NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 711:

  Azulfidine (Sulfasalazine) may be ordered for a client who has ulcerative colitis. Which of the following is a nursing implication for this drug?

  A. Limit fluids to 500 mL/day.

  B. Administer 2 hours before meals.

  C. Observe for skin rash and diarrhea.

  D. Monitor blood pressure, pulse.

  Correct Answer: C

  (A) Fluids up to 2500?000 mL/day are needed to prevent kidney stones. (B) The client should be instructed to take oral preparations with meals or snacks to lessen gastric irritation. (C) Sulfasalazine causes skin rash and diarrhea. (D) Blood pressure and pulse are not altered by sulfasalazine.

• Question 712:

  A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom. Which nursing action is the most appropriate?

  A. Put in a nasogastric tube and lavage the child's stomach.

  B. Monitor muscular status.

  C. Teach mother poison prevention techniques.

  D. Place child on respiratory assistance.

  Correct Answer: A

  (A) The immediate treatment for drug overdose is removal of the drug from the stomach by either forced emesis or gastric lavage. The child's unconscious state prohibits forced emesis. (B) Toxic amounts of salicylates directly affect the respiratory system, which could lead to respiratory failure. (C) The mother's anxiety is probably so high that preventive guidance will be ineffective. (D) Respiratory assistance is not needed if the child's respiratory function is unaltered.

• Question 713:

  MgSO4 blood levels are monitored and the nurse would be prepared to administer the following antidote for MgSO4 side effects or toxicity:

  A. Magnesium oxide

  B. Calcium hydroxide

  C. Calcium gluconate

  D. Naloxone (Narcan)

  Correct Answer: C

  (A, B) These drugs are not antidotes for MgSO4. (C) This drug is the standard antidote and should always be readily available when MgSO4is being administered. (D) This drug is an antidote for narcotics, not MgSO4.

• Question 714:

  The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?

  A. Pulse rate of 50?0 bpm by her third postpartum day

  B. Diuresis by her second or third postpartum day

  C. Vaginal discharge or rubra, serosa, then rubra

  D. Diaphoresis by her third postpartum day

  Correct Answer: C

  (A) Bradycardia is an expected assessment during the postpartum period. (B) Diuresis can occur during labor and the postpartum period and is an expected physiological adaptation. (C) A return of rubra after the serosa period may indicate a postpartal complication. (D) Diaphoresis, especially at night, is an expected physiological change and does not indicate an infectious process. Bradycardia, diuresis, and diaphoresis are normal postpartum physiological responses to adjust

  the cardiac output and blood volume to the nonpregnant state.

• Question 715:

  Which of the following signs might indicate a complication during the labor process with vertex presentation?

  A. Fetal tachycardia to 170 bpm during a contraction

  B. Nausea and vomiting at 8-10 cm dilation

  C. Contraction lasting 60 seconds

  D. Appearance of dark-colored amniotic fluid

  Correct Answer: D

  (A) Fetal tachycardia may indicate fetal hypoxia; however, 170 bpm is only mild tachycardia. (B) Nausea and vomiting occur frequently during transition and are not a complication. (C) Contractions frequently last 60-10 seconds during the transitional phase of labor and are not considered a complication as long as the uterus relaxes completely between contractions. (D) Passage of meconium in a vertex presentation is a sign of fetal distress; this may be normal in a breech presentation owing to pressure on the presenting part.

• Question 716:

  After a 10-year-old child with insulin-dependent diabetes mellitus receives her dinner tray, she tells the nurse that she hates broccoli and wants some corn on the cob. The nurse's appropriate response is:

  A. "No vegetable exchanges are allowed."

  B. "Corn and other starchy vegetables are considered to be bread exchanges."

  C. "Yes, you may exchange any vegetable for any other vegetable."

  D. "Yes, but only one-half ear is allowed."

  Correct Answer: B

  (A)

  Sites for injection need to be rotated, including abdominal sites, to enhance insulin absorption. (B) The pinch technique is the most effective method for obtaining skin tightness to allow easy entrance of the needle to subcutaneous tissues.

  (C)

  Massaging the site of injectionfacilitates absorption of the insulin. (D) Changing the needle will break the sterility of the system. It has become acceptable practice to reuse disposable needles and syringes for 3? days.

• Question 717:

  A 42-year-old client on an inpatient psychiatric unit comments that he was brought to the hospital by his wife because he had taken too many pills and states, "I just couldn't take it anymore." The nurse's best response to this disclosure would be:

  A. "You shouldn't do things like that, just tell someone you feel bad."

  B. "Tell me more about what you couldn't take anymore."

  C. "I'm sure you probably didn't mean to kill yourself."

  D. "How long have you been in the hospital."

  Correct Answer: B

  (A) Disapproving gives the impression that the nurse has a right to pass judgment on the client's thoughts, actions, or ideas. (B) Giving a broad opening gives the client encouragement to continue with verbalization. (C) Failing to acknowledge the client's feelings conveys a lack of understanding and empathy. (D) Changing the subject takes the conversation away from the client and is indicative of the nurse's anxiety or insensitivity.

• Question 718:

  A complication for which the nurse should be alert following a liver biopsy is:

  A. Hepatic coma

  B. Jaundice

  C. Ascites

  D. Shock

  Correct Answer: D

  (A) Hepatic coma may occur in liver disease due to the increased NH3levels, not due to liver biopsy. (B) Jaundice may occur due to increased bilirubin levels, not due to liver biopsy. (C) Ascites would occur due to portal hypertension, not due to liver biopsy. (D) Hemorrhage and shock are the most likely complications after liver biopsy because of already existing bleeding tendencies in the vascular makeup of the liver.

• Question 719:

  The nurse is caring for a laboring client. Assessment data include cervical dilation 9 cm; contractions every 1? minutes; strong, large amount of "bloody show." The most appropriate nursing goal for this client would be:

  A. Maintain client's privacy.

  B. Assist with assessment procedures.

  C. Provide strategies to maintain client control.

  D. Enlist additional caregiver support to ensure client's safety.

  Correct Answer: C

  (A) Privacy may help the laboring client feel safer, but measures that enhance coping take priority. (B) The frequency of assessments do increase in transition, but helping the client to maintain control and cope with this phase of labor takes on importance. (C) This laboring client is in transition, the most difficult part of the first stage of labor because of decreased frequency, increased duration and intensity, and decreased resting phase of the uterine contraction. The client's ability to cope is most threatened during this phase of labor, and nursing actions aredirected toward helping the client to maintain control. (D) Safety is a concern throughout labor, but helping the client to cope takes on importance in transition.

• Question 720:

  The nurse would be sure to instruct a client on the signs and symptoms of an eye infection and hemorrhage. These signs and symptoms would include:

  A. Blurred vision and dizziness

  B. Eye pain and itching

  C. Feeling of eye pressure and headache

  D. Eye discharge and hemoptysis

  Correct Answer: B

  (A) Although blurred vision may occur, dizziness would not be associated with an infection or hemorrhage. (B) Eye pain is a symptom of hemorrhage within the eye, and itching is associated with infection. (C) Nausea and headache would not be usual symptoms of eye hemorrhage or infection. (D) Some eye discharge might be anticipated if an infection is present; hemoptysis would not.