NCLEX Review Questions (Answers and Rationale)

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  1. A = the client needs specific information about the effects of the drug, specifically its effect on the blood. The statement about weekly blood tests to determine safe dosage and monitoring for effects on the blood gives the client specific information to ensure follow up with the required protocol for Clorazil therapy. Lack of accurate knowledge can lead to noncompliance with necessary follow-up procedures and noncompliance with medication.

  2. C = the older adults’ taste buds retain their sensitivity to carbohydrates. In addition, carbohydrates. Tend to be food items that are easy to chew. Older adults lose their sensitivity to sour and salty foods. Older adults may find greasy foods harder to digest and therefore may avoid them; however, preference for greasy foods is not related to changes in taste associated with age.

  3. D = because the client eats excessively whenever she is upset. The best nursing diagnosis is effective coping. There are no data on the family to support Disabled Family Coping. The client’s bingering and purging behavior occurs in response to her difficulty with coping. If the client were only overeating and not purging then Imbalanced Nutrition: More than body requirements would be an appropriate diagnosis. The client does not report nervousness and tension that would lead to a nursing diagnosis of Generalized Anxiety.

  4. D = Many women who acquire gonorrhea are asymptomatic or experience mild symptoms that are easily ignored. They are not necessarily more reluctant than men to seek medical treatment, but they are more likely not to realize they have been affected with a disease. Gonorrhea is easily transmitted to all women and can result in serious consequences such as pelvic inflammatory disease and infertility.

  5. A = caffeinated beverages and alcohol should be avoided because they stimulate gastric acid production and irritate gastric mucosa. The client should avoid foods that cause discomfort; however, there is no need to follow a soft, bland diet. Eating six small meals daily is no longer a common treatment for peptic ulcer disease. Milk in large quantities is not recommended because it actually stimulates further production of gastric acids.

  6. C = A low sodium diet is frequently an effective mechanism for reducing the frequency and severity of the disease episodes. About three-quarters of clients with Meniere’s disease respond to treatment with a low salt diet.

  7. D =Tympanoplasty involves surgical reconstruction as the tympanic membrane and is done to re-establish middle ear function, close perforation, prevent recurrent infections.

  8. A = primary cancer prevention targets healthy individuals and includes steps to avoid factors that might lead to the development of diseases.

  9. D = Fatigue is a common complaint of individuals receiving medication therapy.

  10. B = It is appropriate and ethical to respect the client’s truly autonomous choice not to know particular information. The client’s best interests should be determined by the client after he or she receives all the necessary information and in conjunction with other people of the client’s choice, including family, physicians and other healthcare personnel

  11. D = When a wound eviscerates, the nurse should cover the open area with sterile dressing moistened with sterile normal saline and then cover it with a dry dressing. The surgeon should then be notified to take the client back to the operating room to close the incision under general anesthesia.

  12. B = The client’s body temperature should be assessed every 4 hour during the first 24 hour because the client is still at risk for hypothermia or malignant hyperthermia. The client does not be checked every 2 hour unless indicated by an abnormal finding.

  13. D = Identification of causes of medication errors requires inservice education to inform the staff of strategies to decrease these errors. Errors are frequently the result of systemic problems that can be identified and rectified through problem-solving technique and changes in procedures.

  14. A = Benztropine (Congentine) frequently causes the side effects of blurred vision.

  15. A = A follow-up care is essential to present relapse. The recovery has just begun when the treatment program ends. The first few months after program completion can be difficult and dangerous for the chemically dependent client. The nurse is responsible for discharge plans that include arrangements for counseling, self help group meetings and other forms of after care.

  16. C = IUD is suitable for client who desire long-term contraceptive use and are in a monogamous relationships. Because of the increased risk of spread of infection with an IUD if an STD occurs, the device is not appropriate for women with multiple partners or history of STDs.

  17. D = the symptoms of BPH are related to obstruction as a result of an enlarged prostate. Difficulty in starting the urinary stream is a common symptom, along with dribbling, hesitancy and urinary retention.

  18. D = Methocarbamol (Robaxin) is a muscle relaxant and acts primarily to relieve muscle spasms.

  19. B = Migraine headaches are believed to be caused by a vascular disturbance involving branches of the carotid artery where vasoconstriction of blood vessels apparently occurs first.

  20. A = There are many mechanisms of action for chemotherapeutic agents, but most affect the rapidly dividing cells-both cancerous and noncancerous. Cancer cells are characterized by rapid cell division. Chemotherapy slows cell division.

  21. C = Advocacy role of the nurse implies that the nurse will ensure that the client’s wishes are being respected and that she is making informed decisions.

  22. B = the nurse should notify the anesthesiologist because a serum potassium level of 5.8 mEq/L places the client at risk for dysrhythmias when under general anesthesia.

  23. B = If not contraindicated for moral, cultural or religious reasons, a condom with spermicide is often recommended for contraception after delivery until the client’s 6-weeks post partum examination. This method has no effect on the neonate who is breastfeeding.

  24. A = typically, a 4-month-old infant should be able to sit with support from a person holding the infant lightly in the area of the hips or lower chest.

  25. A = It is appropriate for an unlicensed assistant to mark the time of measurement and fluid level in the collection container.

  26. D = Nausea and gastrointestinal upset is a common but usually temporary side effects of Paroxetine (Paxil). Therefore, the nurse would instruct the client to take the medication with food to minimize nausea and stomach upset.

  27. B = the nurse serves as the accomplice because she participate or cooperate through another act essential to the consummation of the crime.

  28. D = A 4-year-old is old enough to be able to cooperate and stop the behavior. Therefore, the first step is to obtain the child’s cooperation.

  29. C = In the traditional Mexican household, the man is the head of the family and makes the major decisions. Efforts should be made to reach the father as soon as possible to acquire his permission.

  30. B = Respondeat superior is Latin for “the master is responsible for the acts of his servants.” The nurse, as an employee of the hospital, was acting according to the established policy of the hospital. Because the nurse followed hospital policy, it is unlikely that this incident involved malpractice, negligence or tort law.

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