NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 781:

  When inspecting a cardiovascular client, the nurse notes that he needs to sit upright to breathe. This behavior is most indicative of:

  A. Pericarditis

  B. Anxiety

  C. Congestive heart failure

  D. Angina

  Correct Answer: C

  (A) Pericarditis can cause dyspnea but primarily causes chest pain. (B) Anxiety can cause dyspnea resulting in SOB, yet it is not typically influenced by degree of head elevation. (C) The inability to oxygenate well without being upright is most indicative of congestive heart failure, due to alveolar drowning. (D) Angina causes primarily chest pain; any SOB associated with angina is not influenced by body position.

• Question 782:

  Which of the following nursing orders should be included in the plan of care for a client with hepatitis C?

  A. The nurse should use universal precautions when obtaining blood samples.

  B. Total bed rest should be maintained until the client is asymptomatic.

  C. The client should be instructed to maintain a low semi-Fowler position when eating meals.

  D. The nurse should administer an alcohol backrub at bedtime.

  Correct Answer: A

  (A) The source of infection with hepatitis C is contaminated blood products. (B) Modified bed rest should be maintained while the client is symptomatic. Routine activities can be slowly resumed once the client is asymptomatic. (C) Nausea and vomiting occur frequently with hepatitis C. A high Fowler position may decrease the tendency to vomit. (D) The buildup of bilirubin in the client's skin may cause pruritus. Alcohol is a drying agent.

• Question 783:

  The primary reason that an increase in heart rate (100 bpm) detrimental to the client with a myocardial infarction (MI) is that:

  A. Stroke volume and blood pressure will drop proportionately

  B. Systolic ejection time will decrease, thereby decreasing cardiac output

  C. Decreased contractile strength will occur due to decreased filling time

  D. Decreased coronary artery perfusion due to decreased diastolic filling time will occur, which will increase ischemic damage to the myocardium

  Correct Answer: D

  (A) Decreased stroke volume and blood pressure will occur secondary to decreased diastolic filling. (B) Tachycardia primarily decreases diastole; systolic time changes very little. (C) Contractility decreases owing to the decreased filling time and decreased time for fiber lengthening. (D) Decreased O2 supply due to decreased time for filling of the coronary arteriesincreases ischemia and infarct size. Tachycardia primarily robs the heart of diastolic time, which is the primary time for coronary artery filling.

• Question 784:

  A long-term goal for the nurse in planning care for a depressed, suicidal client would be to:

  A. Provide him with a safe and structured environment.

  B. Assist him to develop more effective coping mechanisms.

  C. Have him sign a "no-suicide" contract.

  D. Isolate him from stressful situations that may precipitate a depressive episode.

  Correct Answer: B

  (A) This statement represents a short-term goal. (B) Long-term therapy should be directed toward assisting the client to cope effectively with stress. (C) Suicide contracts represent short-term interventions. (D) This statement represents an unrealistic goal. Stressful situations cannot be avoided in reality.

• Question 785:

  When teaching a mother of a 4-month-old with diarrhea about the importance of preventing dehydration, the nurse would inform the mother about the importance of feeding her child:

  A. Fruit juices

  B. Diluted carbonated drinks

  C. Soy-based, lactose-free formula

  D. Regular formulas mixed with electrolyte solutions

  Correct Answer: C

  (A) Diluted fruit juices are not recommended for rehydration because they tend to aggravate the diarrhea. (B) Diluted soft drinks have a high-carbohydrate content, which aggravates the diarrhea. (C) Soy-based, lactose-free formula reduces stool output and duration of diarrhea in most infants. (D) Regular formulas contain lactose, which can increase diarrhea.

• Question 786:

  The nurse is aware that nutrition is an important aspect of care for a client with hepatitis. Which of the following diets would be most therapeutic?

  A. High protein and low carbohydrate

  B. Low calorie and low protein

  C. High carbohydrate and high calorie

  D. Low carbohydrate and high calorie

  Correct Answer: C

  (A)

  Protein increases the workload of the liver. Increased carbohydrates provide needed calories and promote palatability. (B) Dietary intake should be adequate to ensure wound healing. (C) Increased carbohydrates provide needed calories.

  (D)

  A highcalorie diet is best obtained from carbohydrates because of their palatability. Fats increase the workload of the liver.

• Question 787:

  Which of the following would have the physiological effect of decreasing intracranial pressure (ICP)?

  A. Increased core body temperature

  B. Decreased serum osmolality

  C. Administration of hypo-osmolar fluids

  D. Decreased PaCO2

  Correct Answer: D

  (A) An increase in core body temperature increases metabolism and results in an increase in ICP. (B) Decreased serum osmolality indicates a fluid overload and may result in an increase in ICP. (C) Hypo-osmolar fluids are generally voided in the neurologically compromised. Using IV fluids such as D5W results in the dextrose being metabolized, releasing free water that is absorbed by the brain cells, leading to cerebral edema. (D) Hypercapnia and hypoventilation, which cause retention of CO2 and lead to respiratory acidosis, both increase ICP. CO2 is the most potent vasodilator known.

• Question 788:

  Which of the following would the nurse expect to find following respiratory assessment of a client with advanced emphysema?

  A. Distant breath sounds

  B. Increased heart sounds

  C. Decreased anteroposterior chest diameter

  D. Collapsed neck veins

  Correct Answer: A

  (A) Distant breath sounds are found in clients with emphysema owing to increased anteroposterior chest diameter, overdistention, and air trapping. (B) Deceased heart sounds arepresent because of the increased anteroposterior chest diameter. (C) A barrel- shaped chest is characteristic of emphysema. (D) Increased distention of neck veins is found owing to right-sided heart failure, which may be present in advanced emphysema.

• Question 789:

  A client is 6 weeks pregnant. During her first prenatal visit, she asks, "How much alcohol is safe to drink during pregnancy?" The nurse's response is:

  A. Up to 1 oz daily

  B. Up to 2 oz daily

  C. Up to 4 oz weekly

  D. No alcohol

  Correct Answer: D

  (A, B, C) No amount of alcohol has been determined safe for pregnant women. Alcohol should be avoided owing to the risk of fetal alcohol syndrome. (D) The recommended safe dosage of alcohol consumption during pregnancy is none.

• Question 790:

  The most commonly known vectors of Lyme disease are:

  A. Mites

  B. Fleas

  C. Ticks

  D. Mosquitoes

  Correct Answer: C

  (A) Mites are not the common vector of Lyme disease. (B) Fleas are not the common vector of Lyme disease. (C) Ticks are the common vector of Lyme disease. (D) Mosquitoes are not the common vector of Lyme disease.