NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 831:

  Provide the 1-minute Apgar score for an infant born with the following findings: Heart rate:

  Above 100 Respiratory effort: Slow, irregular Muscle tone: Some flexion of extremities Reflex irritability: Vigorous cry Color: Body pink, blue extremities

  A. 7

  B. 10

  C. 8

  D. 9

  Correct Answer: A

  (A) Seven out of a possible perfect score of 10 is correct. Two points are given for heart rate above 100; 1 point is given for slow, irregular respiratory effort; 1 point is given for some flex- ion of extremities in assessing muscle tone; 2 points are given for vigorous cry in assessing reflex irritability; 1 point is assessed for color when the body is pink with blue extremities (acrocyanosis). (B) For a perfect Apgar score of 10, the infant would have a heart rate over 100 but would also have a good cry, active motion, and be completely pink. (C) For an Apgar score of 8 the respiratory rate, muscle tone, or color would need to fall into the 2-point rather than the 1-point category. (D) For this infant to receive an Apgar score of 9, four of the areas evaluated would need ratings of 2 points and one area, a rating of 1 point.

• Question 832:

  The child with iron poisoning is given IV deforoxamine mesylate (Desferal). Following administration, the child suffers hypotension, facial flushing, and urticaria. The initial nursing intervention would be to:

  A. Discontinue the IV

  B. Stop the medication, and begin a normal saline infusion

  C. Take all vital signs, and report to the physician

  D. Assess urinary output, and if it is 30 mL an hour, maintain current treatment

  Correct Answer: B

  (A) The IV line should not be discontinued because other IV medications will be needed. (B) Stop the medication and begin a normal saline infusion. The child is exhibiting signs of an allergic reaction and could go into shock if the medication is not stopped. The line should be kept opened for other medication. (C) Taking vital signs and reporting to the physician is not an adequate intervention because the IV medication continues to flow. (D) Assessing urinary output and, if it is 30 mL an hour, maintaining current treatment is an inappropriate intervention owing to the child's obvious allergic reaction.

• Question 833:

  The physician recommends immediate hospital admission for a client with PIH. She says to the nurse, "It's not so easy for me to just go right to the hospital like that." After acknowledging her feelings, which of these approaches by the nurse would probably be best?

  A. Stress to the client that her husband would want her to do what is best for her health.

  B. Explore with the client her perceptions of why she is unable to go to the hospital.

  C. Repeat the physician's reasons for advising immediate hospitalization.

  D. Explain to the client that she is ultimately responsible for her own welfare and that of her baby.

  Correct Answer: B

  (A) This answer does not hold the client accountable for her own health. (B) The nurse should explore potential reasons for the client's anxiety: are there small children at home, is the husband out of town? The nurse should aid the client in seeking support or interventions to decrease the anxiety of hospitalization. (C) Repeating the physician's reason for recommending hospitalization may not aid the client in dealing with her reasons for anxiety. (D) The concern for self and welfare of baby may be secondary to a woman who is in a crisis situation. The nurse should explore the client's potential reasons for anxiety. For example, is there another child in the home who is ill, or is there a husband who is overseas and not able to return on short notice?

• Question 834:

  The nurse would expect to include which of the following when planning the management of the client with Lyme disease?

  A. Complete bed rest for 6? weeks

  B. Tetracycline treatment

  C. IV amphotericin B

  D. High-protein diet with limited fluids

  Correct Answer: B

  (A) The client is not placed on complete bed rest for 6 weeks. (B) Tetracycline is the treatment of choice for children with Lyme disease who are over the age of 9. (C) IV amphotericin B is the treatment for histoplasmosis. (D) The client is not restricted to a high- protein diet with limited fluids.

• Question 835:

  The primary reason for sending a burn client home with a pressure garment, such as a Jobst garment, is that the garment:

  A. Decreases hypertrophic scar formation

  B. Assists with ambulation

  C. Covers burn scars and decreases the psychological impact during recovery

  D. Increases venous return and cardiac output by normalizing fluid status

  Correct Answer: A

  (A) Tubular support, such as that received with a Jobst garment, applies tension of 10?0 mm Hg. This amount of uniform pressure is necessary to prevent or reduce hypertrophic scarring. Clients typically wear a pressure garment for 6?2 months during the recovery phase of their care. (B) Pressure garments have no ambulatory assistive properties. (C) Pressure garments can worsen the psychological impact of burn injury, especially if worn on the face. (D) Pressure garments do not normalize fluid status.

• Question 836:

  Dietary planning is an essential part of the diabetic client's regimen. The American Diabetes Association recommends which of the following caloric guidelines for daily meal planning?

  A. 50% complex carbohydrate, 20%?5% protein, 20%?5% fat

  B. 45% complex carbohydrate, 25%?0% protein, 30%?5% fat

  C. 70% complex carbohydrate, 20%?0% protein, 10%?0% fat

  D. 60% complex carbohydrate, 12%?5% protein, 20%?5% fat

  Correct Answer: D

  (A) The percentage of carbohydrates is too low to maintain blood sugar levels. The percent range of protein is too high and may cause extra workload on the kidney as it is metabolized. (B) The percentage of carbohydrates is too low to maintain blood sugar levels. The percent range of protein is too high and may cause extra workload on the kidney. (C) The percentage of carbohydrates is too high; the percent range of protein is too high, and of fat, too low. (D) This combination provides enough carbohydrates to maintain blood glucose levels, enough protein to maintain body repair, and enough fat to ensure palatability.

• Question 837:

  The initial treatment for a client with a liquid chemical burn injury is to:

  A. Irrigate the area with neutralizing solutions

  B. Flush the exposed area with large amounts of water

  C. Inject calcium chloride into the burned area

  D. Apply lanolin ointment to the area

  Correct Answer: B

  (A) In the past, neutralizing solutions were recommended, but presently there is concern that these solutions extend the depth of burn area. (B) The use of large amounts of water to flush the area is recommended for chemical burns. (C) Calcium chloride is not recommended therapy and would likely worsen the problem. (D) Lanolin is of no benefit in the initial treatment of a chemical injury and may actually extend a thermal injury.

• Question 838:

  Which of the following should be included in discharge teaching for a client with hepatitis C?

  A. He should take aspirin as needed for muscle and joint pain.

  B. He may become a blood donor when his liver enzymes return to normal.

  C. He should avoid alcoholic beverages during his recovery period.

  D. He should use disposable dishes for eating and drinking.

  Correct Answer: C

  (A) Aspirin is hepatotoxic, may increase bleeding, and should be avoided. (B) Blood should not be donated by a client who has had hepatitis C because of the possibility of transmission of disease. (C) Alcohol is detoxified in the liver. (D) Hepatitis C is not spread through the oral route.

• Question 839:

  Three weeks following discharge, a male client is readmitted to the psychiatric unit for depression. His wife stated that he had threatened to kill himself with a handgun. As the nurse admits him to the unit, he says, "I wish I were dead because I am worthless to everyone; I guess I am just no good." Which response by the nurse is most appropriate at this time?

  A. "I don't think you are worthless. I'm glad to see you, and we will help you."

  B. "Don't you think this is a sign of your illness?"

  C. "I know with your wife and new baby that you do have a lot to live for."

  D. "You've been feeling sad and alone for some time now?"

  Correct Answer: D

  (A) This response does not acknowledge the client's feelings. (B) This is a closed question and does not encourage communication. (C) This response negates the client's feelings and does not require a response from the client. (D) This acknowledges the client's implied thoughts and feelings and encourages a response.

• Question 840:

  The nurse should know that according to current thinking, the most important prognostic factor for a client with breast cancer is:

  A. Tumor size

  B. Axillary node status

  C. Client's previous history of disease

  D. Client's level of estrogen-progesterone receptor assays

  Correct Answer: B

  (A) Although tumor size is a factor in classification of cancer growth, it is not an indicator of lymph node spread. (B) Axillary node status is the most important indicator for predicting how far the cancer has spread. If the lymph nodes are positive for cancer cells, the prognosis is poorer. (C) The client's previous history of cancer puts her at an increased risk for breast cancer recurrence, especially if the cancer occurred in the other breast. It does not predict prognosis, however. (D) The estrogen-progesterone assay test is used to identify present tumors being fedfrom an estrogen site within the body. Some breast cancers grow rapidly as long as there is an estrogen supply such as from the ovaries. The estrogen-progesterone assay test does not indicate the prognosis.