NCLEX QUESTIONS Summer 2010 Set 2 (Answers follow all questions) Fundamentals of Nursing 1. The nurse assesses an older client in an assisted living facility who is crying uncontrollably and who tells the nurse, I am going to be evicted because I ran out of money to live here. Which of the following is the priority response by the nurse? A. I am sure something will work out for you. B. Can you ask any of your family for money? C. You will qualify for Medicaid now that you have no money. D. There are other financial options available to you. Maternity 2. The nurse informs a graduate nurse on a postpartum unit that the human chorionic gonadotropin (HCG) would no longer be detected in the client s blood at: A. One week postpartum B. Two days postpartum C. Four weeks postpartum D. One hour postpartum Pediatrics 3. The nurse identifies which of the following as a characteristic of defecation in toddlers? A. Control of defecation normally begins after 3 years of age B. Toddlers frequently delay defecation because of play C. Constipation is a common problem among toddlers D. Control of defecation starts between 1 and 2 years of age
Neurological Disorders (Adult) 4. Which of the following should the nurse assess to provide the most accurate information regarding a client suspected of having a C4 injury? A. Ask the client to shrug the shoulders while applying downward pressure B. Ask the client to straighten the flexed arms while applying resistance C. Ask the client to grasp an object and make a fist D. Ask the client to lift the arms while applying resistance Musculoskeletal/Integumentary Disorders (Adult) 5. The nurse assesses which of the following clinical manifestations in a client with osteomyelitis? Select all that apply: A. Night sweats B. Cool extremities C. Petechiae D. Fever E. Nausea F. Restlessness Oncological/Immune Disorders (Adult) 6. The nurse should instruct a client that which of the following is the most effective prevention against bladder cancer? A. Drink 8 to 10 glasses of fluid per day B. Void at least five times per day C. Stop smoking D. Take herbal supplements
Cardiovascular Disorders (Adult) 7. A client is brought to the emergency room with a third-degree heart block after experiencing an acute anterior myocardial infarction. Which of the following interventions is the priority on an emergency basis? A. Temporary pacemaker B. Administer lidocaine C. Cardioversion D. Administer atropine Respiratory Disorders (Adult) 8. When preparing a client to collect a sputum specimen, it would be essential for the nurse to explain which of the following aspects of the procedure? A. Avoid mouth care prior to collecting the specimen B. Breathe deeply followed by coughing up sputum C. Collect the specimen before bedtime D. Restrict fluids prior to expectorating sputum Endocrine Disorders (Adult) 9. The nurse is caring for a client with myxedema. Which of the following would indicate to the nurse that the client s condition is deteriorating? A. An increase in pulse rate and respirations B. Cold skin and episodes of chills C. Difficulty in arousing the client for medications D. Client complaints of palpitations GI/GU Disorders (Adult) 10. The nurse administers which of the following prescribed medications to a client with recurrent urinary tract infections caused by Escherichia coli? A. Hyoscyamine sulfate (Levsin) B. Bethanechol chloride (Urecholine) C. Sulfamethoxazole and trimethoprim (Bactrim DS) D. Phenazopyridine hydrochloride (Pyridium)
Sensory Disorders (Adult) 11. During the initial assessment of a patient, the nurse observes the presence of bright red drainage on the eye dressing. Which of the following should be the nurse s first action? A. Report the findings to the physician B. Continue to monitor the vital signs and pain C. Note the amount of drainage on the client s record D. Mark the drainage on the dressing and monitor the amount and color Psychiatric and Mental Health (Adult) 12. A mother brings her adolescent son into a clinic and expresses concerns that the son has been experiencing blurred vision, dizziness, a sense of well-being, and slurred speech. Which of the following questions is priority for the nurse to ask? A. How long have you noticed these clinical manifestations and behavior? B. Has your son s school work declined? C. Has your son withdrawn and seems to spend more time alone? D. Have you noticed your son inhaling paint and cleaning or aerosol products?
Answers 1. D: The priority response for the nurse to make to a client who has exhausted all personal financial resources in an assisted living facility is that there are other options available. Those other options may include family support or Medicaid. The nurse is not in a position to discuss or advise the client about financial matters. A financial adviser would be the best person to advise the client. 2. A: HCG is produced by the placenta and is nonexistent by the first week postpartum. 3. D: Control of defecation generally starts in toddlers between 1 and 2 years of age. Children between 3 and 6 years of age frequently delay defecation because of play and may experience constipation. 4. A: Asking a client to shrug the shoulders while applying resistance will provide the most accurate information in a client suspected of a C4 injury. Asking a client to straighten the flexed arms while applying resistance would assess for a C7 injury. Asking the client to grasp an object and make a fist would assess for a C8 injury. Asking the client to lift the arms while applying resistance would assess for a C5 injury. 5. A, D, E, and F: Osteomyelitis is an infection of the bone characterized by both local and systemic manifestations. Systemic manifestations include fever, chills, night sweats, nausea, malaise, and restlessness. 6. C: Persons at greatest risk for bladder cancer are Caucasian men over 50 years of age who have had occupational exposures to dyes, rubber, and leather industries, and who smoke. Since age, race, and occupation are not alterable, the best alternative is to stop smoking. Clients should be provided with smoking-cessation information and support to reduce their risk of several cancers and other health problems. 7. A: A third-degree heart block is a lethal rhythm. It is the complete blockage of the atrial impulses into the ventricles. The block may be at the A-V node, bundle of His, or bundle branches, resulting in the atria and ventricles beating independently of each other. The atrial rate is usually normal while the ventricular rate is very slow and below 55 beats per minute. The causes may be an anterior myocardial infarction, coronary artery disease, surgery, aging, or drug toxicity such as digoxin, procaoinamide (Procanbid), or verapamil (Calan). 8. B: Breathing deeply should be followed by coughing up sputum in the collection process of a sputum specimen. Mouth care should be offered prior to collecting a sputum specimen. The specimen should be collected in the morning and fluids encouraged before coughing up the specimen. 9. C: The most life-threatening complication for the client with myxedema is myxedema coma. This client already has decreased metabolism and as the condition worsens, cardiac, respiratory, and neurological systems slow down even more. The client then goes
into a coma and may die from circulatory and respiratory collapse. If a client with myxedema becomes unable to be aroused, the client may be progressing into a coma. In myxedema the client experiences a decrease in pulse rate and respirations, has cold skin, and often has complaints of being chilled due to the decreased metabolic rate. Clients with increased metabolism complain of palpitations. 10. C: Sulfamethoxazole and trimethoprim (Bactrim DS) is an antibiotic and a drug of choice in the treatment of urinary tract infections. Hyoscyamine sulfate (Levsin) is an anticholinergic used in specific spastic disorders. Bethanechol chloride (Urecholine) is a cholinergic agonist used in urinary retention. Phenazopyridine hydrochloride (Pyridium) is a urinary analgesic given to produce an analgesic effect on the urinary mucosa. 11. A: Bright red drainage on the dressing may indicate hemorrhage and must be reported to the physician immediately. Although monitoring vital signs and the client s pain and recording the amount and color of the drainage are all important interventions, reporting the finding is the priority so emergency measures can be instituted. 12. D: The priority question to ask the mother of a child suspected of inhaling substances is if she has noticed the child inhaling paint or cleaning or aerosol products. Reference Gauwitz, D. (2007). Complete Review for the NCLEX-RN Examination. Clifton, NY: Thomson Delmar Learning.