NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 751:

  The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which of the following indicates that he understands this teaching?

  A. "I'll be sure to rise slowly and sit for a few minutes after lying down."

  B. "I'll be sure to walk at least 2- blocks every day."

  C. "I'll be sure to restrict my fluid intake to four or five glasses a day."

  D. "I'll be sure not to take any more aspirin while I am on this drug."

  Correct Answer: A

  (A) This response will help to prevent the occurrence of postural hypotension, a common side effect of this drug and a common reason for falls. (B) Although walking is an excellent exercise, it is not specific to the reduction of risks associated with diuretic therapy. (C) Clients on diuretic therapy are generally taught to ensure that their fluid intake is at least 2000?000 mL daily, unless contraindicated. (D) Aspirin is a safe drug to take along with furosemide.

• Question 752:

  A 6-month-old infant has developmental delays. His weight falls below the 5th percentile when plotted on a growth chart. A diagnosis of failure to thrive is made. What behaviors might indicate the possibility of maternal deprivation?

  A. Responsive to touch, wants to be held

  B. Uncomforted by touch, refuses bottle

  C. Maintains eye-to-eye contact

  D. Finicky eater, easily pacified, cuddly

  Correct Answer: B

  (A) Normal infant attachment behaviors include responding to touch and wanting to be held. (B) Maternal deprivation behaviors include poor feeding, stiffening and refusal to eat, and inconsistencies in responsiveness. (C) Attachment behavior includes maintaining eye contact. (D) Maternal deprivation behaviors include displeasure with touch and physical contact.

• Question 753:

  A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 lb from her 7th to 8th month; her face and hands indicate edema. She is diagnosed as having PIH and referred to the high-risk prenatal clinic. The client's weight increase is most likely due to:

  A. Overeating and subsequent obesity

  B. Obesity prior to conception

  C. Hypertension due to kidney lesions

  D. Fluid retention

  Correct Answer: D

  (A) Overeating can lead to obesity, but not to edema. (B) There is no indication of obesity prior to pregnancy. PIH is more prevalent in the underweight than in the obese in this age group. (C) Hypertension can be due to kidney lesions, but it would have been apparent earlier in the pregnancy. (D) The weight gain in PIH is due to the retention of sodium ions and fluid and is one of the three cardinal symptoms of PIH.

• Question 754:

  To prevent fungal infections of the mouth and throat, the nurse should teach clients on inhaled steroids to:

  A. Rinse the plastic holder that aerosolizes the drug with hydrogen peroxide every other day

  B. Rinse the mouth and gargle with warm water after each use of the inhaler

  C. Take antacids immediately before inhalation to neutralize mucous membranes and prevent infection

  D. Rinse the mouth before each use to eliminate colonization of bacteria

  Correct Answer: B

  (A)

  It is sufficient to rinse the plastic holders with warm water at least once per day. (B) It is important to rinse the mouth after each use to minimize the risk of fungal infections by reducing the droplets of the glucocorticoid left in the oral cavity.

  (C)

  Antacids act by neutralizing or reducing gastric acid, thus decreasing the pH of the stomach. "Neutralizing" the oral mucosa prior to inhalation of a steroid inhaler does not minimize the risk of fungal infections. (D) Rinsing prior to the use of the glucocorticoid will not eliminate the droplets left on the oral mucous membranes following the use of the inhaler.

• Question 755:

  A client is admitted to the labor unit. On vaginal examination, the presenting part in a cephalic presentation was at station plus two. Station 12 means that the:

  A. Presenting part is 2 cm above the level of the ischial spines

  B. Biparietal diameter is at the level of the ischial spines

  C. Presenting part is 2 cm below the level of the ischial spines

  D. Biparietal diameter is 5 cm above the ischial spines

  Correct Answer: C

  (A) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is above the ischial spines, the station is negative. (B) When the biparietal diameter is at the level of the ischial spines, the presenting part is generally at a +4 or +5 station. (C) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is below the ischial spines, the station is positive. Thus, 2 cm below the ischial spines is the station +2. (D) When the biparietal diameter is above the ischial spines by 5 cm, the presenting part is usually engaged or at station 0.

• Question 756:

  The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:

  A. Immediate treatment of mild PIH includes the administration of a variety of medications

  B. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation

  C. Self-discipline is required to control caloric intake throughout the pregnancy

  D. The client may not recognize the early symptoms of PIH

  Correct Answer: D

  (A) Mild PIH is not treated with medications. (B) Emotional stress is not the cause of blood pressure elevation in PIH. (C) Excessive caloric intake is not the cause of weight gain in PIH. (D) The client most frequently is not aware of the signs and symptoms in mild PIH.

• Question 757:

  Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who suffered partial- and fullthickness burns to 25% of her body?

  A. Urine output

  B. Edema

  C. Hypertension

  D. Bulging fontanelle

  Correct Answer: A

  (A) Urinary output is a reliable indicator of renal perfusion, which in turn indicates that fluid resuscitation is adequate. IV fluids are adjusted based on the urinary output of the child during fluid resuscitation. (B) Edema is an indication of increased capillary permeability following a burn injury. (C) Hypertension is an indicator of fluid volume excess. (D) Fontanelles close by 18 months of age.

• Question 758:

  A mother came to the pediatric clinic with her 17- month-old child. The mother would like to begin toilet training. What should the nurse teach her about implementing toilet training?

  A. Take two or three favorite toys with the child.

  B. Have a child-sized toilet seat or training potty on hand.

  C. Explain to the child she is going to "void" and "defecate."

  D. Show disapproval if she does not void or defecate.

  Correct Answer: B

  (A) Giving her toys will distract her and interfere with toilet training because of inappropriate reinforcement. (B) A child-sized toilet seat or training potty gives a child a feeling of security. (C) She should use words that are age appropriate for the child. (D) Children should be praised for cooperative behavior and/or successful evacuation.

• Question 759:

  A client is in early labor. Her fetus is in a left occipitoanterior (LOA) position; fetal heart sounds are best auscultated just:

  A. Below the umbilicus toward left side of mother's abdomen

  B. Below the umbilicus toward right side of mother's abdomen

  C. At the umbilicus

  D. Above the umbilicus to the left side of mother's abdomen

  Correct Answer: A

  (A) LOA identifies a fetus whose back is on its mother's left side, whose head is the presenting part, and whose back is toward its mother's anterior. It is easiest to auscultate fetal heart tones (FHTs) through the fetus's back. (B) The identified fetus's back is on its mother's left side, not right side. It is easiest to auscultate FHTs through the fetus's back. (C) In an LOA position, the fetus's head is presenting with the back to the left anterior side of the mother. The umbilicus is too high of a landmark for auscultating the fetus's heart rate through its back. (D) This is the correct auscultation point for a fetus in the left sacroanterior position, where the sacrum is presenting, not LOA.

• Question 760:

  A nasogastric (NG) tube inserted preoperatively is attached to low, intermittent suctions. A client with an NG tube exhibits these symptoms: He is restless; serum electrolytes are Na 138, K 4.0, blood pH 7.53. This client is most likely experiencing:

  A. Hyperkalemia

  B. Hyponatremia

  C. Metabolic acidosis

  D. Metabolic alkalosis

  Correct Answer: D

  (A) Sodium level is within normal limits. (B) Sodium level is within normal limits. (C) pH level is consistent with alkalosis. (D) With an NG tube attached to low, intermittent suction, acids are removed and a client will develop metabolic alkalosis.