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NCLEX QUESTIONS Spring 2011 Set 1 (Answers follow all questions) Fundamentals of Nursing 1. A hospitalized client has daily weights ordered. The client is able to stand, and the nursing unit has an electronic digital scale to use for client weights. Which intervention best ensures that the client's daily weight is accurate? A. Asking the client to wear supportive shoes before stepping on the scale B. Ensuring that the scale is calibrated and "zeroed" before a weight is obtained C. Weighing the client by moving the sliding indicator until the scale balances D. Weighing the client at different times of the day

Maternal-Child Health 2. A nurse's laboring client has decided to try to get through labor without an epidural. The client is requesting intravenous pain medication instead. The nurse determines that which factor would contraindicate the administration of nalbuphine hydrochloride (Nubin)? A. Transition stage of labor B. Fetal heart rate (FHR) of 110 beats per minute C. Presence of variability D. Presence of variable decelerations

Pediatrics 3. A clinic nurse is educating a parent in administration of eye drops to a 3-year-old who has purulent drainage out of both eyes, swollen eyelids, and inflamed conjunctiva and has been diagnosed with bacterial conjunctivitis. The most important fact that the nurse needs to teach the parent is to: A. Have the child sitting when administering the medication B. Have the child be in Trendelenburg's position when administering the medication C. Restrain the child prior to administering the medication D. Tell the child in detail exactly what will take place so that the child will be cooperative

Neurological Disorders (Adult) 4. A client is admitted to an emergency department (ED). A nurse in the ED documents that the client is "postical upon transfer" as evidenced by which observation? A. Yellowing of the skin B. Recently experienced a seizure and is in a drowsy or confused state C. Severe itching of the eyes D. Abnormal sensations including tingling of the skin

Musculoskeletal/Integumentary Disorders (Adult) 5. Which treatments should a nurse plan for a client seen in the clinic for a second-degree ankle sprain? A. Rest, elevate the extremity, apply ice, and apply a compression bandage B. Perform range of motion to determine the extent of injury, apply heat, check circulation and sensation, and examine the ankle C. Reduce pain with moist heat, then apply ice to reduce swelling; check circulation, motion, and sensation; and elevate the ankle D. Refer the client immediately to an orthopedic surgeon, administer analgesics, control swelling with ice, and encourage rest and elevation

Oncological/Immune Disorders (Adult) 6. A nurse is caring for a client diagnosed with hepatocellular carcinoma who is exhibiting a paraneoplastic syndrome. For which signs should the nurse assess? A. Erythrocytosis and hypercalcemia B. Hyperkalemia and hyperalbuminemia C. Hypernatremia and hypomagnesemia D. Hypocalcemia and hyperleukocytosis

Cardiovascular Disorders (Adult) 7. Following a normal chest x-ray for a client who had cardiac surgery, a nurse receives an order to remove the chest tubes. Which intervention should the nurse plan to implement first? A. Auscultate the client's lung sounds B. Administer 4 mg morphine sulfate intravenously C. Turn off the suction to the chest drainage system D. Prepare the dressing supplies at the client's bedside

Respiratory Disorders (Adult) 8. Following a thoracotomy to remove a lung tumor, a nurse is preparing a client to be discharged to home. Which are appropriate teaching points for the client? Select all that apply: A. Avoid lifting greater than 20 pounds B. Build up exercise endurance C. Continue to build endurance even when dyspneic D. Expect return to normal activity level and strength within 1 month E. Make time for frequent rest periods with activity

Endocrine Disorders (Adult) 9. Which of the following questions should the nurse ask during an admission interview for a client admitted with a diagnosis of pheochromocytoma? A. "Do you ever notice or feel an increase in your heart beating?" B. "Do you suddenly feel warm and flushed when you get out of bed?" C. "Do your symptoms subside when you eat simple sugars?" D. "Do the attacks make you feel like you want to rest awhile and sleep?"

GI/GU Disorders (Adult) 10. What notation should a nurse document as an appropriate outcome in the plan of care for a client with chronic renal failure? A. Consumption of three large meals daily without nausea B. Daily weight gain of no more than 3 pounds C. Reduced serum albumin levels within 1 week D. Absence of bleeding

Sensory Disorders (Adult) 11. A client has a hearing loss from a suspected acoustic neuroma. Which diagnostic test should a nurse plan to prepare the client to confirm the presence of a tumor? A. Tympanometry B. Arteriogram of the cranial vessels C. Magnetic resonance imaging (MRI) D. Auditory canal biopsy

Psychiatric and Mental Health (Adult) 12. A nurse is assessing a client recently admitted into a psychiatric unit for observation. Which client behavior is indicative of impaired cognition? A. The client will be free of agitation, hyperactivity, and restless behavior B. The client will appropriately verbalize feelings of anger C. The client will be free of aggression and threatened behavior toward others D. The client will demonstrate lessened buying sprees and grandiosity

ANSWERS 1. B: Electronic digital scales should be calibrated and "zeroed" before weighing the client to ensure accuracy. 2. A: Systemic medications should not be administered when advanced dilation is present because they can lead to respiratory depression if administered too close to the time of delivery. 3. C: It is necessary to secure the child prior to administering the medication to ensure that the child receives the entire prescribed dose. A 3-year-old child is able to understand what is occurring in relation to the limited amount of experiences the child has had. The child is likely to resist instillation of the eye drops because a child is told not to put anything in the eyes and is likely to remember painful experiences such as dust or a foreign object that has gotten into the eye. 4. B: The client has experienced a tonic-clonic seizure recently and is now in a state of deep relaxation and is breathing quietly. During this period the client may be unconscious, gradually awakens, but is often confused and disoriented. Often the client is amnesic regarding the seizure. 5. A: A second-degree ankle sprain involves tearing of ligament fibers producing edema, tenderness, pain with motion, joint instability, and partial loss of normal joint function. Rest prevents further injury and promotes healing. However, encourage walking with a normal gait as soon as possible, allowing for some discomfort. Inversion should be avoided. Ice and elevation control swelling. Compression with an elastic bandage controls bleeding, reduces edema, and provides support for injured tissues. 6. A: Erythrocytosis and hypercalcemia occur in hepatocellular carcinoma due to the cancer cells secreting parathyroid hormone and erythropoietin. 7. B: Because the peak action of morphine sulfate is 10 to 15 minutes, this should be administered first. 8. A, B, E: With discharge after thoracotomy, the client should be instructed to avoid lifting more than 20 pounds until healing is complete. The client should work up to an appropriate exercise level and take rest periods during activity. 9. A: Pheochromocytoma is a tumor in the adrenal medulla that secretes excessive amounts of epinephrine and norepinephrine. Palpitations are a major clinical manifestation. Postural hypotension occurs frequently and would be noted with dizziness and cold and clammy skin. Hyperglycemia is another classic manifestation. Clinical manifestations that subside when simple sugars are eaten are characteristic of hypoglycemia. The "attacks" that occur are a result of the release of the catecholamines and cause the client to be extremely anxious, tremulous, and weak. 10. D: The client with chronic renal failure is at risk for bleeding because of impaired platelet function. The absence of bleeding is an appropriate client outcome.

11. C: MRI with gadolinium enhancement is the most reliable test in determining size and anatomic location of an acoustic neuroma. 12. C: The priority nursing outcome for a client in the manic state of a bipolar disorder is that the client will be free from aggression and threatened behavior toward others.

References Ohman, K. (2010). Davis's Q &A for the NCLEX-RN Examination, Philadelphia: PA: F.A. Davis Company.

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