NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 791:

  A child is admitted to the emergency room with her mother. Her mother states that she has been exposed to chickenpox. During the assessment, the nurse would note a characteristic rash:

  A. That is covered with vesicular scabs all in the macular stage

  B. That appears profusely on the trunk and sparsely on the extremities

  C. That first appears on the neck and spreads downward

  D. That appears especially on the cheeks, which gives a "slapped-cheek" appearance

  Correct Answer: B

  (A) A rash with vesicular scabs in all stages (macule, papule, vesicle, and crusts). (B) A rash that appears profusely on the trunk and sparsely on the extremities. (C) A rash that first appears on the neck and spreads downward is characteristic of rubeola and rubella. (D) A rash, especially on the cheeks, that gives a "slapped-cheek" appearance is characteristic of roseola.

• Question 792:

  When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the nurse take?

  A. Continue monitoring because this is a normal occurrence.

  B. Turn client on right side.

  C. Decrease IV fluids.

  D. Report to physician or midwife.

  Correct Answer: D

  (A) This is not a normal occurrence. Late decelerations need prompt intervention for immediate infant recovery. (B) To increase O2 perfusion to the unborn infant, the mother should be placed on her left side. (C) IV fluids should be increased, not decreased. (D) Immediate action is warranted, such as reporting findings, turning mother on left side, administering O2, discontinuing oxytocin (Pitocin), assessing maternal blood pressure and the labor process, preparing for immediate cesarean delivery, and explaining plan of action to client.

• Question 793:

  Priapism may be a sign of:

  A. Altered neurological function

  B. Imminent death

  C. Urinary incontinence

  D. Reproductive dysfunction

  Correct Answer: A

  (A) Priapism in the trauma client is due to the neurological dysfunction seen in spinal cord injury. Priapism is an abnormal erection of the penis; it may be accompanied by pain and tenderness. This may disappear as spinal cord edema is relieved. (B) Priapism is not associated with death. (C) Urinary retention, rather than incontinence, may occur. (D) Reproductive dysfunction may be a secondary problem.

• Question 794:

  One of the most dramatic and serious complications associated with bacterial meningitis is Waterhouse- Friderichsen syndrome, which is:

  A. Peripheral circulatory collapse

  B. Syndrome of inappropriate antiduretic hormone

  C. Cerebral edema resulting in hydrocephalus

  D. Auditory nerve damage resulting in permanent hearing loss

  Correct Answer: A

  (A) Waterhouse-Friderichsen syndrome is peripheral circulatory collapse, which may result in extensive and diffuse intravascular coagulation and thrombocytopenia resulting in death. (B) Syndrome of inappropriate antidiuretic hormone is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. (C) Cerebral edema resulting in hydrocephalus is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. (D) Auditory nerve damage resulting in permanent hearing loss is a complication of meningitis, but it is not Waterhouse- Friderichsen syndrome.

• Question 795:

  As the nurse assesses a male adolescent with chlamydia, the nurse determines that a sign of chlamydia is:

  A. Enlarged penis

  B. Secondary lymphadenitis

  C. Epididymitis

  D. Hepatomegaly

  Correct Answer: C

  (A)

  An enlarged penis is not a sign of chlamydia. (B) Secondary lymphadenitis is a complication of lymphogranuloma venereum. (C) Untreated chlamydial infection can spread from the urethra, causing epididymitis, which presents as a tender, scrotal swelling.

  (D)

  Hepatomegaly is not a complication.

• Question 796:

  A male client receives 10 U of regular human insulin SC at 9:00 AM. The nurse would expect peak action from this injection to occur at: A. 9:30 AM

  B. 10:30 AM

  C. 12 noon

  D. 4:00 PM

  Correct Answer: C

  (A) This is too early for peak action to occur. (B) This is too early for peak action to occur. (C) Regular insulin peak action occurs 2? hours after administration. (D) This is too late for peak action to occur.

• Question 797:

  When a client is receiving vasoactive therapy IV, such as dopamine (Intropin), and extravasation occurs, the nurse should be prepared to administer which of the following medications directly into the site?

  A. Phentolamine (Regitine)

  B. Epinephrine

  C. Phenylephrine (Neo-Synephrine)

  D. Sodium bicarbonate

  Correct Answer: A

  (A) Phentolamine is given to counteract the-adrenergic effects that cause ischemia and necrosis of local tissue. (B) Epinephrine is an endogenous catecholamine that produces vasoconstriction and increases heart rate and contractility. (C) Phenylephrine causes constriction of arterioles of skin, mucous membranes, and viscera, which in turn can cause ischemia and necrosis. (D) Sodium bicarbonate is an alkalinizing agent that is incompatible with dopamine.

• Question 798:

  Which of the following would differentiate acute from chronic respiratory acidosis in the assessment of the trauma client?

  A. Increased PaCO2

  B. Decreased PaO2

  C. Increased HCO3

  D. Decreased base excess

  Correct Answer: C

  (A) Increased CO2 will occur in both acute and chronic respiratory acidosis. (B) Hypoxia does not determine acid-base status. (C) Elevation of HCO3 is a compensatory mechanism in acidosis that occurs almost immediately, but it takes hours to show any effect and days to reach maximum compensation. Renal disease and diuretic therapy may impair the ability of the kidneys to compensate. (D) Base excess is a nonrespiratory contributor to acid-base balance. It would increase to compensate for acidosis.

• Question 799:

  Discharge teaching was effective if the parents of a child with atopic dermatitis could state the importance of:

  A. Maintaining a high-humidified environment

  B. Furry, soft stuffed animals for play

  C. Showering 3- times a day

  D. Wrapping hands in soft cotton gloves

  Correct Answer: D

  (A) Maintaining a low-humidified environment. (B) Avoiding furry, soft stuffed animals for play, which may increase symptoms of allergy. (C) Avoiding showering, which irritates the dermatitis, and encouraging bathing 4 times a day in colloid bath for temporary relief. (D) Wrapping hands in soft cotton gloves to prevent skin damage during scratching.

• Question 800:

  After 3 weeks of treatment, a severely depressed client suddenly begins to feel better and starts interacting appropriately with other clients and staff. The nurse knows that this client has an increased risk for:

  A. Suicide

  B. Exacerbation of depressive symptoms

  C. Violence toward others

  D. Psychotic behavior

  Correct Answer: A

  (A) When the severely depressed client suddenly begins to feel better, it often indicates that the client has made the decision to kill himself or herself and has developed a plan to do so. (B) Improvement in behavior is not indicative of an exacerbation of depressive symptoms. (C) Thedepressed client has a tendency for self-violence, not violence toward others. (D) Depressive behavior is not always accompanied by psychotic behavior.