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NCLEX-RN Exam Questions - Part 102
1. A female client was recently diagnosed with gastric cancer. She entered the hospital and had a total gastrectomy with esophagojejunostomy. Her postoperative recovery was uneventful. On conducting discharge teaching, the nurse discusses changes in bodily function and lifestyle changes with the client. In order to prevent pernicious anemia, the nurse stresses that the client must:
A) Receive monthly blood transfusions
B) Increase the amount of iron in her diet
C) Eat small quantities several times daily until she is able to tolerate food in moderate portions
D) Understand the need for Vitamin B12 replacement therapy
2. A female client was employed as a client care technician in a hemodialysis unit. She recently began to experience extreme fatigue, being able to sleep for 1620 hours at a time. She also noted that her urine was tea colored, which she rationalized was a result of the vitamins she began taking to alleviate fatigue. She was diagnosed with hepatitis B. After a brief hospital stay, she is discharged to her parents home. Her mother asks the nurse if any precautions are necessary to prevent transmission to the clients family. The nurse explains necessary precautions, which include:
A) Isolation of the client from the remainder of the family
B) Separate bathroom facilities if possible; if not, then cleansing daily of the facilities with a chloride solution
C) No necessary precautions because she is beyond the contagious phase
D) Laundering clothes separately in cold water with a chloride solution
3. A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is NPO with IV fluids infusing at 100 mL/hour. He is experiencing excruciating abdominal pain. Based on an analysis of these data, which nursing diagnosis would receive the highest priority?
A) Pain related to stimulation of nerve endings associated with obstruction of the pancreatic tract
B) Fluid volume deficit related to vomiting and nasogastric tube drainage
C) Knowledge deficit related to treatment regimen
D) Altered nutrition: less than body requirements, related to inadequate intake associated with current anorexia, nausea, vomiting, and digestive enzyme loss
4. A male client has burns over 90% of his body after an automobile accident resulting in a fire. He was trapped inside the auto and pulled out by a bystander. After several months in the hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization the nursing staff has been aware of psychological changes the client faces after burns over a large portion of his body resulting in disfigurement. The nursing staff can best foster the clients self- esteem by:
A) Adhering to a strict schedule of diet, exercise, and wound care
B) Allowing him to go to physical therapy for whirlpool treatment when other clients were not in physical therapy
C) Following a standardized plan of care for burn clients formulated by a world-renowned burn center
D) Allowing him to plan, assist in, and perform his own care whenever possible
5. A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately:
A) 10 weeks
B) 16 weeks
C) 20 weeks
D) 30 weeks
A) Receive monthly blood transfusions
B) Increase the amount of iron in her diet
C) Eat small quantities several times daily until she is able to tolerate food in moderate portions
D) Understand the need for Vitamin B12 replacement therapy
2. A female client was employed as a client care technician in a hemodialysis unit. She recently began to experience extreme fatigue, being able to sleep for 1620 hours at a time. She also noted that her urine was tea colored, which she rationalized was a result of the vitamins she began taking to alleviate fatigue. She was diagnosed with hepatitis B. After a brief hospital stay, she is discharged to her parents home. Her mother asks the nurse if any precautions are necessary to prevent transmission to the clients family. The nurse explains necessary precautions, which include:
A) Isolation of the client from the remainder of the family
B) Separate bathroom facilities if possible; if not, then cleansing daily of the facilities with a chloride solution
C) No necessary precautions because she is beyond the contagious phase
D) Laundering clothes separately in cold water with a chloride solution
3. A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is NPO with IV fluids infusing at 100 mL/hour. He is experiencing excruciating abdominal pain. Based on an analysis of these data, which nursing diagnosis would receive the highest priority?
A) Pain related to stimulation of nerve endings associated with obstruction of the pancreatic tract
B) Fluid volume deficit related to vomiting and nasogastric tube drainage
C) Knowledge deficit related to treatment regimen
D) Altered nutrition: less than body requirements, related to inadequate intake associated with current anorexia, nausea, vomiting, and digestive enzyme loss
4. A male client has burns over 90% of his body after an automobile accident resulting in a fire. He was trapped inside the auto and pulled out by a bystander. After several months in the hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization the nursing staff has been aware of psychological changes the client faces after burns over a large portion of his body resulting in disfigurement. The nursing staff can best foster the clients self- esteem by:
A) Adhering to a strict schedule of diet, exercise, and wound care
B) Allowing him to go to physical therapy for whirlpool treatment when other clients were not in physical therapy
C) Following a standardized plan of care for burn clients formulated by a world-renowned burn center
D) Allowing him to plan, assist in, and perform his own care whenever possible
5. A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately:
A) 10 weeks
B) 16 weeks
C) 20 weeks
D) 30 weeks
1. Right Answer: D
Explanation: (A) Monthly blood transfusions are not indicated postgastrectomy. (B) Increasing iron in the clients diet may cause irritation and will not alleviate pernicious anemia. (C) It may be necessary that the client eat small meals several times per day, but this measure has no relevance to prevention of pernicious anemia. (D)Pernicious anemia is caused by lack of Vitamin B12, and replacement therapy will be necessary because the clients stomach has been removed.
2. Right Answer: B
Explanation: (A) Isolation is not necessary, even in the acute phase. (B) Separate bathroom facilities are recommended. If unavailable, daily cleansing with a chloride solution is recommended. (C) Precautions continue to be necessary while the client is in the active phase of hepatitis. (D) Clothes are to be laundered separately in hot water with a chloride solution.
3. Right Answer: A
Explanation: (A) Relief of pain is the primary goal of nursing intervention because this client is experiencing acute pain. (B) Fluid volume deficit is being treated with IV fluid replacement. (C) Knowledge deficit will not be addressed at this time because a client in acute pain is not ready to learn. (D) Alteration in nutrition is the third priority after relief of pain and fluid volume deficit.
4. Right Answer: D
Explanation: (A) A regimented schedule, allowing no flexibility, will not foster the clients self-esteem. (B) Isolating the client may only enhance his feelings of social isolation due to his disfigurement. (C) Standardized care plans must be personalized and adapted to each clients situation. (D) Allowing the client control over his care will foster his self-esteem and prepare him for life outside of the hospital.
5. Right Answer: C
Explanation: (A) At 10 weeks, the fundus is located slightly above the symphysis pubis. (B) At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus.(C) At 20 weeks, the fundus is located approximately at the umbilicus. (D) At 30 weeks, the fundal height is about 30 cm, or 10 cm above the umbilicus.
Explanation: (A) Monthly blood transfusions are not indicated postgastrectomy. (B) Increasing iron in the clients diet may cause irritation and will not alleviate pernicious anemia. (C) It may be necessary that the client eat small meals several times per day, but this measure has no relevance to prevention of pernicious anemia. (D)Pernicious anemia is caused by lack of Vitamin B12, and replacement therapy will be necessary because the clients stomach has been removed.
2. Right Answer: B
Explanation: (A) Isolation is not necessary, even in the acute phase. (B) Separate bathroom facilities are recommended. If unavailable, daily cleansing with a chloride solution is recommended. (C) Precautions continue to be necessary while the client is in the active phase of hepatitis. (D) Clothes are to be laundered separately in hot water with a chloride solution.
3. Right Answer: A
Explanation: (A) Relief of pain is the primary goal of nursing intervention because this client is experiencing acute pain. (B) Fluid volume deficit is being treated with IV fluid replacement. (C) Knowledge deficit will not be addressed at this time because a client in acute pain is not ready to learn. (D) Alteration in nutrition is the third priority after relief of pain and fluid volume deficit.
4. Right Answer: D
Explanation: (A) A regimented schedule, allowing no flexibility, will not foster the clients self-esteem. (B) Isolating the client may only enhance his feelings of social isolation due to his disfigurement. (C) Standardized care plans must be personalized and adapted to each clients situation. (D) Allowing the client control over his care will foster his self-esteem and prepare him for life outside of the hospital.
5. Right Answer: C
Explanation: (A) At 10 weeks, the fundus is located slightly above the symphysis pubis. (B) At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus.(C) At 20 weeks, the fundus is located approximately at the umbilicus. (D) At 30 weeks, the fundal height is about 30 cm, or 10 cm above the umbilicus.
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