Blog about quiz / question and answer NCLEX (National Council Licensure Examination) For Nursing Student, Example Question NCLEX RN and NCLEX PN. Exam for Nurse
1. A nurse reviews the physician’s orders for a client with Guillain-Barré syndrome Which order if noted in the client’s record should the nurse question?
A. Vital signs every 2 to 4 hours
B. Clear liquid diet
C. Passive range-of-motion (ROM) exercises three times daily
D. Bilateral calf measurements three times daily
Answer: B. Clear liquid diet
Rationale: Clients with Guillain-Barré syndrome have dysphagia. Clients with dysphagia are more likely to aspirate clear liquids than thick or semisolid foods. Clients with Guillain-Barré syndrome are at risk for hypotension and hypertension, bradycardia, and respiratory depression, and require frequent monitoring of vital signs. Passive ROM exercises can help prevent contractures, and checking calf measurements can help detect deep vein thrombosis, for which they are at risk.
Test-Taking Strategy: Use the process of elimination and note the key words should the nurse question. Even if you were unaware of the problems with Guillain-Barré syndrome and dysphagia, options 1, 3, and 4 are generally part of routine nursing care. Review the manifestations associated with this disorder 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/Neurological
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 394-395.
2. A nurse is assisting in caring for a client with multiple myeloma and has been monitoring the administration of an intravenous solution infusing at 100 mL per hour. Which finding would indicate a positive response to this treatment?
A. Weight increase of 1 kg
B. White blood cell count of 6000 per mm
C. Respirations of 18 breaths per minute
D. Creatinine of 1.0 mg/dl
Answer: D. Creatinine of 1.0 mg/dl
Rationale: In multiple myeloma, hydration is essential to prevent renal damage resulting from the Bence Jones protein precipitating in the renal tubules and from excessive calcium and uric acid in the blood. Creatinine is the most accurate measure of renal status. Options 1, 2, and 3 will not evaluate a response to this treatment.
Test-Taking Strategy: Use the process of elimination and recall that renal failure is a concern in multiple myeloma. Eliminate options 2 and 3 because hydration does not relate to white blood cell count or respirations. Weight gain is not a positive sign when concerned with renal status; therefore eliminate option A. Review care to the client with multiple myeloma if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Adult Health/Oncology
References: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 428.
Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 428.
3. A comatose client is admitted to the hospital. Laboratory values are as follows: Blood glucose 368 mg/dl, arterial pH 7.2, arterial bicarbonate 14 mEq/L, and positive test result for serum ketones. The client’s admitting diagnosis is diabetic ketoacidosis (DKA). During the initial data collection, the nurse would expect to note which of the following?
A. Hypertension
B. Moist mucous membranes
C. Fruity breath odor
D. Slow regular breathing
Answer: C. Fruity breath odor
Rationale: Diabetic ketoacidosis is usually preceded by a day or more of polyuria and polydipsia associated with marked fatigue, nausea, and vomiting. A fruity breath odor, dry cracked mucous membranes, hypotension, and rapid, deep breathing would be noted.
Test-Taking Strategy: Use the process of elimination. Recalling that rapid, deep breathing; fruity breath; and dehydration are associated with DKA will assist in answering the question. Review the manifestations associated with DKA if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Endocrine
Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 488.
4. Which statement by the spouse of a client with end-stage liver failure indicates the need for additional interventions by the multidisciplinary team for the management of pain?
A. “If the pain increases, I must let the physician know immediately.”
B. “I should have my husband try the breathing exercises to help control pain.”
C. “This narcotic will cause very deep sleep, which is what my husband needs.”
D. “If constipation is a problem, increased fluids will help.”
Answer: C. “This narcotic will cause very deep sleep, which is what my husband needs.”
Rationale: Changes in level of consciousness are a potential indicator of narcotic overdose and indicative of numerous fluid, electrolyte, and oxygenation deficits. It is important for the spouse to understand the differences in sleep related to the relief of pain and changes in neurological status related to deficits. Option 3 is therefore the correct option. Options 1, 2, and 4 all are indicative of an understanding of appropriate steps to be taken in the management of pain.
Test-Taking Strategy: Use the process of elimination. Note the key words need for additional interventions. These words indicate a false-response question and that you need to select the incorrect statement. Option 1 is an accurate statement. Even though the client is end-stage, increases in pain level must be noted and interventions taken to relieve that pain. Option 2 is also correct because nonpharmacological interventions are very useful in the relief of pain. Option 4 is correct and relates to a general principle. Review care to the client with end-stage liver disease if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Fundamental Skills
Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby,
pp. 220-232, 1152-1153.
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