NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 71:

  A client is receiving IV morphine 2 days after colorectal surgery. Which of the following observations indicate that he may be becoming drug dependent?

  A. The client requests pain medicine every 4 hours.

  B. He is asleep 30 minutes after receiving the IV morphine.

  C. He asks for pain medication although his blood pressure and pulse rate are normal.

  D. He is euphoric for about an hour after each injection.

  Correct Answer: D

  (A) Frequent requests for pain medication do not necessarily indicate drug dependence after complex surgeries such as colorectal surgery. (B) Sleeping after receiving IV morphine is not an unexpected effect because the pain is relieved. (C) A person may be in pain even with normal vital signs. (D) A subtle sign of drug dependency is the tendency for the person to appear more euphoric than relieved of pain.

• Question 72:

  A 2-year-old toddler is hospitalized with epiglottitis. In assessing the toddler, the nurse would expect to find:

  A. A productive cough

  B. Expiratory stridor

  C. Drooling

  D. Crackles in the lower lobes

  Correct Answer: C

  (A) A productive cough is not associated with epiglottitis. (B) Children with epiglottitis seldom have expiratory stridor. Inspiratory stridor is more common due to edema of the supraglottic tissues. (C) Because of difficulty with swallowing, drooling often accompanies epiglottitis. (D) Crackles are not heard in the lower lobes with epiglottitis because the infection is usually confined to the supraglottic structures.

• Question 73:

  When assessing a female child for Turner's syndrome, the nurse observes for which of the following symptoms?

  A. Tall stature

  B. Amenorrhea

  C. Secondary sex characteristics

  D. Gynecomastia

  Correct Answer: B

  (A) This syndrome is caused by absence of one of the X chromosomes. These children are short in stature. (B) Amenorrhea is a symptom of Turner's syndrome, which appears at puberty. (C) Sexual infantilism is characteristic of this syndrome. (D) Gynecomastia is a symptom in Klinefelter's syndrome.

• Question 74:

  Nursing assessment of early evidence of septic shock in children at risk includes:

  A. Fever, tachycardia, and tachypnea

  B. Respiratory distress, cold skin, and pale extremities

  C. Elevated blood pressure, hyperventilation, and thready pulses

  D. Normal pulses, hypotension, and oliguria

  Correct Answer: A

  (A) Fever, tachycardia, and tachypnea are the classic early signs of septic shock in children. (B) Respiratory distress, cold skin, and pale extremities are later signs of septic shock. (C) Elevated blood pressure, hyperventilation, and thready pulses are later signs of septic shock. (D) Normal pulses, hypotension, and oliguria are not early signs of septic shock.

• Question 75:

  During the assessment, the nurse observes a client scratching his skin. He has been admitted to rule out Laennec's cirrhosis of the liver. The nurse knows the pruritus is directly related to:

  A. A loss of phagocytic activity

  B. Faulty processing of bilirubin

  C. Enhanced detoxification of drugs

  D. The formation of collateral circulation

  Correct Answer: B

  (A) A loss in the phagocytic activity of the Kupffer cells occurs with cirrhosis of the liver, which increases the susceptibility to infections. (B) The faulty processing of bilirubin produces bilesalts, which are irritating to the skin. (C) The detoxification of drugs is impaired with cirrhosis of the liver. (D) Collateral circulation develops due to portal hypertension. This is manifest through the development of esophageal varices, hemorrhoids, and caput medusae.

• Question 76:

  The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 1? hours if needed. The most likely rationale for this order is:

  A. The client will settle down more quickly if he thinks the staff is medicating him

  B. The medication will sedate the client until the physician arrives

  C. Haloperidol is a minor tranquilizer and will not oversedate the client

  D. Rapid neuroleptization is the most effective approach to care for the violent or potentially violent client

  Correct Answer: D

  (A) If the client could think logically, he would not be paranoid. In fact, he is probably suspicious of the staff, too. Newly admitted clients frequently experience high levels of anxiety, which can contribute to delusions. (B) The goal of pharmacological intervention is to calm the client and assist with reality-based thinking, not to sedate him. (C) Haloperidol is a neuroleptic and antipsychotic drug, not a minor tranquilizer. (D) Haloperidol is a high- potency neuroleptic and first-line choice for rapid neuroleptization, with low potential for sedation.

• Question 77:

  Which of the following lab data is representative of a client with aplastic anemia?

  A. Hemoglobin 9.2, hematocrit 27, red blood cells 3.2 million

  B. White blood cells 4000, erythrocytes 2.5 million, thrombocytes 100,000

  C. White blood cells 3000, hematocrit 27, red blood cells 2.8 million

  D. Red blood cells 1 million, white blood cells 1500, thrombocytes 16,000

  Correct Answer: D

  (A, B, C) Although all of the lab data are abnormal and although these values are decreased in aplastic anemia, the disorder is defined by severe deficits in red cell, white cell, and platelet counts. (D) Aplastic anemia is typically defined in terms of abnormalities of red blood cell count, usually <1 million, white cell count <2,000, and thrombocytes <20,000.

• Question 78:

  A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating include:

  A. Administering diazepam (Valium) 10?5 mg po q4h and q1h prn for hyperventilating episode

  B. Keeping the temperature in the client's room at a high level to reduce respiratory stimulation

  C. Having the client hold her breath or breathe into a paper bag when hyperventilation episodes occur

  D. Using distraction to help control the client's hyperventilation episodes

  Correct Answer: C

  (A) An adult diazepam dosage for treatment of anxiety is 2?0 mg PO 2? times daily. The order as written would place a client at risk for overdose. (B) A high room temperature could increase hyperventilating episodes by stimulating the respiratory system. (C) Breath holding and breathing into a paper bag may be useful in controlling hyperventilation. Both measures increase CO2 retention. (D) Distraction will not prevent or control hyperventilation caused by anxiety or fear.

• Question 79:

  When preparing insulin for IV administration, the nurse identifies which kind of insulin to use?

  A. NPH

  B. Human or pork

  C. Regular

  D. Long acting

  Correct Answer: C

  (A, B, D) Intermediate-acting and long-acting preparations contain materials that increase length of absorption time from the subcutaneous tissues but cause the preparation to be cloudy and unsuitable for IV use. Human insulin must be given SC. (C) Only regular insulin can be given IV.

• Question 80:

  The nurse notes multiple bruises on the arms and legs of a newly admitted client with lupus. The client states, "I get them whenever I bump into anything." The nurse would expect to note a decrease in which of the following laboratory tests?

  A. Number of platelets

  B. WBC count

  C. Hemoglobin level

  D. Number of lymphocytes

  Correct Answer: A

  (A) Thrombocytopenia, a decrease in platelets, occurs in lupus and causes a decrease in blood coagulation and thrombus formation. (B) Clients with lupus will have a decrease in the WBC count decreasing their resistance to infection. (C) Clients with lupus may have a decrease in the hemoglobin level causing anemia. (D) Leukopenia, a decrease in white blood cells, is seen in lupus and decreases resistance to infection.