[Sep-2021] NCLEX-RN Pre-Exam Practice Tests | Exam Questions and Answers for NCLEX Certification Study Guide
National Council Licensure Examination(NCLEX-RN) Certification Sample Questions
NEW QUESTION 311
A 29-year-old client delivered her fifth child by the Lamaze method and developed a postpartal hemorrhage in the recovery room. What are the initial symptoms of shock that she may experience?
- A. Marked elevation in blood pressure, respirations, and pulse
- B. No urinary output, tachycardia, and restlessness
- C. Decreased systolic pressure, cold skin, and anuria
- D. Rapid pulse; narrowed pulse pressure; cool, moist skin
Answer: D
Explanation:
Section: Questions Set D
Explanation:
(A) Early shock does not exhibit the symptom of marked elevation in blood pressure. A narrowing of the pulse pressure is indicative of early shock. (B) Anuria is a clinical finding in late shock. (C) All of these clinical findings are congruent with early shock. (D) Absence of urinary output is a clinical finding in the late phase of shock.
NEW QUESTION 312
Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client's depression alert the nurse to prioritize problems and care by addressing which of the following problems first:
- A. Rest and activity impairment
- B. Possible harm to self
- C. Impaired thinking
- D. Nutritional status
Answer: B
Explanation:
(A) Anorexia and weight loss are problems that need attention in severe depression, but they can be addressed secondary to immediate concerns. (B) Impaired thinking and confusion are problems in severe depression that are addressed with administration of medication, through group and individual psychotherapy, and through activity therapy as motivation and interest increase. (C) Possible harm to self as with suicidal ideation; a suicide plan, means to execute plan; and/or overt gestures or an attempt must be addressed as an immediate concern and safety measures implemented appropriate to the risk of suicide. (D) Rest and activity impairment may take time and further assessment to determine client's sleep pattern and amount of psychomotor retardation with the more immediate concern for safety present.
NEW QUESTION 313
A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain.
She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the following findings in the client's nursing assessment demand immediate nursing action?
- A. Associated symptoms of indigestion and nausea
- B. Restlessness and apprehensiveness
- C. History of hypertension treated with pharmacological therapy
- D. Inability to tolerate assessment session with the admitting nurse
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Indigestion or nausea may accompany angina or myocardial infarction, but they do not indicate imminent danger for the client. (B) Restlessness and apprehensiveness require immediate nursing action because they are indicative of very low oxygenation of body tissues and are frequently the first indication of impending cardiac or respiratory arrest. (C) It is common for the cardiac client to experience fatigue and inability to physically tolerate long assessment sessions. (D) A history of hypertension requires no immediate nursing intervention. In the situation described, the blood pressure is not given and therefore cannot be assumed to be elevated.
NEW QUESTION 314
Succinylcholine chloride (Anectine) is ordered prior to electroconvulsive therapy treatment for depressed clients. The nurse explains that the purpose of the drug is to:
- A. Relieve anxiety
- B. Act as an anesthetic
- C. Relax muscles
- D. Reduce secretions
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Succinylcholine chloride relaxes muscles and decreases the intensity of the seizure. (B) Succinylcholine chloride does not relieve anxiety. (C) Atropine is given to reduce secretions. (D) Thiamylal sodium (Surital) or other phenobarbital preparations are used as brief anesthetics.
NEW QUESTION 315
A 47-year-old male client is admitted for colon surgery. Intravenous antibiotics are begun 2 hours prior to surgery. He has no known infection. The rationale for giving antibiotics prior to surgery is to:
- A. Relieve the client's concern regarding possible infection
- B. Provide cathartic action within the colon
- C. Reduce the risk of intraoperative fever
- D. Reduce the risk of wound infection from anaerobic bacteria
Answer: D
Explanation:
(A) Cathartic drugs promote evacuation of intestinal contents. (B) The client undergoing intestinal surgery is at increased risk for infection from large numbers of anaerobic bacteria that inhabit the intestines. Administering antibiotics prophylactically can reduce the client's risk for infection. (C) Antibiotics are indicated in the treatment of infections and have no effect on emotions. (D) Antipyretics are useful in the treatment of elevated temperatures. Antibiotics would have an effect on infection, which causes temperature elevation, but would not directly affect such an elevation.
NEW QUESTION 316
The most important reason to closely assess circumferential burns at least every hour is that they may result in:
- A. Ventricular arrhythmias
- B. Loss of peripheral pulses
- C. Hypovolemia
- D. Renal damage
Answer: B
Explanation:
(A) Hypovolemia could be a result of fluid loss from thermal injury, but not as a result of the circumferential injury. (B) Renal damage is typically seen because of prolonged hypovolemia or myoglobinuria. (C) Electrical injuries and electrolyte changes typically cause arrhythmias in the burn client. (D) Full-thickness circumferential burns are nonelastic and result in an internal tourniquet effect that compromises distal blood flow when the area involved is an extremity.Circumferential full-thickness torso burns compromise respiratory motion and, when extreme, cardiac return.
NEW QUESTION 317
The parents of a 9-year-old child with acute lymphocytic leukemia expressed concern about his alopecia from cranial irradiation. The nurse explains that:
- A. His hair will grow back in a few months.
- B. There are several wig makers for children.
- C. Most children select a favorite hat to protect their heads.
- D. Alopecia is an unavoidable side effect.
Answer: A
Explanation:
Explanation
(A) Alopecia has occurred, and knowing it is a side effect does not address their concern. (B) Although true, it does not give them hope for the future. (C) Although true, it does not provide them with information of the temporary nature of the situation. (D) Knowing the hair will grow back provides comfort that the alopecia is temporary.
NEW QUESTION 318
Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include:
- A. Change the catheter tubing and bag every 48 hours
- B. Cleanse area around the meatus twice a day
- C. Empty the catheter drainage bag at least daily
- D. Maintain fluid intake of 1200-1500 mL every day
Answer: B
Explanation:
Explanation
(A) Catheter site care is to be done at least twice daily to prevent pathogen growth at the catheter insertion site.
(B) Catheter drainage bags are usually emptied every 8 hours to prevent urine stasis and pathogen growth. (C) Tubing and collection bags are not changed this often, because research studies have not demonstrated the efficacy of this practice. (D) Fluid intake needs to be in the 2000-2500 mL range if possible to help irrigate the bladder and prevent infection.
NEW QUESTION 319
A 48-year-old client presents with a long history of severedepression unrelieved by medication. He is admitted to the hospital for electroconvulsive therapy. Familymembers are very concerned about this therapy and are requesting information about aftereffects of the treatment. The nurse informs the family that he will:
- A. Have transient memory loss, confusion, andheadache
- B. Be alert and oriented immediately after the treatment
- C. Require no special care after the procedure
- D. Have insomnia for the first few days
Answer: A
Explanation:
Explanation
(A) This answer is correct. The client will be confused and have a memory loss, which is usually temporary, after electroconvulsive shock therapy. (B) This answer is incorrect. The client will experience transient memory loss, look bewildered, and be confused initially. (C) This answer is incorrect. The client will sleep immediately following the treatment. (D) This answer is incorrect. Vital signs are taken at least hourly after treatment. The client is monitored for hypotension, tachycardia, respiratory problems, and possible seizure activity.
NEW QUESTION 320
A 55-year-old client is admitted with a diagnosis of renal calculi. He presented with severe right flank pain, nausea, and vomiting. The most important nursing action for him at this time is:
- A. Administration of O2 therapy
- B. Daily weights
- C. Intake and output measurement
- D. Straining of all urine
Answer: D
Explanation:
(A) Intake and output measurements are important but must be accompanied by straining urine. (B) Daily weights would not provide for identification of calculi. (C) Straining urine provides for assessment of calculi and evaluation of calculi descent through ureters and urethra. (D) O2therapy should not be necessary for renal calculi.
NEW QUESTION 321
Priapism may be a sign of:
- A. Reproductive dysfunction
- B. Urinary incontinence
- C. Imminent death
- D. Altered neurological function
Answer: D
Explanation:
Explanation
(A) Priapism in the trauma client is due to the neurological dysfunction seen in spinal cord injury. Priapism is an abnormal erection of the penis; it may be accompanied by pain and tenderness. This may disappear as spinal cord edema is relieved. (B) Priapism is not associated with death. (C) Urinary retention, rather than incontinence, may occur. (D) Reproductive dysfunction may be a secondary problem.
NEW QUESTION 322
A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurse instructs the client to:
- A. Clean the sutured laceration twice a day with povidone- iodine (Betadine)
- B. Take meperidine 50 mg po q4-6h prn for headache
- C. Return to the hospital immediately if he develops confusion, nausea, or vomiting
- D. Remove his scalp sutures after 5 days
Answer: C
Explanation:
Explanation
(A) Povidone-iodine is very irritating to skin and should not be routinely used. (B) Sutures should not be removed by the client. (C) Confusion, nausea, vomiting, and behavioral changes may indicate increasing intracranial pressure as a result of intracerebral bleeding. (D) Use of a narcotic opiate such as meperidine is not recommended in clients with a possible head injury because it may produce sedation, pupil changes, euphoria, and respiratory depression, which may mask the signs of increasing intracranial pressure.
NEW QUESTION 323
The physician prescribes amitriptyline (Elavil) for a client. What does the patient need to know about this medication?
- A. The medication should relieve his symptoms of depression.
- B. Blood must be drawn weekly to test for toxicity.
- C. When the medication is effective, he will experience no anxiety.
- D. Prolonged use of this medication will result in extrapyramidal side effects.
Answer: A
Explanation:
(A) Phenothiazines cause extrapyramidal symptoms. (B) No amount of medication can relieve all anxiety in all cases. (C) The purpose of amitriptyline is to relieve the symptoms of depression because it is an antidepressant. It increases the action of norepinephrine and serotonin on nerve cells. (D) Periodic blood tests are done when lithium is prescribed.
NEW QUESTION 324
The following medications were noted on review of the client's home medication profile. Which of the medications would most likely potentiate or elevate serum digoxin levels?
- A. Thyroid agents
- B. Quinidine
- C. Theophylline
- D. KCl
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Hypokalemia can cause digoxin toxicity. Administration of KCl would prevent this. (B) Thyroid agents decrease digoxin levels. (C) Quinidine increases digoxin levels dramatically. (D) Theophylline is not noted to have an effect on digoxin levels.
NEW QUESTION 325
A client is experiencing muscle weakness and lethargy. His serum K+is 3.2. What other symptoms might he exhibit?
- A. Numbness of extremities
- B. Dysrhythmias
- C. Headache
- D. Tetany
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Tetany is seen with low calcium. (B) Low potassium causes dysrhythmias because potassium is responsible for cardiac muscle activity. (C) Numbness of extremities is seen with high potassium. (D) Headache is not associated with potassium excess or deficiency.
NEW QUESTION 326
A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical examination are normal. How does the nurse interpret the effectiveness of the instruction about diet and weight control?
- A. She needs further instruction and reinforcement.
- B. She needs to be placed on a restrictive diet immediately.
- C. She needs to increase her caloric intake.
- D. She is compliant with her diet as previously taught.
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) She is probably not compliant with her diet and exercise program. Recommended weight gain during second and third trimesters is approximately 12 lb. (B) Because of her excessive weight gain of 10 lb in 2 months, she needs re-evaluation of her eating habits and reinforcement of proper dietary habits for pregnancy. A 2200-calorie diet is recommended for most pregnant women with a weight gain of 27-30 lb over the 9-month period. With rapid and excessive weightgain, PIH should also be suspected. (C) She does not need to increase her caloric intake, but she does need to re-evaluate dietary habits. Ten pounds in 2 months is excessive weight gain during pregnancy, and health teaching is warranted. (D) Restrictive dieting is not recommended during pregnancy.
NEW QUESTION 327
A male client had a right below-the-knee amputation 4 days ago. His incision is healing well. He has gotten out of bed several times and sat at the side of the bed. Each time after returning to bed, he has experienced pain as if it were located in his right foot. Which nursing measure indicates the nurse has a thorough understanding of phantom pain and its management?
- A. Phantom pain is entirely in the client's mind. The client should be instructed that the pain is psychological and should not be treated.
- B. Phantom pain is caused by trauma, spasms, and edema at the incisional site. It will decrease when postoperative edema decreases. It should be treated with nonnarcotic medication whenever possible.
- C. The basis for phantom pain may occur because the nerves still carry pain sensation to the brain even though the limb has been amputated. The pain is real, intense, and should be treated.
- D. The cause of phantom pain is unknown. The nurse should provide the client with support, promote sleep, and handle the injured limb smoothly and gently.
Answer: C
Explanation:
(A) This statement is entirely false. (B) Phantom pain may be caused by nerves continuing to carry sensation to the brain even though the limb is removed. It is real, intense, and should be treated as ordinary pain would. (C) Although the cause of phantom pain is still unknown, thesemeasures may promote the relief of any type of pain, not just phantom pain. (D) Phantom pain is not caused by trauma, spasms, and edema and will not be relieved by decreasing edema.
NEW QUESTION 328
To prevent fungal infections of the mouth and throat, the nurse should teach clients on inhaled steroids to:
- A. Rinse the plastic holder that aerosolizes the drug with hydrogen peroxide every other day
- B. Take antacids immediately before inhalation to neutralize mucous membranes and prevent infection
- C. Rinse the mouth and gargle with warm water after each use of the inhaler
- D. Rinse the mouth before each use to eliminate colonization of bacteria
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) It is sufficient to rinse the plastic holders with warm water at least once per day. (B) It is important to rinse the mouth after each use to minimize the risk of fungal infections by reducing the droplets of the glucocorticoid left in the oral cavity. (C) Antacids act by neutralizing or reducing gastric acid, thus decreasing the pH of the stomach. "Neutralizing" the oral mucosa prior to inhalation of a steroid inhaler does not minimize the risk of fungal infections. (D) Rinsing prior to the use of the glucocorticoid will not eliminate the droplets left on the oral mucous membranes following the use of the inhaler.
NEW QUESTION 329
A female client was recently diagnosed with gastric cancer. She entered the hospital and had a total gastrectomy with esophagojejunostomy. Her postoperative recovery was uneventful. On conducting discharge teaching, the nurse discusses changes in bodily function and lifestyle changes with the client. In order to prevent pernicious anemia, the nurse stresses that the client must:
- A. Increase the amount of iron in her diet
- B. Understand the need for Vitamin B12 replacement therapy
- C. Receive monthly blood transfusions
- D. Eat small quantities several times daily until she is able to tolerate food in moderate portions
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Monthly blood transfusions are not indicated postgastrectomy. (B) Increasing iron in the client's diet may cause irritation and will not alleviate pernicious anemia. (C) It may be necessary that the client eat small meals several times per day, but this measure has no relevance to prevention of pernicious anemia.
(D) Pernicious anemia is caused by lack of Vitamin B12, and replacement therapy will be necessary because the client's stomach has been removed.
NEW QUESTION 330
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 keep a close watch on it for a day or two."
- B. "I'll apply alcohol to the area daily to clean it and prevent any infection."
- C. "I'll make sure I soak the gauze with warm water first, before I take it off each time."
- D. "I'll make sure that I report any drainage around where they operated."
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Before petrolatum gauze is removed, it should be soaked with warm water to prevent trauma to adherent tissues. (B) A yellow exudate often forms normally over the surgical site. Only if it becomes foul- smelling and purulent would it need to be reported. (C) Alcohol should never be used on the site; this would be extremely painful to the infant. (D) Special care and observance should continue until the site is completely covered with clean, pink granulation tissue, which could take 7-10 days.
NEW QUESTION 331
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