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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 14 )

Updated On: 12-Jan-2026
Page 14 of 345
PDF with 862 Questions

A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician?

  1. pH 7.39
  2. White blood cell (WBC) count 10,000 WBCs/mm3
  3. Hematocrit 60%
  4. Bleeding time of 4 minutes

Answer(s): C

Explanation:

(A) Normal pH of arterial blood gases for an infant is 7.35­7.45. (B) Normal white blood cell count in an infant is 6,000­17,500 WBCs/mm3. (C) Normal hematocrit in infant is 28%­42%. A 60% hematocrit may indicate polycythemia, a common complication of cyanotic heart disease. (D) Normal bleeding time is 2­7 minutes.



Nursing care of the infant prior to surgical closure of a meningomyelocele would include:

  1. Cover sac with dry sterile dressing
  2. Cover sac with saline-soaked sterile dressing
  3. Do not apply dressing; keep sac open to air
  4. Aspirate any fluid from sac

Answer(s): B

Explanation:

(A) A dry, sterile dressing would adhere to the sac, causing tissue damage. (B) A saline-soaked sterile dressing protects the sac from contamination by air and prevents drying. (C) A sac open to air causes drying and potential for contamination. (D) This intervention is not an independent nursing action.



A client has consented to have a central venous catheter placed. The best position in which to place the client is the Trendelenburg position. The reason is that the Trendelenburg position:

  1. Allows the physician to visualize the subclavian vein
  2. Reduces the possibility of air embolism
  3. Reduces the possibility of hematoma formation
  4. Makes the procedure more comfortable for the client

Answer(s): B

Explanation:

(A) The subclavian vein is not visible during central line insertion regardless of the client's position. (B) The Trendelenburg position reduces the possibility of air embolism because it places slight positive pressure on the central veins. It also distends the veins, and distention facilitates insertion. (C) This response is untrue; it has no effect on hematoma formation. (D) This position is not necessarily more comfortable for the client, and many clients, especially those who may be short of breath, may find the position uncomfortable and difficult to maintain.



After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis?

  1. One centimeter below the ischial spines
  2. One centimeter above the ischial spines
  3. Has not entered the pelvic inlet yet
  4. Located in the pelvic outlet

Answer(s): B

Explanation:

(A) The ischial spines are located on both sides of the midpelvis. These spines mark the diameter of the narrowest part of the pelvis that the fetus will encounter. They are not sharp protrusions that will harm the fetus. Station refers to the relationship between the ischial spines in the pelvis and the fetus. The ischial spines are designated at 0 station. If the presenting part of the fetus is located above the ischial spines, a negative number is assigned, noting the number of centimeters above the ischial spines. Therefore, 1 centimeter below the ischial spines is designated as +1 station. (B) See explanation in a One centimeter above the ischial spines is designated as +1 station. (C) The pelvic inlet is the first part of the pelvis that the fetus enters in routine delivery. The midpelvis is the second part of the pelvis to be entered by the fetus. The ischial spines are located on both sides of the midpelvis. (D) The pelvic outlet is the last part of the pelvis that the fetus will enter. When the fetus reaches this part of the pelvis, birth is near.



A 24-year-old client presents to the emergency department protesting "I am God." The nurse identifies this as a:

  1. Delusion
  2. Illusion
  3. Hallucination
  4. Conversion

Answer(s): A

Explanation:

(A) Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion is the expression of intrapsychic conflict through sensory or motor manifestations.



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