NCLEX-RN Quiz Part 5 (201-250)

NO.201 A child receiving chemotherapeutic drugs experiences a loss of appetite directly related to the therapy. Which of the following strategies should be most effective in encouraging the child to eat?

A.            Provide a well-balanced diet at usual times, and restrict dessert if the child fails to eat well.

B.            Schedule procedures immediately after eating so that the child will not be tired or in pain at mealtime.

C.            Offer the child a diet with a wider variety of foods and with more seasoning than her usual diet.

D.            Offer the child smaller meals more frequently than usual, and include as many of her favorite foods as possible.

NO.202 A 14-year-old teenager is hospitalized for anorexia nervosa. She is admitted to the adolescent mental health unit and placed on a behavior modification program. Nursing interventions for the teenager will most likely include:

A.            Establishing routine tasks and activities around mealtimes

B.            Administering medications such as lithium

C.            Requiring the client to eat more during meals

D.            Checking the client's room frequently

NO.203 The nurse has been assigned a client who delivered a 6- lb, 12-oz baby boy vaginally 40 minutes ago. The initial assessment of greatest importance for this client would be:

A.            Length of her labor

B.            Type of episiotomy

C.            Amount of IV fluid to be infused

D.            Character of the fundus

NO.204 A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty- eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications?

A.            Fluid volume deficit

B.            Fluid volume excess

C.            Decreased cardiac output

D.            Severe hypotension

NO.205 A schizophrenic is admitted to the psychiatric unit. What affect would the nurse expect to observe?

A.            Anger

B.            Apathy and flatness

C.            Smiling

 D.           Hostility

NO.206 A primigravida with a blood type A negative is at 28 weeks' gestation. Today her physician has ordered a RhoGAM injection. Which statement by the client demonstrates that more teaching is needed related to this therapy?

A.            "I'm getting this shot so that my baby won't develop antibodies against my blood, right?"

B.            "I understand that if my baby is Rh positive I'll be getting another one of these injections."

C.            "This shot should help to protect me in future pregnancies if this baby is Rh positive, like my husband."

D.            "This shot will prevent me from becoming sensitized to Rh-positive blood."

NO.207 A client who has gout is most likely to form which type of renal calculi?

A.            Struvite stones

B.            Staghorn calculi

C.            Uric acid stones

D.            Calcium stones

NO.208 A 55-year-old man is admitted to the hospital with complaints of fatigue, jaundice, anorexia, and clay-colored stools. His admitting diagnosis is "rule out hepatitis." Laboratory studies reveal elevated liver enzymes and bilirubin. In obtaining his health history, the nurse should assess his potential for exposure to hepatitis.

Which of the following represents a high-risk group for contracting this disease?

 A.           Heterosexual males

B.            Oncology nurses

C.            American Indians

D.            Jehovah's Witnesses

NO.209 A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching concerning the warfarin therapy?

A.            "If you forget to take your morning dose, double the night time dose."

B.            "You should take aspirin instead of acetaminophen (Tylenol) for headaches."

C.            "Carry a medications alert card with you at all times."

D.            "You should use a straight-edge razor when shaving your arms and legs."

NO.210 A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to:

A.            Be comforted when he is held

B.            Cry

C.            Not notice that his mother has left

D.            Withdraw and become listless

NO.211 A laboring client presents with a prolapsed cord. The nurse should immediately place the client in what position?

A.            Reverse Trendelenburg

B.            Fowler's

C.            Trendelenburg

D.            Sims'

NO.212 Parents of children receiving chemotherapy should be warned that alopecia is a side effect and that:

A.            Children seldom show concern about losing their hair

B.            The hair will come out gradually, and the loss will not be noticeable for some time

C.            It is best for girls to choose a wig similar to their hair style and color before the hair falls out

D.            The parents will soon get used to seeing their children without hair, and it will no longer bother them

NO.213 A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 lb from her 7th to 8th month; her face and hands indicate edema. She is diagnosed as having PIH and referred to the high-risk prenatal clinic. The client's weight increase is most likely due to:

A.            Overeating and subsequent obesity

B.            Obesity prior to conception

C.            Hypertension due to kidney lesions

D.            Fluid retention

 NO.214 The nurse is caring for a 3-month-old girl with meningitis. She has a positive Kernig's sign. The nurse expects her to react to discomfort if she:

A.            Dorsiflexes her ankle

B.            Flexes her spine

C.            Plantiflexes her wrist

D.            Turns her head to the side

NO.215 A client suspects that she is pregnant. She reports two missed menstrual periods. The first day of her last menstrual period was August 3. Her estimated date of confinement would be:

A.            November 7

B.            November 10

C.            May 7

D.            May 10

NO.216 A 10-year-old boy has been diagnosed with Legg-Calve Perthes disease. Which of the client's responses would indicate compliance during initial therapy?

A.            Drinking large amounts of milk

B.            Not bearing weight on affected extremity

C.            Walking short distances 3 times/day

D.            Putting self on weight reduction diet

NO.217 A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, "Why did this happen to my baby?" is:

A.            "It's God's will. It was probably for the best. There was something probably wrong with your baby."

B.            "You're young. You can have other children later."

C.            "I know your other children will be a great comfort to you."

D.            "I can see you're upset. Would you like to see and hold your baby?"

NO.218 A 16-year-old client with anorexia nervosa is on an inpatient psychiatric unit. She has a fear of gaining weight and is refusing to eat sufficient amounts to maintain body weight for her age, height, and stature. To assist with the problem of powerlessness and plan for the client to no longer need to withhold food to feel in control, the nurse uses the following strategy:

A.            Establish a structured environment with routine tasks and activities. Also, serve meals at the same time each day.

B.            Distract the client during meals to get her to eat because she must take in sufficient amounts to keep from starving.

C.            Do frequent room checks to be sure that the client is not hiding food or throwing it away.

D.            Listen attentively and participate in in-depth discussions about food, because these actions may encourage her to eat.

NO.219 The nurse is caring for a 2-year-old girl with a subdural hematoma of the temporal area as a result of falling out of bed and notices that she has a runny nose. The nurse should:

A.            Call the doctor immediately

 B.           Help her to blow her nose carefully

C.            Test the discharge for sugar

D.            Turn her to her side Answer: C Explanation:

NO.220 Which of the following menu choices would indicate that a client with pressure ulcers understands the role diet plays in restoring her albumin levels?

A.            Broiled fish with rice

B.            Bran flakes with fresh peaches

C.            Lasagna with garlic bread

D.            Cauliflower and lettuce salad

NO.221 The nurse would be sure to instruct a client on the signs and symptoms of an eye infection and hemorrhage. These signs and symptoms would include:

A.            Blurred vision and dizziness

B.            Eye pain and itching

C.            Feeling of eye pressure and headache

D.            Eye discharge and hemoptysis

NO.222 A client has ascites, which is caused by:

A.            Decreased plasma proteins

B.            Electrolyte imbalance

C.            Decreased renal function

D.            Portal hypertension

NO.223 A 19-year-old primigravida is admitted to the labor and delivery suite of the hospital. Her husband is accompanying her. The couple tells the nurse that this is the first hospital admission for her. The client's vaginal exam indicates she is 3 cm dilated, 80% effaced, and at _0 station. Based on the vaginal exam, she is in:

A.            Stage 2, latent phase

B.            Stage 1, active phase

C.            Stage 3, transition phase

D.            Stage 1, latent phase

NO.224 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.            Have insomnia for the first few days

D.            Require no special care after the procedure

NO.225 Which of the following procedures is necessary to establish a definitive diagnosis of breast cancer?

A.            Diaphanography

B.            Mammography

C.            Thermography

D.            Breast tissue biopsy

NO.226 Following a vaginal delivery, the postpartum nurse should observe for:

A.            Dystocia, kraurosis

B.            Chadwick's sign

C.            Fatigue, hemorrhoids

D.            Hemorrhage and infection

NO.227 What is the appropriate nursing action for a child with increased intracranial pressure?

A.            Head of bed elevated 45 degrees with child's head maintained in a neutral position

B.            Child lying flat

C.            Head turned to side

D.            Frequent visitation for stimulation

NO.228 A 4 year old has an imaginary playmate, which concerns the mother. The nurse's best response would be:

A.            "I understand your concern and will assist you with a referral."

B.            "Try not to worry because you will just upset your child."

C.            "Just ignore the behavior and it should disappear by age 8."

D.            "This is appropriate behavior for a preschooler and should not be a concern."

NO.229 Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following statements by the client would validate an understanding of his medication?

A.            "I would notify my physician immediately if I experience nausea, vomiting, and double vision."

B.            "I could stop taking this medication when I begin to feel better."

C.            "I should only take the medication if my heart rate is greater than 100 bpm."

D.            "I should always take this medication with an antacid."

NO.230 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

NO.231 A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She has been admitted to the pediatric unit after surgical repair of the cleft lip. Which of the following nursing interventions would be appropriate during the first 24 hours?

A.            Position on side or abdomen.

B.            Maintain elbow restraints in place unless she is being directly supervised.

C.            Clean suture line every shift.

D.            Offer pacifier when she cries.

NO.232 An expected response to sodium polystyrene sulfonate (Kayexalate) is:

A.            Increase in serum magnesium

B.            Increase in serum HCO3

C.            Decrease in serum potassium

D.            Decrease in serum calcium

NO.233 At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her contractions are every 5 minutes and last 60 seconds, her cervix is closed, and the suture placed

around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is still intact. She is very concerned about delivering prematurely. She asks the RN, "What is the greatest risk to my baby if it is born prematurely?" The RN's answer should be:

A.            Hyperglycemia

B.            Hypoglycemia

C.            Lack of development of the intestines

D.            Lack of development of the lungs

NO.234 The nurse caring for a client who has pneumonia, which is caused by a gram-positive bacteria, inspects her sputum. Because the client's pneumonia is caused by a gram-positive bacteria, the nurse experts to find the sputum to be:

A.            Bright red with streaks

B.            Rust colored

C.            Green colored

D.            Pink-tinged and frothy

NO.235 Primary nursing diagnoses for the antisocial client are:

A.            Alteration in perception and altered self-concept

B.            Impaired social interaction, ineffective individual coping, and altered self-concept

C.            Altered communication processes and altered recreational patterns

D.            Altered body image and altered thought processes

NO.236 The mother of a preschooler reports to the nurse that he frequently tells lies. The admission assessment of the child indicates possible child abuse. The nurse knows that his:

A.            Behavior is not normal, and a child psychiatrist should be consulted.

B.            Mother is lying to protect herself.

C.            Lying is normal behavior for a preschool child who is learning to separate fantasy from reality.

D.            Behavior indicates a developmental delay, because preschoolers should be able to tell right from wrong.

NO.237 A 30-year-old client has just been treated in the ER for bruises and abrasions to her face and a broken arm from domestic violence, which has been increasing in frequency and intensity over the last few months. The nurse assesses her as being very anxious, fearful, bewildered, and feeling helpless as she states, "I don't know what to do, I'm afraid to go home." The best response by the nurse to the client would be:

A.            "I wouldn't want to go home either; call a friend who could help you."

B.            "Did you do something that could have made him so angry?"

C.            "Let's talk about people and resources available to you so that you don't have to go home."

D.            "I'll call the police and they will take care of him, and you can go home and get some rest."

NO.238 The 4th of July holiday comes while a client is in the hospital being treated for schizophrenia. She is taking chlorpromazine and has improved to the point of being allowed to go with a group to the park for a picnic. The side effect of chlorpromazine that the nurse needs to keep in mind during this outing is:

A.            Hypotension

B.            Photosensitivity

C.            Excessive appetite

D.            Dryness of the mouth

NO.239 The nurse would teach a male client ways to minimize the risk of infection after eye surgery. Which of the following indicates the client needs further teaching?

A.            "I will wash my hands before instilling eye medications."

B.            "I will wear sunglasses when going outside."

C.            "I will wear an eye patch for the first 3 postoperative days."

D.            "I will maintain the sterility of the eye medications."

NO.240 Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include:

A.            Cleanse area around the meatus twice a day

B.            Empty the catheter drainage bag at least daily

C.            Change the catheter tubing and bag every 48 hours

D.            Maintain fluid intake of 1200-1500 mL every day

NO.241 A 45-year-old male client was admitted to a chemical dependency treatment center following legal problems related to alcohol abuse. He states, "I know that alcohol is a problem for some people, but I can stop whenever I want to. I'm never sick or miss work, and no one can complain about me." During the initial assessment, the best response by the nurse would be:

A.            "The fact is you are an alcoholic or you wouldn't be here."

B.            "I understand it took strength to admit yourself to the unit, and I will do my part to help you to stay alcohol- free."

C.            "If you can stop drinking when you want to, why don't you stop?"

D.            "It's good that you can stop drinking when you want to."

NO.242 A client is experiencing mucosal cell damage secondary to chemotherapy. Because of mucosal ulcers, eating has become increasingly uncomfortable for her. Which of the following interventions would be most effective in getting her to eat?

A.            Local anesthetics or mouth washes applied to ulcers 30 minutes prior to meals

B.            A bland, moist, soft diet

C.            Staying with the client and providing distraction during meals

D.            Cleaning the mouth carefully with lemon glycerin swabs and milk of magnesia before meals

NO.243 A client's prenatal screening indicated that she has no immunity to rubella. She is now 10 weeks pregnant. The best time to immunize her is:

A.            In the immediate postpartum period

B.            After the first trimester

 C.           At 28 weeks' gestation

D.            Within 72 hours postpartum

NO.244 A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, "The doctor said I have stones that need to be removed; where are they?" The nurse knows that the best explanation for this is to tell her that:

A.            There are stones present in her gallbladder

B.            There are stones present in her kidneys

C.            There are stones present in her common bile duct

D.            There are no stones, but her gallbladder is irritated and caused her nausea, vomiting, and pain

NO.245 On the third postpartum day, the nurse would expect the lochia to be:

A.            Rubra

B.            Serosa

C.            Alba

D.            Scant

NO.246 Clients receiving antipsychotic drug therapy will often exhibit extrapyramidal side effects that are reversible with which of the following agents ordered by the physician?

A.            Phenothiazines

 B.           Anticholinergics

C.            Anti-Parkinsonian drugs

D.            Tricyclic agents Answer: B Explanation:

NO.247 A male client is undergoing cardiac tests. He has been instructed to wear a Holter monitor. The nurse knows she has included the appropriate information in her teaching when the client tells her:

A.            "He should remove the electrodes for bathing."

B.            "Damage to his heart muscle will be recorded by the monitor."

C.            "He is to keep a record of everything he does during the day."

D.            "He is to refrain from activities that cause chest pain."

NO.248 A 1000-mL dose of D5W 12 normal saline is to be infused in 8 hours. The drop factor for the tubing is 60 gtt/min. How many drops per minute should the nurse administer?

A.            75 gtt/min

B.            100 gtt/min

C.            125 gtt/min

D.            150 gtt/min

NO.249 A client tells the nurse that he has been hearing voices that tell him to kill his girlfriend because she is a spy. He further states that he is having difficulty not obeying the voices because, if he does not, his house will be burned down. The highest priority nursing diagnosis for him at this time is:

A.            Sensory-perceptual alteration: auditory command hallucinations

 B.           Alteration in thought processes: paranoid delusions

C.            Potential for violence directed at others

D.            Impaired verbal communication: loose associations

NO.250 A female client has experienced varying degrees of depression throughout her life. Now that she is postmenopausal, her depression has increased. She is unable to motivate herself to clean her house or even to get out of bed and get dressed in the morning. The client was begun on fluoxetine (Prozac) therapy. When educating her about fluoxetine, what might the nurse caution her about?

A.            A daily dose of fluoxetine may be taken in the morning or evening.

B.            Fluoxetine is not sedating; therefore, restrictions on driving and other hazardous activities are not necessary.

C.            Rashes or pruritus usually occur early in the therapy and are treatable without discontinuing the medication.

D.            It is safe to take over-the-counter or other prescription medications with fluoxetine.