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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 18 )

Updated On: 12-Jan-2026
Page 18 of 345
PDF with 862 Questions

An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action?

  1. Apply ice packs to both legs.
  2. Begin débridement by removing all charred clothing from wound.
  3. Apply Silvadene cream (silver sulfadiazine).
  4. Immerse both legs in cool water.

Answer(s): D

Explanation:

(A) Ice creates a dramatic temperature change in the tissue, which can cause further thermal injury. (B) Charred clothing should not be removed from wound first. This creates further tissue damage. Débridement is not the first nursing action. (C) Applying silver sulfadiazine cream first insulates heat in injured tissue and increases potential for infection. (D) Emergency care of a thermal burn is immersing both legs in cool water. Cool water permits gradual temperature change and prevents further thermal damage.



The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase?

  1. Mother is concerned about her recovery.
  2. Mother calls infant by name.
  3. Mother lightly touches infant.
  4. Mother is concerned about her weight gain.

Answer(s): B

Explanation:

(A) This observation can be made during the taking-in phase when the mother's needs are more important. (B) This observation can be made during the taking-hold phase when the mother is actively involved with herself and the infant. (C, D) This observation can be made during the taking-in phase.



A 60-year-old male client was hospitalized 3 days ago with the diagnosis of acute anterior wall myocardial infarction. Today he has been complaining of increasing weakness and shortness of breath. Crackles in both lung bases are audible on auscultation. He is developing:

  1. An extension of his myocardial infarction
  2. Pneumonia
  3. Pulmonary edema
  4. Pulmonary emboli

Answer(s): C

Explanation:

(A) Extensions of his myocardial infarction would be chest pain unrelieved with nitroglycerin, cardiac enzyme elevations, and electrocardiographic changes. (B) Persons with pneumonia may complain of weakness and shortness of breath and have crackles in their lung bases. However, they would also have sputum production and leukocytosis. (C) Persons who have had myocardial infarctions (especially anterior wall) are at risk of developing left ventricular heart failure, which is a major cause of pulmonary edema. Pulmonary edema is manifest by shortness of breath, weakness, and crackles on auscultation of the lung fields. (D) Pulmonary emboli may be accompanied by shortness of breath, weakness, and crackles. However, the pulmonary hypertension that accompanies pulmonary emboli results in signs of increased systemic venous pressure as well.



A client calls the prenatal clinic to schedule an appointment. She states she has missed three menstrual periods and thinks she might be pregnant. During her first visit to the prenatal clinic, it is confirmed that she is pregnant. The registered nurse (RN) learns that her last menstrual period began on June 10. According to Nägele's rule, the estimated date of confinement is:

  1. March 17
  2. June 3
  3. August 30
  4. January 10

Answer(s): A

Explanation:

(A) Using Nägele's rule, count back 3 calendar months from the first day of the last menstrual period. The answer is March 10. Then add 7 days and 1 year, which would be March 17 of the following year. (B, C, D) This date is incorrect.



A male client has asthma and his physician has prescribed beclomethasone (Vanceril) 3 puffs tid in addition to his other medications. After taking his beclomethasone, the client should be instructed to:

  1. Clean his inhaler with warm water and soak it in a10% bleach solution
  2. Drink a glass of water
  3. Sit and rest
  4. Use his bronchodilator inhaler

Answer(s): B

Explanation:

(A) Inhalers should be cleaned once a day. They should be taken apart, washed in warm water, and dried according to manufacturer's instructions. Soaking in bleach is inappropriate. (B) A common side effect of inhaled steroid preparations is oral candidal infection. This can be prevented by drinking a glass of water or gargling after using a steroid inhaler. (C) There is nothing wrong with sitting and resting after using a steroid inhaler, but it is not necessary. (D) If a person is using a steroid inhaler as well as a bronchodilator inhaler, the bronchodilator shouldalways be used first. The reason for this is that the bronchodilator opens up the person's airways so that when the steroid inhaler is used next, there will be better distribution of medication.



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