NCLEX-RN Exam Part 8 (526-600)

NCLEX-RN Exam Part 8 

QUESTION 526 A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, “The doctor said I have stones that need to be removed; where are they?” The nurse knows that the best explanation for this is to tell her that:

A. There are stones present in her gallbladder

B. There are stones present in her kidneys

C. There are stones present in her common bile duct

D. There are no stones, but her gallbladder is irritated and caused her nausea, vomiting, and pain

 

QUESTION 527A postoperative TURP client is ordered continuous bladder irrigations. Later in the evening on the first postoperative day, he complains of increasing suprapubic pain. When assessing the client, the nurse notes diminished flow of bloody urine and several large blood clots in the drainage tubing. Which one of the following should be the initial nursing intervention?

A. Call the physician about the problem.

B. Irrigate the Foley catheter.

C. Change the Foley catheter.

D. Administer a prescribed narcotic analgesic.

 

.QUESTION 528 The health team needs to realize that the compulsive concern with cleanliness that a client with severe anxiety exhibits is most likely an attempt to:

A. Reduce his anxiety

B. Avoid going to psychotherapy

C. Manipulate the health team members

D. Increase his self-image by showing higher standards than the fellow clients

 

QUESTION 529 A 74-year-old client seen in the emergency room is exhibiting signs of delirium. His family states that he has not slept, eaten, or taken fluids for the past 24 hours. The planning of nursing care for a delirious client is based on which of the following premises?

A. The delirious client is capable of returning to his previous level of functioning.

B. The delirious client is incapable of returning to his previous level of functioning.

C. Delirium entails progressive intellectual and behavioral deterioration.

D. Delirium is an insidious process.

 

QUESTION 530 A client is experiencing visual problems at school. She has complained of difficulty seeing the blackboard and squinting. She no longer likes to participate in physical activities such as softball. The client has displayed possible classic symptoms of which refractive error?

1. Astigmatism
2. Hyperopia
3. Myopia
4. Amblyopia

 

QUESTION 531 A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period was February 16, with 3 days of spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to be:

A. November 23rd

B. December 26th

C. September 14th

D. December 9th

 

QUESTION 532 A female client was employed as a client care technician in a hemodialysis unit. She recently began to experience extreme fatigue, being able to sleep for 16–20 hours at a time. She also noted that her urine was tea colored, which she rationalized was a result of the vitamins she began taking to alleviate fatigue. She was diagnosed with hepatitis B. After a brief hospital stay, she is discharged to her parent’s home. Her mother asks the nurse if any precautions are necessary to prevent transmission to the client’s family. The nurse explains necessary precautions, which include:

A. Isolation of the client from the remainder of the family

B. Separate bathroom facilities if possible; if not, then cleansing daily of the facilities with a chloride solution

C. No necessary precautions because she is beyond the contagious phase

D. Laundering clothes separately in cold water with a chloride solution

 

QUESTION 533 A 30-year-old female client is receiving antineoplastic chemotherapy. Which of the following symptoms should especially concern the nurse when caring for her?

A. Respiratory rate of 16 breaths/min

B. Pulse rate of 80 bpm

C. Complaints of muscle aches

D. A sore throat

 

QUESTION 534 A female client presents to the obstetric-gynecology clinic for a pregnancy test, the result which turns out to be positive. Her last menstrual period began December 10, 1993. Using Nägele’s rule, the nurse estimates her date of delivery to be:

A. September 17, 1994

B. September 10, 1994

C. September 3, 1994

D. August 17, 1994

 

QUESTION 535 A female client has a chest tube placed. It is accidentally pulled out of the intrapleural space when she is ambulating. The first action the nurse should take is to:

A. Instruct the client to cough deeply to re-expand her lung

B. Put on sterile gloves and replace the tube

C. Apply a petrolatum dressing over the site

D. Auscultate the lung to determine if she needs the tube replaced

 

QUESTION 536 The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at nine weeks’ gestation. An appropriate response by the nurse would be:

A. “It must be God’s will and probably is for the best.”

B. “This must be a difficult time for you. Would you like to talk about it?”

C. “I’m sure your other children will be a comfort for you.”

D. “Don’t worry, you’re still young. If I were you I’d just try again.”

 

QUESTION 537 A client is dilated 8 cm and entering the transition phase of labor. Common behaviors of the laboring woman during transition are:

A. Frustration, vague in communication

B. Seriousness, some difficulty following directions

C. Calmness, follows directions easily

D. Excitement, openness to instructions

 

QUESTION 538 A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures should be included in the postoperative care?

A. Encourage the child to cough up blood if present.

B. Give warm clear liquids when fully alert.

C. Have child gargle and do toothbrushing to remove old blood.

D. Observe for evidence of bleeding.

 

QUESTION 539 A primipara is assessed on arrival to the postpartum unit. The nurse finds her uterus to be boggy. The nurse’s first action should be to:

A. Call the physician

B. Assess her vital signs

C. Give the prescribed oxytocic drug

D. Massage her fundus

 

.QUESTION 540 A 19-year-old primigravida is admitted to the labor and delivery suite of the hospital. Her husband is accompanying her. The couple tells the nurse that this is the first hospital admission for her. The client’s vaginal exam indicates she is 3 cm dilated, 80% effaced, and at _0 station. Based on the vaginal exam, she is in:

A. Stage 2, latent phase

B. Stage 1, active phase

C. Stage 3, transition phase

D. Stage 1, latent phase

 

QUESTION 541 A 10-year-old boy has been diagnosed with Legg-Calvé Perthes disease. Which of the client’s responses would indicate compliance during initial therapy?

A. Drinking large amounts of milk

B. Not bearing weight on affected extremity

C. Walking short distances 3 times/day

D. Putting self on weight reduction diet

 

QUESTION 542 A 32-year-old male client is a marketing representative. His job requires him to have a tremendous amount of energy during the day. He frequently uses cocaine to sustain his energy level. Lately he has increased his use of cocaine and even experimented with crack cocaine. Realizing he can no longer continue this destructive behavior, he is seeking treatment for cocaine addiction. In planning nursing care for the client’s inpatient stay, which expected outcome is most appropriate?

A. He will attend four consecutive group educational sessions on substance abuse.

B. He will name activities that he would most likely be involved in posttreatment.

C. He will meet with his family in counseling sessions and discuss his feelings.

D. He will be able to deal with his feelings through participation in group therapy sessions.

 

QUESTION 543 A 12-year-old girl has been diagnosed with insulindependent diabetes mellitus. Which of these principles would best guide her nutritional management?

A. Concentrated sweets are taken during increased activity.

B. Food restriction is imposed to reduce weight.

C. Caloric distribution should be calculated to fit activity patterns.

D. Fat requirements are increased owing to the possibility of ketoacidosis.

 

QUESTION 544 A female client at 36 weeks’ gestation is experiencing preterm labor. Her physician has prescribed two doses of betamethasone 12 mg IM q24h. The nurse explains that she is receiving this drug to:

A. Treat fetal respiratory distress syndrome

B. Prevent uterine infection

C. Promote fetal lung maturation

D. Increase uteroplacental circulation

 

QUESTION 545 A client is pregnant for the fourth time and has had three normal vaginal deliveries. She is in active labor and fully dilated. Suddenly she calls, “Nurse, the baby is coming.” As the

nurse responds to her call, which one of the following observations should the nurse make first?

A. Inspect the perineum.

B. Time the contractions.

C. Prepare a sterile area for delivery.

D. Auscultate for fetal heart rate (FHR).

 

QUESTION 546 When interviewing parents who are suspected of child abuse, the nurse would use which of the following interview techniques?

A. Be direct, honest, and attentive.

B. Approach them in the emergency room as soon as you suspect abuse to “clear the air” right away.

C. Ask the parents what they could have done differently to prevent this from happening to the child.

D. After the interview, call child protective services.

 

QUESTION 547 An 82-year-old former restaurant owner walks to the nursing station and states, “I have to go. The restaurant opens at 11 am.” Which response by the nurse is the most appropriate?

A. “Go back to your room. You do not own a restaurant.”

B. “You are in the hospital now. Calm down.”

C. “You once owned a restaurant. Tell me about it.”

D. “It is snowing outside. The restaurant is closed.”

 

QUESTION 548 A female client has been diagnosed with chronic renal failure. She is a candidate for either peritoneal dialysis or hemodialysis and must make a choice between the two. Which information should the nurse give her to help her decide?

A. Hemodialysis involves less time to filter the blood; but the client must consider travel time, distance, and inconvenience.

B. Hemodialysis involves more time to filter the blood than does peritoneal dialysis.

C. Peritoneal dialysis has almost no complications and is less time consuming than hemodialysis. Therefore it is preferred.

D. Peritoneal dialysis requires that a home health nurse prepare and administer the treatments.

 

QUESTION 549 A 24-year-old graduate student recognizes that he has a phobi

A. He suffers severe anxiety when he is in darkness. It has altered his lifestyle because he is unable to go to a movie theater, concert, and other events that may require absence of light. The client is seeking assistance because he is no longer able to socialize with friends due to his phobi

A. The psychologist working with him is using desensitization. He has asked the nursing staff to assist the client in muscle relaxation techniques. What result would indicate client education has been successful?

A. He enters a movie theater, sits in his chair, and replaces anxiety with relaxation as the theater darkens.

B. He enters a concert, but as the lights dim, he does not experience anxiety.

C. He states that he no longer fears dark places.

D. He takes a part-time job as a photographic assistant. His job necessitates his working in a darkroom.

 

QUESTION 550 A female client is exhibiting signs of respiratory distress. Which of the following signs indicate a possible pneumothorax?

A. Crackles or rales on the affected side

B. Bradypnea and bradycardia

C. Shortness of breath and sharp pain on the affected side

D. Increased breath sounds on the affected side

 

QUESTION 551 After instructing a female client on circumcision care, the nursery nurse asks her to restate some of the key points covered. Which statement shows that the client will properly care for her son’s circumcision?

A. “I’ll make sure I soak the gauze with warm water first, before I take it off each time.” B. “I’ll make sure that I report any drainage around where they operated.”

C. “I’ll apply alcohol to the area daily to clean it and prevent any infection.” D. “I’ll keep a close watch on it for a day or two.”

 

QUESTION 552 An 11-month-old infant is admitted with a possible diagnosis of pyloric stenosis. Which of the following best describes the characteristic clinical manifestations of pyloric stenosis?

A. Pain, especially when eating

B. Poor appetite and sucking reflex

C. Increased frequency and quantity of stools

D. Palpable olive-shaped mass in the epigastrium just right of the umbilical cord

 

QUESTION 553 A 15-year-old female adolescent is frequently breaking the rules of the unit. She has left the unit and was found smoking in the bathroom and spending a large amount of time in the male ward. Which statement by the nurse would best explain to the teenager why she must follow the rules of the unit?

A. “It is not easy, but the rules must be followed so that everyone can get a fair chance.”

 B. “If you do not follow the rules, you will be transferred to the closed, locked unit.”

C. “You are not being fair to the other clients by getting them involved in your deviant behavior.”

D. “Break the rules, all you want, but don’t get caught again!”

 

QUESTION 554 A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is NPO with IV fluids infusing at 100 mL/hour. He is experiencing excruciating abdominal pain. Based on an analysis of these data, which nursing diagnosis would receive the highest priority?

A. Pain related to stimulation of nerve endings associated with obstruction of the pancreatic tract

B. Fluid volume deficit related to vomiting and nasogastric tube drainage

C. Knowledge deficit related to treatment regimen

D. Altered nutrition: less than body requirements, related to inadequate intake associated with current anorexia, nausea, vomiting, and digestive enzyme loss

 

QUESTION 555 A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus.

The nurse estimates the fetal gestational age to be approximately:

A. 10 weeks

B. 16 weeks

C. 20 weeks

D. 30 weeks

 

QUESTION 556 A male client has been an insulin-dependent diabetic for approximately 30 years. He frequently indulges in highsugar foods and forgets to take his insulin. He has not experienced acute diabetic emergencies over the years but is now beginning to demonstrate symptoms of diabetic peripheral neuropathy. This distresses him because dancing is one of his favorite pastimes. He decides to question his wife’s home health nurse about diabetic peripheral neuropathy. The nurse points out his noncompliance to his diabetic diet and insulin regimen. The client answers the nurse, “It has been my experience that the diabetic diet is very difficult to follow. As far as the insulin, isn’t a fellow allowed to forget now and then?” The client’s actions and response best demonstrate:

1. Depression
2. Anger
3. Denial
4. Bargaining

 

QUESTION 557 A 10-year-old has been diagnosed with acute poststreptococcal glomerulonephritis. The clinical findings were proteinuria, moderately elevated blood pressure, and periorbital edem A. Which dietary plan is most appropriate for this client?“

A. Low-protein diet

B. Low-sodium diet

C. Increased fluid intake

D. High-cholesterol diet

 

QUESTION 558 A 50-year-old male client is to receive chemotherapy. The physician’s orders include antiemetics. When planning his care, the nurse should take into consideration that antiemetics are best administered in the following way:

A. Give antiemetics when nausea is experienced and continue on a regular schedule for 12–24 hours.

B. Give antiemetics prior to the client receiving chemotherapy and continue on a regular basis for at least 24–48 hours after chemotherapy.

C. Give antiemetics one at a time because combinations of antiemetics cause overwhelming side effects.

D. Give antiemetics intermittently during the entire course of chemotherapy.

 

QUESTION 559 The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on oral griseofulvin. The nurse should emphasize which of these instructions to the mother and/or child?

A. Administer oral griseofulvin on an empty stomach for best results.

B. Discontinue drug therapy if food tastes funny.

C. May discontinue medication when the child experiences symptomatic relief.

D. Observe for headaches, dizziness, and anorexi

 

QUESTION 560 A female client at 10 weeks’ gestation complains to her physician of slight vaginal bleeding and mild cramps.

On examination, her physician determines that her cervix is closed. The client is exhibiting signs of:

A. An inevitable abortion

B. A threatened abortion

C. An incomplete abortion

D. A missed abortion

 

QUESTION 561 A male infant is to be discharged home this morning. Which instruction related to his cord care should be included in his mother’s discharge teaching plan?

A. Keep the umbilical area moist with Vaseline until the stump falls off.

B. Keep the umbilical area covered at all times with the diaper.

C. Clean the umbilical cord with alcohol at each diaper change.

D. Clean the umbilical cord daily with soap and water during the bath.

 

QUESTION 562 A male client has heart failure. He has been instructed to gradually increase his activities. Which signs and symptoms of worsening heart failure should the nurse tell him to watch for that would indicate a need for him to lower his activity level?

A. Pain in his legs when he walks

B. Thirst, weight loss, and polyuria

C. Drowsiness and lethargy after his activities

D. Weight gain, edema in his lower extremities, and shortness of breath

 

QUESTION 563 The physician has ordered that ampicillin 250 mg IV be given over 30 minutes. The medication is diluted as recommended in 10 mL in the volume control chamber of a set that has a tubing of 12 mL. Which nursing measure is most accurate considering these facts?

A. Infuse volume at 44 mL/hr.

B. Infuse volume at 22 mL/hr.

C. Infuse volume at 10 mL/hr.

D. Infuse volume at 30 mL/hr.

 

QUESTION 564 A 26-year-old client has no children. She has had an abdominal hysterectomy. In the first 24 hours postoperatively, the nurse would be concerned if the client:

A. Cries easily and says she is having abdominal pain

1. Develops a temperature of 102_F
2. Has no bowel sounds
3. Has a urine output of 200 mL for 4 hours

 

QUESTION 565 A male client has a history of diverticulosis. He has questions about the foods that he should eat. His nurse gives him the following information:

A. He should be on a high-fiber diet.

B. He should eat a low-residue diet.

C. He should drink minimal amounts of fluids.

D. He does not need to make any modifications.

 

QUESTION 566 A male client is admitted to the psychiatric unit after experiencing severe depression. He states that he intends to kill himself, but he asks the nurse not to repeat his intentions to other staff members. Which response demonstrates understanding and appropriate action on the part of the nurse?

A. “I understand you’re depressed, but killing yourself is not a reasonable option.”

B. “We need to discuss this further, but right now let’s complete these forms.”

C. “Don’t do that, you have so much to live for. You have a wonderful wife and children. The client in the next room has no one.”

D. “This is very serious. I do not want any harm to come to you. I will have to report this to the rest of the staff.”

 

QUESTION 567 A term neonate has experienced no distress at birth and has an Apgar score of 9. Her bmother has asked to breastfeed her following delivery. Immediately after birth, the neonate was most susceptible to heat loss. The most appropriate intervention to conserve heat loss and promote bonding is to:

A. Place her under the radiant warmer

B. Dry her with blankets

C. Place her to her mother’s breast

D. Place her on a heated pad

 

QUESTION 568 A 24-year-old male client is admitted with a diagnosis of sickle cell anemi

A. The nurse discusses his disease with him and emphasizes the following information:

A. He should monitor his sputum, stools, and urine for signs of bleeding.

B. His daily diet should include a large amount of fluid.

C. He should not be concerned about having to fly on a commuter airplane on a weekly basis.

D. He should not worry about having children because this disease is passed on only by female carriers.

 

QUESTION 569 An alcoholic client who is completing the inpatient segment of a substance abuse program was placed on disulfiram (Antabuse) drug therapy. What should the nurse include in the discharge instructions?

A. If disulfiram is taken and alcohol ingested, the client experiences nausea, vomiting and elevated blood pressure.

B. Disulfiram is most effective when prescribed as late as possible in a recovery program.

C. Disulfiram works on the desensitization principle.

D. The effects of disulfiram can be triggered by alcohol 5 days to 2 weeks after the drug is discontinued.

 

QUESTION 570 As soon as a child has been diagnosed as “hearing impaired,” special education should begin. Which of the following special education tasks is the most difficult for a severely hearing-impaired child?

A. Auditory training

1. Speech
2. Lip reading
3. Signing

 

 

QUESTION 571 A female client has just died. Her family is requesting that all nursing staff leave the room. The family’s religious leader has arrived and is ready to conduct a ceremony for the deceased in the room, requesting that only family members be present. The nurse assigned to the client should perform the appropriate nursing action, which might include:

A. Inform the family that it is the hospital’s policy not to conduct religious ceremonies in client rooms.

B. Refuse to leave the room because the client’s body is entrusted in the nurse’s care until it can be brought to the morgue.

C. Tell the family that they may conduct their ceremony in the client’s room; however, the nurse must attend.

D. Respect the client’s family’s wishes.

 

QUESTION 572 A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful?

A. Examine the 4 year old first.

B. Provide time for play and becoming acquainted.

C. Have the mother leave the room with one child, and examine the other child privately.

D. Examine painful areas first to get them “over with.”

 

QUESTION 573 A 7-year-old girl has been diagnosed with juvenile arthritis and has been placed on daily aspirin. Which statement made by the parent indicates a need for further teaching?

A. “My daughter takes her aspirin with her meals.”

B. “Her gums have been bleeding frequently. Maybe she is brushing too hard.”

C. “I give her aspirin on a regular schedule every day.”

D. “One sign of aspirin toxicity can be ringing in the ears.”

 

QUESTION 574 A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar puncture. In light of this procedure and developmental characteristics of this age group, which nursing measure is most appropriate?

A. Emphasize those aspects of the procedure that require cooperation.

B. Tell the child not to cry or yell.

C. Tell the child that he will get a “stick” in his back.

D. Use medical terminology when explaining the procedure to the client.

 

QUESTION 575 A 6-year-old girl has been diagnosed with a urinary tract infection secondary to vesicoureteral reflux. Which statement by her mother indicates a need for further teaching?

A. “I have taught her to wipe from front to back after urinating.”

B. “I make sure she drinks plenty of fluids every day.”

C. “She enjoys wearing nylon panties, but I make her change them everyday.”

D. “She tries to empty her bladder completely after she urinates, like I told her.”

 

QUESTION 576 A female client is admitted to the emergency department complaining of severe right-sided abdominal pain and vaginal spotting. She states that her last menstrual period was about 2 months ago. A positive pregnancy test result and ultrasonography confirm an ectopic pregnancy. The nurse could best explain to the client that her condition is caused by:

A. Abnormal development of the embryo

B. A distended or ruptured fallopian tube

C. A congenital abnormality of the tube

D. A malfunctioning of the placenta

 

QUESTION 577 The FHR pattern in a laboring client begins to show early decelerations. The nurse would best respond by:

A. Notifying the physician

B. Changing the client to the left lateral position

C. Continuing to monitor the FHR closely

D. Administering O2 at 8 L/min via face mask

 

QUESTION 578 A female client is anticipating a visit with her parents over the Thanksgiving holidays. She has recently begun experiencing periods of extreme shortness of breath, which her physician has labeled as panic attacks. Which of the following statements by the nurse would enhance therapeutic communication?

A. “Why do you feel this way?”

B. “Tell me about your dislike for your parents.”

C. “Don’t worry, everything will be all right on your visit with your parents.”

D. “Perhaps you and I can discover what produces your anxiety.”

 

QUESTION 579 A 28-year-old client comes to the clinic for her first prenatal examination. In relating her obstetrical history, she tells the nurse that she has been pregnant twice before. She had a “miscarriage” with the first pregnancy after 6 weeks. With the second pregnancy, she delivered twin girls at 31 weeks’ gestation. One of the twins was stillborn and the other twin died at 4 days of age. Using a five-digit system, the nurse records her as being:

1. 2-0-2-1-0
2. 2-2-2-1-2
3. 3-0-1-1-0
4. 2-1-1-0-0

QUESTION 580 A murmur has been discovered during the routine physical examination of a 1-year-old child. The parent is extremely concerned about this diagnosis. Which of the following explanations by the nurse indicates understanding of this dysfunction?

A. The blood shifts from the right to the left atrium

B. Surgical closure by suture or patch is recommended before school age.

C. Most atrial septal defects close spontaneously.

D. The child can be treated medically with antibiotics to prevent bacterial endocarditis.

 

QUESTION 581 Seven days ago, a 45-year-old female client had an ileostomy. She is self-sufficient and well otherwise. Which of the following long-term objectives would be unrealistic?

A. She should be able to control evacuation of her bowels.

B. She should be able to return to a regular diet.

C. She should be able to resume sexual activity.

D. She should be able to manage her own care.

 

QUESTION 582 A female client is concerned that she is in a “high-risk” group for the development of acquired immunodeficiency syndrome (AIDS). She wants to know about the advisability of donating blood. Which of the following responses is correct?

A. “Individuals who donate blood are at risk of getting the AIDS virus. You should not donate.”

B. “It’s OK for you to donate because the blood bank has a test that is 100% effective.”

C. “You should not donate since it takes time to develop antibodies to the AIDS virus. If you donate blood before you develop the antibody, you could pass it on in the blood.”

D. “It is not a good idea for you to donate. If you have AIDS, the information is made public and could destroy your personal life.”

 

QUESTION 583 A 40-year-old client has lived for 8 years with an abusive spouse. She married her husband in her senior year of high school after becoming pregnant. Shortly after the baby was born, he began to physically abuse her. She has attempted to leave him several times, but she has always returned. She is unable to support herself financially, and her husband threatens to kill her if she leaves him. This time, her husband has beaten her so badly she cannot stop the bleeding from the gash above her eye. She admits her husband caused her injury. In assessing a person after experiencing spousal abuse, which need has the highest priority?

A. Assess the level of anxiety, coping responses, and support systems.

B. Assess the history of physical abuse.

C. Assess suicide potential.

D. Assess drug and