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Question 1

A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain. She is receiving O2 via nasal cannula at 2 L/min for dyspne

a. Which of the following findings in the client's nursing assessment demand immediate nursing action?

AAssociated symptoms of indigestion and nausea

BRestlessness and apprehensiveness

CInability to tolerate assessment session with the admitting nurse

DHistory of hypertension treated with pharmacological therapy

Answer : B

(A) Indigestion or nausea may accompany angina or myocardial infarction, but they do not indicate imminent danger for the client. (B) Restlessness and apprehensiveness require immediate nursing action because they are indicative of very low oxygenation of body tissues and are frequently the first indication of impending cardiac or respiratory arrest. (C) It is common for the cardiac client to experience fatigue and inability to physically tolerate long assessment sessions. (D) A history of hypertension requires no immediate nursing intervention. In the situation described, the blood pressure is not given and therefore cannot be assumed to be elevated.

Question 2

Which of the following blood values would require further nursing action in a newborn who is 4 hours old?

AHemoglobin 17.2 g/dL

BPlatelets 250,000/mm3

CSerum glucose 30 mg/dL

DWhite blood cells 18,000/mm3

Answer : C

(A) The normal range for hemoglobin in the newborn is 17--19 g/dL; 17.2 g/dL is within normal limits. (B) A normal value range for platelets in the newborn is 150,000--400,000 mm3; 250,000/mm3 is within normal range. (C) A serum glucose of 30 mg/dL in the first 72 hours of life is indicative of hypoglycemia and warrants further intervention. (D) On the day of birth, a white blood cell count of 18,000--40,000/mm3 is normal in the newborn.

Question 3

The nurse is assessing and getting a history from a client treated for depression with a monoamine oxidase (MAO) antidepressant. The most serious side effect associated with this antidepressant and the ingestion of tyramine in aged foods may be:

AHypertensive crisis

BSevere rash

CSevere hypotension

DSevere diarrhea

Answer : A

(A) The most serious adverse reactions of MAO inhibitors involve blood pressure and ingestion of tyramine-containing foods, which may provoke a hypertensive crisis. (B) MAO inhibitors cause adverse reactions affecting the central nervous system and serious adverse reactions involving blood pressure. (C) MAO inhibits false neurotransmitters (phenylalanines) and may produce hypotensive reactions from gradual accumulation of these neurotransmitters. (D) The most serious adverse reactions of MAO inhibitors involve blood pressure.

Question 4

To prevent transmission of bacterial meningitis, the nurse would instruct an infected baby's mother to:

AAvoid touching the baby while in the room.

BStay outside of the baby's room.

CWear a gown and gloves and wash her hands before and after leaving the room.

DWear a mask while in the room.

Answer : C

(A) The mother should be allowed and encouraged to touch her baby. (B) With care, transmission can be prevented. There is no need for the mother to stay outside the room. (C) Everyone entering the baby's room should take appropriate measures to prevent transmission of pathogens. (D) Wearing a mask will not protect against transmission of pathogens.

Question 5

A 58-year-old client on a general surgery unit is scheduled for transurethral resection of the prostate (TURP) in 2 hours. The nurse explains to the client that this procedure means:

ARemoval of the prostate tissue by way of a lower abdominal midline incision through the bladder and into the prostate gland

BRemoval of prostate tissue by a resectoscope that is inserted through the penile urethra

CRemoval of the prostate tissue by an open surgical approach through an incision between the ischial tuberosities, the scrotum, and the rectum

DRemoval of prostate tissue by an open surgical approach through a low horizontal incision, bypassing the bladder, to the prostate gland

Answer : B

(A) This describes a suprapubic (transvesical) prostatectomy procedure. (B) This is the correct description of a TURP procedure. (C) This describes a perineal prostatectomy procedure. (D) This describes a retropubic (extravesical) prostatectomy procedure.

Question 6

As the nurse assesses a male adolescent with chlamydia, the nurse determines that a sign of chlamydia is:

AEnlarged penis

BSecondary lymphadenitis

CEpididymitis

DHepatomegaly

Answer : C

(A) An enlarged penis is not a sign of chlamydia. (B) Secondary lymphadenitis is a complication of lymphogranuloma venereum. (C) Untreated chlamydial infection can spread from the urethra, causing epididymitis, which presents as a tender, scrotal swelling. (D) Hepatomegaly is not a complication.

Question 7

For the past several months, an elderly female client with Alzheimer's disease has experienced paranoia; hallucinations; and aggressive, disruptive behavior. The family is utilizing haloperidol as needed to control her behavior. On nursing assessment, you note that the client demonstrates involuntary movements of the tongue and fingers. This may most likely indicate:

ATardive dyskinesia, which may be a side effect of antipsychotic medication

BEarly symptoms of Parkinson's disease

CA more advanced stage of Alzheimer's disease than previously experienced by the client

DThe need to change her medication from haloperidol to another antipsychotic drug to lessen symptoms

Answer : A

(A) Tardive dyskinesia is a common side effect of antipsychotic medications such as haloperidol. Discontinuing the medication can alleviate symptoms. (B) Although mild tremors are an early sign of Parkinson's disease, haloperidol must be discontinued first and the client further evaluated. (C) These symptoms do not necessarily indicate a more advanced stage of Alzheimer's disease. (D) Most antipsychotic drugs are chemically similar and will produce the same side effects.

NCLEX National Council Licensure Examination(NCLEX-RN) NCLEX-RN Exam Questions