NCLEX-RN NCLEX Exam Questions and Free Practice Test

Question 121

- (Topic 4)
A client is being discharged from the hospital tomorrow following a colon resection with a left colostomy. The nurse knows that the client understands the discharge teaching about care of her colostomy when she says:

A. ??I know that I am not supposed to irrigate my colostomy.??

B. ??My stool will be soft like paste.??

C. ??My stoma should be red and slightly raised.??

D. ??The skin around my stoma may become irritated from the enzymes in my stool.??

Correct Answer:C
(A) A left colostomy indicates an ascending colon resection. This type of colostomy can be irrigated. (B) The stool from an ascending colon resection should be formed. (C) The healthy stoma should be red and slightly raised. If it begins to turn dark or blue, the client should see the physician immediately. (D) The stool in the ascending colon does not usually have many enzymes in it. Stool from an ileostomy has more enzymes and is more irritating to the skin.

Question 122

- (Topic 2)
A mother is unsure about the type of toys for her 17-month-old child. Based on knowledge of growth and development, what toy would the nurse suggest?

A. A pull toy to encourage locomotion

B. A mobile to improve hand-eye coordination

C. A large toy with movable parts to improve pincer grasp

D. Various large colored blocks to teach visual discrimination

Correct Answer:A
(A) Increased locomotive skills make push-pull toys appropriate for the energetic toddler.
(B) Infants progress from reflex activity through simple repetitive behaviors to imitative behavior. Hand-eye coordination forms the foundation of other movements. (C) At age 8 months, infants begin to have pincer grasp. Toys that help infants develop the pincer grasp are recommended for this age group. (D) Various large colored blocks are suggested toys for infants 6–12 months of age to help visual stimulation.

Question 123

- (Topic 3)
In client teaching, the nurse should emphasize that fetal damage occurs more frequently with ingestion of drugs during:

A. First trimester

B. Second trimester

C. Third trimester

D. Every trimester

Correct Answer:A
(A) Organogenesis occurs in the first trimester. Fetus is most susceptible to malformation during this period. (B) Organogenesis has occurred by the second trimester. (C) Fetal development is complete by this time. (D) The dangerous period for fetal damage is the first trimester, not the entire pregnancy.

Question 124

- (Topic 1)
A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After establishing a clear airway, administering supplemental O2, and establishing IV access, the next nursing intervention would be to:

A. Pass a nasogastric tube through the left nostril

B. Place a 4 X 4 gauze in the nares to impede the flow

C. Gently suction the nasal drainage to protect the airway

D. Perform a halo test and glucose level on the drainage

Correct Answer:D
(A) Basilar skull fracture may cause dural lacerations, which result in CSF leaking from the ears or nose. Insertion of a tube could lead to CSF going into the brain tissue or sinuses.
(B) Tamponading flow could worsen the problem and increase ICP. (C) Suction could increase brain damage and dislocate tissue. (D) Testing the fluid from the nares would determine the presence of CSF. Elevation of the head, notification of the medical staff, and prophylactic antibiotics are appropriate therapy.

Question 125

- (Topic 3)
A pregnant client experiences a precipitous delivery. The nursing action during a precipitous delivery is to:

A. Control the delivery by guiding expulsion of fetus

B. Leave the room to call the physician

C. Push against the perineum to stop delivery

D. Cross client??s legs tightly

Correct Answer:A
(A) Controlling the rapid delivery will reduce the risk of fetal injury and perineal lacerations.
(B) The nurse should always remain with a client experiencing a precipitous delivery. (C) Pushing against the perineum may cause fetal distress. (D) Crossing of legs may cause fetal distress and does not stop the delivery process.

Question 126

- (Topic 7)
Cystic fibrosis is transmitted as an autosomal recessive trait. This means that:

A. Mothers carry the gene and pass it to their sons

B. Fathers carry the gene and pass it to their daughters

C. Both parents must have the disease for a child to have the disease

D. Both parents must be carriers for a child to have the disease

Correct Answer:D
(A) Cystic fibrosis is not an X-linked or sex-linked disease. (B) The only characteristic on the Y chromosome is the trait for hairy ears. (C) Both parents do not need to have the disease but must be carriers. (D) If a trait is recessive, two genes (one from each parent) are necessary to produce an affected child.

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