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National Council Licensure Examination(NCLEX-RN)

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Question # 111

A 40-year-old client has lived for 8 years with an abusive spouse. She married her husband in her senior year of high school after becoming pregnant. Shortly after the baby was born, he began to physically abuse her. She has attempted to leave him several times, but she has always returned. She is unable to support herself financially, and her husband threatens to kill her if she leaves him. This time, her husband has beaten her so badly she cannot stop the bleeding from the gash above her eye. She admits her husband caused her injury. In assessing a person after experiencing spousal abuse, which need has the highest priority?

Options:

A.  

Assess the level of anxiety, coping responses, and support systems.

B.  

Assess the history of physical abuse.

C.  

Assess suicide potential.

D.  

Assess drug and alcohol use.

Discussion 0
Question # 112

A 50-year-old male client is to receive chemotherapy. The physician’s orders include antiemetics. When planning his care, the nurse should take into consideration that antiemetics are best administered in the following way:

Options:

A.  

Give antiemetics when nausea is experienced and continue on a regular schedule for 12–24 hours.

B.  

Give antiemetics prior to the client receiving chemotherapy and continue on a regular basis for at least24–48 hours after chemotherapy.

C.  

Give antiemetics one at a time because combinations of antiemetics cause overwhelming side effects.

D.  

Give antiemetics intermittently during the entire course of chemotherapy.

Discussion 0
Question # 113

The physician has ordered that ampicillin 250 mg IV be given over 30 minutes. The medication is diluted as recommended in 10 mL in the volume control chamber of a set that has a tubing of 12 mL. Which nursing measure is most accurate considering these facts?

Options:

A.  

Infuse volume at 44 mL/hr.

B.  

Infuse volume at 22 mL/hr.

C.  

Infuse volume at 10 mL/hr.

D.  

Infuse volume at 30 mL/hr.

Discussion 0
Question # 114

A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period was February 16, with 3 days of spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to be:

Options:

A.  

November 23rd

B.  

December 26th

C.  

September 14th

D.  

December 9th

Discussion 0
Question # 115

The nurse instructs a client on the difference between true labor and false labor. The nurse explains, “In true labor:

Options:

A.  

Uterine contractions will weaken with walking.”

B.  

Uterine contractions will strengthen with walking.”

C.  

The cervix does not dilate.”

D.  

The fetus does not descend.”

Discussion 0
Question # 116

A 1000-mL dose of D5W 1⁄2 normal saline is to be infused in 8 hours. The drop factor for the tubing is 60 gtt/min. How many drops per minute should the nurse administer?

Options:

A.  

75 gtt/min

B.  

100 gtt/min

C.  

125 gtt/min

D.  

150 gtt/min

Discussion 0
Question # 117

A laboring client presents with a prolapsed cord. The nurse should immediately place the client in what position?

Options:

A.  

Reverse Trendelenburg

B.  

Fowler’s

C.  

Trendelenburg

D.  

Sims’

Discussion 0
Question # 118

A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of:

Options:

A.  

Impaired communication

B.  

Sensory-perceptual alterations

C.  

Altered thought processes

D.  

Impaired social interaction

Discussion 0
Question # 119

A client’s congestive heart failure has been treated, and he will soon be discharged. Discharge teaching should include instruction to call the physician if he notices a 2-lb weight gain in a 24-hour period. Increased weight gain may indicate:

Options:

A.  

A diet too high in calories and saturated fat

B.  

Decreasing cardiac output

C.  

Decreasing renal function

D.  

Development of diabetes insipidus

Discussion 0
Question # 120

A 52-year-old client’s abdominal aortic aneurysm ruptured. She received rapid massive blood transfusions for bleeding. One potential complication of blood administration

for which she is especially at risk is:

Options:

A.  

Air embolus

B.  

Circulatory overload

C.  

Hypocalcemia

D.  

Hypokalemia

Discussion 0
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