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(Answers Follow All Questions) : Nclex Questions Summer 2010 Set 2
(Answers Follow All Questions) : Nclex Questions Summer 2010 Set 2
Fundamentals of Nursing
1. The nurse assesses an older client in an assisted living facility who is crying
uncontrollably and who tells the nurse, I am going to be evicted because I ran out
of money to live here. Which of the following is the priority response by the
nurse?
Maternity
2. The nurse informs a graduate nurse on a postpartum unit that the human
chorionic gonadotropin (HCG) would no longer be detected in the clients blood
at:
Pediatrics
4. Which of the following should the nurse assess to provide the most accurate
information regarding a client suspected of having a C4 injury?
A. Night sweats
B. Cool extremities
C. Petechiae
D. Fever
E. Nausea
F. Restlessness
6. The nurse should instruct a client that which of the following is the most
effective prevention against bladder cancer?
7. A client is brought to the emergency room with a third-degree heart block after
experiencing an acute anterior myocardial infarction. Which of the following
interventions is the priority on an emergency basis?
A. Temporary pacemaker
B. Administer lidocaine
C. Cardioversion
D. Administer atropine
9. The nurse is caring for a client with myxedema. Which of the following would
indicate to the nurse that the clients condition is deteriorating?
11. During the initial assessment of a patient, the nurse observes the presence of
bright red drainage on the eye dressing. Which of the following should be the
nurses first action?
12. A mother brings her adolescent son into a clinic and expresses concerns that
the son has been experiencing blurred vision, dizziness, a sense of well-being, and
slurred speech. Which of the following questions is priority for the nurse to ask?
1. D: The priority response for the nurse to make to a client who has exhausted all
personal financial resources in an assisted living facility is that there are other options
available. Those other options may include family support or Medicaid. The nurse is not
in a position to discuss or advise the client about financial matters. A financial adviser
would be the best person to advise the client.
2. A: HCG is produced by the placenta and is nonexistent by the first week postpartum.
4. A: Asking a client to shrug the shoulders while applying resistance will provide the
most accurate information in a client suspected of a C4 injury. Asking a client to
straighten the flexed arms while applying resistance would assess for a C7 injury. Asking
the client to grasp an object and make a fist would assess for a C8 injury. Asking the
client to lift the arms while applying resistance would assess for a C5 injury.
6. C: Persons at greatest risk for bladder cancer are Caucasian men over 50 years of age
who have had occupational exposures to dyes, rubber, and leather industries, and who
smoke. Since age, race, and occupation are not alterable, the best alternative is to stop
smoking. Clients should be provided with smoking-cessation information and support to
reduce their risk of several cancers and other health problems.
9. C: The most life-threatening complication for the client with myxedema is myxedema
coma. This client already has decreased metabolism and as the condition worsens,
cardiac, respiratory, and neurological systems slow down even more. The client then goes
into a coma and may die from circulatory and respiratory collapse. If a client with
myxedema becomes unable to be aroused, the client may be progressing into a coma. In
myxedema the client experiences a decrease in pulse rate and respirations, has cold skin,
and often has complaints of being chilled due to the decreased metabolic rate. Clients
with increased metabolism complain of palpitations.
11. A: Bright red drainage on the dressing may indicate hemorrhage and must be reported
to the physician immediately. Although monitoring vital signs and the clients pain and
recording the amount and color of the drainage are all important interventions, reporting
the finding is the priority so emergency measures can be instituted.
12. D: The priority question to ask the mother of a child suspected of inhaling substances
is if she has noticed the child inhaling paint or cleaning or aerosol products.
Reference
Gauwitz, D. (2007). Complete Review for the NCLEX-RN Examination. Clifton, NY: Thomson Delmar
Learning.