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Question 1

The following nursing diagnosis is written for a comatose client with cirrhosis of the liver and secondary splenomegaly---High risk for injury: Increased susceptibility to bleeding related to:

AIncreased absorption of vitamin K

BThrombocytopenia due to hypersplenism

CDiminished function of the Kupffer cells

DIncreased synthesis of the clotting factors

Answer : B

(A) There is a decreased absorption of vitamin K with cirrhosis of the liver. This decrease impairs blood coagulation and the formation of prothrombin. (B) Thrombocytopenia, an increased destruction of platelets, occurs secondary to hypersplenism. (C) A diminished function of the Kupffer cells occurs with cirrhosis of the liver, causing the client to become more susceptible to infections. (D) A decrease in the synthesis of fibrinogen and clotting factors VII, IX, and X occurs with cirrhosis of the liver and increases the susceptibility to bleeding.

Question 2

A 30-year-old client in the third trimester of her pregnancy asks the nurse for advice about upper respiratory discomforts. She complains of nasal stuffiness and epistaxis, most noticeable on the left side. Which reply by the nurse is correct?

A''It sounds as though you are coming down with a bad cold. I'll ask the doctor to prescribe a decongestant for relief of symptoms.''

B''A good vaporizer will help; avoid the cool air kind. Also, try saline nose drops, and spend less time on your left side.''

C''These discomforts are all a result of increased blood supply; one of the pregnancy hormones, estrogen, causes them.''

D''This is most unusual. I'm sure your obstetrician will want you to see an ENT (ear, nose, throat) specialist.''

Answer : C

(A) Decongestants may exaggerate the nasal stuffiness associated with pregnancy. Judicious use of decongestants and nasal sprays is advocated during pregnancy. (B) Cool air vaporizers and saline drops may help to relieve the nasal stuffiness. Positioning on either lateral side does not decrease nasal stuffiness or prevent epistaxis. (C) Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation, which contributes to epistaxis. The nurse may recommend cool air vaporizers and saline drops to help with the nasal stuffiness. (D) Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation discomforts associated with pregnancy.

Question 3

A client calls the prenatal clinic to schedule an appointment. She states she has missed three menstrual periods and thinks she might be pregnant. During her first visit to the prenatal clinic, it is confirmed that she is pregnant. The registered nurse (RN) learns that her last menstrual period began on June 10. According to Ngele's rule, the estimated date of confinement is:

AMarch 17

BJune 3

CAugust 30

DJanuary 10

Answer : A

(A) Using Ngele's rule, count back 3 calendar months from the first day of the last menstrual period. The answer is March 10. Then add 7 days and 1 year, which would be March 17 of the following year. (B, C, D) This date is incorrect.

Question 4

A male client is experiencing extreme distress. He begins to pace up and down the corridor. What nursing intervention is appropriate when communicating with the pacing client?

AAsk him to sit down. Speak slowly and use short, simple sentences.

BHelp him to recognize his anxiety.

CWalk with him as he paces.

DIncrease the level of his supervision.

Answer : C

(A) The nurse should not ask him to sit down. Pacing is the activity he has chosen to deal with his anxiety. The nurse dealing with this client should speak slowly and with short, simplesentences. (B) The client may already recognize the anxiety and is attempting to deal with it. (C) Walk with the client as he paces. This gives support while he uses anxiety-generated energy. (D) Increasing the level of supervision may be appropriate after he stops pacing. It would minimize self-injury and/or loss of control.

Question 5

The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be a reaction to which of the following medications if applied in large amounts?

ANeosporin sulfate

BMafenide acetate

CSilver sulfadiazine

DPovidone-iodine

Answer : B

(A) The side effects of neomycin sulfate include rash, urticaria, nephrotoxicity, and ototoxicity. (B) The side effects of mafenide acetate include bone marrow suppression, hemolytic anemia, eosinophilia, and metabolic acidosis. The hyperventilation is a compensatory response to the metabolic acidosis. (C) The side effects of silver sulfadiazine include rash, itching, leukopenia, and decreased renal function. (D) The primary side effect of povidone- iodine is decreased renal function.

Question 6

In the coronary care unit, a client has developed multifocal premature ventricular contractions. The nurse should anticipate the administration of:

AFurosemide

BNitroglycerin

CLidocaine

DDigoxin

Answer : C

(A) Furosemide is a loop diuretic. (B) Nitroglycerin is a vasodilator. (C) Lidocaine is the drug of choice to treat ectopic ventricular beats. (D) Digoxin slows down the electrical impulses and increases ventricular contractions, but it does not rapidly correct ventricular ectopy.

Question 7

A client had a right below-the-knee amputation 4 days ago. He is complaining of pain in his right lower leg. The nurse should:

ARemind the client that he no longer has that part of his leg and assure him he will be OK

BCall the physician to request a psychological consultation for the client

CTurn on the television to distract the client's attention from his amputated leg

DGive the client his order of Demerol 50 mg IM prn

Answer : D

(A) The nurse is ignoring the client's pain. Telling the client that he will be OK will not relieve his phantom pain. (B) The client does not need a psychological consultation. Phantom pain is a normal sensation experienced by clients with amputations. (C) Using the television as a distractor will not relieve the client's phantom pain. (D) Phantom pain is a normal, very real experience for an amputee and should be treated with pain medication.

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