............................................................................................................................

............................................................................................................................

NCLEX QUESTI ON TRAI NER

Nursing ........................................................................................................................................................................................................ 15

NCLEX QUESTION TRAINER EXPLANATIONS

TEST 1

• The nurse is caring for clients in the outpatient clinic. Which of the following messages should the

nurse return FIRST?

• A mother reports that the umbilical cord of her five-day-old infant is dry and hard to the touch.
• A mother reports that the “soft spot” on the head of her four-day-old infant feels slightly elevated

when the baby sleeps.

• A mother reports that the circumcision of her 3-day-old infant is covered with yellowish exudate.
• A father reports that he bumped the crib of his two-day-old infant and she violently extended her

extremities and returned to them their previous position.Strategy: Determine the significance of each assessment and how it relates to a newborn.(1) expected outcome; falls off within 1-2 weeks; no tub baths until the cord falls off (2) correct–fontanelle should feel soft and flat; fullness or bulging indicates increased intracranial pressure (3) normal healing, don't remove exudate; clean with warm water (4) motor reflex is normal; disappears after 3-4 months

• The parents of a child with hemophilia want to know the cause of the disease. Which of the following

would be the BEST response by the nurse?

• “The father transmits the gene to his son.”
• “Both the mother and the father carry a recessive trait.”
• “The mother transmits the gene to her son.”
• “There is a 50% chance that the mother will pass the trait to each of her daughters.”

Strategy: Think about each statement. Is it true?

(1) affected male inherits gene from his mother and can transmit it only to his daughters (2) it is not an autosomal recessive trait (3) correct–hemophilia is a sex-linked disorder (4) there is a 50% chance that the mother will pass the trait to each of the children

PRE PA RA T I ON F OR T H E NURSI NG LICENSURE EXA MI NATION ................................................16 ........................................................................................................................................................................................................

Nursing

• A six-month-old is brought to the clinic for a well-baby check-up. During the exam, the nurse should

expect to assess which of the following?

• A pincer grasp.
• Sitting with support.
• Tripling of the birth weight.
• Presence of the posterior fontanelle.

Strategy: Think about each answer.

(1) present at nine months of age (2) correct–six-month-old should sit with help (3) present at one year (4) fontanelle is closed by two to three months

• A 48-year-old man with an endotracheal tube needs suctioning. Which of the following statements is

an accurate description of how the nurse should perform the procedure?

• Insert the suction catheter four inches into the tube. Apply suction for 30 seconds, using a

twirling motion as the catheter is withdrawn.

• Hyperoxygenate the client and then insert the suction catheter into the tube. Suction while you

remove the catheter using a back and forth motion.

• Explain the procedure to the patient. Insert the catheter while gently applying suction, and

withdraw using a twisting motion.

• Insert the suction catheter until resistance is met, then withdraw it slightly. Apply suction

intermittently as the catheter is withdrawn.Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?(1) catheter is inserted until resistance met; never suction longer than 10-15 sec (2) use twirling motion when withdrawing catheter (3) suction is never applied when catheter is inserted (4) correct–insert suction catheter until resistance is met without applying suction, withdraw 0.4-0.8 in (1-2 cm), apply intermittent suction with twirling motion

• A 47-year-old woman comes to the outpatient psychiatric clinic for treatment of a fear of heights. The

nurse knows that phobias involve

• projection and displacement.
• sublimation and internalization.
• rationalization and intellectualization.
• reaction formation and symbolization.

Strategy: Think about each answer.

(1) correct–projection (attributing one's thoughts or impulses to another) and displacement (shifting of emotion concerning person or object to another neutral or less dangerous object or person) (2) sublimation (diversion of unacceptable drives into socially acceptable channels) and internalization (incorporation of someone else's opinion as one's own) (3) rationalization (attempt to make behavior appear to be result of logical thinking), intellectualization (excessive reasoning or logic used to avoid experiencing disturbing feelings) (4) reaction formation (development of conscious attitudes and behavior patterns into opposite of what one really wants to do), symbolization (something represents something else); symbolization is involved in phobias

............................................................................................................................

NCLEX QUESTI ON TRAI NER

Nursing ........................................................................................................................................................................................................ 17

• The prenatal client at eight-weeks gestation has a positive VDRL. In preparing the teaching plan,

which of the following would be MOST appropriate for the nurse to include?

• The importance of not taking any medications so as not to damage the fetus.
• Instructing the client on the importance of taking the penicillin for the prescribed time.
• Instructing the client to refrain from sexual activity.
• Maintaining the confidentiality of sexual partners or contacts.

Strategy: Think "Maslow."

(1) physical, true to some extent with regard to pregnant client not taking medication over-the- counter unless prescribed by a doctor, but not highest priority (2) correct–physical, vitally important to complete all the penicillin (3) physical, more important to be treated for disease (4) psychosocial, communicable diseases are reportable; partners or contacts need to be found and notified so they may be treated

• An elderly client who has been recently immobilized is ordered to begin passive range-of-motion

(ROM) exercises. What should the nurse understand about ROM before initiating this order?

• Passive range-of-motion exercises increase muscle strength.
• A full range of motion must be completed for the elderly client.
• Exercises should be completed to the point of discomfort.
• A sufficient range of motion assists the elderly to carry out activities of daily living (ADLs).

Strategy: Think about each answer.

(1) inaccurate statement (2) ROM may be limited (3) should not be done to point of discomfort (4) correct–full range of motion may not be needed or accomplished without discomfort for an elderly client; emphasis should be on ROMs that support ADLs

• A 65-year-old man is scheduled for a colon resection this morning. Last night he had polyethylene

glycolelectrolyte solution (GoLytely) and a soapsuds enema. This morning he passes a medium amount of soft, brown stool. The nurse should know that this

• indicates that the bowel preparation is incomplete.
• is evidence that the patient ate something after midnight.
• is an expected finding before this type of surgery.
• is the last stool that was left in the colon.

Strategy: Think about each answer.

(1) correct–colon should not have remaining soft stool (2) anything eaten after midnight would not appear as stool by the next morning (3) not expected; need to clean GI tract for surgery (4) assumption, not substantiated

PRE PA RA T I ON F OR T H E NURSI NG LICENSURE EXA MI NATION ................................................18 ........................................................................................................................................................................................................

Nursing

• The nurse cares for a newborn infant with fetal alcohol syndrome. The nurse would expect to see

which of the following physical characteristics?

• An infant that is large for gestational age (LGA) with craniofacial abnormalities and

hydrocephalus.

• An infant with a small head circumference, low birth weight, and undeveloped cheekbones.
• An infant with a small head circumference, low birth weight, and excessive rooting and sucking

behaviors.

• An infant with a normal head circumference, low birth weight, and respiratory distress syndrome.

Strategy: All answers are assessment. Determine how each assessment relates to fetal alcohol syndrome.(1) usually small for gestational age (2) correct–seen with fetal alcohol syndrome (3) may have feeding difficulties and poor sucking ability (4) head circumference usually small, respiratory distress related to preterm birth, neurologic damage, small trachea, floppy epiglottis

• The physician orders hydromorphone hydrochloride (Dilaudid) 15 mg IM for a 56-year-old woman.

Side effects of this medication that the nurse should observe the patient for include

• photosensitivity and constipation.
• hypotension and respiratory depression.
• tardive dyskinesia and diplopia.
• dry mouth and tinnitus.

Strategy: Recall the classification of the drug.

(1) these side effects are not seen with this medication (2) correct–narcotic analgesic used for moderate to severe pain, monitor vital signs frequently (3) these side effects are not seen with this medication (4) these side effects are not seen with this medication

• The outpatient clinic nurse is caring for a 66-year-old woman with insulin-dependent diabetes

mellitus (IDDM). Because the client is unwilling to perform blood glucose monitoring, she tests her urine for sugar and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because

• the renal threshold for glucose is elevated in the elderly.
• blood glucose monitoring is easier and less costly for clients to perform.
• urine testing for glucose provides false-positive readings.
• determination of the color on a reagent strip varies from person to person.

Strategy: Think about each answer.

(1) correct–the level at which glucose starts to appear in the urine increases, leading to false- negative readings, results in elevated glucose levels (2) more expensive procedure (3) provides false-negative readings, may be negative from 0-180 mg/dL (4) results are expressed as a percentage according to color change