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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 22 )

Updated On: 12-Jan-2026
Page 22 of 345
PDF with 862 Questions

A 30-year-old client has a history of several recent traumatic experiences. She presents at the physician's office with a complaint of blindness. Physical exam and diagnostic testing reveal no organic cause. The nurse recognizes this as:

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

Answer(s): D

Explanation:

(A) The client's blindness is real. 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.



Following a vaginal delivery, the postpartum nurse should observe for:

  1. Dystocia, kraurosis
  2. Chadwick's sign
  3. Fatigue, hemorrhoids
  4. Hemorrhage and infection

Answer(s): D

Explanation:

(A) Dystocia is difficult labor. The delivery has occurred. Kraurosis is atrophy and dryness of skin and any mucous membrane (vulva). (B) Chadwick's sign is a bluish color of vaginal mucosa suggestive of pregnancy. (C) Fatigue is a common symptom in the postpartal period. Hemorrhoids may occur with pregnancy. (D) Hemorrhage and infection are potential complications of vaginal delivery. Hemorrhage may result from retained placental fragments or soft uterus. Infection may occur from the introduction of organisms into the uterus during the delivery.



A nurse is performing a vaginal exam on a client in active
labor. An important landmark to assess during labor
and delivery are the ischial spines because:

  1. Ischial spines are the narrowest diameter of the pelvis
  2. Ischial spines are the widest diameter of the pelvis
  3. They represent the inlet of birth canal
  4. They measure pelvic floor

Answer(s): A

Explanation:

(A) The fetal descent, or station, is determined by the relationship of the presenting part to the spine. (B) Ischial spines are the narrowest measurement. (C) Ischial spines measure the pelvic outlet. (D) Pelvic floor measurement is not related to fetal descent.



A laboring client presents with a prolapsed cord. The nurse should immediately place the client in what position?

  1. Reverse Trendelenburg
  2. Fowler's
  3. Trendelenburg
  4. Sims'

Answer(s): C

Explanation:

(A) Reverse Trendelenburg position increases pressure on the perineum. This position will not relieve cord pressure. (B) Fowler's position increases perineal pressure. Cord pressure would not be relieved. (C) Trendelenburg position will decrease perineal pressure. Cord compression will be decreased and increase in fetal blood flow occurs. (D) Sims' position does not relieve pressure on cord or perineum.



A 70-year-old client has pneumonia and has just had a respiratory arrest. He has just been intubated with an 8- mm endotracheal tube. During auscultation of his chest, breath sounds were found to be absent on the left side.
The nurse identifies the most likely cause of this as:

  1. Inappropriate endotracheal tube size
  2. Left-sided pneumothorax
  3. Right mainstem bronchus intubation
  4. Pneumonia

Answer(s): C

Explanation:

(A) Appropriate endotracheal tube sizes for adults range from 7.0­8.5 mm. (B) Pneumothorax could be indicated by an absence of breath sounds on the affected side. However, in a recently intubated client, the first priority would be to consider tube malposition. (C) During intubation, the right mainstem bronchus can be inadvertently entered if the endotracheal tube is inserted too far. Left mainstem bronchus intubation almost never occurs because of the angle of the left mainstem bronchus. (D) Breath sounds for someone with pneumonia may be decreased over the areas of consolidation. However, in a recently intubated client, the first priority would be to consider tube malposition.



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