NCLEX Questions
The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal delivery. The mother is bottle feeding her baby. Which client finding indicates a problem at this time? a) Firm fundus at the symphysis. b) White, thick vaginal discharge. c) Striae that are silver in color. d) Soft breasts without milk.
a) CORRECT ANSWER Firm fundus at the symphysis. Reason: By 4 to 6 weeks postpartum, the fundus should be deep in the pelvis and the size of a nonpregnant uterus. Subinvolution, caused by infection or retained placental fragments, is a problem associated with a uterus that is larger than expected at this time. Normal expectations include a white, thick vaginal discharge, striae that are beginning to fade to silver, and breasts that are soft without evidence of milk production (in a bottle-feeding mother).
A child, age 3, is brought to the emergency department in respiratory distress caused by acute epiglottiditis. Which clinical manifestations should the nurse expect to assess? a) Severe sore throat, drooling, and inspiratory stridor b) Low-grade fever, stridor, and a barking cough c) Pulmonary congestion, a productive cough, and a fever d) Sore throat, a fever, and general malaise
a) CORRECT ANSWER Severe sore throat, drooling, and inspiratory stridor Reason: A child with acute epiglottiditis appears acutely ill and clinical manifestations may include drooling (because of difficulty swallowing), severe sore throat, hoarseness, a high temperature, and severe inspiratory stridor. A low-grade fever, stridor, and barking cough that worsens at night are suggestive of croup. Pulmonary congestion, productive cough, and fever along with nasal flaring, retractions, chest pain, dyspnea, decreased breath sounds, and crackles indicate pneumococcal pneumonia. A sore throat, fever, and general malaise point to viral pharyngitis.
Before discharge, which instruction should a nurse give to a client receiving digoxin (Lanoxin)? a) "Take an extra dose of digoxin if you miss one dose." b) "Call the physician if your heart rate is above 90 beats/minute." c) "Call the physician if your pulse drops below 80 beats/minute." d) "Take digoxin with meals."
b) CORRECT ANSWER "Call the physician if your heart rate is above 90 beats/minute." Reason: The nurse should instruct the client to notify the physician if his heart rate is greater than 90 beats/minute because cardiac arrhythmias may occur with digoxin toxicity. To prevent toxicity, the nurse should instruct the client never to take an extra dose of digoxin if he misses a dose. The nurse should show the client how to take his pulse and tell him to call the physician if his pulse rate drops below 60 beats/minute — not 80 beats/minute, which is a normal pulse rate and doesn't warrant action. The client shouldn't take digoxin with meals; doing so slows the absorption rate.
A nurse is instructing a client with bipolar disorder on proper use of lithium carbonate (Eskalith), the drug's adverse effects, and symptoms of lithium toxicity. Which client statement indicates that additional teaching is required? a) "I can still eat my favorite salty foods." b) "When my moods fluctuate, I'll increase my dose of lithium." c) "A good blood level of the drug means the drug concentration has stabilized." d) "Eating too much watermelon will affect my lithium level."
b) CORRECT ANSWER "When my moods fluctuate, I'll increase my dose of lithium." Reason: A client who states that he'll increase his dose of lithium if his mood fluctuates requires additional teaching because increasing the dose of lithium without evaluating the client's laboratory values can cause serious health problems, such as lithium toxicity, overdose, and renal failure. Clients taking lithium don't need to limit their sodium intake. A low-sodium diet causes lithium retention. A therapeutic lithium blood level indicates that the drug concentration has stabilized. The client demonstrates effective teaching by stating his lithium levels will be affected by foods that have a diuretic effect, such as watermelon, cantaloupe, grapefruit juice, and cranberry juice.
A client with Rh isoimmunization gives birth to a neonate with an enlarged heart and severe, generalized edema. The neonate is immediately transferred to the neonatal intensive care unit. Which nursing diagnosis is most appropriate for the client? a) Ineffective denial related to a socially unacceptable infection b) Impaired parenting related to the neonate's transfer to the intensive care unit c) Deficient fluid volume related to severe edema d) Fear related to removal and loss of the neonate by statute
b) CORRECT ANSWER Impaired parenting related to the neonate's transfer to the intensive care unit Reason: Because the neonate is severely ill and needs to be placed in the neonatal intensive care unit, the client may have a nursing diagnosis of Impaired parenting related to the neonate's transfer to the neonatal intensive care unit. (Another pertinent nursing diagnosis may be Compromised family coping related to lack of opportunity for bonding.) Rh isoimmunization isn't a socially unacceptable infection. This condition causes an excess fluid volume (not deficient) related to cardiac problems. Rh isoimmunization doesn't lead to loss of the neonate by statute.
A 10-month-old child has cold symptoms. The mother asks how she can clear the infant's nose. Which of the following would be the nurse's best recommendation? a) Use a cool air vaporizer with plain water. b) Use saline nose drops and then a bulb syringe. c) Blow into the child's mouth to clear the infant's nose. d) Administer a nonprescription vasoconstrictive nose spray.
b) CORRECT ANSWER Use saline nose drops and then a bulb syringe. Reason: Although a cool air vaporizer may be recommended to humidify the environment, using saline nose drops and then a bulb syringe before meals and at nap and bed times will allow the child to breathe more easily. Saline helps to loosen secretions and keep the mucous membranes moist. The bulb syringe then gently aids in removing the loosened secretions. Blowing into the child's mouth to clear the nose introduces more organisms to the child. A nonprescription vasoconstrictive nasal spray is not recommended for infants because if the spray is used for longer than 3 days a rebound effect with increased inflammation occurs.
The major goal of therapy in crisis intervention is to: a) withdraw from the stress. b) resolve the immediate problem. c) decrease anxiety. d) provide documentation of events.
b) CORRECT ANSWER resolve the immediate problem. Reason: During a period of crisis, the major goal is to resolve the immediate problem, with hopes of getting the individual to the level of functioning that existed before the crisis or to a higher level of functioning. Withdrawing from stress doesn't address the immediate problem and isn't therapeutic. The client's anxiety will decrease after the immediate problem is resolved. Providing support and safety are necessary interventions while working toward accomplishing the goal. Documentation is necessary for maintaining accurate records of treatment; it isn't a major goal.
The nurse should instruct the family of a child with newly diagnosed hyperthyroidism to: a) Keep their home warmer than usual. b) Encourage plenty of outdoor activities. c) Promote interactions with one friend instead of groups. d) Limit bathing to prevent skin irritation.
c) CORRECT ANSWER Promote interactions with one friend instead of groups. Reason: Children with hyperthyroidism experience emotional labiality that may strain interpersonal relationships. Focusing on one friend is easier than adapting to group dynamics until the child's condition improves. Because of their high metabolic rate, children with hyperthyroidism complain of being too warm. Bright sunshine may be irritating because of disease-related ophthalmopathy. Sweating is common and bathing should be encouraged.
A client has an episiotomy to widen her birth canal. Birth extends the incision into the anal sphincter. This complication is called: a) a first-degree laceration. b) a second-degree laceration. c) a third-degree laceration. d) a fourth-degree laceration.
c) CORRECT ANSWER a third-degree laceration. Reason: Birth may extend an episiotomy incision to the anal sphincter (a third-degree laceration) or the anal canal (a fourth-degree laceration). A first-degree laceration involves the fourchette, perineal skin, and vaginal mucous membranes. A second-degree laceration extends to the fasciae and muscle of the perineal body
The neonate of a client with type 1 diabetes is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is: a) peripheral acrocyanosis. b) bradycardia. c) lethargy. d) jaundice.
c) CORRECT ANSWER lethargy. Reason: Lethargy in the neonate may be seen with hypoglycemia because of a lack of glucose in the nerve cells. Peripheral acrocyanosis is normal in the neonate because of immature capillary function. Tachycardia — not bradycardia — is seen with hypoglycemia. Jaundice isn't a sign of hypoglycemia.
A young man with early-stage testicular cancer is scheduled for a unilateral orchiectomy. The client confides to the nurse that he is concerned about what effects the surgery will have on his sexual performance. Which of the following responses by the nurse provides accurate information about sexual performance after an orchiectomy? a) "Most impotence resolves in a couple of months." b) "You could have early ejaculation with this type of surgery." c) "We will refer you to a sex therapist because you will probably notice erectile dysfunction." d) "Because your surgery does not involve other organs or tissues, you'll likely not notice much change in your sexual performance."
d) CORRECT ANSWER "Because your surgery does not involve other organs or tissues, you'll likely not notice much change in your sexual performance." Reason: Although there may not be a big change in sexual function with a unilateral orchiectomy, the loss of a gonad and testosterone may result in decreased libido and sterility. Sperm banking may be an option worth exploring if the number and motility of the sperm are adequate. Remember, the population most affected by testicular cancer is generally young men ages 15 to 34, and in this crucial stage of life, sexual anxieties may be a large concern.
A client has refused to take a shower since being admitted 4 days earlier. He tells a nurse, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which nursing action is most appropriate? a) Dismantling the showerhead and showing the client that there is nothing in it b) Explaining that other clients are complaining about the client's body odor c) Asking a security officer to assist in giving the client a shower d) Accepting these fears and allowing the client to take a sponge bath
d) CORRECT ANSWER Accepting these fears and allowing the client to take a sponge bath Reason: By acknowledging the client's fears, the nurse can arrange to meet the client's hygiene needs in another way. Because these fears are real to the client, providing a demonstration of reality by dismantling the shower head wouldn't be effective at this time. Explaining that other clients are complaining about his body odor or asking a security officer to assist in giving the client a shower would violate the client's rights by shaming or embarrassing him.
