NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 721:

  Iron dextran (Imferon) is a parenteral iron preparation.

  The nurse should know that it:

  A. Is also called intrinsic factor

  B. Must be given in the abdomen

  C. Requires use of the Z-track method

  D. Should be given SC

  Correct Answer: C

  (A) Intrinsic factor is needed to absorb vitamin B12.(B) Iron dextran is given parenterally, but Z-track in a large muscle. (C) A Ztrack method of injection is required to prevent staining and irritation of the tissue. (D) An SC injection is not deep enough and may cause subcutaneous fat abscess formation.

• Question 722:

  A postpartum client complains of rectal pressure and severe pain in her perineum; this may be indicative of:

  A. Afterbirth pains

  B. Constipation

  C. Cystitis

  D. A hematoma of the vagina or vulva

  Correct Answer: D

  (A) Afterbirth pains are a common complaint in the postpartum client, but they are located in the uterus. (B) Constipation may cause rectal pressure but is not usually associated with "severe pain." (C) Cystitis may cause pain, but the location is different. (D) Hematomas are frequently associated with severe pain and pressure. Further assessments are indicated for this client.

• Question 723:

  An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction?

  A. Boardlike, rigid abdomen

  B. Loss of the urge to defecate

  C. Liquid stool

  D. Abdominal pain

  Correct Answer: C

  (A) A boardlike, rigid abdomen would point to a perforated bowel, not a fecal impaction. (B) When a client is fecally impacted, a common symptom is the urge to defecate but the inability to do so. (C) When an impaction is present, only liquid stool will be able to pass around the impacted site. (D) Abdominal pain without distention is not a sign of a fecal impaction.

• Question 724:

  Prenatal clients are routinely monitored for early signs of pregnancy-induced hypertension (PIH). For the prenatal client, which of the following blood pressure changes from baseline would be most significant for the nurse to report as indicative of PIH?

  A. 136/88 to 144/93

  B. 132/78 to 124/76

  C. 114/70 to 140/88

  D. 140/90 to 148/98

  Correct Answer: C

  (A) These blood pressure changes reflect only an 8 mm Hg systolic and a 5 mm Hg diastolic increase, which is insufficient for blood pressure changes indicating PIH. (B) These blood pressure changes reflect a decrease in systolic pressure of 8 mm Hg and diastolic pressure of 2 mm Hg; these values are not indicative of blood pressure increases reflecting PIH. (C) The definition of PIH is an increase in systolic blood pressure of 30 mm Hg and/or diastolic blood pressure of 15 mm Hg. These blood pressures reflect a change of 26 mm Hg systolically and 18mm Hg diastolically. (D) These blood pressures reflect a change of only 8 mm Hg systolically and 8 mm Hg diastolically, which is insufficient for blood pressure changes indicating PIH.

• Question 725:

  A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty- eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications?

  A. Fluid volume deficit

  B. Fluid volume excess

  C. Decreased cardiac output

  D. Severe hypotension

  Correct Answer: B

  (A) Fluid volume deficit resulting from fluid shifts to the interstitial spaces occurs in the first 48 hours. (B) Forty-eight hours to 72 hours after the burn injury and fluid resuscitation, capillary permeability is restored and fluid requirements decrease. Interstitial fluid returns rapidly to the vascular compartment, and the nurse must monitor the child for signs and symptoms of hypervolemia. (C) Increased cardiac output results as fluids shift back to the vascular compartment. (D) Hypertension is the result of hypervolemia.

• Question 726:

  Respiratory function is altered in a 16-year-old asthmatic. Which of the following is the cause of this alteration?

  A. Altered surfactant production

  B. Paradoxical movements of the chest wall

  C. Increased airway resistance

  D. Continuous changes in respiratory rate and depth

  Correct Answer: C

  (A) Altered surfactant production is found in sudden infant death syndrome. (B) Paradoxical breathing occurs when a negative intrathoracic pressure is transmitted to the abdomen by a weakened, poorly functioning diaphragm. (C) Asthma is characterized by spasm and constriction of the airways resulting in increased resistance to airflow. (D) If the pulmonary tree is obstructed for any reason, inspired air has difficulty overcoming the resistance and getting out. The rate of respiration increases in order to compensate, thus increasing air exchange.

• Question 727:

  A 56-year-old psychiatric inpatient has had recurring episodes of depression and chronic low self-esteem. She feels that her family does not want her around, experiences a sense of helplessness, and has a negative view of herself. To assist the client in focusing on her strengths and positive traits, a strategy used by the nurse would be to:

  A. Tell the client to attend all structured activities on the unit

  B. Encourage or direct client to attend activities that offer simple methods to attain success

  C. Increase the client's self-esteem by asking that she make all decisions regarding attendance in group activities

  D. Not allow any dependent behaviors by the client because she must learn independence and will have to ask for any assistance from staff

  Correct Answer: B

  (A)

  The nurse should encourage activities gradually, as client's energy level and tolerance for shared activities improve. (B) Activities that focus on strengths and accomplishments, with uncomplicated tasks, minimize failure and increase self-worth. (C) Asking a client to set a goal to make all decisions about attending group activities is unrealistic, and such decisions are not always under the client's control; this sets up the client for further failure and possibly decreased self-worth.

  (D)

  Encouragement toward independence does promote increased feelings of selfworth; however, clients may need assistance with decision making and problem solving for various situations and on an individual basis.

• Question 728:

  The nurse is teaching a mother care of her child's spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be:

  A. "Blowing air under the cast using a hair dryer on cool setting often relieves itching."

  B. "Slide a ruler under the cast and scratch the area."

  C. "Guide a towel under and through the cast and move it back and forth to relieve the itch."

  D. "Gently thump on cast to dislodge dried skin that causes the itching."

  Correct Answer: A

  (A) Cool air will often relieve pruritus without damaging the cast or irritating the skin. (B) The nurse should never force anything under the cast, because the cast may become damaged and skin breakdown may occur. (C) Forcing an object under the cast could lead to cast damage and skin breakdown. The object may become lodged under the cast necessitating cast removal. (D) This technique does not dislodge skin cells. It could damage the cast and cause skin breakdown.

• Question 729:

  Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client's depression alert the nurse to prioritize problems and care by addressing which of the following problems first:

  A. Nutritional status

  B. Impaired thinking

  C. Possible harm to self

  D. Rest and activity impairment

  Correct Answer: C

  (A) Anorexia and weight loss are problems that need attention in severe depression, but they can be addressed secondary to immediate concerns. (B) Impaired thinking and confusion are problems in severe depression that are addressed with administration of medication, through group and individual psychotherapy, and through activity therapy as motivation and interest increase. (C) Possible harm to self as with suicidal ideation; a suicide plan, means to execute plan; and/or overt gestures or an attempt must be addressed as an immediate concern and safety measures implemented appropriate to the risk of suicide. (D) Rest and activity impairment may take time and further assessment to determine client's sleep pattern and amount of psychomotor retardation with the more immediate concern for safety present.

• Question 730:

  In performing the initial nursing assessment on a client at the prenatal clinic, the nurse will know that which of the following alterations is abnormal during pregnancy?

  A. Striae gravidarum

  B. Chloasma

  C. Dysuria

  D. Colostrum

  Correct Answer: C

  (A) Striae gravidarum are the normal stretch marks that frequently occur on the breasts, abdomen, and thighs as pregnancy progresses. (B) Chloasma is the "mask of pregnancy" that normally occurs in many pregnant women. (C) Dysuria is an abnormal danger sign during pregnancy and may indicate a urinary tract infection. (D) Colostrum is a yellow breast secretion that is normally present during the last trimester of pregnancy.