NCLEX QUESTIONS Spring 2010 Set 1 (Answers follow all questions) Fundamentals of Nursing 1. A nurse is preparing to care for a client who has returned to the nursing unit following cardiac catheterization performed through the femoral artery. The nurse plans to allow which client position or activity following the procedure? A. Bed rest in high Fowler s position B. Bed rest with bathroom privileges only C. Bed rest with head elevation at 60 degrees D. Bed rest with head elevation no greater than 30 degrees Maternity 2. A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction? A. Late decelerations B. Early decelerations C. Short-term variability D. Variable decelerations Pediatrics 3. A 1-year-old child with hypospadias is scheduled for surgery to correct this condition. The nurse prepares a nursing care plan for this child and understands that this surgery is taking place at a time when: A. Fears of separation are great. B. Sibling rivalry will cause regression to occur. C. Concern over size and function of the penis is present. D. Embarrassment about voiding irregularities is common. Neurological Disorders (Adult) 4. The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client s peripheral response to pain? A. Sternal rub B. Nail bed pressure C. Pressure on the orbital rim D. Squeezing of the sternocleidomastoid muscle
Musculoskeletal/Integumentary Disorders (Adult) 5. The nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. The nurse immediately: A. Calls the physician B. Applies ice to the site C. Rewraps the stump with an elastic compression bandage D. Applies a dry sterile dressing and elevates it on one pillow Oncological/ Immune Disorders (Adult) 6. As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of the greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed when the client states: A. I should avoid blowing my nose. B. I may need a platelet transfusion if my platelet count is too low. C. I m going to take aspirin for my headache as soon as I get home. D. I will count the number of pads and tampons I use when menstruating. Cardiovascular Disorders (Adult) 7. A nurse is evaluating the condition of a client after pericardiocentesis is performed to treat cardiac tamponade. Which of the following observations would indicate that the procedure was unsuccessful? A. Rising blood pressure B. Clearly audible heart sounds C. Client expressions of relief D. Rising central venous pressure Respiratory Disorders (Adult) 8. A client has begun therapy with theophylline (Theo-24). A nurse plans to teach the client to limit the intake of which of the following while taking this medication? A. Coffee, cola, and chocolate B. Oysters, lobster, and shrimp C. Melons, oranges, and pineapple D. Cottage cheese, cream cheese, and dairy creamers
Endocrine Disorders (Adult) 9. A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in an emergency room. Which finding would a nurse expect to note as confirming this diagnosis? A. Comatose state B. Decreased urine output C. Increased respirations and an increase in ph D. Elevated blood glucose level and low plasma bicarbonate level GI/GU Disorders (Adult) 10. A client diagnosed with polycystic kidney disease has been taught about the treatment plan for this disease. The nurse determines that the client needs additional teaching if the client states that the treatment plan includes: A. Genetic counseling B. Sodium restriction C. Increased water intake D. Antihypertensive medications Sensory Disorders (Adult) 11. The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which of the following cranial nerves would identify a complication specifically associated with this surgery? A. Cranial nerve I, olfactory B. Cranial nerve IV, trochlear C. Cranial nerve III, oculomotor D. Cranial nerve VII, facial nerve Psychiatric and Mental Health (Adult) 12. The client is admitted to a mental health unit for treatment of psychotic behavior. The client is at the locked exit door and is shouting, Let me out! There s nothing wrong with me. I don t belong here. The nurse analyzes this behavior as: A. Denial B. Projection C. Regression D. Rationalization
Answers 1. B: After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for 4-6 hours. If the femoral artery was used, bed rest is enforced for 3-4 hours (or as prescribed by the physician). The client may turn from side to side. The affected leg is kept straight and the head is elevated no more than 30 degrees until hemostasis is adequately achieved. 2. D: Variable decelerations occur if the umbilical cord becomes compressed, thus reducing blood flow between the placenta and the fetus. Early decelerations result from pressure on the fetal head during a contraction. Late decelerations are an ominous pattern in labor because they suggest uteroplacental insufficiency during a contraction. Short-term variability refers to the beat-to-beat range in the fetal heart rate. 3. A: At the age of 1 year, a child s fears of separation are great because the child is facing the developmental task of trusting others. Options 3 and 4 might be issues if the child were older. No data in the question allow one to determine that siblings exist. 4. B: Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle. 5. C: If the client with an amputation has a cast or elastic compression bandage that slips off, the nurse must wrap the stump immediately with another elastic compression bandage. Otherwise, excessive edema will form rapidly, which could cause a significant delay in rehabilitation. If the client has a cast that slipped off, the nurse would have to call the physician so that a new one could be applied. Elevation on one pillow is not going to impede the development of edema greatly once compression is released. Ice would be of limited value in controlling edema from this cause. If the physician were called, the order likely would be to reapply the compression dressing. 6. C: During the period of greatest bone marrow suppression (the nadir), the platelet count may be low, less than 20,000 cells/mm3. Option 3 describes an incorrect statement by the client. Aspirin and nonsteroidal anti-inflammatory drugs and products that contain aspirin should be avoided because of their antiplatelet activity; thus, further teaching is needed. Options 1, 2 and 4 are correct statements by the client to prevent and monitor bleeding. 7. D: Following pericardiocentesis, a rise in blood pressure and a fall in central venous pressure are expected. The client usually expresses immediate relief. Heart sounds are no longer muffled or distant.
8. A: Theophylline (Theo-24) is a methylxanthine bronchodilator. The nurse teaches the client to limit the intake of xanthine-containing foods while taking this medication. These foods include coffee, cola, and chocolate. 9. D: In DKA, the arterial ph is lower than 7.35, plasma bicarbonate is lower than 15 meq/l, the blood glucose level is higher than 250 mg/dl, and ketones are present in the blood and urine. The client would be experiencing polyuria, and Kussmaul s respirations would be present. A comatose state may occur if DKA is not treated, but coma would not confirm the diagnosis. 10. B: Individuals with polycystic kidney disease seem to waste rather than retain sodium. Thus, they need increased sodium and water intake. Aggressive control of hypertension is essential. Genetic counseling is advisable because of the hereditary nature of the disease. 11. D: Treatment for acoustic neuroma is surgical removal via a craniotomy. Extreme care is taken to preserve remaining hearing and preserve the function of the facial nerve. Acoustic neuromas rarely recur following surgical removal. 12. A: Denial is refusal to admit to a painful reality, which is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other persons, objects, or situations. In regression, the client returns to an earlier, more comforting, although less mature, way of behaving. Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller and the listener. References Silvestri, L.A. (2008). Comprehensive Review for the NCLEX-RN Examination (4th edition). St Louis, MO: Saunders.