January 6, 2011
NCLEX QUESTIONS OF THE DAY
ANSWERS JANUARY 5 QUESTIONS
1. In preparation for discharge of a client with arterial insufficiency and Raynaud's disease, client teaching
instructions should include
a. Walking several times each day as a part of an exercise routine
b. Keeping the heat up so that the environment is warm
c. Wearing TED hose during the day
d. Using hydrotherapy for increasing oxygenation
Answer: b
Rationale: The client's instructions should include keeping the environment warm to prevent vasoconstriction.
Wearing gloves, warm clothes, and socks will also be useful in preventing vasoconstriction, but TED hose would
not be therapeutic. Walking will most likely increase pain.
2. When a client asks the nurse why the physician says he "thinks" he has tuberculosis, the nurse explains to him
that diagnosis of tuberculosis can take several weeks to confirm. Which of the following statements supports this
answer?
a. A positive reaction to a tuberculosis skin test indicates that the client has active tuberculosis, even if one
negative sputum is obtained
b. A positive sputum culture takes at least 3 weeks, due to the slow reproduction of the bacillus
c. Because small lesions are hard to detect on chest x-rays, x-rays usually need to be repeated during
several consecutive weeks
d. A client with a positive smear will have to have a positive culture to confirm the diagnosis
Answer: b
Rationale: Answer b is correct because the culture takes 3 weeks to grow. Usually even very small lesions can be
seen on x-rays due to the natural contrast of the air in the lungs; therefore, chest x-rays do not need to be repeated
frequently (c). Clients may have positive smears but negative cultures if they have been on medication (d). A
positive skin test indicates the person only has been infected with tuberculosis but may not necessarily have active
disease (a).
3. The nurse is counseling a client with the diagnosis of glaucoma. She explains that if left untreated, this condition
leads to
a. Blindness
b. Myopia
c. Retrolental fibroplasia
d. Uveitis
Answer: a
Rationale: The increase in intraocular pressure causes atrophy of the retinal ganglion cells and the optic nerve, and
leads eventually to blindness.
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January 6, 2011
4. A nursing assessment for initial signs of hypoglycemia will include
a. Pallor, blurred vision, weakness, behavioral changes
b. Frequent urination, flushed face, pleural friction rub
c. Abdominal pain, diminished deep tendon reflexes, double vision
d. Weakness, lassitude, irregular pulse, dilated pupils
Answer: a
Rationale: Weakness, fainting, blurred vision, pallor and perspiration are all common symptoms when there is too
much insulin or too little food - hypoglycemia. The signs and symptoms in answers (b) and (c) are indicative of
hyperglycemia.
5. The physician has ordered a 24-hour urine specimen. After explaining the procedure to the client, the nurse
collects the first specimen. This specimen is then
a. Discarded, then the collection begins
b. Saved as part of the 24-hour collection
c. Tested, then discarded
d. Placed in a separate container and later added to the collection
Answer: a
Rationale: The first specimen is discarded because it is considered "old urine" or urine that was in the bladder
before the test began. After the first discarded specimen, urine is collected for 24 hours.
JANUARY 6, 2011 QUESTIONS
1. Following an accident, a client is admitted with a head injury and concurrent cervical spine injury. The physician
will use Crutchfield tongs. The purpose of these tongs is to
a. Hypoextend the vertebral column
b. Hyperextend the vertebral column
c. Decompress the spinal nerves
d. Allow the client to sit up and move without twisting his spine
2. The most appropriate nursing intervention for a client requiring a finger probe pulse oximeter is to
a. Apply the sensor probe over a finger and cover lightly with gauze to prevent skin breakdown
b. Set alarms on the oximeter to at least 100 percent
c. Identify if the client has had a recent diagnostic test using intravenous dye
d. Remove the sensor between oxygen saturation readings
3. A client being treated for esophageal varices has a Sengstaken- Blakemore tube inserted to control the bleeding.
The most important assessment is for the nurse to
a. Check that a hemostat is at the bedside
b. Monitor IV fluids for the shift
c. Regularly assess respiratory status
d. Check that the balloon is deflated on a regular basis
4. A 55-year-old client with sever epigastric pain due to acute pancreatitis has been admitted to the hospital. The
client's activity at this time should be
a. Ambulation as desired
b. Bedrest in supine position
c. Up ad lib and right side-lying position in bed
d. Bedrest in Fowler's position
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January 6, 2011
5. Of the following blood gas values, the one the nurse would expect to see in the client with acute renal failure is
a. pH 7.49, HCO3 24, PCO2 46
b. pH 7.49, HCO3 14, PCO2 30
c. pH 7.26, HCO3 24, PCO2 46
d. pH 7.26, HCO3 14, PCO2 30
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