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

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Question 1

Diabetes during pregnancy requires tight metabolic control of glucose levels to prevent
perinatal mortality. When evaluating the pregnant client, the nurse knows the
recommended serum glucose range during pregnancy is:

  • A. 70 mg/dL and 120 mg/dL
  • B. 100 mg/dL and 200 mg/dL
  • C. 40 mg/dL and 130 mg/dL
  • D. 90 mg/dL and 200 mg/dL


Answer : A

Explanation: (A) The recommended range is 70120 mg/dL to reduce the risk of perinatal mortality. (B, C, D) These levels are not recommended. The higher the blood glucose, the worse the prognosis for the fetus. Hypoglycemia can also have detrimental effects on the fetus.

Question 2

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?

  • A. Neosporin sulfate
  • B. Mafenide acetate
  • C. Silver sulfadiazine
  • D. Povidone-iodine


Answer : B

Explanation: (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 3

The nurse should know that according to current thinking, the most important prognostic
factor for a client with breast cancer is:

  • A. Tumor size
  • B. Axillary node status
  • C. Client’s previous history of disease
  • D. Client’s level of estrogen-progesterone receptor assays


Answer : B

Explanation: (A) Although tumor size is a factor in classification of cancer growth, it is not an indicator of lymph node spread. (B) Axillary node status is the most important indicator for predicting how far the cancer has spread. If the lymph nodes are positive for cancer cells, the prognosis is poorer. (C) The clients previous history of cancer puts her at an increased risk for breast cancer recurrence, especially if the cancer occurred in the other breast. It does not predict prognosis, however. (D) The estrogen-progesterone assay test is used to identify present tumors being fedfrom an estrogen site within the body. Some breast cancers grow rapidly as long as there is an estrogen supply such as from the ovaries. The estrogen-progesterone assay test does not indicate the prognosis.

Question 4

A client is 6 weeks pregnant. During her first prenatal visit, she asks, “How much alcohol is
safe to drink during pregnancy?” The nurse’s response is:

  • A. Up to 1 oz daily
  • B. Up to 2 oz daily
  • C. Up to 4 oz weekly
  • D. No alcohol


Answer : D

Explanation: (A, B, C) No amount of alcohol has been determined safe for pregnant women. Alcohol should be avoided owing to the risk of fetal alcohol syndrome. (D) The recommended safe dosage of alcohol consumption during pregnancy is none.

Question 5

Pregnant women with diabetes often have problems related to the effectiveness of insulin
in controlling their glucose levels during their second half of pregnancy. The nurse teaches
the client that this is due to:

  • A. Decreased glomerular filtration and increased tubular absorption
  • B. Decreased estrogen levels
  • C. Decreased progesterone levels
  • D. Increased human placental lactogen levels


Answer : D

Explanation: (A) There is a rise in glomerular filtration rate in the kidneys in conjunction with decreased tubular glucose reabsorption, resulting in glycosuria. (B) Insulin is inhibited by increased levels of estrogen. (C) Insulin is inhibited by increased levels of progesterone. (D) Human placental lactogen levels increase later in pregnancy. This hormonal antagonist reduces insulins effectiveness, stimulates lipolysis, and increases the circulation of free fatty acids.

Question 6

A 38-year-old pregnant woman visits her nurse practitioner for her regular prenatal
checkup. She is 30 weeks gestation. The nurse should be alert to which condition related
to her age?

  • A. Iron-deficiency anemia
  • B. Sexually transmitted disease (STD)
  • C. Intrauterine growth retardation
  • D. Pregnancy-induced hypertension (PIH)


Answer : D

Explanation: (A) Iron-deficiency anemia can occur throughout pregnancy and is not age related. (B) STDs can occur prior to or during pregnancy and are not age related. (C) Intrauterine growth retardation is an abnormal process where fetal development and maturation are delayed. It is not age related. (D) Physical risks for the pregnant client older than 35 include increased risk for PIH, cesarean delivery, fetal and neonatal mortality, and trisomy.

Question 7

To ensure proper client education, the nurse should teach the client taking SL nitroglycerin
to expect which of the following responses with administration?

  • A. Stinging, burning when placed under the tongue
  • B. Temporary blurring of vision
  • C. Generalized urticaria with prolonged use
  • D. Urinary frequency


Answer : A

Explanation: (A) Stinging or burning when nitroglycerin is placed under the tongue is to be expected. This effect indicates that the medication is potent and effective for use. Failure to have this response means that the client needs to get a new bottle of nitroglycerin. (B, C, D) The other responses are not expected in this situation and are not even side effects.

Question 8

After 3 weeks of treatment, a severely depressed client suddenly begins to feel better and
starts interacting appropriately with other clients and staff. The nurse knows that this client
has an increased risk for:

  • A. Suicide
  • B. Exacerbation of depressive symptoms
  • C. Violence toward others
  • D. Psychotic behavior


Answer : A

Explanation: (A) When the severely depressed client suddenly begins to feel better, it often indicates that the client has made the decision to kill himself or herself and has developed a plan to do so. (B) Improvement in behavior is not indicative of an exacerbation of depressive symptoms. (C) Thedepressed client has a tendency for self-violence, not violence toward others. (D) Depressive behavior is not always accompanied by psychotic behavior.

Question 9

A client with a C-34 fracture has just arrived in the emergency room. The primary nursing
intervention is:

  • A. Stabilization of the cervical spine
  • B. Airway assessment and stabilization
  • C. Confirmation of spinal cord injury
  • D. Normalization of intravascular volume


Answer : B

Explanation: (A) If cervical spine injury is suspected, the airway should be maintained using the jaw thrust method that also protects the cervical spine. (B) Primary intervention is protection of the airway and adequate ventilation. (C, D) All other interventions are secondary to adequate ventilation.

Question 10

Proper positioning for the child who is in Bryant’s traction is:

  • A. Both hips flexed at a 90-degree angle with the knees extended and the buttocks elevated off the bed
  • B. Both legs extended, and the hips are not flexed
  • C. The affected leg extended with slight hip flexion
  • D. Both hips and knees maintained at a 90-degree flexion angle, and the back flat on the bed


Answer : A

Explanation: (A) The childs weight supplies the countertraction for Bryants traction; the buttocks are slightly elevated off the bed, and the hips are flexed at a 90-degree angle. Both legs are suspended by skin traction. (B) The child in Bucks extension traction maintains the legs extended and parallel to the bed. (C) The child in Russell traction maintains hip flexion of the affected leg at the prescribed angle with the leg extended. (D) The child in 9090 traction maintains both hips and knees at a 90-degree flexion angle and the back is flat on the bed.

Question 11

When assessing a child with diabetes insipidus, the nurse should be aware of the cardinal
signs of:

  • A. Anemia and vomiting
  • B. Polyuria and polydipsia
  • C. Irritability relieved by feeding formula
  • D. Hypothermia and azotemia


Answer : B

Explanation: (A) Anemia and vomiting are not cardinal signs of diabetes insipidus. (B) Polyuria and polydipsia are the cardinal signs of diabetes insipidus. (C) Irritability relieved by feeding water, not formula, is a common sign, but not the cardinal sign, of diabetes insipidus. (D) Hypothermia and azotemia are signs, but not cardinal signs, of diabetes insipidus.

Question 12

The following medications were noted on review of the clients home medication profile.
Which of the medications would most likely potentiate or elevate serum digoxin levels?

  • A. KCl
  • B. Thyroid agents
  • C. Quinidine
  • D. Theophylline


Answer : C

Explanation: (A) Hypokalemia can cause digoxin toxicity. Administration of KCl would prevent this. (B) Thyroid agents decrease digoxin levels. (C) Quinidine increases digoxin levels dramatically. (D) Theophylline is not noted to have an effect on digoxin levels.

Question 13

A 25-year-old client believes she may be pregnant with her first child. She schedules an
obstetric examination with the nurse practitioner to determine the status of her possible
pregnancy. Her last menstrual period began May 20, and her estimated date of
confinement using Ngeles rule is:

  • A. March 27
  • B. February 1
  • C. February 27
  • D. January 3


Answer : C

Explanation: (A)March 27 is a miscalculation. (B) February 1 is a miscalculation. (C) February 27 is the correct answer. To calculate the estimated date of confinement using Nageles rule, subtract 3 months from the date that the last menstrual cycle began and then add 7 days to the result. (D) January 3 is a miscalculation.

Question 14

The predominant purpose of the first Apgar scoring of a newborn is to:

  • A. Determine gross abnormal motor function
  • B. Obtain a baseline for comparison with the infant’s future adaptation to the environment
  • C. Evaluate the infant’s vital functions
  • D. Determine the extent of congenital malformations


Answer : C

Explanation: (A) Apgar scores are not related to the infants care, but to the infants physical condition. (B) Apgar scores assess the current physical condition of the infant and are not related to future environmental adaptation. (C) The purpose of the Apgar system is to evaluate the physical condition of the newborn at birth and to determine if there is an immediate need for resuscitation. (D) Congenital malformations are not one of the areas assessed with Apgar scores.

Question 15

Nursing care for the substance abuse client experiencing alcohol withdrawal delirium
includes:

  • A. Maintaining seizure precautions
  • B. Restricting fluid intake
  • C. Increasing sensory stimuli
  • D. Applying ankle and wrist restraints


Answer : A

Explanation: (A) These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. (B) Fluid intake should be increased to prevent dehydration. (C) Environmental stimuli should be decreased to prevent precipitation of seizures. (D) Application of restraints may cause the client to increase his or her physical activity and may eventually lead to exhaustion.

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