

  A. Thioridazine (Mellaril), lithium, and benztropine

  B. Atropine, sodium brevitol, and succinylcholine chloride (Anectine)

  C. Sodium, potassium, and magnesium

  D. Carbamazepine (Tegretol), haloperidol, and trihexyphenidyl (Artane)

  Correct Answer: B

  (A) Thioridazine (an antipsychotic drug), lithium (an antimanic drug), and benztropine (an antiparkinsonism agent) are generally administered to treat schizophrenic and bipolar disorders. (B) Atropine (a cholinergic blocker), sodium brevitol (a shortacting anesthetic), and succinylcholine (a neuromuscular blocker) are administered either before or during ECT to coun teract bradycardia and to provide anesthesia and total muscle relaxation. (C) These are electrolyte substances administered to correct fluid and electrolyte imbalances in the body. (D) Carbamazepine (an anticonvulsant), haldoperidol (an antipsychotic), and trihexyphenydyl (an antiparkinsonism agent) are usually administered in psychiatric settings to control problems associated with psychotic behavior.

• Question 62:

  A client develops complications following a hysterectomy. Blood cultures reveal Pseudomonas aeruginosa. The nurse expects that the physician would order an appropriate antibiotic to treat P. aeruginosa such as:

  A. Cefoperazone (Cefobid)

  B. Clindamycin (Cleocin)

  C. Dicloxacillin (Dycill)

  D. Erythromycin (Erythrocin)

  Correct Answer: A

  (A) Cefoperazone is indicated in the treatment of infection withPseudomonas aeruginosa. (B) Clindamycin is not indicated in the treatment of infection withP. aeruginosa.(C) Dicloxacillin is not indicated in the treatment of infection withP. aeruginosa.(D) Erythromycin is not indicated in the treatment of infection withP. aeruginosa.

• Question 63:

  Loss of appetite for a child with leukemia is a major recurrent problem. The plan of care should be designed to:

  A. Reinforce attempts to eat

  B. Help the child gain weight

  C. Increase his appetite

  D. Make mealtimes pleasant

  Correct Answer: A

  (A)

  Ignoring refusals to eat and rewarding eating attempts are the most successful means of increasing intake. (B) This goal is not specific enough or related to the loss of appetite. (C) This goal is not possible at this time based on his illness.

  (D)

  This goal is helpful, but alone will not address his loss of appetite.

• Question 64:

  A child has a nursing diagnosis of fluid volume excess related to compromised regulatory mechanisms. Which of the following nursing interventions is the most accurate measure to include in his care?

  A. Weigh the child twice daily on the same scale.

  B. Monitor intake and output.

  C. Check urine specific gravity of each voiding.

  D. Observe for edema.

  Correct Answer: A

  (A) Although all of these interventions are important aspects of care, weight is the most sensitive indicator of fluid balance. (B) Although monitoring intake and output is important, weight is a more accurate indicator of fluid status. (C) Urine specific gravity does not necessarily indicatefluid volume excess. (D) Edema may not be apparent, yet the client may have fluid volume excess.

• Question 65:

  A client had a cardiac catheterization with angiography and thrombolytic therapy with streptokinase. The nurse should initiate which of the following interventions immediately after he returns to his room?

  A. Place him on NPO restriction for 4 hours.

  B. Monitor the catheterization site every 15 minutes.

  C. Place him in a high Fowler position.

  D. Ambulate him to the bathroom to void.

  Correct Answer: B

  (A) A contrast dye, iodine, is used in this procedure. This dye is nephrotoxic. The client must be encouraged to drink plenty of liquids to assist the kidneys in eliminating the dye. (B) Streptokinase activates plasminogen, dissolving fibrin deposits. To prevent bleeding, pressure is applied at the insertion site. The client is assessed for both internal and external bleeding. (C) The extremity used for the insertion site must be kept straight and be immobilized because of the potential for bleeding. (D) The client is kept on bed rest for 8?2 hours following the procedure because of the potential for bleeding.

• Question 66:

  In discussing the plan of care for a child with chronic nephrosis with the mother, the nurse identifies that the purpose of weighing the child is to:

  A. Measure adequacy of nutritional management

  B. Check the accuracy of the fluid intake record

  C. Impress the child with the importance of eating well

  D. Determine changes in the amount of edema

  Correct Answer: D

  (A) Weighing a child with nephrosis is to assess for edema, not nutrition. (B, C) This is not the purpose for weighing the child. (D) Weight and measurement are the primary ways of evaluating edema and fluid shifts.

• Question 67:

  A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She has been admitted to the pediatric unit after surgical repair of the cleft lip. Which of the following nursing interventions would be appropriate during the first 24 hours?

  A. Position on side or abdomen.

  B. Maintain elbow restraints in place unless she is being directly supervised.

  C. Clean suture line every shift.

  D. Offer pacifier when she cries.

  Correct Answer: B

  (A) Placing the infant on her abdomen may allow for injury to the suture line. (B) Elbow restraints prevent the infant from touching the suture line and yet leaves hands free. (C) The suture line is cleaned as often as every hour to prevent crusting and scarring. (D) Sucking of a bottle or pacifier places pressure on the suture line and may delay healing and cause scarring.

• Question 68:

  A 4 year old has an imaginary playmate, which concerns the mother. The nurse's best response would be:

  A. "I understand your concern and will assist you with a referral."

  B. "Try not to worry because you will just upset your child."

  C. "Just ignore the behavior and it should disappear by age 8."

  D. "This is appropriate behavior for a preschooler and should not be a concern."

  Correct Answer: D

  (A) This is normal for a preschooler, and a referral is not appropriate. (B) Telling a parent not to worry is unhelpful. This response does not address the mother's concern. (C) This response is incorrect. The behavior is normal and will usually disappear by the time the child enters school. (D) This behavior is normal development for a preschooler.

• Question 69:

  A family by court order undergoes treatment by a family therapist for child abuse. The nurse, who is the child's case manager knows that treatment has been effective when:

  A. The child is removed from the home and placed in foster care

  B. The child's parents identify the ways in which he is different from the rest of the family

  C. The child's father is arrested for child abuse

  D. The child's parents can identify appropriate behaviors for children in his age group

  Correct Answer: D

  (A) Removing an abused child from the home and placement in a foster home are not the desired outcome of treatment. (B) Children who are perceived as "different" from the rest of the family are more likely to be abused. (C) Although legal action may be taken against abusive parents, it is not an indicator of an effective treatment program. (D) Identification of age-appropriate behaviors is essential to the role of parents, because misunderstanding children's normal developmental needs often contributes to abuse or neglect.

• Question 70:

  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

  Correct Answer: C

  (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.