NCLEX-RN Exam Part 9 (601-675)

NCLEX-RN Exam Part 9 

QUESTION 601 An 8-year-old boy has been diagnosed with hemophili

A. Which of the following diagnostic blood studies is characteristically abnormal in this disorder?

A. Partial thromboplastin time

B. Platelet count

C. Complete blood count

D. Bleeding time

 

QUESTION 602 A 44-year-old female client is receiving external radiation to her scapula for metastasis of breast cancer. Teaching related to skin care for the client would include which of the following?

A. Teach her to completely clean the skin to remove all ointments and markings after each treatment.

B. Teach her to cover broken skin in the treated area with a medicated ointment.

C. Encourage her to wear a tight-fitting vest to support her scapul A.

D. Encourage her to avoid direct sunlight on the area being treated.

 

QUESTION 603 A client has renal failure. Today’s lab values indicate he has an elevated serum potassium. What additional priority information does the nurse need to obtain?

A. Evaluation of his level of consciousness

B. Evaluation of an electrocardiogram

C. Measurement of his urine output for the past 8 hours

D. Serum potassium lab values for the last several days

 

QUESTION 604 At 12 hours postvaginal delivery, a female client is without complications. Which of the following assessment findings would warrant further nursing interventions?

A. Apical pulse of 52 bpm

B. Uterine fundus palpable left of midline

C. No bowel movement since delivery

D. Oral temperature of 100.4F

 

QUESTION 605 During the admitting mental health assessment, a client demonstrates involuntary muscular activity. He has a marked facial tic around the mouth that is distracting to the nurse during the interview. The nurse recognizes the behavior and documents it as:

1. Dyskinesia
2. Akathisia
3. Echopraxia
4. Echolalia

 

QUESTION 606 A client’s wife is concerned over his behavior in recent months. He has been diagnosed with Parkinson’s disease, and she is telling his nurse that he has been doing “strange things.” The nurse reassures the wife that the following behavior is normal with Parkinson’s disease:

A. “Your husband will experience some periods of muscle flaccidity. Be sure to make him sit down during these periods.”

B. “Your husband may move his hands in motions that look like he is rolling a pill between his fingers.”

C. “Twitching of the muscles is to be expected and can occur at any time during the day.”

D. “Parkinson’s disease causes severe pain in the joints. You should give your husband Tylenol at those times.”

 

QUESTION 607 A 45-year-old male client experiences a sense of depression because he has not yet achieved his life’s goals. His career has not been satisfying. He is still looking for the right job. His wife spends too much money, and his children seem to ignore him while being very selfish. He is tired of all of their attitudes and is considering buying a red Corvette convertible. While obtaining these data concerning the client’s feelings about his life, the nurse is able to determine he is experiencing what psychological crisis according to Erikson’s stages?

A. Identity versus role confusion

B. Integrity versus despair

C. Intimacy versus isolation

D. Generativity versus self-absorption

 

QUESTION 608 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. Massage the client’s calves briskly every shift.

C. Keep the client’s legs extended and discourage any movement.

D. Have the client tighten and relax leg muscles several times daily.

 

QUESTION 609 Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?

E. She uses the bulb syringe to help clear her baby’s nose when milk is regurgitated.

F. She places her infant on her right side after feeding her.

G. She props the bottle in the crib to feed her baby,which allows her to write birth announcements and feed her baby at the same time.

H. She burps her baby by placing her in a sitting position, supporting her head and neck and gently massaging her back.

 

QUESTION 610 A 4 days postpartum client who is gravida 3, para 3, isexamined by the home health nurse during her first postpartum home visit. The nurse notes that she has a pink vaginal discharge with a serosanguineous consistency. The nurse would most accurately chart the client’s lochia as:

1. Rubra
2. Rosa
3. Serosa
4. Alba

 

QUESTION 611 A male client seeks counseling after his wife of 19 years threatened to divorce him. For most of their marriage, he has physically and verbally abused her. When asked about his behavior in the process of the nursing assessment, the client states, “I was mean to my wife because she insists on cooking meals and wearing clothes that I do not like.” This defense mechanism is an example of:

1. Repression
2. Regression
3. Reaction formation

D. Rationalization

 

QUESTION 612 A female client has experienced varying degrees of depression throughout her life. Now that she is postmenopausal, her depression has increased. She is unable to motivate herself to clean her house or even to get out of bed and get dressed in the morning. The client was begun on fluoxetine (Prozac) therapy. When educating her about fluoxetine, what might the nurse caution her about?

A. A daily dose of fluoxetine may be taken in the morning or evening.

B. Fluoxetine is not sedating; therefore, restrictions on driving and other hazardous activities are not necessary.

C. Rashes or pruritus usually occur early in the therapy and are treatable without discontinuing the medication.

D. It is safe to take over-the-counter or other prescription medications with fluoxetine.

 

QUESTION 613 A male client is experiencing extreme distress. He begins to pace up and down the corridor. What nursing intervention is appropriate when communicating with the pacing client?

A. Ask him to sit down. Speak slowly and use short, simple sentences.

B. Help him to recognize his anxiety.

C. Walk with him as he paces.

D. Increase the level of his supervision.

 

QUESTION 614 A 1-year-old child is to receive an IM injection ordered by his pediatrician. He has fallen asleep in his mother’s arms when the nurse approaches. Which approach is most appropriate at this time?

A. Give the injection in the vastus lateralis site before the child awakens.

B. Awaken the child first and give the injection in the ventrogluteal site.

C. Awaken the child first and give the injection in the dorsogluteal site.

D. Ask the mother to place the child on the examination table and leave the room, and then give the injection in an appropriate site.

 

QUESTION 615 A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?

A. “I did not get the raise because my boss does not like me.”

B. “I felt a lump in my breast 2 weeks ago. I put off getting it checked until after my sister’s wedding.” C. “My son died 3 years ago. I still cannot bring myself to clean out his room.”

D. “My husband told me this morning that he wants a divorce. I am upset, but I cannot discuss the matter with him until after my company’s board meeting today.”

 

QUESTION 616 A young child has been placed in a spica cast. The chief concern of the nurse during the first few hours is:

A. Prevention of neurovascular complications

B. Prevention of loss of muscle tone

C. Immobilization of the affected limb

D. Using heated fans to dry the cast

 

QUESTION 617 Newborns are routinely screened for phenylketonuri

A. The nursery nurse ensures that this screening test is performed:

A. Immediately after birth, because the most accurate result is obtained at this time B. After 2–3 days of milk ingestion

C. At 2–3 days of age regardless of amount of milk feedings

D. At 1 month, because the biochemical buildup of phenylalanine takes 1 month to detect

 

QUESTION 618 A female client plans to bottle-feed her newborn. Her physician has ordered bromocriptine (Parlodel) to suppress lactation. Which of the following instructions about bromocriptine should be given by the nurse?

A. Bromocriptine stimulates the production of prolactin.

B. Hypertension is a primary side effect.

C. Bromocriptine is generally taken for 5 days.

D. Her blood pressure must be stable before starting bromocriptine.

 

QUESTION 619 For the past several months, an elderly female client with Alzheimer’s disease has experienced paranoia; hallucinations; and aggressive, disruptive behavior. The family is utilizing haloperidol as needed to control her behavior. On nursing assessment, you note that the client demonstrates involuntary movements of the tongue and fingers. This may most likely indicate:

A. Tardive dyskinesia, which may be a side effect of antipsychotic medication

B. Early symptoms of Parkinson’s disease

C. A more advanced stage of Alzheimer’s disease than previously experienced by the client

D. The need to change her medication from haloperidol to another antipsychotic drug to lessen symptoms

 

QUESTION 620 A client is receiving peritoneal dialysis. He has been taught to warm the dialyzing fluid prior to instilling it because:

A. Warmed solution helps keep the body temperature maintained within a normal range during instillation

B. Warmed solution helps dilate the peritoneal blood vessels

C. Warmed solution decreases the risk of peritoneal infection D. Warmed solution promotes a relaxed abdominal muscle

 

QUESTION 621 A female client comes for her second prenatal visit. The nurse-midwife tells her, “Your blood tests reveal that you do not show immunity to the German measles.” Which notation will the nurse include in her plan of care for the client? “Will need . . .

A. Rh-immune globulin at the next visit”

B. Rh-immune globulin within 3 days of delivery”

C. Rubella vaccine at the next visit”

D. Rubella vaccine after delivery on the day of discharge”

 

QUESTION 622 An infant weighing 15 lb has just been treated for severe diarrhea in the hospital. Discharge instructions by the nurse will include maintenance fluid requirements for the pediatric client. Which of the following values best indicates the nurse’s understanding of normal fluid requirements for this infant?

A. 240 mL/day

B. 680 mL/day

C. 330 mL/day

D. 960 mL/day

 

QUESTION 623 A male client tells his nurse that he has had an ulcer in the past and is afraid it is “flaring up again.” The nurse begins to ask him specific questions about his symptoms. The nurse knows that a symptom that might indicate a serious complication of an ulcer is:

A. Pain in the middle of the night

B. A bowel movement every 3–5 days

1. Melena
2. Episodes of nausea and vomiting

 

QUESTION 624 A 78-year-old female client has a total hip arthroplasty. Her nurse should know that which of the following is contraindicated?

A. Encourage exercises in the unaffected extremities.

B. Encourage her to cross and uncross her legs.

C. Check neurological and circulatory status of the affected leg hourly.

D. Place a trochanter roll along the upper thigh of the affected leg.

 

QUESTION 625 A female client has been recently diagnosed as bipolar. She has taken lithium for the past several weeks to control mani

A. What must be included in client education regarding lithium toxicity?

A. Maintain a normal diet; however, limit salt intake to no more than 3 g/day.

B. Take lithium between meals to increase absorption.

C. Withhold lithium if experiencing diarrhea, vomiting, or diaphoresis.

D. For pain or fever, avoid aspirin or acetaminophen (Tylenol). Nonsteroidal anti-inflammatory drugs are preferred.

 

QUESTION 626 A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy:

A. Prevents the development of ophthalmia neonatorum

B. Assists the baby’s clotting mechanism

C. Breaks down bilirubin in the skin into substances that can be excreted in stool or urine

D. Increases levels of unconjugated bilirubin, thereby preventing kernicterus (brain damage)

 

QUESTION 627 A 4-week-old infant is admitted to the emergency room in respiratory distress. Which of the following statements indicates the nurse’s knowledge of the anatomy of the respiratory system in pediatric clients?

A. The diameter of the trachea is much smaller in children than in adults.

B. The tongue is proportionally smaller in children than in adults

C. The pediatric airway is more rigid than that of the adults.

D. The length of the pediatric airway is longer in children than in adults.

 

QUESTION 628 A client has chronic obstructive pulmonary disease. She is slowly losing weight, and her daughter is very concerned about increasing her nutrition. The nurse helps the daughter devise a plan of care for her mother. The plan of care should include which of the following interventions to promote nutrition?

A. Offer her oral hygiene before and after meals.

B. Encourage her to consume milk products.

C. Encourage her to engage in an activity before a meal to stimulate her appetite.

D. Restrict her fluid intake to three glasses of water a day.

 

QUESTION 629 A female client at 37 weeks’ gestation has just undergone a nonstress test. The results were two fetal movements with a corresponding increase in fetal heart rate (FHR) of 15 bpm lasting 15 seconds within a 20-minute period. Her results would be classified as:

A. Reactive; needs follow-up contraction stress test

B. Reactive; no contraction stress test required

C. Non-reactive; needs follow-up contraction stress test

D. Non-reactive; no contraction stress test required

 

QUESTION 630 A client who is gravida 1 para 1 vaginally delivered a 7- lb girl. She received a midline episiotomy at delivery. When assessing the level of her uterus immediately following delivery, the nurse would expect the fundus to be located:

A. At the umbilicus

B. At the symphysis pubis

C. Midway between the umbilicus and the xiphoid process

D. Midway between the umbilicus and the symphysis pubis

 

QUESTION 631 A client is a victim of domestic violence. She is now receiving assistance at a shelter for battered women. She tells the nurse about the cycle of violence that she has been experiencing in her relationship with her husband of 5 years. In the “tension-building phase,” the nurse might expect the client to describe which of the following?

A. Promises of gifts that her husband made to her

B. Acute battering of the client, characterized by his volatile discharge of tension

C. Minor battering incidents, such as the throwing of food or dishes at her

D. A period of tenderness between the couple

 

QUESTION 632 The physician of a client diagnosed with alcoholism orders neomycin 0.5 g q6h to prevent hepatic com

A. Neomycin decreases serum ammonia levels by:

A. Decreasing nitrogen-forming bacteria in the intestines

B. Acidifying colon contents by causing ammonia retention in the colon

C. Decreasing the uptake of vitamin D, thereby drawing more water into the colon

D. Irritating the bowel and promoting evacuation of stool

 

QUESTION 633 A 6-year-old girl is visiting the outpatient clinic because she has a fever and a rash. The doctor diagnoses chickenpox. Her mother asks the nurse how many baby aspirins her daughter can have for fever. The nurse should:

A. Advise the mother not to give her aspirin

B. Ask if the client is allergic to aspirin before giving further information

C. Assess the function of the client’s cranial nerve VIII

D. Check the aspirin bottle label to determine milligrams per tablet

 

QUESTION 634 The healthcare team determines that an elderly client has had progressive changes in memory over the last 2 years that have interfered with her personal, social, or occupational functioning. Her memory, learning, attention, and judgment have all been affected in some way. These symptoms describe which of the following conditions?

1. Dementia
2. Parkinsonism
3. Delirium
4. Mania

.

QUESTION 635 A 48-year-old male client is hospitalized with mild ascites, bruising, and jaundice. He has a 20-year history of alcohol abuse. The client is diagnosed with cirrhosis. His serum ammonia level is high, indicating hepatic encephalopathy. He has esophageal varices. Which of the following may cause the varices to rupture?

A. Lifting heavy objects

B. Walking briskly

C. Ingestion of barbiturates

D. Ingestion of antacids

 

QUESTION 636After 7 hours in restraints and a total of 30-mg haloperidol in divided doses, a client complains of stiffness in his neck and his tongue “pulling to one side.” These extrapyramidal symptoms (EPS) will most likely be relieved by the administration of:

A. Lorazepam (Ativan)

B. Benztropine (Cogentin)

C. Thiothixene (Navane)

D. Flurazepan (Dalmane)

 

QUESTION 637A chronic alcoholic client’s condition deteriorates, and he begins to exhibit signs of hepatic com A. Which of the following is an early sign of impending hepatic coma?

1. Hiccups
2. Anorexia
3. Mental confusion
4. Fetor hepaticus

 

QUESTION 638 A client who has been diagnosed with anorexia nervosa refuses to eat lunch. The most therapeutic response by the nurse to her refusal is:

A. “Okay, missing one meal won’t hurt.”

B. “You’ll have to eat lunch, or we’ll force-feed you.”

C. “It’s not appropriate for you to try to manipulate the staff into granting your wishes.”

D. “We will not allow you to starve yourself. You may choose to eat voluntarily or be fed.”

 

QUESTION 639 A client is resting comfortably after delivering her first child. When assessing her pulse rate, the nurse would

recognize the following finding to be typical:

E. Thready pulse

F. Irregular pulse

1. Tachycardia
2. Bradycardia

 

QUESTION 640 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. Help her to blow her nose carefully

C. Test the discharge for sugar

D. Turn her to her side

 

QUESTION 641A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U +1 in contrast to the previous assessment of U _2. The immediate nursing response is to:

A. Administer methergine IM

B. Remove the retained placental fragments

C. Assist the client to the bathroom and provide cues to stimulate urination

D. Massage the fundus until firm

 

QUESTION 642 A 64-year-old client is admitted to the hospital with benign prostatic hypertrophy (BPH). He has a history of adult-onset diabetes and hypertension and is scheduled to undergo a resection of the prostate. When recording his health history, the nurse asks about his chief complaint. The most serious symptom that may accompany BPH is:

A. Acute urinary retention

B. Hesitancy in starting urination

C. Increased frequency of urination

D. Decreased force of the urinary stream

 

QUESTION 643 Following TURP, which of the following instructions would be appropriate to prevent or alleviate anxiety concerning the client’s sexual functioning?

A. “You may resume sexual intercourse in 2 weeks.”

B. “Many men experience impotence following TURP.”

C. “A transurethral resection does not usually cause impotence.”

D. “Check with your doctor about resuming sexual activity.”

 

QUESTION 644 Before giving methergine postpartum, the nurse should assess the client for:

A. Decreased amount of lochial flow

B. Elevated blood pressure

1. Flushing
2. Afterpains

 

QUESTION 645 A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take his medicine after she leaves. The nurse looks around the room and sees that she and the client are the only ones in the room. The nurse’s most therapeutic response will be:

A. “I don’t see your mother in the room. Let’s talk about how you’re feeling.”

B. “OK, I’ll come back later when you’re feeling more like taking your medicine.”

C. “She may be here, but I can’t see her.”

D. “Why don’t you finish talking to her, and I’ll wait.”

 

QUESTION 646 Degenerative disorders are attributed to many factors. As a nurse assigned to a convalescent home, one must often educate families about how such conditions occur. Which of the following statements might the nurse need to explore when a daughter tries to explain to her mother what caused her degenerative disorder?

A. “Some folks believe that aging causes this, Mother.”

B. “Perhaps, it’s the way your parents used those double- bind messages, Mother.”

C. “I know some people who are having this problem and they were exposed to chemicals at work, Mother.”

D. “It can be caused by lots of things, toxic agents and even alcohol, Mother.”

 

QUESTION 647 A 42-year-old male client has been treated at an alcoholic rehabilitation center for physiological alcohol dependence. The nurse will be able to determine that he is preparing for discharge and is effectively coping with his problem when he shares with her the following information:

A. “I know that I will not ever be able to socially drink alcohol again and will need the support of the AA group.”

B. “I know that I can only drink one or two drinks at social gatherings in the future, but at least I don’t have to continue AA.”

C. “I really wasn’t addicted to alcohol when I came here, I just needed some help dealing with my divorce.”

D. “It really wasn’t my fault that I had to come here. If my wife hadn’t left, I wouldn’t have needed those drinks.”

 

QUESTION 648 A client at 9 weeks’ gestation comes for an initial prenatal visit. On assessment, the nurse discovers this is her second pregnancy. Her first pregnancy resulted in a spontaneous abortion. She is 28 years old, in good health, and works full-time as an elementary school teacher. This information alerts the nurse to which of the following:

A. An increased risk in maternal adaptation to pregnancy

B. The need for anticipatory guidance regarding the pregnancy

C. The need for teaching regarding family planning

D. An increased risk for subsequent abortions

 

QUESTION 649 A client is admitted to the psychiatric unit after lavage and stabilization in the emergency room for an overdose of antidepressants. This is her third attempt in 2 years. The highest priority intervention at this time is to:

A. Assess level of consciousness

B. Assess suicide potential

C. Observe for sedation and hypotension

D. Orient to her room and unit rules

 

QUESTION 650 A seventh grader lost consciousness after being hit in the head with a basketball. In the emergency room his vital signs are stable, and he demonstrates no neurologic deficit. He will not be admitted to the hospital. It is most important that you advise his mother to:

A. Encourage him to drink plenty of fluids

B. Expect him to have nausea with vomiting

C. Keep him awake for the next 12 hours

D. Wake him up every 1–2 hours during the night

 

QUESTION 651 A newborn girl’s father expresses concern that the newborn does not have good control of her hands and arms.

It is important for the father to realize certain neurological patterns that characterize the newborn:

A. Mild hypotonia is expected in the upper extremities.

B. Purposeless, uncoordinated movements of the arms are indicative of neurological dysfunction.

1. Function progresses in a head-to-toe, proximal-distal fashion.
2. Asymmetrical movement of the extremities is not unusual and will disappear with maturation of the centra nervous system.

 

QUESTION 652A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from:

1. Crying
2. Falling asleep
3. Rolling from his back to his tummy
4. Sucking his thumb

 

QUESTION 653 The client will be more comfortable and the results more accurate when the nurse prepares the client for

Leopold’s maneuvers by having her:

A. Empty her bladder

B. Lie on her left side

C. Place her arms over her head

D. Force fluids 1 hour prior to procedure

 

QUESTION 654 In counseling a client, the nurse emphasizes the danger signals during pregnancy. On the next visit, the client identifies which of the following as a danger signal that should be reported immediately?

1. Backache
2. Leaking of clear yellow fluid from breasts
3. Constipation with hemorrhoids
4. Visual changes

 

QUESTION 655 A female client with major depression stated that “life is hopeless and not worth living.” The nurse should place highest priority on which of the following questions?

A. “How has your appetite been recently?”

B. “Have you thought about hurting yourself?”

C. “How is your relationship with your husband?”

D. “How has your depression affected your daily livingactivities?”

 

QUESTION 656 A 35-year-old primigravida comes to the clinic for her first prenatal visit. The midwife, on examining the client, suspects that she is approximately 11 weeks pregnant. The pregnancy is positively confirmed by finding:

A. Chadwick’s sign

B. FHR by ultrasound

C. Enlargement of the uterus

D. Breast tenderness and enlargement

 

QUESTION 657 A family is experiencing changes in their lifestyle in many ways. The invalid grandmother has moved in with them. The couple have a 2-year-old son by their marriage, and the wife has two children by her previous marriage. The older children are in high school. In applying systems theory to this family, it is important for the nurse to remember which of the following principles?

A. The parts of a system are only minimally related.

B. Dysfunction in one part affects every other part.

C. A family system has no boundaries.

D. Healthy families are enmeshed.

QUESTION 658 In healthcare settings, nurses must be familiar with primary, secondary, and tertiary levels of care. As a nurse in the community, which of the following interventions might be a primary prevention strategy?

A. Crisis intervention with an intoxicated teenager whose mother just committed suicide

B. Referring a client who has been on a detoxification unit to a rehabilitation center

C. Teaching fifth-grade children the harmful effects of substance abuse

D. Counseling a client with post-traumatic stress disorder

 

QUESTION 659 A client’s prenatal screening indicated that she has no immunity to rubell

A. She is now 10 weeks pregnant. The best time to immunize her is:

A. In the immediate postpartum period

B. After the first trimester

C. At 28 weeks’ gestation

D. Within 72 hours postpartum

 

QUESTION 660 When assessing the client 6 hours postpartum, the fundus is found to be U +3, displaced to the right of midline, and slightly boggy. The nurse would first:

A. Increase the IV oxytocin drip rate

B. Give methergine IM

C. Assess for a full bladder

D. Grasp the uterus and massage vigorously

 

QUESTION 661 The nurse in the mental health center is instructing a depressed client about the dietary restrictions necessary in taking her medication, which is a monoamine oxidase (MAO) inhibitor. Which of the following is she restricting from the client’s diet?

A. Cream cheese

B. Fresh fruits

C. Aged cheese

D. Yeast bread

 

QUESTION 662 Two weeks after a client’s admission for depression, the physician orders a consult for electroconvulsive therapy (ECT). Which of the following conditions, if present, would be a contraindication for ECT?

A. Brain tumor or other space-occupying lesion

B. History of mitral valve prolapse

C. Surgically repaired herniated lumbar disk

D. History of frequent urinary tract infections

 

QUESTION 663 A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, “Why did this happen to my baby?” is:

A. “It’s God’s will. It was probably for the best. There was something probably wrong with your baby.”

B. “You’re young. You can have other children later.”

C. “I know your other children will be a great comfort to you.”

D. “I can see you’re upset