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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 31 )

Updated On: 12-Jan-2026
Page 31 of 345
PDF with 862 Questions

Succinylcholine chloride (Anectine) is ordered prior to electroconvulsive therapy treatment for depressed clients. The nurse explains that the purpose of the drug is to:

  1. Relax muscles
  2. Relieve anxiety
  3. Reduce secretions
  4. Act as an anesthetic

Answer(s): A

Explanation:

(A) Succinylcholine chloride relaxes muscles and decreases the intensity of the seizure. (B) Succinylcholine chloride does not relieve anxiety. (C) Atropine is given to reduce secretions. (D) Thiamylal sodium (Surital) or other phenobarbital preparations are used as brief anesthetics.



Clients receiving antipsychotic drug therapy will often exhibit extrapyramidal side effects that are reversible with which of the following agents ordered by the physician?

  1. Phenothiazines
  2. Anticholinergics
  3. Anti-Parkinsonian drugs
  4. Tricyclic agents

Answer(s): B

Explanation:

(A) This answer is incorrect. Phenothiazines are antipsychotic drugs and produce the symptoms. (B) This answer is correct. Anticholinergic agents are often used prophylactically for extrapyramidal symptoms. They balance cholinergic activity in the basal ganglia of the brain. (C) This answer is incorrect. Anti- Parkinsonian drugs would increase the symptoms. (D) This answer is incorrect. Tricyclic agents are used for symptoms of depression.



A 10-month-old infant's mother says that he takes fresh whole milk eagerly, but that when she offered him baby foods at 6 months of age, he pushed them out of his mouth. Because he has gained weight appropriately, she has quit trying to get him to eat other foods. The nurse's response is based on the knowledge that:

  1. Milk intake should be limited to no more than four 8-oz bottles per day and should be followed by iron-enriched cereal or other solid foods or juices
  2. Milk is an excellent food and will meet his nutritional needs adequately until he is ready to eat solid foods
  3. It is acceptable to continue to give him whole milk and to delay giving solid foods as long as he takes a vitamin supplement daily
  4. He should be started on iron-enriched cereal, meat, vegetables, fruits, and juices prior to bottle feeds. Milk intake should be limited to 1 qt/day

Answer(s): D

Explanation:

(A) If the infant is given the bottle first, he will be less likely to be hungry enough to eat the solid foods. (B) Milk is deficient in iron, vitamin C, zinc, and fluoride. It does not provide an adequate diet. (C) The vitamin supplement will help, but the infant needs an iron supplement. (D) Giving the solid food when the infant is hungriest will increase the likelihood that he will eat. The more solid food he takes, the less milk he will desire.



A 27-year-old primigravida stated that she got up from the chair to fix dinner and bright red blood was running down her legs. She denies any pain previously or currently. The client is very concerned about whether her baby will be all right. Her vital signs include P 120 bpm, respirations 26 breaths/min, BP 104/58 mm Hg, temperature 98.2_F, and fetal heart rate 146 bpm. Laboratory findings revealed hemoglobin 9.0 g/dL, hematocrit 26%, and coagulation studies within normal range. On admission, the peripad she wore was noted to be half saturated with bright red blood. A medical diagnosis of placenta previa is made. The priority nursing diagnosis for this client would be:

  1. Decreased cardiac output related to excessive bleeding
  2. Potential for fluid volume excess related to fluid resuscitation
  3. Anxiety related to threat to self
  4. Alteration in parenting related to potential fetal injury

Answer(s): A

Explanation:

(A) Based on the client's history, presence of bright red vaginal bleeding, and hemoglobin value on admission, the priority nursing diagnosis would be decreased cardiac output related to excessive bleeding. (B) This nursing diagnosis is a potential problem that does not exist at the present time, and therefore is not the priority problem. (C) The client's expressed anxiety is for her child. The fetus will remain physiologically safe if the decreased cardiac output is resolved. (D) Initial spontaneous bleeding with placenta previa is rarely life threatening to the mother or the fetus. Delivery of the fetus will be postponed until fetal maturity is achieved and survival is likely.



The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this finding?

  1. Palpate these pulses again in 15 minutes.
  2. Use a Doppler to determine presence and strength of these pulses.
  3. Document the finding that the pulses are not palpable.
  4. Call the physician and notify the physician of this finding.

Answer(s): B

Explanation:

(A) Palpating these pulses again in 15 minutes may only result in the same findings. (B) Any time during an assessment that the nurse is unable to palpate pulses, the nurse should then obtain a Doppler and assess for presence or absence of the pulse and pulse strength, if a pulse is present. (C) Pulses may be present and assessed through use of a Doppler. Absence of palpable pulses does not indicate absence of blood flow unless pulses cannot be located with a Doppler. (D) The nurse would only call the physician after determining that the pulses are absent by both palpation and Doppler.



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