National Council Licensure Examination(NCLEX-RN) v5.0 (NCLEX-RN)

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Total 862 questions

A 3-year-old child is hospitalized with burns covering her trunk and lower extremities.
Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child?

  • A. Blood pressure
  • B. Serum potassium level
  • C. Urine output
  • D. Pulse rate

Answer : C

(A) Blood pressure can remain normotensive even in a state of hypovolemia. (B) Serum potassium is not reliable for determining adequacy of fluid resuscitation. (C) Urine output, alteration in sensorium, and capillary refill are the most reliable indicators for assessing adequacy of fluid resuscitation. (D) Pulse rate may vary for many reasons and is not a reliable indicator for assessing adequacy of fluid resuscitation.

Which of the following would the nurse expect to find following respiratory assessment of a client with advanced emphysema?

  • A. Distant breath sounds
  • B. Increased heart sounds
  • C. Decreased anteroposterior chest diameter
  • D. Collapsed neck veins

Answer : A

(A) Distant breath sounds are found in clients with emphysema owing to increased anteroposterior chest diameter, overdistention, and air trapping. (B) Deceased heart sounds arepresent because of the increased anteroposterior chest diameter. (C) A barrel- shaped chest is characteristic of emphysema. (D) Increased distention of neck veins is found owing to right-sided heart failure, which may be present in advanced emphysema.

A child is admitted to the emergency room with her mother. Her mother states that she has been exposed to chickenpox. During the assessment, the nurse would note a characteristic rash:

  • A. That is covered with vesicular scabs all in the macular stage
  • B. That appears profusely on the trunk and sparsely on the extremities
  • C. That first appears on the neck and spreads downward
  • D. That appears especially on the cheeks, which gives a slapped-cheek appearance

Answer : B

(A) A rash with vesicular scabs in all stages (macule, papule, vesicle, and crusts). (B) A rash that appears profusely on the trunk and sparsely on the extremities. (C) A rash that first appears on the neck and spreads downward is characteristic of rubeola and rubella.
(D) A rash, especially on the cheeks, that gives a slapped-cheek appearance is characteristic of roseola.

Priapism may be a sign of:

  • A. Altered neurological function
  • B. Imminent death
  • C. Urinary incontinence
  • D. Reproductive dysfunction

Answer : A

(A) Priapism in the trauma client is due to the neurological dysfunction seen in spinal cord injury. Priapism is an abnormal erection of the penis; it may be accompanied by pain and tenderness. This may disappear as spinal cord edema is relieved. (B) Priapism is not associated with death. (C) Urinary retention, rather than incontinence, may occur. (D)
Reproductive dysfunction may be a secondary problem.

A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical examination are normal. How does the nurse interpret the effectiveness of the instruction about diet and weight control?

  • A. She is compliant with her diet as previously taught.
  • B. She needs further instruction and reinforcement.
  • C. She needs to increase her caloric intake.
  • D. She needs to be placed on a restrictive diet immediately.

Answer : B

(A) She is probably not compliant with her diet and exercise program. Recommended weight gain during second and third trimesters is approximately 12 lb. (B) Because of her excessive weight gain of 10 lb in 2 months, she needs re-evaluation of her eating habits and reinforcement of proper dietary habits for pregnancy. A 2200-calorie diet is recommended for most pregnant women with a weight gain of 2730 lb over the 9-month period. With rapid and excessive weightgain, PIH should also be suspected. (C) She does not need to increase her caloric intake, but she does need to re-evaluate dietary habits.
Ten pounds in 2 months is excessive weight gain during pregnancy, and health teaching is warranted. (D) Restrictive dieting is not recommended during pregnancy.

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

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.

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

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.

The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should:

  • A. Increase his nasal O2 to 6 L/min
  • B. Place him in a lateral Sims’ position
  • C. Encourage pursed-lip breathing
  • D. Have him breathe into a paper bag

Answer : C

(A) Giving too high a concentration of O2 to a client with em-physema may remove his stimulus to breathe. (B) The client should sit forward with his hands on his knees or an overbed table and with shoulders elevated. (C) Pursed-lip breathing helps the client to blow off CO2 and to keep air passages open. (D) Covering the face of a client extremely short of breath may cause anxiety and further increase dyspnea.

A client with bipolar disorder taking lithium tells the nurse that he has ringing in his ears, blurred vision, and diarrhea. The nurse notices a slight tremor in his left hand and a slurring pattern to his speech. Which of the following actions by the nurse is appropriate?

  • A. Administer a stat dose of lithium as necessary.
  • B. Recognize this as an expected response to lithium.
  • C. Request an order for a stat blood lithium level.
  • D. Give an oral dose of lithium antidote.

Answer : C

(A) These symptoms are indicative of lithium toxicity. A stat dose of lithium could be fatal.
(B) These are toxic effects of lithium therapy. (C) The client is exhibiting symptoms of lithium toxicity, which may be validated by lab studies. (D) There is no known lithium antidote.

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

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.

A psychotic client who believes that he is God and rules all the universe is experiencing which type of delusion?

  • A. Somatic
  • B. Grandiose
  • C. Persecutory
  • D. Nihilistic

Answer : B

(A) These delusions are related to the belief that an individual has an incurable illness. (B)
These delusions are related to feelings of self-importance and uniqueness. (C) These delusions are related to feelings of being conspired against. (D) These delusions are related to denial of self-existence.

A pregnant woman at 36 weeks gestation is followed for PIH and develops proteinuria. To increase protein in her diet, which of the following foods will provide the greatest amount of protein when added to her intake of 100 mL of milk?

  • A. Fifty milliliters light cream and 2 tbsp corn syrup
  • B. Thirty grams powdered skim milk and 1 egg
  • C. One small scoop (90 g) vanilla ice cream and 1 tbsp chocolate syrup
  • D. One package vitamin-fortified gelatin drink

Answer : B

(A) This choice would provide more unwanted fat and sugar than protein. (B) Skim milk would add protein. Eggs are good sources of protein while low in fat and calories. (C) The benefit of protein from ice cream would be outweighed by the fat content. Chocolate syrup has caffeine, which is contraindicated or limited in pregnancy. (D) Although most animal proteins are higher in protein than plant proteins, gelatin is not. It loses protein during the processing for food consumption.

A six-month-old infant has been admitted to the emergency room with febrile seizures. In the teaching of the parents, the nurse states that:

  • A. Sustained temperature elevation over 103F is generally related to febrile seizures
  • B. Febrile seizures do not usually recur
  • C. There is little risk of neurological deficit and mental retardation as sequelae to febrile seizures
  • D. Febrile seizures are associated with diseases of the central nervous system

Answer : C

(A) The temperature elevation related to febrile seizures generally exceeds 101F, and seizures occur during the temperature rise rather than after a prolonged elevation. (B)
Febrile seizures may recur and are more likely to do so when the first seizure occurs in the
1st year of life. (C) There is little risk of neurological deficit, mental retardation, or altered behavior secondary to febrile seizures. (D) Febrile seizures are associated with disease of the central nervous system.

To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and O2 demand will occur with which of the following?

  • A. Positive inotropic therapy
  • B. Negative chronotropic therapy
  • C. Increase in balance of myocardial O2 supply and demand
  • D. Afterload reduction therapy

Answer : A

(A) Inotropic therapy will increase contractility, which will increase myocardial O2 demand.
(B) Decreased heart rate to the point of bradycardia will increase coronary artery filling time. This should be used cautiously because tachycardia may be a compensatory mechanism to increase cardiac output. (C) The goal in the care of the MI client with angina is to maintain a balance between myocardial O2 supply and demand. (D) Decrease in systemic vascular resistance by drug therapy, such as IV nitroglycerin or nitroprusside, or intra-aortic balloon pump therapy, would decrease myocardial work and O2 demand.

The nurse practitioner determines that a client is approximately 9 weeks gestation. During the visit, the practitioner informs the client about symptoms of physical changes that she will experience during her first trimester, such as:

  • A. Nausea and vomiting
  • B. Quickening
  • C. A 6–8 lb weight gain
  • D. Abdominal enlargement

Answer : A

(A) Nausea and vomiting are experienced by almost half of all pregnant women during the first 3 months of pregnancy as a result of elevated human chorionic gonadotropin levels and changed carbohydrate metabolism. (B) Quickening is the mothers perception of fetal movement and generally does not occur until 1820 weeks after the last menstrual period in primigravidas, but it may occur as early as 16 weeks in multigravidas. (C) During the first trimester there should be only a modest weight gain of 24 lb. It is not uncommon for women to lose weight during the first trimester owing to nausea and/or vomiting. (D)
Physical changes are not apparent until the second trimester, when the uterus rises out of the pelvis.

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Total 862 questions