NCLEX-RN Exam Part 3 (151-225)

NCLEX-RN Exam Part 3

QUESTION 151

 A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom. Which nursing action is the most appropriate?

A. Put in a nasogastric tube and lavage the child’s stomach.

B. Monitor muscular status.

C. Teach mother poison prevention techniques.

D. Place child on respiratory assistance.

 

QUESTION 152

 Azulfidine (Sulfasalazine) may be ordered for a client who has ulcerative colitis. Which of the following is a nursing implication for this drug?

A. Limit fluids to 500 mL/day.

B. Administer 2 hours before meals.

C. Observe for skin rash and diarrhe A.

D. Monitor blood pressure, pulse.

 

QUESTION 153

A dose of theophylline may need to be altered if a client with COPD:

A. Is allergic to morphine

B. Has a history of arthritis

C. Operates machinery

D. Is concurrently on cimetidine for ulcers

 

QUESTION 154

A 56-year-old client is admitted to the psychiatric unit in a state of total despair. She feels hopeless and worthless, has a flat affect and very sad appearance, and is unable to feel pleasure from anything. Her husband has been assisting her at home with the housework and cooking; however, she has not been eating much, lies around or sits in a chair most of the day, and is becoming confused and thinks her family does not want her around anymore. In assessing the client, the nurse determines that her behavior is consistent with:

A. Transient depression

B. Mild depression

C. Moderate depression

D. Severe depression

 

QUESTION 155

 A client is pregnant with her second child. Her last menstrual period began on January 15. Her expected date of delivery would be:

A. October 8

B. October 15

C. October 22

D. October 29

 

QUESTION 156

  Which of the following changes in blood pressure readings should be of greatest concern to the nurse when assessing a prenatal client?

 A. 130/88 to 144/92

B. 136/90 to 148/100

C. 150/96 to 160/104

D. 118/70 to 130/88

 

QUESTION 157

The nurse would assess the client’s correct understanding of the fertility awareness methods that enhance conception, if the client stated that:

A. “My sexual partner and I should have intercourse when my cervical mucosa is thick and cloudy.”

B. “At ovulation, my basal body temperature should rise about 0.5F.”

C. “I should douche immediately after intercourse.”

D. “My sexual partner and I should have sexual intercourse on day 14 of my cycle regardless of the length of the cycle.”

 

QUESTION 158 

In evaluating the laboratory results of a client with severe pressure ulcers, the nurse finds that her albumin level is low. A decrease in serum albumin would contribute to the formation of pressure ulcers because:

A. The proteins needed for tissue repair are diminished.

B. The iron stores needed for tissue repair are inadequate.

C. A decreased serum albumin level indicates kidney disease.

D. A decreased serum albumin causes fluid movement into the blood vessels, causing dehydration.

 

QUESTION 159

 A client is being discharged on warfarin (Coumadin), an oral anticoagulant. The nurse instructs him about using this drug. Which following response by the client indicates the need for further teaching?

A. “I should shave with my electric razor while on Coumadin.”

B. “I will inform my dentist that I am on anticoagulant therapy before receiving dental work.”

C. “I will continue with my usual dosage of aspirin for my arthritis when I return home.”

D. “I will wear an ID bracelet stating that I am on anticoagulants.”

 

QUESTION 160

 When a client with pancreatitis is discharged, the nurse needs to teach him how to prevent another occurrence of acute pancreatitis. Which of the following statements would indicate he has an understanding of his disease?

A. “I will not eat any raw or uncooked vegetables.”

B. “I will limit my alcohol to one cocktail per day.”

C. “I will look into attending Alcoholics Anonymous meetings.”

D. “I will report any changes in bowel movements to my doctor.”

 

QUESTION 161

 A client decided early in her pregnancy to breast-feed her first baby. She gave birth to a normal, full-term girl and is now progressing toward the establishment of successful lactation. To remove the baby from her breast, she should be instructed to:

A. Gently pull the infant away

B. Withdraw the breast from the infant’s mouth

C. Compress the areolar tissue until the infant drops the nipple from her mouth

D. Insert a clean finger into the baby’s mouth beside the nipple

 

QUESTION 162 

A parent told the public health nurse that her 6-year-old son has been taking tetracycline for a chronic skin condition. The parent asked if this could cause any problems for the child. What should the nurse explain to the parent?

A. Giving tetracycline to a child younger than 8 years may cause permanent staining of his teeth.

B. If you give tetracycline with milk, it may be absorbed readily.

C. The medication should be given to adults, not children.

D. Secondary infections of chronic skin disorders do not respond to antibiotics.

 

QUESTION 163

 MgSO4 is ordered IV following the established protocol for a client with severe PIH. The anticipated effects of this therapy are anticonvulsant and:

A. Vasoconstrictive

B. Vasodilative

C. Hypertensive

D. Antiemetic

 

QUESTION 164 

The nurse is preparing a 6-year-old child for an IV insertion. Which one of the following statements by the nurse is appropriate when preparing a child for a potentially painful procedure?

A. “Some say this feels like a pinch or a bug bite. You tell me what it feels like.”

B. “This is going to hurt a lot; close your eyes and hold my hand.”

C. “This is a terrible procedure, so don’t look.”

D. “This will hurt only a little; try to be a big boy.”

 

QUESTION 165

  A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, “Oh dear, I feel like I have to urinate again!” Which of the following is the most appropriate initial nursing response?

A. Assure her that this is most likely the result of bladder spasms.

B. Check the collection bag and tubing to verify that the catheter is draining properly.

C. Instruct her to do Kegel exercises to diminish the urge to void.

D. Ask her if she has felt this way before.

 

QUESTION 166

  A six-month-old infant is receiving ribavirin for the treatment of respiratory syncytial virus. Ribavirin is administered via which one of the following routes?

A. Oral

B. IM

C. IV

D. Aerosol

 

QUESTION 167

 A pregnant client is at the clinic for a third trimester prenatal visit. During this examination, it has been determined that her fetus is in a vertex presentation with the occiput located in her right anterior quadrant. On her chart this would be noted as:

A. Right occipitoposterior

B. Right occipitoanterior

C. Right sacroanterior

D. LOA

 

QUESTION 168

 Which of the following menu choices would indicate that a client with pressure ulcers understands the role diet plays in restoring her albumin levels?

 

A. Broiled fish with rice

B. Bran flakes with fresh peaches

C. Lasagna with garlic bread

D. Cauliflower and lettuce salad

 

 

QUESTION 169

 A 42-year-old client with bipolar disorder has been hospitalized on the inpatient psychiatric unit. She is dancing around, talking incessantly, and singing. Much of the time the client is anorexic and eats very little from her tray before she is up and about again. The nurse’s intervention would be to:

A. Confront the client with the fact that she will have to eat more from her tray to sustain her

B. Try to get the client to focus on her eating by offering a detailed discussion on the importance of nutrition

C. Let her have snacks and drinks anytime that she wants them because she will not eat at regular meal times

D. Not expect the client to sit down for complete meals; monitor intake, offering snacks and juice frequently

 

QUESTION 170 

A 35-weeks-pregnant client is undergoing a nonstress test (NST). During the 20-minute

examination, the nurse notes three fetal movements accompanied by accelerations of the fetal heart rate, each 15 bpm, lasting

15 seconds. The nurse interprets this test to be:

A. Nonreactive

B. Reactive

C. Positive

D. Negative

 

QUESTION 171 

A 30-year-old client has just been treated in the ER for bruises and abrasions to her face and a broken arm from domestic violence, which has been increasing in frequency and intensity over the last few months. The nurse assesses her as being very anxious, fearful, bewildered, and feeling helpless as she states, “I don’t know what to do, I’m afraid to go home.” The best response by the nurse to the client would be:

 

A. “I wouldn’t want to go home either; call a friend who could help you.”

B. “Did you do something that could have made him so angry?”

C. “Let’s talk about people and resources available to you so that you don’t have to go home.”

D. “I’ll call the police and they will take care of him, and you can go home and get some rest.”

 

QUESTION 172 

A 74-year-old obese man who has undergone open reduction and internal fixation of the right hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to right lower leg pain, described as “a cramp in my leg.” An appropriate nursing action is to:

A. Assess for pain with plantiflexion

B. Assess for edema and heat of the right leg

C. Instruct him to rub the cramp out of his leg

D. Elevate right lower extremity with pillows propped under the knee

 

QUESTION 173

 A 26-year-old client is admitted to the labor, delivery, recovery, postpartum unit. The nurse completes her assessment and determines the client is in the first stage of labor. The nurse should instruct her:

A. To hold her breath during contractions

B. To be flat on her back

C. Not to push with her contractions

D. To push before becoming fully dilated

 

QUESTION 174

 A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse?

 

A. “Keep breathing with your abdominal muscles as long as you can.”

B. “Make sure you take a deep cleansing breath as the contractions start, focus on an object, and breathe about 16–20 times a minute with shallow chest breaths.”

C. “Find a comfortable position before you start a contraction. Once the contraction has started, take slow breaths using your abdominal muscles.”

D. “If a woman in labor listens to her body and takes rapid, deep breaths, she will be able to deal with her contractions quite well.”

 

QUESTION 175

 A couple is planning the conception of their first child.

The wife, whose normal menstrual cycle is 34 days in length, correctly identifies the time that she is most likely to ovulate if she states that ovulation should occur on day:

A.            14+2 days

B.            16+2 days

C.            20+2 days

D.            22+2 days

 

QUESTION 176

  A nurse should carefully monitor a client for the following side effect of MgSO4:

A.            Visual blurring

B.            Tachypnea

C.            Epigastric pain

D.            Respiratory depression

 

QUESTION 177 

The nurse would teach a male client ways to minimize the risk of infection after eye surgery. Which of the following indicates the client needs further teaching?

A. “I will wash my hands before instilling eye medications.”

B. “I will wear sunglasses when going outside.”

C. “I will wear an eye patch for the first 3 postoperative days.”

D. “I will maintain the sterility of the eye medications.”

 

QUESTION 178

 With a geriatric client, the nurse should also assess whether he has been obtaining a yearly vaccination against influenz

A. Why is this assessment important?

A. Influenza is growing in our society.

B. Older clients generally are sicker than others when stricken with flu.

C. Older clients have less effective immune systems.

D. Older clients have more exposure to the causative agents.

 

QUESTION 179

 A client delivered her first-born son 4 hours ago. She asks the nurse what the white cheeselike substance is under the baby’s arms. The nurse should respond:

A. “This is a normal skin variation in newborns. It will go away in a few days.”

B. “Let me have a closer look at it. The baby may have an infection.”

C. “This material, called vernix, covered the baby before it was born. It will disappear in a few days.”

D. “Babies sometimes have sebaceous glands that get plugged at birth. This substance is an example of that condition.”

 

QUESTION 180

 A 26-year-old client is in a treatment center for aprazolam (Xanax) abuse and continues to manifest moderate levels of anxiety 3 weeks into the rehabilitation program, often requesting medication for “his nerves.” Included in the client’s plan of care is to identify alternate methods of coping with stress and anxiety other than use of medication. After intervening with assistance in stress reduction techniques, identifying feelings and past coping, the nurse evaluates the outcome as being met if:

 

A. Client promises that he will not abuse aprazolam after discharge

B. Client demonstrates use of exercise or physical activity to handle nervous energy following conflicts of everyday life

C. Client is able to verbalize effects of substance abuse on the body

D. Client has remained substance free during hospitalization and is discharged

 

QUESTION 181 

In assessing the nature of the stool of a client who has cystic fibrosis, what would the nurse expect to see?

A. Clay-colored stools

B. Steatorrhea stools

C. Dark brown stools

D. Blood-tinged stools

 

QUESTION 182

 A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful?

A. Pork chop, baked acorn squash, brussel sprouts

B. Chicken breast, rice, and green beans

C. Roast beef, baked potato, and diced carrots

D. Tuna casserole, noodles, and spinach

 

QUESTION 183 

The nurse is teaching a 10-year-old insulin-dependent diabetic how to administer insulin. Which one of the following steps must be taught for insulin administration?

A. Never use abdominal site for a rotation site.

B. Pinch the skin up to form a subcutaneous pocket.

C. Avoid applying pressure after injection.

D. Change needles after injection.

 

QUESTION 184

A client is experiencing muscle weakness and lethargy. His serum K+is 3.2. What other symptoms might he exhibit?

 

A. Tetany

B. Dysrhythmias

C. Numbness of extremities

D. Headache

 

QUESTION 185  Other drugs may be ordered to manage a client’s ulcerative colitis. Which of the following medications, if ordered, would the nurse question?

A. Methylprednisolone sodium succinate (Solu-Medrol)

B. Loperamide (Imodium)

C. Psyllium

D. 6-Mercaptopurine

 

QUESTION 186  An 8-week-old infant has been diagnosed with gastroesophageal reflux. The nurse is teaching the infant’s mother to care for the infant at home. Which one of the following statements by the nurse is appropriate regarding the infant’s home care?

A. “Lay the infant flat on her left side after feeding.”

B. “Feed the infant every 4 hours with half-strength formula.”

C. “Antacids need to be given an hour before feeding.”

D. “Play activities should be carried out before instead of after feedings.”

 

QUESTION 187  A mother is unsure about the type of toys for her 17-month-old child. Based on knowledge of growth and development, what toy would the nurse suggest?

A. A pull toy to encourage locomotion

B. A mobile to improve hand-eye coordination

C. A large toy with movable parts to improve pincer grasp

D. Various large colored blocks to teach visual discrimination

 

QUESTION 188  A group of nursing students at a local preschool day care center are going to screen each child’s fine and gross motor, language, and social skills. The students will use which one of the most widely used screening tests?

A. Revised Prescreening Developmental Questionnaire

B. Goodenough Draw-a-Person Screening Test

C. Denver Development Screening Test

D. Caldwell Home Inventory

 

 QUESTION 189  A gravida 2 para 1 client is hospitalized with severe preeclampsi

A. While she receives magnesium sulfate

(MgSO4) therapy, the nurse knows it is safe to repeat the dosage if:

A.            Deep tendon reflexes are absent

B.            Urine output is 20 mL/hr

C.            MgSO4serum levels are>15 mg/dL

D.            Respirations are>16 breaths/min

 

QUESTION 190  In addition to changing the mother’s position to relieve cord pressure, the nurse may employ the following measure (s) in the event that she observes the cord out of the vagina:

A. Immediately pour sterile saline on the cord, and repeat this every 15 minutes to prevent drying.

B. Cover the cord with a wet sponge.

C. Apply a cord clamp to the exposed cord, and cover with a sterile towel.

D. Keep the cord warm and moist by continuous applications of warm, sterile saline compresses.

 

 

QUESTION 191  Following a gastric resection, which of the following actions would the nurse reinforce with the client in order to alleviate the distress from dumping syndrome?

A. Eating three large meals a day

B. Drinking small amounts of liquids with meals

C. Taking a long walk after meals

D. Eating a low-carbohydrate diet

 

 

QUESTION 192  A 54-year-old client is admitted to the hospital with a possible gastric ulcer. He is a heavy smoker. When discussing his smoking habits with him, the nurse should advise him to:

A. Smoke low-tar, filtered cigarettes

B. Smoke cigars instead

C. Smoke only right after meals

D. Chew gum instead

 

QUESTION 193  A client with severe PIH receiving MgSO4 is placed in a quiet, darkened room. The nurse bases this action on the following understanding:

 

A. The client is restless.

B. The elevated blood pressure causes photophobi A.

C. Noise or bright lights may precipitate a convulsion.

D. External stimuli are annoying to the client with PIH.

 

QUESTION 194

Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, “Begin oxytocin induction at 1 mU/min.” The nurse should:

A. Begin the oxytocin induction as ordered

B. Increase the dosage by 2 mU/min increments at 15-minute intervals

C. Maintain the dosage when duration of contractions is 40–60 seconds and frequency is at 212–4 minute intervals

D. Question the order

 

QUESTION 195

A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the gravida and para system to record the client’s

obstetrical history, the nurse should record:

A. Gravida 3 para 1

B. Gravida 3 para 2

C. Gravida 2 para 1

D. Gravida 2 para 2

 

QUESTION 196

Which of the following would indicate the need for further teaching for the client with COPD? The client verbalizes the need to:

A. Eat high-calorie, high-protein foods

B. Take vitamin supplementation

C. Eliminate intake of milk and milk products

D. Eat small, frequent meals

 

QUESTION 197

The nurse provides a male client with diet teaching so that he can help prevent constipation in the future. Which food choices indicate that this teaching has been understood?

A. Omelette and hash browns

B. Pancakes and syrup

C. Bagel with cream cheese

D. Cooked oatmeal and grapefruit half

 

.

 

QUESTION 198

In cleansing the perineal area around the site of catheter insertion, the nurse would:

 

A. Wipe the catheter toward the urinary meatus

B. Wipe the catheter away from the urinary meatus

C. Apply a small amount of talcum powder after drying the perineal area

D. Gently insert the catheter another 12 inch after cleansing to prevent irritation from the balloon

 

QUESTION 199

A 7-year-old child is brought to the ER at midnight by his mother after symptoms appeared abruptly. The nurse’s initial assessment reveals a temperature of 104.5F (40.3C), difficulty swallowing, drooling, absence of a spontaneous cough, and agitation. These symptoms are indicative of which one of the following?

A. Acute tracheitis

B. Acute spasmodic croup

C. Acute epiglottis

D. Acute laryngotracheobronchitis

 

 

QUESTION 200

A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will:

A. Drink at least 8 oz of cranberry juice daily

B. Maintain a fluid intake of at least 2000 mL daily

C. Wash her hands before and after voiding

D. Limit her fluid intake after 6 PM so that there is not a great deal of urine in her bladder while she sleeps

 

 

QUESTION 201

A pregnant client experiences a precipitous delivery. The nursing action during a precipitous delivery is to:

A. Control the delivery by guiding expulsion of fetus

B. Leave the room to call the physician

C. Push against the perineum to stop delivery

D. Cross client’s legs tightly

 

QUESTION 202

A client is diagnosed with organic brain disorder. The nursing care should include:

 

A. Organized, safe environment

B. Long, extended family visits

C. Detailed explanations of procedures

D. Challenging educational programs

 

QUESTION 203

A premature infant needs supplemental O2 therapy. A nursing intervention that reduces the risk of retrolental fibroplasia is to:

A. Maintain O2at <40%

B. Maintain O2at>40%

C. Give moist O2at>40%

D. Maintain on 100% O2

 

 

QUESTION 204

A 35-year-old client is admitted to the hospital with diabetic ketoacidosis. Results of arterial blood gases are pH 7.2, PaO2 90, PaCO2 45, and HCO3 16. The nursing assessment of arterial blood gases indicate the presence of:

A. Respiratory alkalosis

B. Respiratory acidosis

C. Metabolic alkalosis

D. Metabolic acidosis

 

QUESTION 205

A client presents to the psychiatric unit crying hysterically. She is diagnosed with severe anxiety disorder. The first nursing action is to:

A. Demand that she relax

B. Ask what is the problem

C. Stand or sit next to her

D. Give her something to do

 

QUESTION 206

A primigravida is at term. The nurse can recognize the second stage of labor by the client’s desire to:

A. Push during contractions

B. Hyperventilate during contractions

C. Walk between contractions

D. Relax during contractions

 

QUESTION 207

The nurse working with a client who is out of control should follow a model of intervention that includes which of the following?

A. Approach the client on a continuum of least restrictive care.

B. Challenge client’s behavior immediately with steps to prevent injury to self or others.

C. Leave the aggressive client to himself or herself, and take other clients away.

D. To ensure safety of other clients, place client in seclusion immediately when he or she begins shouting.

 

QUESTION 208

A pregnant client continues to visit the clinic regularly during her pregnancy. During one of her visits while lying supine on the examining table, she tells the RN that she is becoming light-headed. The RN notices that the client has pallor in her face and is perspiring profusely.

The first intervention the RN should initiate is to:

A. Place the examining table in the Trendelenburg position

B. Assess the client to see if she is having vaginal bleeding

C. Obtain the client’s vital signs immediately

D. Help the client to a sitting position Answer: D

 

QUESTION 209

A mother who is breast-feeding her newborn asks the RN, “How can I express milk from my breasts manually?” The RN tells her that the correct method for manual milk expression includes using the thumb and the index finger to:

B. Alternately compress and release each nipple

C. Roll the nipple and gently pull the nipple forward

D. Slide the thumb and index finger forward from the outer border of the areola toward the end of the nipple

E. Compress and release each breast at the outer border of the areola

 

QUESTION 210

A client has been in labor for 10 hours. Her contractions have become hypoactive and slowed in duration. The fetus is at 0 station, cervix is dilated 8 cm and effaced 90%. The physician orders an oxytocin (Pitocin) infusion to be started at once. The RN begins the oxytocin infusion. It is important that the RN discontinue the infusion if which one of the following occur?

 

A. The client’s contractions are <2 minutes apart.

B. Duration of the contractions are 60 seconds.

C. The uterus relaxes between contractions.

D. The client complains that she is tired.

 

QUESTION 211

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 administration of other drugs

B. Prevents entry of air into tubing

C. Prevents inadvertent administration of a large amount of fluids

D. Prevents phlebitis

 

QUESTION 212

A pregnant client experiences spontaneous rupture of membranes. The first nursing action is to:

A. Assess the client’s respirations

B. Notify the physician

C. Auscultate fetal heart rate

D. Transfer to delivery suite

 

QUESTION 213

A 30-year-old client has a history of several recent traumatic experiences. She presents at the physician’s office with a complaint of blindness. Physical exam and diagnostic testing reveal no organic cause. The nurse recognizes this as:

A. Delusion

B. Illusion

C. Hallucination

D. Conversion

 

QUESTION 214

A client was not using his seat belt when involved in a car accident. He fractured ribs 5, 6, and 7 on the left and developed a left pneumothorax. Assessment findings include:

A. Crackles and paradoxical chest wall movement

B. Decreased breath sounds on the left and chest pain with movement

C. Rhonchi and frothy sputum

D. Wheezing and dry cough

 

 

QUESTION 215

An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action?

A. Apply ice packs to both legs.

B. Begin débridement by removing all charred clothing from wound.

C. Apply Silvadene cream (silver sulfadiazine).

D. Immerse both legs in cool water.

 

QUESTION 216

The physician is preparing to induce labor on a 40-week multigravid

A. The nurse should anticipate the administration of:

A. Oxytocin (Pitocin)

B. Progesterone

C. Vasopressin (Pitressin)

D. Ergonovine maleate

 

QUESTION 217

A pregnant client during labor is irritable and feels the urge to vomit. The nurse should recognize this as the:

A. Fourth stage of labor

B. Third stage of labor

C. Transition stage of labor

D. Second stage of labor

 

QUESTION 218

A physician’s order reads: Administer KCl 10% oral solution 1.5 mL. The KCl bottle reads 20 mEq/15 mL. What dosage should the nurse administer to the infant?

 

A. 1 mEq

B. 1.13 mEq

C. 2 mEq

D. Not enough information to calculate

 

QUESTION 219

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