NCLEX NCLEX-RN Online Practice Questions and Exam Preparation

NCLEX NCLEX-RN Online Questions & Answers

• Question 751:

  In addition to changing the mother's position to relieve cord pressure, the nurse may employ the following measure (s) in the event that she observes the cord out of the vagina:

  A. Immediately pour sterile saline on the cord, and repeat this every 15 minutes to prevent drying.
  B. Cover the cord with a wet sponge.
  C. Apply a cord clamp to the exposed cord, and cover with a sterile towel.
  D. Keep the cord warm and moist by continuous applications of warm, sterile saline compresses.
  D. Keep the cord warm and moist by continuous applications of warm, sterile saline compresses.

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  (A) Saline should be warmed; waiting 15 minutes may not keep the cord moist. (B) This choice does not specify what the sponge was "wet" with. (C) This measure would stop circulation to the fetus. (D) The cord should be kept warm and moist to maintain fetal circulation. This measure is an accepted nursing action.

• Question 752:

  A 3-month-old infant has had a unilateral cleft lip repair. He has resumed feedings of oral formula. The nurse should feed the infant with:

  A. Gavage tube
  B. Nipple and bottle
  C. A straw and cup
  D. Syringe
  D. Syringe

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  (A) A gavage tube may damage suture line. It is the most invasive and should be the last measure. (B) A nipple and bottle require sucking, which may damage sutures. (C) A 3- month-old infant is not able to drink from a straw. (D) A syringe allows for the formula to be placed to the side and back of the mouth. This minimizes the amount of sucking needed.

• Question 753:

  A male client is scheduled to have angiography of his left leg. The nurse needs to include which of the following when preparing the client for this procedure?

  A. Validate that he is not allergic to iodine or shellfish.
  B. Instruct him to start active range of motion of his left leg immediately following the procedure.
  C. Inform him that he will not be able to eat or drink anything for 4 hours after the procedure.
  D. Inform him that vital signs will be taken every hour for 4 hours after the procedure.
  A. Validate that he is not allergic to iodine or shellfish.

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  (A) Angiography, an invasive radiographic examination, involves the injection of a contrast solution (iodine) through a catheter that has been inserted into an artery. (B) The client is kept on complete bed rest for 6?2 hours after the procedure. The extremity in which the catheter was inserted must be immobilized and kept straight during this time. (C) The contrast dye, iodine, is nephrotoxic. The client must be instructed to drink a large quantity of fluids to assist the kidneys in excreting this contrast media. (D) The major complication of this procedure is hemorrhage. Vital signs are assessed every 15 minutes initially for signs of bleeding.

• Question 754:

  A client is experiencing muscle weakness and lethargy. His serum K+is 3.2. What other symptoms might he exhibit?

  A. Tetany
  B. Dysrhythmias
  C. Numbness of extremities
  D. Headache
  B. Dysrhythmias

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  (A) Tetany is seen with low calcium. (B) Low potassium causes dysrhythmias because potassium is responsible for cardiac muscle activity. (C) Numbness of extremities is seen with high potassium. (D) Headache is not associated with potassium excess or deficiency.

• Question 755:

  At her monthly prenatal visit, a client reports experiencing heartburn. Which nursing measure should be included in her plan of care to help alleviate it?

  A. Restrict fluid intake.
  B. Use Alka-Seltzer as necessary.
  C. Eat small, frequent bland meals.
  D. Lie down after eating.
  C. Eat small, frequent bland meals.

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  (A) At least eight glasses of fluid per day are encouraged to help dilute stomach contents, thereby decreasing irritation. (B) Alka Seltzer contains aspirin, which is irritating to gastric mucosa, and therefore should be avoided. (C) Small, frequent bland meals help to decrease gastric pressure and to prevent reflux. (D) Lying down after meals may cause gastric reflux and prevents optimal gastric emptying.

• Question 756:

  A client has received preoperative teaching for the vertical partial laryngectomy that he is scheduled to have in the morning. The nurse determines that the teaching has been effective when the client states:

  A. "I know I will need special swallowing training after my surgery."
  B. "The quality of my voice will be excellent after surgery."
  C. "I will have very little difficulty swallowing after surgery."
  D. "I may also have to have a radical neck dissection done."
  C. "I will have very little difficulty swallowing after surgery."

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  (A) A client with a supraglottic (horizontal partial) laryngectomy would require special swallowing training, not a vertical partial laryngectomy. (B) The quality of the client's voice will be altered but adequate for communication. (C) The client will have minimal difficulty swallowing. (D) A radical neck dissection may be done with a total laryngectomy, but not with a partial laryngectomy.

• Question 757:

  Which of the following nursing actions is essential to prevent drug-resistant tuberculosis?

  A. Monitor liver function.
  B. Monitor renal function.
  C. Assess knowledge of respiratory isolation.
  D. Monitor compliance with drug therapy.
  D. Monitor compliance with drug therapy.

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  (A) Monitoring liver function will not prevent the development of drug-resistant organisms. (B) Monitoring renal function will not prevent the development of drug-resistant organisms. (C) Knowledge of respiratory isolation will reduce

  transmission of tuberculosis but will not prevent development of drug-resistant organisms. (D) Noncompliance with prescribed antituberculosis drug regimen is the primary cause of drug-resistant organisms.

  Noncompliance permits the mutation of organisms.

• Question 758:

  The nurse in the mental health center is instructing a depressed client about the dietary restrictions necessary in taking her medication, which is a monoamine oxidase (MAO) inhibitor. Which of the following is she restricting from the client's diet?

  A. Cream cheese
  B. Fresh fruits
  C. Aged cheese
  D. Yeast bread
  C. Aged cheese

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  (A) Cream cheese does not contain tyramine, which might cause a hypertensive crisis. (B) Fresh fruits do not contain tyramine, which might cause a hypertensive crisis. (C) Aged or matured cheese combined with a monoamine oxidase predisposes the client to a hypertensive crisis. (D) Bread products raised with yeast do not contain tyramine.

• Question 759:

  An infant weighing 15 lb has just been treated for severe diarrhea in the hospital. Discharge instructions by the nurse will include maintenance fluid requirements for the pediatric client. Which of the following values best indicates the nurse's understanding of normal fluid requirements for this infant?

  A. 240 mL/day
  B. 680 mL/day
  C. 330 mL/day
  D. 960 mL/day
  B. 680 mL/day

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  (A, C, D) These answers are incorrect. (B) Normal fluid requirement for this pediatric client is based on the fact that 0?0 kg of weight equals 100 mL/kg per day. This infant weighs 15 pounds (6.8 kg). Thus, 100 mL X 6.8 = 680 mL/day.

• Question 760:

  The nurse has been assigned a client who delivered a 6- lb, 12-oz baby boy vaginally 40 minutes ago. The initial assessment of greatest importance for this client would be:

  A. Length of her labor
  B. Type of episiotomy
  C. Amount of IV fluid to be infused
  D. Character of the fundus
  D. Character of the fundus

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  The length of labor has little bearing on the fourth stage of labor. The type of labor and delivery is significant. (B) The type of episiotomy will affect the client's comfort level. However, the nurse's assessment and implementations center on prevention of hemorrhage during the fourthstage of labor. The amount of bleeding from the episiotomy or hematoma formation is of higher priority than the type of episiotomy. (C) The amount of IV fluid to be infused is a nursing function to be attended to; however, it is lower in priority than determining if hemorrhaging is occurring. (D) Character of the fundus would be the priority nursing assessment because changes in uterine tone may identify possible postpartum hemorrhage.