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NCLEX-RN exam covers a wide range of topics related to nursing practice, including health promotion and maintenance, pharmacology, physiological adaptation, psychosocial integrity, and safe and effective care environment. NCLEX-RN exam is designed to test both the test-taker's knowledge and their ability to apply that knowledge in real-world nursing situations.
NEW QUESTION # 49
In performing the initial nursing assessment on a client at the prenatal clinic, the nurse will know that which of the following alterations is abnormal during pregnancy?
- A. Dysuria
- B. Chloasma
- C. Striae gravidarum
- D. Colostrum
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Striae gravidarum are the normal stretch marks that frequently occur on the breasts, abdomen, and thighs as pregnancy progresses. (B) Chloasma is the "mask of pregnancy" that normally occurs in many pregnant women. (C) Dysuria is an abnormal danger sign during pregnancy and may indicate a urinary tract infection. (D) Colostrum is a yellow breast secretion that is normally present during the last trimester of pregnancy.
NEW QUESTION # 50
Pin care is a part of the care plan for a client who is in skeletal traction. When assessing the site of pin insertion, which one of the following findings would the nurse know as an indicator of normal wound healing?
- A. Edema
- B. Erythema
- C. Exudate
- D. Crust
Answer: D
Explanation:
(A) Exudate (moist, active drainage) is a clinical sign of wound infection. (B) Crust (dry,
scaly) is part of the normal stages of wound healing and should not be removed from around the pin site. It usually sloughs off after the underlying tissue has healed. (C) Edema (swelling) is a clinical sign of wound infection. (D) Erythema (redness) is a clinical sign of wound infection.
NEW QUESTION # 51
A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:
- A. Changing tracheostomy dressing only as necessary using one-half strength hydrogen peroxide to cleanse the site
- B. Deflating the cuff for 10 minutes every other hour instead of 5 minutes every hour
- C. Reporting any signs of crepitus immediately to the physician
- D. Avoiding manipulation of the tracheostomy including cuff deflation
Answer: D
Explanation:
Explanation
(A) The tracheal cuff should not be deflated within the first 24 hours following surgery. (B) To minimize bleeding, any manipulation, including cuff deflation, should be avoided. (C) Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician. (D) The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.
NEW QUESTION # 52
At 38 weeks' gestation, a client is in active labor. She is using her Lamaze breathing techniques. The RN is coaching her breathing and encouraging her to relax and work with her contractions. Which one of the following complaints by the client will alert the RN that she is beginning to hyperventilate with her breathing?
- A. "I am cold."
- B. "I have a backache."
- C. "I feel dizzy."
- D. "I am nauseous."
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Cold is not a symptom of hyperventilation. This could be due to the temperature of the room. (B) Backache is not a symptom of hyperventilation. This is probably due to the gravid uterus and its effect on the back muscles, or it may be due to the client's position in bed. (C) Dizziness is the first symptom of hyperventilation. It occurs because the body is eliminating too much CO2. (D) Nausea is not a symptom of hyperventilation. It could be a symptom of pain.
NEW QUESTION # 53
To prevent thrombophlebitis in a client on complete bed rest, the nursing care plan should include:
- A. Dangle the client's legs over the edge of the bed every shift.
- B. Have the client tighten and relax leg muscles several times daily.
- C. Massage the client's calves briskly every shift.
- D. Keep the client's legs extended and discourage any movement.
Answer: B
Explanation:
Explanation
(A) Dangling the client's legs over the edge of the bed will contribute to stasis and pooling of blood and increases the risk of thrombus formation. (B) Massaging the client's calves could result in dislodging an embolus. (C) Decreased movement will contribute to pooling of blood and increased risk of venous thrombosis. (D) Tightening and relaxing leg muscles increases circulation and decreases the risk of venous thrombosis.
NEW QUESTION # 54
One afternoon 3 weeks into his alcohol treatment program, a client says to the nurse, "It's really not all my fault that I have a drinking problem. Alcoholism runs in my family. Both my grandfather and father were heavy drinkers." The nurse's best response would be:
- A. "Risk factors can often be controlled by self-responsibility."
- B. "Your grandfather and father were both alcoholics?"
- C. "It sounds like you're intellectualizing your drinking problem."
- D. "That might be a problem. Tell me more about them."
Answer: A
Explanation:
Section: Questions Set G
Explanation:
(A) Focusing is an effective therapeutic strategy. This response, however, allows the client to "defocus" off the topic of learning how to accept responsibility for his behavior and future growth. (B) The nurse can educate the client about both the "genetic risk" for the development of alcoholism and ways to make long-term healthy lifestyle changes. (C) This response is inappropriately confrontational and condescending to the client. (D) Reflection of content can be an effective verbal therapeutic technique. It is used inappropriately here.
NEW QUESTION # 55
A 71-year-old client fell and injured her left leg while cooking in the kitchen. Her husband calls the ambulance, and she is taken to the emergency department at a local hospital. X-ray reports confirm that she has an intertrochanteric fracture of the left femur. Her left leg will require skeletal traction initially and then surgery. The nurse knows that this type of traction will be used:
- A. Intermittently to place a pull over the pelvis and lower spine
- B. By inserting pins to provide steady pull on the bone
- C. With weights at both ends of the bed to maintain pull on the upper extremity
- D. To suspend the leg in a sling without pull on the extremity
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Skeletal traction is the application of traction directly to bone with the use of pins and wires or tongs for the purpose of providing a strong, steady, continuous longitudinal pull on the bone. It is indicated for preoperative immobilization and positioning of hip and femur fractures. (B) A type of skeletal traction (balanced suspension with a Thomas splint and Pearson attachment) uses a sling to support the extremity, but it also uses weights to provide a strong, steady continuouspull on the extremity. A sling is used instead of pins. (C) Pelvic traction provides an intermittent pull over the pelvis and bone, whereas skeletal traction is continuous. Pelvic traction does not use pins. (D) Skeletal traction uses weights at the end of the bed to provide a continuous pull on long bones. Weights are not applied to both ends of the bed.
NEW QUESTION # 56
The nurse is caring for a 2-year-old girl with a subdural hematoma of the temporal area as a result of falling out of bed and notices that she has a runny nose. The nurse should:
- A. Call the doctor immediately
- B. Test the discharge for sugar
- C. Help her to blow her nose carefully
- D. Turn her to her side
Answer: B
Explanation:
(A) The nasal discharge could be due to a cold. It is necessary to gather additional assessment data to identify a possible cerebrospinal fluid leak. (B) If the discharge is cerebrospinal fluid, it would not be safe to encourage the girl to blow her nose. (C) Cerebrospinal fluid is positive for sugar; mucus is not. (D) Turning her to her side will have no effect on her "runny nose." It is necessary to gather further assessment data.
NEW QUESTION # 57
A burn victim's immunization history is assessed by the nurse. Which immunization is of priority concern?
- A. Hepatitis B vaccine
- B. Inactivated poliovirus vaccine
- C. Oral poliovirus vaccine
- D. Tetanus toxoid
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Oral poliovirus vaccine is given to prevent polio. Polio is transmitted by direct contact with an infected person. (B) Inactivated poliovirus vaccine is given to adults and immunosuppressed individuals. Polio is transmitted by direct contact with an infected person. (C) Tetanus toxoid prevents tetanus. Tetanus is transmitted through contaminated wounds. (D) Hepatitis B vaccine prevents hepatitis B infection. Hepatitis B is transmitted through contact with infected blood or body fluids.
NEW QUESTION # 58
A client was admitted with rib fractures and a pneumothorax, which were sustained as a result of a motor vehicle accident. A chest tube was placed on the left side to reinflate his lung, and he was transferred to a client unit. Twenty-four hours after admission he continues to have bloody sputum, develops increasing hypoxemia, and his chest x-ray shows patchy infiltrates. The nurse analyzes these symptoms as being consistent with:
- A. Pneumonia
- B. Pulmonary edema
- C. Pulmonary contusions
- D. Tension pneumothorax
Answer: C
Explanation:
Explanation
(A) Pneumonia may be reflected by patchy infiltrates. In addition, fever, an increasing white blood cell count, and copious sputum production would be present. (B) Blunt chest traumacauses a bruising process in which interstitial and alveolar edema and hemorrhage occur. This is manifest by gradual deterioration over 24 hours of arterial blood gases and the continued production of bloody sputum. Patchy infiltrates are evident on chest xray 24 hours postinjury. (C) Pulmonary edema usually results from left heart failure. It is manifest by pink, frothy sputum; increasing dyspnea; tachycardia; and crackles on auscultation. (D) Tension pneumothorax is a potential complication for someone with rib fractures and a chest tube. It is manifest by diminished breath sounds on the affected side, rapidly deteriorating arterial blood gases in the presence of an open airway, and shock that is unexplained by other injuries.
NEW QUESTION # 59
The nurse assesses a client on the second postpartum day and finds a dark red discharge on the peripad. The stain appears to be about 5 inches long. Which of the following correctly describes the character and amount of lochia?
- A. Lochia rubra, moderate
- B. Lochia alba, light
- C. Lochia granulosa, heavy
- D. Lochia serosa, heavy
Answer: A
Explanation:
(A) Lochia alba occurs approximately 10 days after birth and is yellow to white. A discharge is classified as light when less than a 4-inch stain exists. (B) Lochia serosa is pink to brown and occurs 3-4 days after delivery. A stain is classified as heavy when a peripad is saturated in 1 hour. (C) Lochia granulosa is not a proper classification. (D) Lochia rubra is red, consisting mainly of blood, debris, and bacteria, and lasts from the time of delivery to 3-4 days afterward. A stain is classified as moderate when less than a 6-inch stain exists.
NEW QUESTION # 60
A 5-year-old child is hospitalized for an acute illness. The nurse encourages the family to bring her favorite objects from home. What is the nurse's rationale?
- A. To establish a trusting relationship
- B. To keep the child calm
- C. To prevent or minimize separation anxiety
- D. To reduce fear of the unknown
Answer: C
Explanation:
(A) Objects from home do not reduce fear of the unknown. Children need explanations, reassurance, and preparation for the unknown. Also, parental presence can promote comfort and feelings of security. (B) A calm, relaxed, and reassuring manner will assist in calming the child. The child's objects from home will not assist in calming the child. (C) A trusting relationship is based on the quality of the nurse-client relationship. Objects from home have no impact. (D) Favorite objects from home assist in creating a familiar setting. Also, these objects may prevent or minimize separation from the child's usual routine and family support.
NEW QUESTION # 61
A child is to receive atropine 0.15 mg (1/400 g) as part of his preoperative medication. A vial containing atropine 0.4 mg (1/150 g)/mL is on hand. How much atropine should be given?
- A. 0.06 mL
- B. Information given insufficient to determine the amount of atropine to be administered
- C. 2.7 mL
- D. 0.38 mL
Answer: D
Explanation:
(A, C) Information was incorrectly placed in the formula, resulting in an incorrect answer.
(B) The answer is correct.
0.4 mg = 1 mL:0.15 mg 5 = mL
0.4 x = 0.15 x = 0.15/0.4 x = 0.375 or 0.38 mL
(D) Sufficient information is provided to determine the amount of atropine to administer. The amount of atropine available and the amount of atropine ordered is required to determine the amount of atropine to be given.
NEW QUESTION # 62
A client on the infectious disease unit is discussing transmission of human immunodeficiency virus (HIV).
The nurse would need to provide more client education based on which client statement?
- A. "HIV can be transmitted to an unborn infant."
- B. "HIV is a virus that is easily transmitted by casual contact."
- C. "Condoms reduce the transmission of HIV."
- D. "HIV is a virus transmitted by sexual contact."
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) HIV is transmitted through unprotected sexual contact. (B) Condoms are an effective barrier to prevent HIV transmission. (C) HIV is not easily transmitted by casual contact. (D) HIV can be transmitted intrauterinely at the time of delivery, and by breast-feeding.
NEW QUESTION # 63
The nurse is in the hallway and one of the visitors faints. The nurse should:
- A. Apply a cool cloth to the victim's neck and forehead until he recovers
- B. Sit the victim up and lightly slap his face
- C. Elevate the victim's legs
- D. Sit the victim up and place the head between the knees
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Sitting the client up defeats the goal of re-establishing cerebral blood flow. (B) Elevating the legs anatomically redirects blood flow to the cerebral area. (C) This strategy is a nice general comfort measure after the victim has regained consciousness. (D) This strategy is not as effective a strategy in helping the client to regain consciousness as elevating the legs.
NEW QUESTION # 64
Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients?
- A. Thiamine and pyroxidine
- B. Folic acid and niacin
- C. Vitamin C and zinc
- D. Vitamin A and biotin
Answer: A
Explanation:
Explanation
(A) Chronic alcoholism can lead to deficiencies of B complex vitamins including thiamine and pyroxidine. (B) Chronic alcoholism can lead to deficiencies of vitamins A, D, K, and B complex. (C) Chronic alcoholism can lead to deficiencies of vitamins A, D, K, and B complex. (D) Vitamins A, D, K, and B require bile salts to be absorbed from the gastrointestinal tract. A damaged liver does not form bile salts.
NEW QUESTION # 65
When assessing residual volume in tube feeding, the feeding should be delayed if the amount of gastric contents (residual) exceeds:
- A. 25 mL
- B. 30 mL
- C. 50 mL
- D. 20 mL
Answer: C
Explanation:
Explanation
(A) A residual volume of 20 mL is not excessive. (B) A residual volume of 25 mL is not excessive. (C) A residual volume of 30 mL is not excessive. (D) Tube feedings should be withheld and physician notified for residual volumes of 50-100 mL.
NEW QUESTION # 66
A 2-month-old infant is receiving IV fluids with a volume control set. The nurse uses this type of tubing because it:
- A. Prevents entry of air into tubing
- B. Prevents administration of other drugs
- C. Prevents phlebitis
- D. Prevents inadvertent administration of a large amount of fluids
Answer: D
Explanation:
Explanation
(A) A volume control set has a chamber that permits the administration of compatible drugs. (B) Air may enter a volume control set when tubing is not adequately purged. (C) A volume control set allows the nurse to control the amount of fluid administered over a set period. (D) Contamination of volume control set may cause phlebitis.
NEW QUESTION # 67
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NCLEX-RN exam is divided into four main categories: Safe and Effective Care Environment, Health Promotion and Maintenance, Psychosocial Integrity, and Physiological Integrity. Each of these categories is further divided into subcategories which include topics such as infection control, pharmacology, and patient education. NCLEX-RN exam is designed to assess not only the individual’s knowledge of these topics but also their ability to apply this knowledge in a clinical setting.
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