NCLEX NCLEX-RN Online Practice Questions and Exam Preparation

NCLEX NCLEX-RN Online Questions & Answers

• Question 771:

  A client has just been transferred to the floor from the labor and delivery unit following delivery of a stillborn term infant. She is very despondent. When the nurse attempts to take her vital signs, she responds in anger, stating, "You leave me alone. You don't care anything about me. It's people like you who let my baby die." The nurse's best course of action is to:

  A. Quietly leave her room, allowing her more private time to deal with her loss.
  B. Tell her that what happened was for the best and that she is still young and can have other children.
  C. Tell her how sorry you are, and let her know that her child is now a little angel in heaven.
  D. Tell her how sorry you are about the loss of her baby, and acknowledge her anger as being a normal stage of grief. Assure her that you are there to help her in any way you can.
  D. Tell her how sorry you are about the loss of her baby, and acknowledge her anger as being a normal stage of grief. Assure her that you are there to help her in any way you can.

  ---

  (A)

  Parents do need their privacy following a loss, but the nurse still has a responsibility to provide postpartum physical care. (B) This is a negative statement, which is not therapeutic. The client is not concerned about future children but is in the first stages of grief, denial, and anger. (C) This is a negative statement, which is not therapeutic. The client does not want to hear about her baby in heaven. She cannot believe that God could love or want her child more than she could.

  (D)

  Acknowledging that anger is normal and beneficial will help the client to understand the normal stages of grief. Expressing sorrow over her loss and assuring her that the support is there to take care of her physical and emotional needs will help to promote a trusting relationship.

• Question 772:

  A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurse instructs the client to:

  A. Clean the sutured laceration twice a day with povidone- iodine (Betadine)
  B. Remove his scalp sutures after 5 days
  C. Return to the hospital immediately if he develops confusion, nausea, or vomiting
  D. Take meperidine 50 mg po q4?h prn for headache
  C. Return to the hospital immediately if he develops confusion, nausea, or vomiting

  ---

  (A) Povidone-iodine is very irritating to skin and should not be routinely used. (B) Sutures should not be removed by the client. (C) Confusion, nausea, vomiting, and behavioral changes may indicate increasing intracranial pressure as a result of intracerebral bleeding. (D) Use of a narcotic opiate such as meperidine is not recommended in clients with a possible head injury because it may produce sedation, pupil changes, euphoria, and respiratory depression, which may mask the signs of increasing intracranial pressure.

• Question 773:

  The nurse is teaching a client how to perform monthly testicular self-examination (TSE) and states that it is best to perform the procedure right after showering. This statement is made by the nurse based on the knowledge that:

  A. The client is more likely to remember to perform the TSE when in the nude
  B. When the scrotum is exposed to cool temperatures, the testicles become large and bulky
  C. The scrotum will be softer and more relaxed after a warm shower, making the testicles easier to palpate
  D. The examination will be less painful at this time
  C. The scrotum will be softer and more relaxed after a warm shower, making the testicles easier to palpate

  ---

  (A) Nudity is not a trigger for reminding males to perform TSE. (B) Testicles become more firm when exposed to cool temperatures, but not large and bulky. (C) The testicles will be lower and more easily palpated with warmer temperatures. A protective mechanism of the body to protect sperm production is for the scrotum to pull closer to the body when exposed to cooler temperatures. (D) The examination should not be painful.

• Question 774:

  A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and kill her. The best verbal response to the client by the nurse at this time is:

  A. "I understand that the voices are real to you, but I want you to know I don't hear them. They are a symptom of your illness."
  B. "Just don't pay attention to the voices. They'll go away after some medication."
  C. "You can't leave here. This unit is locked and the doctor has not ordered your discharge."
  D. "We will have to put you in seclusion and restraints for a while. You could hurt someone with thoughts like that."
  A. "I understand that the voices are real to you, but I want you to know I don't hear them. They are a symptom of your illness."

  ---

  (A) This response validates the client's experience and presents reality to him. (B) This nontherapeutic response minimizes and dismisses the client's verbalized experience. (C) This response can be interpreted by a paranoid client as a threat, thereby increasing the client's potential for violence and loss of control. (D) This response is also threatening. The client's behavior does not call for restraints because he has not lost control or hurt anyone. If seclusion or restraints were indicated, the nurse should never confront the client alone.

• Question 775:

  A 48-year-old client is in the surgical intensive care unit after having had three-vessel coronary artery bypass surgery yesterday. She is extubated, awake, alert and talking. She is receiving digitalis for atrial arrhythmias. This morning serum electrolytes were drawn. Which abnormality would require immediate intervention by the nurse after contacting the physician?

  A. Serum osmolality is elevated indicating hemoconcentration. The nurse should increase IV fluid rate.
  B. Serum sodium is low. The nurse should change IV fluids to normal saline.
  C. Blood urea nitrogen is subnormal. The nurse should increase the protein in the client's diet as soon as possible.
  D. Serum potassium is low. The nurse should administer KCl as ordered.
  D. Serum potassium is low. The nurse should administer KCl as ordered.

  ---

  (A) An elevated serum osmolality poses no immediate danger and is not corrected rapidly. (B) A low serum sodium alone does not warrant changing IV fluids to normal saline. Other assessment parameters, such as hydration status, must be considered. (C) A low serum blood urea nitrogen is not necessarily indicative of protein deprivation. It may also be the result of overhydration. (D)A low serum potassium potentiates the effects of digitalis, predisposing the client to dangerous arrhythmias. It must be corrected immediately.

• Question 776:

  A client is dilated 8 cm and entering the transition phase of labor. Common behaviors of the laboring woman during transition are:

  A. Frustration, vague in communication
  B. Seriousness, some difficulty following directions
  C. Calmness, follows directions easily
  D. Excitement, openness to instructions
  A. Frustration, vague in communication

  ---

  (A) During the transition phase, the mother may become frustrated and unclear in her communication owing to severe pain and fear of loss of control. (B) These behaviors are common in the active phase of labor. (C) These behavioral clues are seen in the latent phase of labor. (D) These characteristics are observed in the latent phase of labor.

• Question 777:

  At her first prenatal visit, a 21-year-old woman who is gravida 2, para 0, ab 1, is currently at 32 weeks' gestation and has a history of drug abuse, smoking, and occasional ethyl alcohol use. Fetal ultrasound tests indicate poor fetal growth. The most likely reason for the infant's intrauterine growth retardation is:

  A. The client's young age
  B. The client's previous abortion
  C. The client's history of drug, ethyl alcohol, and tobacco use
  D. The client's late prenatal care
  C. The client's history of drug, ethyl alcohol, and tobacco use

  ---

  (A) Although adolescents frequently have a higher incidence of low-birth-weight infants, this client is 21 years old. (B) Uncomplicated induced abortions have not been proved to influence the growth of infants of subsequent pregnancies. (C) Compounds in cigarettes and some illicit drugs cause maternal vasoconstriction and a subsequent reduction in O2 availability for the fetus owing to the resulting reduction in uteroplacental blood flow. As few as one or two drinks of alcohol per day will decrease birth weight. (D) Although early prenatal care has been shown to improve pregnancy outcomes, not seeking care until the second week of gestation does not, in and of itself, cause intrauterine growth retardation.

• Question 778:

  A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse:

  A. Must use the least restrictive measure possible to control the behavior
  B. Should put the client in seclusion until he promises to behave appropriately
  C. Should apply full restraints until the behavior is under control
  D. Should allow other clients to observe the acting out so that they can learn from the experience
  A. Must use the least restrictive measure possible to control the behavior

  ---

  (A) This answer is correct. Least restrictive measures should always be attempted before a client is placed in seclusion or restraints. The nurse should first try a calm verbal approach, suggest a quiet room, or request that the client take "timeout" before placing the client in seclusion, givingmedication as necessary, or restraining. (B) This answer is incorrect. A calm verbal approach or requesting that a client go to his room should be attempted before restraining. (C) This answer is incorrect. Restraints should be applied only after all other measures fail to control the behavior. (D) This answer is incorrect. Other clients should be removed from the area. It is often very anxiety producing for other clients to see a peer out of control. It could also lead to mass acting- out behaviors.

• Question 779:

  The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should:

  A. Increase his nasal O2 to 6 L/min
  B. Place him in a lateral Sims' position
  C. Encourage pursed-lip breathing D. Have him breathe into a paper bag
  C. Encourage pursed-lip breathing D. Have him breathe into a paper bag

  ---

  (A) Giving too high a concentration of O2 to a client with em-physema may remove his stimulus to breathe. (B) The client should sit forward with his hands on his knees or an overbed table and with shoulders elevated. (C) Pursed-lip breathing helps the client to blow off CO2 and to keep air passages open. (D) Covering the face of a client extremely short of breath may cause anxiety and further increase dyspnea.

• Question 780:

  A client is 2 hours post ventriculoperitoneal shunt placement. How should the nurse position the client?

  A. Head of bed elevated 30 degrees on nonoperative side
  B. Head of bed elevated 30 degrees on operative side
  C. Bed flat on operative side
  D. Bed flat on nonoperative side
  D. Bed flat on nonoperative side

  ---

  (A) Elevation of head on nonoperative side would be the position for the late postoperative period. (B) Positioning on operative side puts pressure on the suture lines and on the shunt valve. Elevation of head in immediate postoperative period may cause rapid reduction of cerebrospinal fluid. (C) Placement on operative side puts pressure on the suture lines and shunt valve. (D) Flat position on nonoperative side in the immediate postoperative period prevents pressure on shunt valve and rapid reduction in cerebrospinal fluid.