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Question 1

A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain his personal hygiene without assistance. Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of:

ALoss of ability to speak and communicate effectively

BAspiration and weight loss

CSecondary infection resulting from poor oral hygiene

DDrooling

Answer : B

(A) Loss of ability to speak is not dysphasia. Although the client may have difficulty communicating, alternative measures can be developed to enhance communication. This goal, while important, is of a lesser priority. (B) Dysphasia is difficulty swallowing, which could result in aspiration of food and inability to eat, causing weight loss. (C) A secondary infection could result from poor oral hygiene, which could enhance the client's inability to eat, but this goal is of a lesser priority. (D) Drooling normally occurs in clients with amyotrophic lateral sclerosis and may require suctioning. Drooling, while aggravating for the client, does not pose an immediate danger.

Question 2

The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury. Normal fluid intake for a child of 2 years is:

A900 mL/24 hr

B1300 mL/24 hr

C1600 mL/24 hr

D2000 mL/24 hr

Answer : C

(A, B, D) These values are incorrect. Normal intake for a child of 2 years is about 1600 mL in 24 hours. (C) This value is correct. Normal intake for a child of 2 years is about 1600 mL in 24 hours.

Question 3

A client is admitted to the labor room. She is dilated 4 cm. She is placed on electric fetal monitoring. Which of the following observations necessitates notifying the physician?

AContractions every 2 minutes, lasting 100 seconds

BFetal heart decelerations during a contraction

CBeat-to-beat variability between contractions

DFetal heart decelerations at the beginning of contractions

Answer : A

(A) These are tetanic in nature and can cause rupture of the uterus. (B) The FHR decreases during contractions owing to vasoconstriction and should recover after the contraction. (C) Beat-to-beat variability is a normal finding and demonstrates fetal well-being. (D) The FHR may decrease at the beginning of a contraction owing to head compression.

Question 4

A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his admission, he has become dependent and demanding to the nursing staff. The nurse identifies this behavior as which defense mechanism?

ADenial

BDisplacement

CRegression

DProjection

Answer : C

(A) Denial is the disowning of consciously intolerable thoughts. (B) Displacement is the referring of a feeling or emotion from one person, object, or idea to another. (C) Regression is returning to an earlier stage of development. (D) Projection is attributing one's own thoughts, feelings, or impulses to another person.

Question 5

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

AThe more specific a client's plan, the more likely he or she is to attempt suicide.

BA client who is unsuccessful at a first suicide attempt is not likely to make future attempts.

CA client who threatens suicide is just seeking attention and is not likely to attempt suicide.

DNurses who care for a client who has attempted suicide should not make any reference to the word ''suicide'' in order to protect the client's ego.

Answer : A

(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.

Question 6

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 7

A client had a cardiac catheterization with angiography and thrombolytic therapy with streptokinase. The nurse should initiate which of the following interventions immediately after he returns to his room?

APlace him on NPO restriction for 4 hours.

BMonitor the catheterization site every 15 minutes.

CPlace him in a high Fowler position.

DAmbulate him to the bathroom to void.

Answer : B

(A) A contrast dye, iodine, is used in this procedure. This dye is nephrotoxic. The client must be encouraged to drink plenty of liquids to assist the kidneys in eliminating the dye. (B) Streptokinase activates plasminogen, dissolving fibrin deposits. To prevent bleeding, pressure is applied at the insertion site. The client is assessed for both internal and external bleeding. (C) The extremity used for the insertion site must be kept straight and be immobilized because of the potential for bleeding. (D) The client is kept on bed rest for 8--12 hours following the procedure because of the potential for bleeding.

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