NCLEX-RN NCLEX National Council Licensure Examination(NCLEX-RN)

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Question: 1 On the third postpartum day, the nurse would expect the lochia to be: A. Rubra B. Serosa C. Alba D. Scant Answer: A Explanation: (A) This discharge occurs from delivery through the... 3rd day. There is dark red blood, placental debris, and clots. (B) This discharge occurs from days 4-10. The lochia is brownish, serous, and thin. (C) This discharge occurs from day 10 through the 6thweek. The lochia is yellowish white. (D) This is not a classification of lochia but relates to the amount of discharge. Question: 2 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 Answer: C Explanation: (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: 3 Which stage of labor lasts from delivery of the baby to delivery of the placenta? A. Second B. Third C. Fourth D. Fifth Answer: B Explanation: (A) This stage is from complete dilatation of the cervix to delivery of the fetus. (B) This is the correct stage for the definition. (C) This stage lasts for about 2 hours after the delivery of the placenta. (D) There is no fifth stage of labor. Question: 4 A client develops complications following a hysterectomy. Blood cultures reveal Pseudomonas aeruginosa. The nurse expects that the physician would order an appropriate antibiotic to treat P. aeruginosa such as: A. Cefoperazone (Cefobid) B. Clindamycin (Cleocin) C. Dicloxacillin (Dycill) D. Erythromycin (Erythrocin) Answer: A Explanation: (A) Cefoperazone is indicated in the treatment of infection withPseudomonas aeruginosa.(B) Clindamycin is not indicated in the treatment of infection withP. aeruginosa.(C) Dicloxacillin is not indicated in the treatment of infection withP. aeruginosa.(D) Erythromycin is not indicated in the treatment of infection withP. aeruginosa. Question: 5 A couple is experiencing difficulties conceiving a baby. The nurse explains basal body temperature (BBT) by instructing the female client to take her temperature: A. Orally in the morning and at bedtime B. Only one time during the day as long as it is always at the same time of day C. Rectally at bedtime D. As soon as she awakens, prior to any activity Answer: D Explanation: (A) Monitoring temperature twice a day predicts the biphasic pattern of ovulation. (B) Prediction of ovulation relies on consistency in taking temperature. (C)Nightly rectal temperatures are more accurate in predicting ovulation. (D) Activity changes the accuracy of basal body temperature and ability to detect the luteinizing hormone surge. Question: 6 A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating include: A. Administering diazepam (Valium) 1015 mg po q4h and q1h prn for hyperventilating episode B. Keeping the temperature in the client’s room at a high level to reduce respiratory stimulation C. Having the client hold her breath or breathe into a paper bag when hyperventilation episodes occur D. Using distraction to help control the client’s hyperventilation episodes Answer: C Explanation: (A) An adult diazepam dosage for treatment of anxiety is 210 mg PO 24 times daily. The order as written would place a client at risk for overdose. (B) A high room temperature could increase hyperventilating episodes by stimulating the respiratory system. (C) Breath holding and breathing into a paper bag may be useful in controlling hyperventilation. Both measures increase CO2 retention. (D) Distraction will not prevent or control hyperventilation caused by anxiety or fear. Question: 7 A client delivered a stillborn male at term. An appropriate action of the nurse would be to: A. State, "You have an angel in heaven." B. Discourage the parents from seeing the baby. C. Provide an opportunity for the parents to see and hold the baby for an undetermined amount of time. D. Reassure the parents that they can have other children. Answer: C Explanation: (A) This is not a supportive statement. There are also no data to indicate the family’s religious beliefs. (B) Seeing their baby assists the parents in the grieving process. This gives them the opportunity to say "good-bye." (C) Parents need time to get to know their baby. (D) This is not a comforting statement when a baby has died. There are also no guarantees that the couple will be able to have another child. Question: 8 A 29-year-old client is admitted for a hysterectomy. She has repeatedly told the nurses that she is worried about having this surgery, has not slept well lately, and is afraid that her husband will not find her desirable after the surgery. Shortly into the preoperative teaching, she complains of a tightness in her chest, a feeling of suffocation, lightheadedness, and tingling in her hands. Her respirations are rapid and deep. Assessment reveals that the client is: A. Having a heart attack B. Wanting attention from the nurses C. Suffering from complete upper airway obstruction D. Hyperventilating Answer: D Explanation: (A) Classic symptoms of a heart attack include heaviness or squeezing pain in the chest, pain spreading to the jaw, neck, and arm. Nausea and vomiting, sweating, and shortness of breath may be present. The client does not exhibit these symptoms. (B) Clients suffering from anxiety or fear prior to surgical procedures may develop hyperventilation. This client is not seeking attention. (C) Symptoms of complete airway obstruction include not being able to speak, and no airflow between the nose and mouth. Breath sounds are absent. (D) Tightness in the chest; a feeling of suffocation; lightheadedness; tingling in the hands; and rapid, deep respirations are signs and symptoms of hyperventilation. This is almost always a manifestation of anxiety. Question: 9 A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains of severe abdominal pain. Assessment reveals abdominal rigidity and distention, increased temperature, and tachycardia. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has developed: A. Gastritis B. Evisceration C. Peritonitis D. Pulmonary embolism Answer: C Explanation: (A) Assessment findings for gastritis would reveal anorexia, nausea and vomiting, epigastric fullness and tenderness, and discomfort. (B) Evisceration is the extrusion of abdominal viscera as a result of trauma or sutures failing in a surgical incision. (C) Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and fluid into the abdominal cavity. This causes infection and irritation. (D) Assessment findings of pulmonary embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath, anxiety or panic, and wheezing and coughing often accompanied by blood-tinged sputum. Question: 10 A 35-year-old client is admitted to the hospital for elective tubal ligation. While the nurse is doing preoperative teaching, the client says, "The anesthesiologist said she was going to give me balanced anesthesia. What exactly is that?" The best explanation for the nurse to give the client would be that balanced anesthesia: A. Is a type of regional anesthesia B. Uses equal amounts of inhalation agents and liquid agents C. Does not depress the central nervous system D. Is a combination of several anesthetic agents or drugs producing a smooth induction and minimal complications Answer: D Explanation: (A) Regional anesthesia does not produce loss of consciousness and is indicated for excision of moles, cysts, and endoscopic surgeries. (B) Varying amounts of anesthetic agents are used when employing balanced anesthesia. Amounts depend on age, weight, condition of the client, and surgical procedure. (C) General anesthesia is a druginduced depression of the central nervous system that produces loss of consciousness and decreased muscle activity. (D) Balanced anesthesia is a combination of a number of anesthetic agents that produce a smooth induction, appropriate depth of anesthesia, and appropriate muscle relaxation with minimal complications. Question: 11 Following a gastric resection, a 70-year-old client is admitted to the postanesthesia care unit. He was extubated prior to leaving the suite. On arrival at the postanesthesia care unit, the nurse should: A. Check airway, feeling for amount of air exchange noting rate, depth, and quality of respirations B. Obtain pulse and blood pressure readings noting rate and quality of pulse C. Reassure the client that his surgery is over and that he is in the recovery room D. Review physician’s orders, administering medications as ordered Answer: A Explanation: (A) Adequate air exchange and tissue oxygenation depend on competent respiratory function. Checking the airway is the nurse’s priority action. (B) Obtaining the vital signs is an important action, but it is secondary to airway management. (C) Reorienting a client to time, place, and person after surgery is important, but it is secondary to airway and vital signs. (D) Airway management takes precedence over physician’s orders unless they specifically relate to airway management. Question: 12 A 25-year-old client is admitted for a tonsillectomy. She tells the nurse that she has had episodes of muscle cramps, weakness, and unexplained temperature elevation. Many years ago her father died shortly after surgery after developing a high fever. She further tells the nurse that her surgeon is having her take dantrolene sodium (Dantrium) prophylactically prior to her tonsillectomy. Dantrolene sodium is ordered preoperatively to reduce the risk or prevent: A. Infection postoperatively B. Malignant hyperthermia C. Neuroleptic malignant syndrome D. Fever postoperatively Answer: B Explanation: (A, D) Dantrolene sodium is a peripheral skeletal muscle relaxant and would have no effect on a postoperative infection. (B) Dantrolene sodium is indicated prophylactically for clients with malignant hyperthermia or with a family history of the disorder. The mortality rate for malignant hyperthermia is high. (C) Neuroleptic malignant syndrome is an exercise-induced muscle pain and spasm and is unrelated to malignant hyperthermia. Question: 13 The family member of a child scheduled for heart surgery states, "I just don’t understand this open-heart or closedheart business. I’m so confused! Can you help me understand it?" The nurse explains that patent ductus arteriosus repair is: A. Open-heart surgery. The child will be placed on a heart-lung machine while the surgery is being performed. B. Closed-heart surgery. It does not require that the child be placed on the heart-lung machine while the surgery is being performed. C. A pediatric version of the coronary artery bypass graft surgery performed on adults. It is an open-heart surgery. D. A pediatric version of percutaneous transluminal coronary angioplasty performed on adults. It is a closed-heart surgery. Answer: B Explanation: (A) Patent ductus arteriosus repair is a closed-heart procedure. The client is not placed on a heart-lung machine. (B) Patent ductus arteriosus is a ductus arteriosus that does not close shortlyafter birth but remains patent. Repair is a closed-heart procedure involving ligation of the patent ductus arteriosus. (C) Coronary artery bypass graft surgery is an open-heart surgical procedure in which blocked coronary arteries are bypassed using vessel grafts. (D) Percutaneous transluminal coronary angioplasty is a closedheart procedure that improves coronary blood flow by increasing the lumen size of narrowed vessels. Question: 14 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. 0.38 mL C. 2.7 mL D. Information given insufficient to determine the amount of atropine to be administered Answer: B 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. Question: 15 A 47-year-old male client is admitted for colon surgery. Intravenous antibiotics are begun 2 hours prior to surgery. He has no known infection. The rationale for giving antibiotics prior to surgery is to: A. Provide cathartic action within the colon B. Reduce the risk of wound infection from anaerobic bacteria C. Relieve the client’s concern regarding possible infection D. Reduce the risk of intraoperative fever Answer: B Explanation: (A) Cathartic drugs promote evacuation of intestinal contents. (B) The client undergoing intestinal surgery is at increased risk for infection from large numbers of anaerobic bacteria that inhabit the intestines. Administering antibiotics prophylactically can reduce the client’s risk for infection. (C) Antibiotics are indicated in the treatment of infections and have no effect on emotions. (D) Antipyretics are useful in the treatment of elevated temperatures. Antibiotics would have an effect on infection, which causes temperature elevation, but would not directly affect such an elevation. Question: 16 A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is being given digoxin. Prior to administering the medication, the nurse should: A. Not give the digoxin if the pulse is_60 B. Not give the digoxin if the pulse is_100 C. Take the apical pulse for a full minute D. Monitor for visual disturbances, a side effect of digoxin Answer: C Explanation: (A) Digoxin should not be given to adults with an apical pulse < 60 bpm. (B) Digoxin should be given to children with an apical pulse > 100 bpm. With a pulse < 100 bpm, the medication should be withheld and the physician notified. (C) Prior to digoxin administration in both children and adults, an apical pulse should be taken for 1 full minute. Aside from the rate per minute, the nurse should note any sudden increase or decrease in heart rate, irregular rhythm, or regularization of a chronic irregular heart rhythm. (D) Early indications of digoxin toxicity, such as visual disturbances, occur rarely as initial signs in children. Question: 17 A 35-year-old client has returned to her room following surgery on her right femur. She has an IV of D5 in onehalf normal saline infusing at 125 mL/hr and is receiving morphine sulfate 1015 mg IM q4h prn for pain. She last voided 51/2 hours ago when she was given her preoperative medication. In monitoring and promoting return of urinary function after surgery, the nurse would: A. Provide food and fluids at the client’s request B. Maintain IV, increasing the rate hourly until the client voids C. Report to the surgeon if the client is unable to void within 8 hours of surgery D. Hold morphine sulfate injections for pain until the client voids, explaining to her that morphine sulfate can cause urinary retention Answer: C Explanation: (A) Provision of food and fluid promotes bowel elimination. Nutritional needs postoperatively are determined by the physician, not the client. (B) Increasing IV fluids postoperatively will not cause a client to void. Any change in rate of administration of IV fluids should be determined by the physician. (C) The postoperative client with normal kidney function who cannot void 8 hours after surgery is retaining urine. The client may need catheterization or medication. The physician must provide orders for both as necessary. (D) Although morphine sulfate can cause urinary retention, withholding pain medication will not ensure that the client will void. The client with uncontrolled pain will probably not be able to void. Question: 18 A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low, intermittent suction with orders to "Irrigate NG tube with sterile saline q1h and prn." The rationale for using sterile saline, as opposed to using sterile water to irrigate the NG tube is: A. Water will deplete electrolytes resulting in metabolic acidosis. B. Saline will reduce the risk of severe, colicky abdominal pain during NG irrigation. C. Water is not isotonic and will increase restlessness and insomnia in the immediate postoperative period. D. Saline will increase peristalsis in the bowel. Answer: A Explanation: (A) Water is a hypotonic solution and will deplete electrolytes and cause metabolic acidosis when used for nasogastric irrigation. (B) Irrigating with saline does not cause abdominal discomfort. Severe, colicky abdominal pain is a symptom of intestinal obstruction. (C) Irrigating with water will not cause restlessness or insomnia in the postoperative client. Restlessness and insomnia can be emotional complications of surgery. (D) A nasogastric tube placed in the stomach is used to decompress the bowel. Irrigating with saline ensures a patent, well- functioning tube. Irrigating with saline will not increase peristalsis. Question: 19 The nurse writes the following nursing diagnosis for a client in acute renal failure–Impaired gas exchange related to: A. Decreased red blood cell production B. Increased levels of vitamin D C. Increased red blood cell production D. Decreased production of renin Answer: A Explanation: (A) Red blood cell production is impaired in renal failure owing to impaired erythropoietin production. This causes a decrease in the delivery of oxygen to the tissue and impairs gas exchange. (B) The conversion of vitamin D to its physiologically active form is impaired in renal failure. (C) In renal failure, a decrease in red blood cell production occurs owing to an impaired production of erythropoietin, leading to impaired gas exchange at the cellular level. (D) The decreased production of renin in renal failure causes an increased production of aldosterone causing sodium and water retention. Question: 20 A 6-year-old child returned to the surgical floor 20 hours ago after an appendectomy for a gangrenous appendix. His mother tells the nurse that he is becoming more restless and is anxious. Assessment findings indicate that the child has atelectasis. Appropriate nursing actions would include: A. Allowing the child to remain in the position of comfort, preferably semi-or high-Fowler position B. Administering analgesics as ordered C. Having the child turn, cough, and deep breathe every 12 hours D. Remaining with the child and keeping as calm and quiet as possible Answer: C Explanation: (A) Allowing the client to remain in the position of comfort will not resolve the atelectasis. This position, if left unchanged, over time may actually increase the atelectasis. (B) Analgesics will not resolve the atelectasis and may contribute to it if proper nursing actions are not taken to help resolve the atelectasis. (C) Having the client turn, cough, and deep breathe every 12 hours will aid in resolving the atelectasis. Surgery clients are at risk for postoperative respiratory complications because pulmonary function is reduced as a result of anesthesia and surgery. (D) Remaining with the client and keeping him calm and quiet will not affect the client’s anxiety, restlessness, or help to resolve the atelectasis. The cause (atelectasis) needs to be treated, not the symptoms (anxiety and restlessness). Question: 21 A 52-year-old female client is admitted to the hospital in acute renal failure. She has been on hemodialysis for the past 2 years. Stat arterial blood gases are drawn on the client yielding the following results: pH 7.30, PCO2 51 mm Hg, HCO3, 18 mEq/L, PaO2, 84 mm Hg. The nurse would interpret these results as: A. Compensated metabolic alkalosis B. Respiratory acidosis C. Partially compensated metabolic alkalosis D. Combined respiratory and metabolic acidosis Answer: D Explanation: (A) Compensated metabolic alkalosis would be reflected by the following: pH within normal limit (7.357.45), PCO2 > 45 mm Hg, HCO3 >26 mEq/L. (B) Respiratory acidosis would be reflected by the following: pH < 7.35, PCO2 > 45 mm Hg, HCO3 within normal limits (2226 mEq/L). (C) Partially compensated metabolic alkalosis would be reflected by the following: pH > 7.45, PCO2 > 45 mm Hg, HCO3 > 26 mEq/L. (D) Combined respiratory and metabolicacidosis would be reflected by the following: pH < 7.35, PCO2 > 45 mm Hg, HCO3 < 22 mEq/L. Question: 22 Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. The physician is immediately notified and orders 50 mL of dextrose and 10 U of regular insulin IV push. The nurse administering these drugs knows the Rationale for this therapy is to: A. Remove the potassium from the body by renin exchange B. Protect the myocardium from the effects of hypokalemia C. Promote rapid protein catabolism D. Drive potassium from the serum back into the cells [Show More]

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