NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 81:

  Which of the following nursing care goals has the highest priority for a child with epiglottitis?

  A. Sleep or lie quietly 10 hr/day.

  B. Consume foods from all four food groups.

  C. Be afebrile throughout her hospital stay.

  D. Participate in play activities 4 hr/day.

  Correct Answer: A

  (A) Of these four goals, maintenance of a calm, quiet atmosphere to reduce anxiety and to allow for rest is the most important. (B) Although nutrition is important, the child needs fluids to maintain fluid and electrolyte balance more than solid foods. In addition, the child may not be able to swallow solid foods owing to epiglottic swelling. (C) This goal is unrealistic because fever is a common symptom of the infection associated with epiglottitis. (D) If overexerted, the child will need more O2 and energy than available, and these requirements may exacerbate the condition.

• Question 82:

  The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the client's chief complaint?

  A. "I've been having a dull pain at the upper left shoulder."

  B. "My legs have been numb for three months."

  C. "I've only been urinating three times a day lately."

  D. "I don't remember anything in particular, I just haven't felt well."

  Correct Answer: D

  (A, B, C) These complaints are not specific signs and symptoms associated with abdominal aortic aneurysm. If symptoms are present, the aneurysm is expanding or rupture is imminent. (D) Many clients may experience no symptoms. The only symptom may be a pulsation noted in the abdomen in the reclining position.

• Question 83:

  When assessing a client, the nurse notes the typical skin rash seen with systemic lupus erythematosus. Which of the following descriptions correctly describes this rash?

  A. Small round or oval reddish brown macules scattered over the entire body

  B. Scattered clusters of macules, papules, and vesicles over the body

  C. Bright red appearance of the palmar surface of the hands

  D. Reddened butterfly shaped rash over the cheeks and nose

  Correct Answer: D

  (A) The appearance of small, round or oval reddish brown macules scattered over the entire body is characteristic of rubeola. (B) The appearance of scattered clusters of macules, papules, and vesicles throughout the body is characteristic of chickenpox. (C) Palmar redness is seen in clients with cirrhosis of the liver. (D) The characteristic butterfly rash over the cheek and nose and into the scalp is seen with systemic lupus erythematosus.

• Question 84:

  The nurse is teaching a client how to perform monthly testicular self-examination (TSE) and states that it is best to perform the procedure right after showering. This statement is made by the nurse based on the knowledge that:

  A. The client is more likely to remember to perform the TSE when in the nude

  B. When the scrotum is exposed to cool temperatures, the testicles become large and bulky

  C. The scrotum will be softer and more relaxed after a warm shower, making the testicles easier to palpate

  D. The examination will be less painful at this time

  Correct Answer: C

  (A) Nudity is not a trigger for reminding males to perform TSE. (B) Testicles become more firm when exposed to cool temperatures, but not large and bulky. (C) The testicles will be lower and more easily palpated with warmer temperatures. A protective mechanism of the body to protect sperm production is for the scrotum to pull closer to the body when exposed to cooler temperatures. (D) The examination should not be painful.

• Question 85:

  A pregnant client is having a nonstress test (NST). It is noted that the fetal heart beat rises 20 bpm, lasting 20 seconds, every time the fetus moves. The nurse explains that:

  A. The test is inconclusive and should be repeated

  B. Further testing is needed

  C. The test is normal and the fetus is reacting appropriately

  D. The fetus is distressed

  Correct Answer: C

  (A) The test results were normal, so there would be no need to repeat to determine results. (B) There are no data to indicate further tests are needed, because the result of the NST was normal. (C) An NST is reported as reactive if there are two to three increases in the fetal heart rate of 15 bpm, lasting at least 15 seconds during a 15-minute period. (D) The NST results were normal, so there was no fetal distress.

• Question 86:

  Parents should be taught not to prop the bottle when feeding their infants. In addition to the risk of choking, it puts the infant at risk for:

  A. Otitis media

  B. Asthma

  C. Conjunctivitis

  D. Tonsillitis

  Correct Answer: A

  (A) Because the eustachian tube is short and straight in the infant, formula that pools in the back of the throat attacks bacteria which can enter the middle ear and cause an infection. (B) Asthma is not associated with propping the bottle. (C) Conjunctivitis is an eye infection and not associated with propping the bottle. (D) Tonsillitis is usually a result of pharyngitis and not propping the bottle.

• Question 87:

  Forty-eight hours after a thyroidectomy, a female client complains of numbness and tingling of the toes and fingers. The nurse notes upper arm and facial twitching. The nurse needs to:

  A. Report the findings to the physician

  B. Assist the client to do range of motion exercises

  C. Check the client's potassium level

  D. Administer the as-needed dose of phenytoin (Dilantin)

  Correct Answer: A

  (A) Muscular hyperactivity and parasthesias may indicate hypocalcemic tetany and require immediate administration of calcium gluconate. Tetany can occur if the parathyroid glands were erroneously excised during surgery. (B) Range of motion exercises are not appropriate topresenting symptoms. (C) These characteristics are not usual signs of potassium imbalance, but of calcium imbalance. (D) Phenytoin is indicated for seizure activity mainly of neurological origin.

• Question 88:

  The nurse is admitting a client with folic acid deficiency anemia. Which of the following questions is most important for the nurse to ask the client?

  A. "Do you take aspirin on a regular basis?"

  B. "Do you drink alcohol on a regular basis?"

  C. "Do you eat red meat?"

  D. "Have your stools been normal?"

  Correct Answer: B

  (A) Aspirin does not affect folic acid absorption. (B) Folic acid deficiency is strongly associated with alcohol abuse. (C) Because folic acid is a coenzyme for single carbon transfer purines, calves liver or other purines are the meat sources. (D) Folic acid does not affect stool character.

• Question 89:

  The physician orders medication for a client's unpleasant side effects from the haloperidol. The most appropriate drug at this time is:

  A. Lorazepam

  B. Triazolam (Halcion)

  C. Benztropine

  D. Thiothixene

  Correct Answer: C

  (A) Lorazepam is a benzodiazepine, or antianxiety agent, that potentiates the effects of _- aminobutyric acid in the CNS, which is not the CNS neurotransmitter EPS. (B) Triazolam is a benzodiazepine sedative-hypnotic whose action is mediated in the limbic, thalamic, and hypothalamic levels of the CNS by - aminobutyric acid. (C) Benztropine is an anticholinergic agent, and the drug of choice for blocking CNS synaptic response, which causes EPS. (D) Thiothixene is an antipsychotic and neuroleptic drug that blocks dopamine neurotransmission at the CNS synapses, thereby causing EPS.

• Question 90:

  A client tells the nurse that he has been hearing voices that tell him to kill his girlfriend because she is a spy. He further states that he is having difficulty not obeying the voices because, if he does not, his house will be burned down. The highest priority nursing diagnosis for him at this time is:

  A. Sensory-perceptual alteration: auditory command hallucinations

  B. Alteration in thought processes: paranoid delusions

  C. Potential for violence directed at others

  D. Impaired verbal communication: loose associations

  Correct Answer: C

  (A) Although the client is having command hallucinations, this is second in priority to real or potential violence, which can be a threat to life itself. (B) Although the client is experiencing delusions, this is also a lower priority than his potential or actual loss of control. (C) Whether real or potential, violence directed at self or others is always high priority. (D) There is no evidence of loosening of associations.