NCLEX-RN Exam Questions Instant Access - No Installation Required

Question 1

A 3-year-old child is in the burn unit following a home accident. The first sign of sepsis in burned children is:

ADisorientation

BLow-grade fever

CDiarrhea

DHypertension

Answer : A

(A) Disorientation is the first sign of sepsis in burn children. (B) Low-grade fever is not indicative of sepsis. (C) Diarrhea is not indicative of sepsis. (D) Hypertension is not indicative of sepsis.

Question 2

A mother is unsure about the type of toys for her 17-month-old child. Based on knowledge of growth and development, what toy would the nurse suggest?

AA pull toy to encourage locomotion

BA mobile to improve hand-eye coordination

CA large toy with movable parts to improve pincer grasp

DVarious large colored blocks to teach visual discrimination

Answer : A

(A) Increased locomotive skills make push-pull toys appropriate for the energetic toddler. (B) Infants progress from reflex activity through simple repetitive behaviors to imitative behavior. Hand-eye coordination forms the foundation of other movements. (C) At age 8 months, infants begin to have pincer grasp. Toys that help infants develop the pincer grasp are recommended for this age group. (D) Various large colored blocks are suggested toys for infants 6--12 months of age to help visual stimulation.

Question 3

A term neonate has experienced no distress at birth and has an Apgar score of 9. Her mother has asked to breastfeed her following delivery. Immediately after birth, the neonate was most susceptible to heat loss. The most appropriate intervention to conserve heat loss and promote bonding is to:

APlace her under the radiant warmer

BDry her with blankets

CPlace her to her mother's breast

DPlace her on a heated pad

Answer : C

(A) A radiant warmer maintains an optimal thermal environment by use of a thermal skin sensor taped to the infant. The warmer limits parental attachment, so, although appropriate, it is not an intervention that promotes infant attachment. (B) Warmed blankets prevent heat loss in the neonate by conduction. In addition, tactile stimuli promote crying and lung expansion. This intervention does not promote attachment, however. (C) Skin-to-skin contact is an effective way to conserve heat after delivery and promotes parental attachment following birth in the healthy term infant. The first period of reactivity lasts approximately 30 minutes following birth. A strong sucking reflex and an active, awake newborn characterize this period. (D) Surfaces of objects warmer than the infant promote overheating by conduction, and neonatal hyperthermia may result.

Question 4

A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse anticipates the physician ordering:

AOxytocin

BMagnesium sulfate (MgSO4)

CAmpicillin

DTetracycline

Answer : C

(A) Oxytocin is prescribed to stimulate uterine contractions. (B)

MgSO4is a central nervous system depressant prescribed to prevent

and control convulsions related to preeclampsia. (C) Ampicillin

is a penicillin derivative with no known teratogenic effects.

This is the safest antibiotic during pregnancy. (D) Tetracycline

stains teeth yellow and is not as safe as ampicillin during pregnancy.

Question 5

A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, ''This is too much trouble. I would rather just have a Foley.'' An appropriate response for the RN teaching him would be:

A''I know. It is a lot to learn. In the long run, though, you will be able to reduce infections if you do an intermittent catheterization program.''

B''It is not too much trouble. This is the best way to manage urination.''

C''OK. I'll ask your physician if we can replace the Foley.''

D''You need to learn this because your doctor ordered it.''

Answer : A

(A) This response acknowledges the client's feelings, gives him factual information, and acknowledges that the final decision is his. (B) This response is judgmental and discourages the client from expressing his feelings about the procedure. (C) Catheterization is a procedure thattakes time to learn, but which, for the spinal cord--injured client, can significantly reduce the incidence of urinary tract infections. A young client with a T-4 injury has the hand function to learn this procedure fairly easily. (D) The final decision about bladder elimination management ultimately rests with the client and not the physician.

Question 6

The physician of an alcoholic client places him on a low-protein, high-carbohydrate diet. When choosing his menu, the client's best choice from the items below would be:

ALiver and onions, macaroni and cheese, tea with sugar

BBaked chicken, baked potato with bacon bits, milk

CWaffles with butter and honey, orange juice

DCheese omelette with ham and mushrooms, milk

Answer : C

(A, B, D) These foods are high in protein, which needs to be restricted. (C) Serum ammonia levels can be decreased by restricting dietary protein intake. Waffles, honey, and orange juice are high in carbohydrate and low or completely lacking in protein. Butter, a concentrated fat, will provide extra calories.

Question 7

A 72-year-old client with a new colostomy is being evaluated at the clinic today for constipation. When discussing diet with the client, the nurse recognizes that which one of the following foods most likely caused this problem?

AFried chicken

BEggs

CTapioca

DCabbage

Answer : C

(A) Fried, greasy food, such as fried chicken, will produce diarrhealike stools in individuals with all types of GI ostomies. (B) Eggs will cause odor-producing stools in individuals with all types of GI ostomies. (C) Tapioca and rice products will cause constipation in individuals with all types of GI ostomies. (D) Cabbage will cause odor-producing and flatus-producing stools in individuals with all types of GI ostomies.

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