Let's Learn NCLEX Questions with Answer 111th Edition
Let's Learn NCLEX Questions with Answer 111th Edition
1. A nurse is reinforcing dietary instructions to a client with congestive heart failure (CHF). The nurse determines that the client understands the instructions if the client states that which of the following food items should be avoided?
A. Leafy green vegetables
B. Catsup
C. Cooked cereal
D. Sherbet
Answer: B. Catsup
Rationale: Catsup is high in sodium. Leafy green vegetables, cooked cereal, and sherbet all are low in sodium. Clients with CHF should monitor sodium intake.
Test-Taking Strategy: Recall that the client with CHF should monitor sodium intake. Use the process of elimination, noting that options 1, 3, and 4 are similar in that they are low-sodium foods. Review the foods high in sodium if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Evaluation
Content Area: Adult Health/Cardiovascular
Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 319.
2. A nurse is assisting in developing a plan of care for a client receiving warfarin sodium (Coumadin). The nurse selects which nursing diagnosis listed in the plan as the priority in caring for this client?
A. Risk for excess fluid volume
B. Risk for activity intolerance
C. Risk for injury
D. Risk for infection
Answer: C. Risk for injury
Rationale: Anticoagulant therapy predisposes the client to injury because of the inhibitory effects of the medication on the body’s normal blood-clotting mechanism. Bruising, bleeding, and hemorrhage may occur in the course of activities of daily living and with other activities. Options 1, 2, and 4 are not specifically related to the care of a client receiving anticoagulants.
Test-Taking Strategy: Recalling that anticoagulants present a risk for bleeding will assist in directing you to option C. Also note that options 1, 2, and 4 are not directly related to this medication. Review the effects of this medication if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Safe, Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Pharmacology
Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, pp. 905-906.
3. A client arrives at the emergency room and complains of severe abdominal pain. The initial diagnosis is an acute condition in the abdomen, and an x-ray and an abdominal ultrasonogram are prescribed to be obtained immediately. The nurse prepares the client for these diagnostic tests and reviews the physician’s orders. Which of the following orders would the nurse question if written on the physician’s order form?
A. Insertion of a nasogastric (NG) tube
B. Insertion of an intravenous (IV) line
C. Administration of an analgesic
D. Maintenance of NPO status
Answer: C. Administration of an analgesic
Rationale: Until a differential diagnosis is determined and a decision about the need for surgery is made, the nurse would question an order to give an analgesic because it could mask the client’s symptoms. The nurse can expect the client to be placed on NPO status and to have an IV line inserted. Insertion of an NG tube may be helpful to provide decompression of the stomach.
Test-Taking Strategy: Use the process of elimination and note that the wording of the question guides you to look for an option that is an incorrect action. Recalling that an abdominal complaint could result in NPO status and insertion of an NG tube, eliminate options 1 and 4 first. From the remaining options, select option 3 over option 2 because an IV line is a standard, accepted intervention to provide fluids to the client who is NPO. Review care to the client with a diagnosis of acute abdominal symptoms if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Safe, Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Gastrointestinal
References: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 122.
Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, p. 3.
4. Abdominal ultrasonography is prescribed for a woman who is pregnant. The nurse provides information to the client regarding the procedure and makes which statement to the woman?
A. “You will be positioned on your side with your head flat.”
B. “The procedure will take about 1 hour.”
C. “You need to be sure to urinate before the procedure.”
D. “You will be positioned on your back and turned slightly to one side with your head elevated.”
Answer: D. “You will be positioned on your back and turned slightly to one side with your head elevated.”
Rationale: The client is positioned on the back with the head and the knees supported by pillows. The client’s head will be elevated, and the client will be turned slightly to one side to prevent supine hypotension. The procedure takes 10 to 30 minutes. A full bladder makes it easier for sound waves to reach the pelvic area, so the client should be instructed to drink 1 to 2 quarts of clear fluid 1 hour before the test. The client should not void until the ultrasound is obtained. Options 1, 2, and 3 are incorrect.
Test-Taking Strategy: Use the process of elimination. Note that both options 1 and 4 address positioning of the client during the test. This indicates that one of these options may be correct. From the remaining options, visualize the procedure to direct you to option D. Review this procedure if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Antepartum
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 325.
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