NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 821:

  Proper positioning for the child who is in Bryant's traction is:

  A. Both hips flexed at a 90-degree angle with the knees extended and the buttocks elevated off the bed

  B. Both legs extended, and the hips are not flexed

  C. The affected leg extended with slight hip flexion

  D. Both hips and knees maintained at a 90-degree flexion angle, and the back flat on the bed

  Correct Answer: A

  (A) The child's weight supplies the countertraction for Bryant's traction; the buttocks are slightly elevated off the bed, and the hips are flexed at a 90-degree angle. Both legs are suspended by skin traction. (B) The child in Buck's extension traction maintains the legs extended and parallel to the bed. (C) The child in Russell traction maintains hip flexion of the affected leg at the prescribed angle with the leg extended. (D) The child in "90?0" traction maintains both hips and knees at a 90-degree flexion angle and the back is flat on the bed.

• Question 822:

  The usual treatment for diabetes insipidus is with IM or SC injection of vasopressin tannate in oil. Nursing care related to the client receiving IM vasopressin tannate would include:

  A. Weigh once a week and report to the physician any weight gain of10 lb.

  B. Limit fluid intake to 500 mL/day.

  C. Store the medication in a refrigerator and allow to stand at room temperature for 30 minutes prior to administration.

  D. Hold the vial under warm water for 10?5 minutes and shake vigorously before drawing medication into the syringe.

  Correct Answer: D

  (A) Weight should be obtained daily. (B) Fluid is not restricted but is given according to urine output. (C) The medication does not have to be stored in a refrigerator. (D) Holding the vial under warm water for 10?5 minutes or rolling between your hands and shaking vigorously before drawing medication into the syringe activates the medication in the oil solution.

• Question 823:

  The day following his admission, the nurse sits down by a male client on the sofa in the dayroom. He was admitted for depression and thoughts of suicide. He looks at the nurse and says, "My life is so bad no one can do anything to help me." The most helpful initial response by the nurse would be:

  A. "It concerns me that you feel so badly when you have so many positive things in your life."

  B. "It will take a few weeks for you to feel better, so you need to be patient."

  C. "You are telling me that you are feeling hopeless at this point?"

  D. "Let's play cards with some of the other clients to get your mind off your problems for now."

  Correct Answer: C

  (A) This response does not acknowledge the client's feelings and may increase his feelings of guilt. (B) This response denotes false reassurance. (C) This response acknowledges the client's feelings and invites a response. (D) This response changes the subject and does not allow the client to talk about his feelings.

• Question 824:

  Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:

  A. Maintaining seizure precautions

  B. Restricting fluid intake

  C. Increasing sensory stimuli

  D. Applying ankle and wrist restraints

  Correct Answer: A

  (A) These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. (B) Fluid intake should be increased to prevent dehydration. (C) Environmental stimuli should be decreased to prevent precipitation of seizures. (D) Application of restraints may cause the client to increase his or her physical activity and may eventually lead to exhaustion.

• Question 825:

  To ensure proper client education, the nurse should teach the client taking SL nitroglycerin to expect which of the following responses with administration?

  A. Stinging, burning when placed under the tongue

  B. Temporary blurring of vision

  C. Generalized urticaria with prolonged use

  D. Urinary frequency

  Correct Answer: A

  (A) Stinging or burning when nitroglycerin is placed under the tongue is to be expected. This effect indicates that the medication is potent and effective for use. Failure to have this response means that the client needs to get a new bottle of nitroglycerin. (B, C, D) The other responses are not expected in this situation and are not even side effects.

• Question 826:

  A client with a C-3? fracture has just arrived in the emergency room. The primary nursing intervention is:

  A. Stabilization of the cervical spine

  B. Airway assessment and stabilization

  C. Confirmation of spinal cord injury

  D. Normalization of intravascular volume

  Correct Answer: B

  (A) If cervical spine injury is suspected, the airway should be maintained using the jaw thrust method that also protects the cervical spine. (B) Primary intervention is protection of the airway and adequate ventilation. (C, D) All other interventions are secondary to adequate ventilation.

• Question 827:

  What is the most effective method to identify early breast cancer lumps?

  A. Mammograms every 3 years

  B. Yearly checkups performed by physician

  C. Ultrasounds every 3 years

  D. Monthly breast self-examination

  Correct Answer: D

  (A) Mammograms are less effective than breast self-examination for the diagnosis of abnormalities in younger women, who have denser breast tissue. They are more effective forwomen older than 40. (B) Up to 15% of early-stage breast cancers are detected by physical examination; however, 95% are detected by women doing breast self- examination. (C) Ultrasound is used primarily to determine the location of cysts and to distinguish cysts from solid masses. (D) Monthly breast self-examination has been shown to be the most effective method for early detection of breast cancer. Approximately 95% of lumps are detected by women themselves.

• Question 828:

  When the nurse is evaluating lab data for a client 18?4 hours after a major thermal burn, the expected physiological changes would include which of the following?

  A. Elevated serum sodium

  B. Elevated serum calcium

  C. Elevated serum protein

  D. Elevated hematocrit

  Correct Answer: D

  (A) Sodium enters the edema fluid in the burned area, lowering the sodium content of the vascular fluid. Hyponatremia may continue for days to several weeks because of sodium loss to edema, sodium shifting into the cells, and later, diuresis. (B) Hypocalcemia occurs because of calcium loss to edema fluid at the burned site (third space fluid). (C) Protein loss occurs at the burn site owing to increased capillary permeability. Serum protein levels remain low until healing occurs. (D) Hematocrit level is elevated owing to hemoconcentration from hypovolemia. Anemia is present in the postburn stage owing to blood loss and hemolysis, but it cannot be assessed until the client is adequately hydrated.

• Question 829:

  In the client with a diagnosis of coronary artery disease, the nurse would anticipate the complication of bradycardia with occlusion of which coronary artery?

  A. Right coronary artery

  B. Left main coronary artery

  C. Circumflex coronary artery

  D. Left anterior descending coronary artery

  Correct Answer: A

  (A) Sinus bradycardia and atrioventricular (AV) heart block are usually a result of right coronary artery occlusion. The right coronary artery perfuses the sinoatrial and AV nodes in mostindividuals. (B) Occlusion of the left main coronary artery causes bundle branch blocks and premature ventricular contractions. (C) Occlusion of the circumflex artery does not cause bradycardia. (D) Sinus tachycardia occurs primarily with left anterior descending coronary artery occlusion because this form of occlusion impairs left ventricular function.

• Question 830:

  A client has been diagnosed as being preeclamptic. The physician orders magnesium sulfate. Magnesium sulfate (MgSO4) is used in the management of preeclampsia for:

  A. Prevention of seizures

  B. Prevention of uterine contractions

  C. Sedation

  D. Fetal lung protection

  Correct Answer: A

  (A) MgSO4 is classified as an anticonvulsant drug. In preeclampsia management, MgSO4 is used for prevention of seizures. (B) MgSO4 has been used to inhibit hyperactive labor, but results are questionable. (C) Negative side effects such as respiratory depression should not be confused with generalized sedation. (D) MgSO4 does not affect lung maturity. The infant should be assessed for neuromuscular and respiratory depression.