NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 731:

  The nurse observes that a client has difficulty chewing and swallowing her food. A nursing response designed to reduce this problem would include:

  A. Ordering a full liquid diet for her

  B. Ordering five small meals for her

  C. Ordering a mechanical soft diet for her

  D. Ordering a puréed diet for her

  Correct Answer: C

  (A) Full liquids would be difficult to swallow if the muscle control of the swallowing act is affected; this is a probable reason for her difficulties, given her medical diagnosis of multiple sclerosis. (B) Five small meals would do little if anything to decrease her swallowing difficulties, other than assure that she tires less easily. (C) A mechanical soft diet should be easier to chew and swallow, because foods would be more evenly consistent. (D) A pureed diet would cause her to regress more than might be needed; the mechanical soft diet should be tried first.

• Question 732:

  One of the medications that is prescribed for a male client is furosemide (Lasix) 80 mg bid. To reduce his risk of falls, the nurse would teach him to take this medication:

  A. On arising and no later than 6 PM

  B. At evenly spaced intervals, such as 8 AM and 8 PM

  C. With at least one glass of water per pill

  D. With breakfast and at bedtime

  Correct Answer: A

  (A) This option provides adequate spacing of the medication and will limit the client's need to get up to go to the bathroom during the night hours, when he is especially at high risk for falls. (B) This option would result in the need to get up during the night to urinate and would thus increase the risk of falls. This option also does not take into consideration the client's usual daily routine. (C) Taking this medication with at least one glass of water would not have an impact on the risk of falls. (D) This option would result in the need to get up during the night to urinate and would thus increase the risk of falls.

• Question 733:

  Which nursing implication is appropriate for a client undergoing a paracentesis?

  A. Have the client void before the procedure.

  B. Keep the client NPO.

  C. Observe the client for hypertension following the procedure.

  D. Place the client on the right side following the procedure.

  Correct Answer: A

  (A) A full bladder would impede withdrawal of ascitic fluid. (B) Keeping the client NPO is not necessary. (C) The client may exhibit signs and symptoms of shock and hypertension. (D) No position change is needed after the procedure.

• Question 734:

  A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching?

  A. "If he develops diarrhea lasting for more than 2? days, I will contact the doctor or nurse."

  B. "I should anticipate that he will gain about 1 lb/day now that he is on continuous feedings."

  C. "It is important to keep the head of his bed elevated or sit him in the chair during feedings."

  D. "I should use prepared or open formula within 24 hours and store unused portions in the refrigerator."

  Correct Answer: B

  (A) Diarrhea is a complication of tube feedings that can lead to dehydration. Diarrhea may be the result of hypertonic formulas that can draw fluid into the bowel. Other causes of diarrhea may be bacterial contamination, fecal impaction, medications, and low albumin. (B) A consistent weight gain of more than 0.22 kg/day (12 lb/day) over several days should be reported promptly. The client should be evaluated for fluid volume excess. (C) Elevating the client's head prevents reflux and thus formula from entering the airway. (D) Bacteria proliferate rapidly in enteral formulas and can cause gastroenteritis and even sepsis.

• Question 735:

  A mother continues to breast-feed her 3-month-old infant. She tells the nurse that over the past 3 days she has not been producing enough milk to satisfy the infant. The nurse advises the mother to do which of the following?

  A. "Start the child on solid food."

  B. "Nurse the child more frequently during this growth spurt."

  C. "Provide supplements for the child between breastfeeding so you will have enough milk."

  D. "Wait 4 hours between feedings so that your breasts will fill up."

  Correct Answer: B

  (A) Solid foods introduced before 4? months of age are not compatible with the abilities of the GI tract and the nutritional needs of the infant. (B) Production of milk is supply and demand. A common growth spurt occurs at 3 months of age, and more frequent nursing will increase the milk supply to satisfy the infant. (C) Supplementation will decrease the infant's appetite and in turn decrease the milk supply. When the infant nurses less often or with less vigor, the amount of milk produced decreases. (D) Rigid feeding schedules lead to a decreased milk supply, whereas frequent nursing signals the mother's body to produce a correspondingly increased amount of milk.

• Question 736:

  A mother frantically calls the emergency room (ER) asking what to do about her 3-year-old girl who was found eating pills out of a bottle in the medicine cabinet. The ER nurse tells the mother to:

  A. Give the child 15 mL of syrup of ipecac.

  B. Give the child 10 mL of syrup of ipecac with a sip of water.

  C. Give the child 1 cup of water to induce vomiting.

  D. Bring the child to the ER immediately.

  Correct Answer: D

  (A) Before giving any emetic, the substance ingested must be known. (B) At least 8 oz of water should be administered along with ipecac syrup to increase volume in the stomach and facilitate vomiting. (C) Water alone will not induce vomiting. An emetic is necessary to facilitate vomiting. (D) Vomiting should never be induced in an unconscious client because of the risk of aspiration.

• Question 737:

  The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take?

  A. Place a tongue blade in the child's mouth.

  B. Restrain the child so he will not injure himself.

  C. Go to the nurses station and call the physician.

  D. Move furniture out of the way and place a blanket under his head.

  Correct Answer: D

  (A) The nurse should not put anything in the child's mouth during a seizure; this action could obstruct the airway. (B) Restraining the child's movements could cause constrictive injury. (C) Staying with the child during a seizure provides protection and allows the nurse to observe the seizure activity. (D) The nurse should provide safety for the child by moving objects and protecting the head.

• Question 738:

  The nurse instructs a pregnant client (G2P1) to rest in a side-lying position and avoid lying flat on her back. The nurse explains that this is to avoid "vena caval syndrome," a condition which:

  A. Occurs when blood pressure increases sharply with changes in position

  B. Results when blood flow from the extremities is blocked or slowed

  C. Is seen mainly in first pregnancies

  D. May require medication if positioning does not help

  Correct Answer: B

  (A) Blood pressure changes are predominantly due to pressure of the gravid uterus. (B) Pressure of the gravid uterus on the inferior vena cava decreases blood return from lower extremities. (C) Inferior vena cava syndrome is experienced in the latter months of pregnancy regardless of parity. (D) There are no medications useful in the treatment of interior vena cava syndrome; alleviating pressure by position changes is effective.

• Question 739:

  During a client's first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus.

  This may be due to:

  A. Endometritis

  B. Fibroid tumor on the uterus

  C. Displacement due to bowel distention

  D. Urine retention or a distended bladder

  Correct Answer: D

  (A, B) Endometritis, urine retention, or bladder distention provide good distractors because they may delay involution but do not usually cause the uterus to be lateral. (C) Bowel distention and constipation are common in the postpartum period but do not displace the uterus laterally. (D) Urine retention or bladder distention commonly displaces the uterus to the right and may delay involution.

• Question 740:

  A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to be boggy, high, and deviated to the right. The most appropriate nursing action is to:

  A. Notify the physician

  B. Place the client on a pad count

  C. Massage the uterus and re-evaluate in 30 minutes

  D. Have the client void and then re-evaluate the fundus

  Correct Answer: D

  (A) The nurse should initiate actions to remove the most frequent cause of uterine displacement, which involves emptying the bladder. Notifying the physician is an inappropriate nursing action. (B) The pad count gives an estimate of blood loss, which is likely to increase with a boggy uterus; but this action does not remove the most frequent cause of uterine displacement, which is a full bladder. (C) Massage may firm the uterus temporarily, but if a full bladder is not emptied, the uterus will remain displaced and is likely to relax again. (D) The most common cause of uterine displacement is a full bladder.