NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 801:

  A 27-year-old man was diagnosed with type I diabetes 3 months ago. Two weeks ago he complained of pain, redness, and tenderness in his right lower leg. He is admitted to the hospital with a slight elevation of temperature and vague complaints of "not feeling well." At

  4:30

  PM on the day of his admission, his blood glucose level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to:

  A.

  Give him 3 tbsp of sugar dissolved in 4 oz of grape juice to drink

  B.

  Ask him to dissolve three pieces of hard candy in his mouth

  C.

  Have him drink 4 oz of orange juice

  D.

  Monitor him closely until dinner arrives

  Correct Answer: C

  (A) The combination of sugar and juice will increase the blood sugar beyond the normal range. (B) Concentrated sweets are not absorbed as fast as juice; consequently, they elevate the blood sugar beyond the normal limit. (C) Four ounces of orange juice will act immediately to raise the blood sugar to a normal level and sustain it for 30 minutes until supper is served. (D) There is an increased potential for the client's blood sugar to decrease even further, resulting in diabetic coma.

• Question 802:

  The cardiac client who exhibits the symptoms of disorientation, lethargy, and seizures may be exhibiting a toxic reaction to:

  A. Digoxin (Lanoxin)

  B. Lidocaine (Xylocaine)

  C. Quinidine gluconate or sulfate (Quinaglute, Quinidex)

  D. Nitroglycerin IV (Tridil)

  Correct Answer: B

  (A) Side effects of digoxin include headache, hypotension, AV block, blurred vision, and yellow-green halos. (B) Side effects of lidocaine include heart block, headache, dizziness, confusion, tremor, lethargy, and convulsions. (C) Side effects of quinidine include heart block, hepatotoxicity, thrombocytopenia, and respiratory depression. (D) Side effects of nitroglycerin include postural hypotension, headache, dizziness, and flushing.

• Question 803:

  A laboratory technique specific for diagnosing Lyme disease is:

  A. Polymerase chain reaction

  B. Heterophil antibody test

  C. Decreased serum calcium level

  D. Increased serum potassium level

  Correct Answer: A

  (A) Polymerase chain reaction is the laboratory technique specific for Lyme disease. (B) Heterophil antibody test is used to diagnose mononucleosis. (C) Lyme disease does not decrease the serum calcium level. (D) Lyme disease does not increase the serum potassium level.

• Question 804:

  A type I diabetic client is diagnosed with cellulitis in his right lower extremity. The nurse would expect which of the following to be present in relation to his blood sugar level?

  A. A normal blood sugar level

  B. A decreased blood sugar level

  C. An increased blood sugar level

  D. Fluctuating levels with a predawn increase

  Correct Answer: C

  (A) Blood sugar levels increase when the body responds to stress and illness. (B) Blood sugar levels increase when the body responds to stress and illness. (C) Hyperglycemia occurs because glucose is produced as the body responds to the stress and illness of cellulitis. (D) Blood sugar levels remain elevated as long as the body responds to stress and illness.

• Question 805:

  A 38-year-old pregnant woman visits her nurse practitioner for her regular prenatal checkup. She is 30 weeks' gestation. The nurse should be alert to which condition related to her age?

  A. Iron-deficiency anemia

  B. Sexually transmitted disease (STD)

  C. Intrauterine growth retardation

  D. Pregnancy-induced hypertension (PIH)

  Correct Answer: D

  (A) Iron-deficiency anemia can occur throughout pregnancy and is not age related. (B) STDs can occur prior to or during pregnancy and are not age related. (C) Intrauterine growth retardation is an abnormal process where fetal development and maturation are delayed. It is not age related. (D) Physical risks for the pregnant client older than 35 include increased risk for PIH, cesarean delivery, fetal and neonatal mortality, and trisomy.

• Question 806:

  Which of the following signs and symptoms indicates a tension pneumothorax as compared to an open pneumothorax?

  A. Ventilation-perfusion (V./Q.) mismatch

  B. Hypoxemia and respiratory acidosis

  C. Mediastinal tissue and organ shifting

  D. Decreased tidal volume and tachypnea

  Correct Answer: C

  (A, B, D) These occur in both tension pneumothorax and open pneumothorax. (C) The tension pneumothorax acts like a one- way valve so that the pneumothorax increases with each breath. Eventually, it occupies enough space to shift mediastinal tissue toward the unaffected side away from the midline. Tracheal deviation, movement of point of maximum impulse, and decreased cardiac output will occur. The other three options will occur in both types of pneumothorax.

• Question 807:

  A client with emphysema is placed on diuretics. In order to avoid potassium depletion as a side effect of the drug therapy, which of the following foods should be included in his diet?

  A. Celery

  B. Potatoes

  C. Tomatoes

  D. Liver

  Correct Answer: B

  (A) Celery is high in sodium. (B) Potatoes are high in potassium. (C) Tomatoes are high in sodium. (D) Liver is high in iron.

• Question 808:

  A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report:

  A. Dizziness and tachypnea

  B. Circumoral pallor and lightheadedness

  C. Headache and facial flushing

  D. Pallor and itching of the face and neck

  Correct Answer: C

  (A) Tachypnea is not a symptom. (B) Circumoral pallor is not a symptom. (C) Autonomic dysreflexia is an uninhibited and exaggerated reflex of the autonomic nervous system to stimulation, which results in vasoconstriction and elevated blood pressure. (D) Pallor and itching are not symptoms.

• Question 809:

  A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:

  A. Bleeding, bruising, and hemorrhage

  B. Increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase

  C. Pain, pallor, pulselessness, paresthesia, and paralysis

  D. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus

  Correct Answer: C

  (A) Bleeding, bruising, and hemorrhage may occur due to injury but are not classic signs of ischemia. (B) An increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase is related to the disruption of muscle

  integrity. (C) Classic signs of ischemia related to vascular injury secondary to long bone fractures include the five "P's":

  pain, pallor, pulselessness, paresthesia, and paralysis. (D) Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus are common clinical manifestations of a fracture but not ischemia.

• Question 810:

  The physician orders fluoxetine (Prozac) for a depressed client. Which of the following should the nurse remember about fluoxetine?

  A. Because fluoxetine is a tricyclic antidepressant, it may precipitate a hypertensive crisis.

  B. The therapeutic effect of the drug occurs 2? weeks after treatment is begun.

  C. Foods such as aged cheese, yogurt, soy sauce, and bananas should not be eaten with this drug.

  D. Fluoxetine may be administered safely in combination with monoamine oxidase (MAO) inhibitors.

  Correct Answer: B

  (A)

  Fluoxetine is not a tricyclic antidepressant. It is an atypical antidepressant. (B) This statement is true. (C) These foods are high in tyramine and should be avoided when the client is taking MAO inhibitors. Fluoxetine is not an MAO inhibitor.

  (D)

  Fatal reactions have been reported in clients receiving fluoxetine in combination with MAO inhibitors.