NCLEX 10000 questions with correct answers
A client has a herniated disk in the region of the third and fourth lumbar
vertebrae. Which nursing assessment finding most supports this
diagnosis?
a. hypoactive bowel sounds
b. severe lower back pain
c. sensory deficits in one arm
d. weakness and atrophy of the arm muscles Correct Answer-b - the
most common finding in a client with a herniated lumbar disk is severe
lower back pain, which radiates to the buttocks, legs, and feet - usually
unilaterally. A herniated disk also may cause sensory and motor loss
(such as foot drop) in the area innervated by the compressed spinal nerve
root. During later stages, it may cause weakness and atrophy of leg
muscles. The condition doesn't affect bowel sounds or the arms.
when caring for a client after a closed renal biopsy, the nurse should:
a. maintain the client on strict bed rest in a supine position for 6 hours
b. insert an indwelling catheter to monitor urine output
c. apply a sandbag to the biopsy site to prevent bleeding
d. administer IV opioid medications to promote comfort Correct
Answer-a - after a renal biopsy, the client is maintained on strict bed rest
in a supine position for at least 6 hours to prevent bleeding. If no
bleeding occurs, the client typically resumes general activity after 24
hours. Urine output is monitored, but an indwelling catheter is not
typically inserted. A pressure dressing is applied over the site, but a
,sandbag is not necessary. Opioids to control pain would not be
anticipated; local discomfort at a biopsy site can be controlled with
analgesics.
a nurse is caring for a client who required chest tube insertion for a
pneumothorax. To assess for pneumothorax resolution, the nurse can
anticipate that the client will require:
a. monitoring of arterial oxygen saturation (SaO2)
b. arterial blood gas (ABG) studies
c. chest auscultation
d. chest x ray Correct Answer-d - chest x ray confirms diagnosis by
revealing air or fluid in the pleural space. SaO2 values may initially
decrease with a pneumothorax but typically return to normal within 24
hours. ABG studies may show hypoxemia, possibly with respiratory
acidosis and hypercapnia but these are not necessarily related to a
pneumothorax. Chest auscultation will determine overall lung status, but
it's difficult to determine if the best has re-expanded sufficiently.
To prevent development of peripheral neuropathies associated with
isoniazid administration, the nurse should teach the client to:
a. avoid excessive sun exposure
b. follow a low-cholesterol diet
c. obtain extra rest
d. supplement the diet with pyridoxine (vitamin B6) Correct Answer-d -
isoniazid competes for the available vitamin B6 in the body and leaves
,the client at risk for developing neuropathies related to vitamin
deficiency. Supplemental vitamin B6 is routinely prescribed to address
this issue. Avoiding sun exposure is a preventative measure to lower the
risk of skin cancer. Following a low-cholesterol diet lowers the
individual's risk of developing atherosclerotic plaque. Rest is important
in maintaining homeostasis but has no real impact on neuropathies.
A child, age 3, is brought to the emergency department in respiratory
distress caused by acute epiglottiditis. Which clinical manifestations
should the nurse expect to assess?
a. severe sore throat, drooling, and inspiratory strider
b. low grade fever, stridor, and a barking cough
c. pulmonary congestion, a productive cough, and a fever
d. sore throat, a fever, and general malaise Correct Answer-a - a child
with acute epiglottiditis appears acutely ill and clinical manifestations
may include drooping (because of difficulty swallowing), severe sore
throat, hoarseness, a high temperature, and severe inspiratory stridor. A
low grade fever, stridor, and barking cough that worsens at night are
suggestive of croup. Pulmonary congestion, productive cough, and fever
along with nasal flaring, retractions, chest pain, dyspnea, decreased
breath sounds, and crackles indicate pneumococcal pneumonia. A sore
throat, fever, and general malaise point to viral pharyngitis.
The nurse should instruct the family of a child with newly diagnosed
hyperthyroidism to:
a. keep their home warmer than usual
, b. encourage plenty of outdoor activities
c. promote interactions with one friend instead of groups
d. limit bathing to prevent skin irritation Correct Answer-c - children
with hyperthyroidism experience emotional labiality that may strain
interpersonal relationships. Focusing on one friend's is easier than
adapting to group dynamics until the child's condition improves.
Because of their high metabolic rate, children with hyperthyroidism
complain of being too warm. Bright sunshine may be irritating because
of disease-related ophthalmopathy. Sweating is common and bathing
should be encouraged.
A nurse is instructing a client with bipolar disorder on proper use of
lithium carbonate (Eskalith), the drug's adverse effects, and symptoms of
lithium toxicity. Which client statement indicates that additional
teaching is required?
a. "I can still eat my favorite salty foods."
b. "when my moods fluctuate, I'll increase my dose of lithium."
c. "a good blood level of the drug means the drug concentration has
stabilized."
d. "eating too much watermelon will affect my lithium level." Correct
Answer-b - a client who states that he'll increase his dose of lithium if
his mood fluctuates requires additional teaching because increasing the
dose of lithium without evaluating the client's laboratory values can
cause serious health problems, such as lithium toxicity, overdose, and
renal failure. Clients taking lithium don't need to limit their sodium
intake. A low sodium diet causes lithium retention. A therapeutic lithium
blood level indicates that the drug concentration has stabilized. The
client demonstrates effective teaching by stating his lithium levels will
A client has a herniated disk in the region of the third and fourth lumbar
vertebrae. Which nursing assessment finding most supports this
diagnosis?
a. hypoactive bowel sounds
b. severe lower back pain
c. sensory deficits in one arm
d. weakness and atrophy of the arm muscles Correct Answer-b - the
most common finding in a client with a herniated lumbar disk is severe
lower back pain, which radiates to the buttocks, legs, and feet - usually
unilaterally. A herniated disk also may cause sensory and motor loss
(such as foot drop) in the area innervated by the compressed spinal nerve
root. During later stages, it may cause weakness and atrophy of leg
muscles. The condition doesn't affect bowel sounds or the arms.
when caring for a client after a closed renal biopsy, the nurse should:
a. maintain the client on strict bed rest in a supine position for 6 hours
b. insert an indwelling catheter to monitor urine output
c. apply a sandbag to the biopsy site to prevent bleeding
d. administer IV opioid medications to promote comfort Correct
Answer-a - after a renal biopsy, the client is maintained on strict bed rest
in a supine position for at least 6 hours to prevent bleeding. If no
bleeding occurs, the client typically resumes general activity after 24
hours. Urine output is monitored, but an indwelling catheter is not
typically inserted. A pressure dressing is applied over the site, but a
,sandbag is not necessary. Opioids to control pain would not be
anticipated; local discomfort at a biopsy site can be controlled with
analgesics.
a nurse is caring for a client who required chest tube insertion for a
pneumothorax. To assess for pneumothorax resolution, the nurse can
anticipate that the client will require:
a. monitoring of arterial oxygen saturation (SaO2)
b. arterial blood gas (ABG) studies
c. chest auscultation
d. chest x ray Correct Answer-d - chest x ray confirms diagnosis by
revealing air or fluid in the pleural space. SaO2 values may initially
decrease with a pneumothorax but typically return to normal within 24
hours. ABG studies may show hypoxemia, possibly with respiratory
acidosis and hypercapnia but these are not necessarily related to a
pneumothorax. Chest auscultation will determine overall lung status, but
it's difficult to determine if the best has re-expanded sufficiently.
To prevent development of peripheral neuropathies associated with
isoniazid administration, the nurse should teach the client to:
a. avoid excessive sun exposure
b. follow a low-cholesterol diet
c. obtain extra rest
d. supplement the diet with pyridoxine (vitamin B6) Correct Answer-d -
isoniazid competes for the available vitamin B6 in the body and leaves
,the client at risk for developing neuropathies related to vitamin
deficiency. Supplemental vitamin B6 is routinely prescribed to address
this issue. Avoiding sun exposure is a preventative measure to lower the
risk of skin cancer. Following a low-cholesterol diet lowers the
individual's risk of developing atherosclerotic plaque. Rest is important
in maintaining homeostasis but has no real impact on neuropathies.
A child, age 3, is brought to the emergency department in respiratory
distress caused by acute epiglottiditis. Which clinical manifestations
should the nurse expect to assess?
a. severe sore throat, drooling, and inspiratory strider
b. low grade fever, stridor, and a barking cough
c. pulmonary congestion, a productive cough, and a fever
d. sore throat, a fever, and general malaise Correct Answer-a - a child
with acute epiglottiditis appears acutely ill and clinical manifestations
may include drooping (because of difficulty swallowing), severe sore
throat, hoarseness, a high temperature, and severe inspiratory stridor. A
low grade fever, stridor, and barking cough that worsens at night are
suggestive of croup. Pulmonary congestion, productive cough, and fever
along with nasal flaring, retractions, chest pain, dyspnea, decreased
breath sounds, and crackles indicate pneumococcal pneumonia. A sore
throat, fever, and general malaise point to viral pharyngitis.
The nurse should instruct the family of a child with newly diagnosed
hyperthyroidism to:
a. keep their home warmer than usual
, b. encourage plenty of outdoor activities
c. promote interactions with one friend instead of groups
d. limit bathing to prevent skin irritation Correct Answer-c - children
with hyperthyroidism experience emotional labiality that may strain
interpersonal relationships. Focusing on one friend's is easier than
adapting to group dynamics until the child's condition improves.
Because of their high metabolic rate, children with hyperthyroidism
complain of being too warm. Bright sunshine may be irritating because
of disease-related ophthalmopathy. Sweating is common and bathing
should be encouraged.
A nurse is instructing a client with bipolar disorder on proper use of
lithium carbonate (Eskalith), the drug's adverse effects, and symptoms of
lithium toxicity. Which client statement indicates that additional
teaching is required?
a. "I can still eat my favorite salty foods."
b. "when my moods fluctuate, I'll increase my dose of lithium."
c. "a good blood level of the drug means the drug concentration has
stabilized."
d. "eating too much watermelon will affect my lithium level." Correct
Answer-b - a client who states that he'll increase his dose of lithium if
his mood fluctuates requires additional teaching because increasing the
dose of lithium without evaluating the client's laboratory values can
cause serious health problems, such as lithium toxicity, overdose, and
renal failure. Clients taking lithium don't need to limit their sodium
intake. A low sodium diet causes lithium retention. A therapeutic lithium
blood level indicates that the drug concentration has stabilized. The
client demonstrates effective teaching by stating his lithium levels will
