National Council Licensure Examination(NCLEX-RN) v5.0

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Exam contains 862 questions

When the nurse is evaluating lab data for a client 1824 hours after a major thermal burn, the expected physiological changes would include which of the following?

  • A. Elevated serum sodium
  • B. Elevated serum calcium
  • C. Elevated serum protein
  • D. Elevated hematocrit


Answer : D

Explanation:
(A) Sodium enters the edema fluid in the burned area, lowering the sodium content of the vascular fluid. Hyponatremia may continue for days to several weeks because of sodium loss to edema, sodium shifting into the cells, and later, diuresis. (B) Hypocalcemia occurs because of calcium loss to edema fluid at the burned site (third space fluid). (C) Protein loss occurs at the burn site owing to increased capillary permeability. Serum protein levels remain low until healing occurs. (D) Hematocrit level is elevated owing to hemoconcentration from hypovolemia. Anemia is present in the postburn stage owing to blood loss and hemolysis, but it cannot be assessed until the client is adequately hydrated.

A diagnosis of hepatitis C is confirmed by a male clients physician. The nurse should be knowledgeable of the differences between hepatitis A, B, and C. Which of the following are characteristics of hepatitis C?

  • A. The potential for chronic liver disease is minimal.
  • B. The onset of symptoms is abrupt.
  • C. The incubation period is 2–26 weeks.
  • D. There is an effective vaccine for hepatitis B, but not for hepatitis C.


Answer : C

Explanation:
(A) Hepatitis C and B may result in chronic liver disease. Hepatitis A has a low potential for chronic liver disease. (B) Hepatitis C and B have insidious onsets. Hepatitis A has an abrupt onset. (C) Incubation periods are as follows: hepatitis C is 226 weeks, hepatitis B is 620 weeks, and hepatitis A is 26 weeks. (D) Only hepatitis B has an effective vaccine.

A client has been diagnosed as being preeclamptic. The physician orders magnesium sulfate. Magnesium sulfate (MgSO4) is used in the management of preeclampsia for:

  • A. Prevention of seizures
  • B. Prevention of uterine contractions
  • C. Sedation
  • D. Fetal lung protection


Answer : A

Explanation:
(A) MgSO4 is classified as an anticonvulsant drug. In preeclampsia management, MgSO4 is used for prevention of seizures. (B) MgSO4 has been used to inhibit hyperactive labor, but results are questionable. (C) Negative side effects such as respiratory depression should not be confused with generalized sedation. (D) MgSO4 does not affect lung maturity. The infant should be assessed for neuromuscular and respiratory depression.

A laboratory technique specific for diagnosing Lyme disease is:

  • A. Polymerase chain reaction
  • B. Heterophil antibody test
  • C. Decreased serum calcium level
  • D. Increased serum potassium level


Answer : A

Explanation:
(A) Polymerase chain reaction is the laboratory technique specific for Lyme disease. (B)
Heterophil antibody test is used to diagnose mononucleosis. (C) Lyme disease does not decrease the serum calcium level. (D) Lyme disease does not increase the serum potassium level.

A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight.
Which of the following nutritional interventions would be most therapeutic for him at this time?

  • A. Small, frequent feedings of foods that can be carried
  • B. Tube feedings with nutritional supplements
  • C. Allowing him to eat when and what he wants
  • D. Giving him a quiet place where he can sit down to eat meals


Answer : A

Explanation:
(A) The manic client is unable to sit still long enough to eat an adequate meal. Small, frequent feedings with finger foods allow him to eat during periods of activity. (B) This type of therapy should be implemented when other methods have been exhausted. (C) The manic client should not be in control of his treatment plan. This type of client may forget to eat. (D) The manic client is unable to sit down to eat full meals.

Hypoxia is the primary problem related to near-drowning victims. The first organ that sustains irreversible damage after submersion in water is the:

  • A. Kidney (urinary system)
  • B. Brain (nervous system)
  • C. Heart (circulatory system)
  • D. Lungs (respiratory system)


Answer : B

Explanation:
(A) The kidney can survive after 30 minutes of water submersion. (B) The cerebral neurons sustain irreversible damage after 46 minutes of water submersion. (C) The heart can survive up to 30 minutes of water submersion. (D) The lungs can survive up to 30 minutes of water submersion.

Which of the following statements relevant to a suicidal client is correct?

  • A. The more specific a client’s plan, the more likely he or she is to attempt suicide.
  • B. A client who is unsuccessful at a first suicide attempt is not likely to make future attempts.
  • C. A client who threatens suicide is just seeking attention and is not likely to attempt suicide.
  • D. Nurses who care for a client who has attempted suicide should not make any reference to the word suicide in order to protect the clients ego.


Answer : A

Explanation:
(A) This is a high-risk factor for potential suicide. (B) A previous suicide attempt is a definite risk factor for subsequent attempts. (C) Every threat of suicide should be taken seriously.
(D) The client should be asked directly about his or her intent to do bodily harm. The client is never hurt by direct, respectful questions.

Assessment of the client with pericarditis may reveal which of the following?

  • A. Ventricular gallop and substernal chest pain
  • B. Narrowed pulse pressure and shortness of breath
  • C. Pericardial friction rub and pain on deep inspiration
  • D. Pericardial tamponade and widened pulse pressure


Answer : C

Explanation:
(A) No S3 or S4 are noted with pericarditis. (B) No change in pulse pressure occurs. (C)
The symptoms of pericarditis vary with the cause, but they usually include chest pain, dyspnea, tachycardia, rise in temperature, and friction rub caused by fibrin or other deposits. The pain seen with pericarditis typically worsens with deep inspiration. (D)
Tamponade is not typically seen early on, and no change in pulse pressure occurs.

Three weeks following discharge, a male client is readmitted to the psychiatric unit for depression. His wife stated that he had threatened to kill himself with a handgun. As the nurse admits him to the unit, he says, I wish I were dead because I am worthless to everyone; I guess I am just no good. Which response by the nurse is most appropriate at this time?

  • A. “I don’t think you are worthless. I’m glad to see you, and we will help you.”
  • B. “Don’t you think this is a sign of your illness?”
  • C. “I know with your wife and new baby that you do have a lot to live for.”
  • D. “You’ve been feeling sad and alone for some time now?”


Answer : D

Explanation:
(A) This response does not acknowledge the clients feelings.
(B) This is a closed question and does not encourage communication.
(C) This response negates the clients feelings and does not require a response from the client. (D) This acknowledges the clients implied thoughts and feelings and encourages a response.

The nurse would need to monitor the serum glucose levels of a client receiving which of the following medications, owing to its effects on glycogenolysis and insulin release?

  • A. Norepinephrine (Levophed)
  • B. Dobutamine (Dobutrex)
  • C. Propranolol (Inderal)
  • D. Epinephrine (Adrenalin)


Answer : D

Explanation:
(A) Norepinephrines side effects are primarily related to safe, effective care environment and include decreased peripheral perfusion and bradycardia. (B) Dobutamines side effects include increased heart rate and blood pressure, ventricular ectopy, nausea, and headache. (C) Propranolols side effects include elevated blood urea nitrogen, serum transaminase, alkaline phosphatase, and lactic dehydrogenase. (D) Epinephrine increases serum glucose levels by increasing glycogenolysis and inhibiting insulin release. Prolonged use can elevate serum lactate levels, leading to metabolic acidosis, increased urinary catecholamines, false elevation of blood urea nitrogen, and decreased coagulation time.

Which of the following medications requires close observation for bronchospasm in the client with chronic obstructive pulmonary disease or asthma?

  • A. Verapamil (Isoptin)
  • B. Amrinone (Inocor)
  • C. Epinephrine (Adrenalin)
  • D. Propranolol (Inderal)


Answer : D

Explanation:
(A) Verapamil has the respiratory side effect of nasal or chest congestion, dyspnea, shortness of breath (SOB), and wheezing. (B) Amrinone has the effect of increased contractility and dilation of the vascular smooth muscle. It has no noted respiratory side effects. (C) Epinephrine has the effect of bronchodilation through stimulation. (D)
Propranolol, esmolol, and labetalol are all - blocking agents, which can increase airway resistance and cause bronchospasms.

Which of the following findings would be abnormal in a postpartal woman?

  • A. Chills shortly after delivery
  • B. Pulse rate of 60 bpm in morning on first postdelivery day
  • C. Urinary output of 3000 mL on the second day after delivery
  • D. An oral temperature of 101F (38.3C) on the third day after delivery


Answer : D

Explanation:
(A) Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous response or to vasomotor changes. If not followed by a fever, it is clinically innocuous. (B) The pulse rate during the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt to the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. (C)
Urinary output increases during the early postpartal period (1224 hours) owing to diuresis.
The kidneys must eliminate an estimated 20003000 mL of extracellular fluid associated with a normal pregnancy. (D) A temperature of 100.4F (38C) may occur after delivery as a result of exertion and dehydration of labor. However, any temperature greater than 100.4F needs further investigation to identify any infectious process.

The physician has ordered that a daily exercise program be instituted by a client with type I diabetes following his discharge from the hospital. Discharge instructions about exercise should include which of the following?

  • A. Exercise should be performed 30 minutes before meals.
  • B. A snack may be needed before and/or during exercise.
  • C. Hyperglycemia may occur 2–4 hours after exercise.
  • D. The blood glucose level should be 100 mg or below before exercise is begun.


Answer : B

Explanation:
(A) Exercise should not be performed before meals because the blood sugar is usually lower just prior to eating; therefore, there is an increased risk for hypoglycemia. (B)
Exercise lowers blood sugar levels; therefore, a snack may be needed to maintain the appropriate glucose level. (C) Exercise lowers blood sugar levels. (D) Exercise lowers blood sugar levels. If the blood glucose level is 100 mg or below at the start of exercise, the potential for hypoglycemia is greater.

When teaching a sex education class, the nurse identifies the most common STDs in the
United States as:

  • A. Chlamydia
  • B. Herpes genitalis
  • C. Syphilis
  • D. Gonorrhea


Answer : A

Explanation:
(A) Chlamydia trachomatis infection is the most common STD in the United States. The
Centers for Disease Control and Prevention recommend screening of all high-risk women, such as adolescents and women with multiple sex partners. (B) Herpes simplex genitalia is estimated to be found in 520 million people in the United States and is rising in occurrence yearly. (C) Syphilis is a chronic infection caused by Treponema pallidum. Over the last several years the number of people infected has begun to increase. (D) Gonorrhea is a bacterial infection caused by the organism Neisseria gonorrhoeae. Although gonorrhea is common, chlamydia is still the most common STD.

One of the most dramatic and serious complications associated with bacterial meningitis is
Waterhouse- Friderichsen syndrome, which is:

  • A. Peripheral circulatory collapse
  • B. Syndrome of inappropriate antiduretic hormone
  • C. Cerebral edema resulting in hydrocephalus
  • D. Auditory nerve damage resulting in permanent hearing loss


Answer : A

Explanation:
(A) Waterhouse-Friderichsen syndrome is peripheral circulatory collapse, which may result in extensive and diffuse intravascular coagulation and thrombocytopenia resulting in death.
(B) Syndrome of inappropriate antidiuretic hormone is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. (C) Cerebral edema resulting in hydrocephalus is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. (D) Auditory nerve damage resulting in permanent hearing loss is a complication of meningitis, but it is not Waterhouse- Friderichsen syndrome.

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Exam contains 862 questions

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