Cisco
CompTIA
ISC
EC-Council
EXIN
Fortinet
ITIL
Juniper
Microsoft
VMware
Avaya
SAP
Google
NVIDIA
Salesforce
Amazon
Palo Alto Networks
ISC2
Splunk
ServiceNow
All Vendors
  2. Home
  3. Exams
  4. NCLEX
  5. NCLEX-RN

NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 34 )

Updated On: 12-Jan-2026
Page 34 of 345
PDF with 862 Questions

A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular disorder. She arrives in her room via stretcher and requires assistance to move to her bed. The nurse notes that her left leg is cold to touch. She complains of having recently experienced muscle spasms in that leg. To determine if these muscle spasms are indicative of intermittent claudication, the nurse would begin her assessment with the following question:

  1. "Would you describe the intensity, duration, and symptoms associated with your pain?"
  2. "Do you experience swelling at the end of the day in the affected and unaffected leg?"
  3. "Have you had any lesions of the affected leg that have been difficult to heal?"
  4. "Do your muscle spasms occur following rest, walking, or exercising?"

Answer(s): D

Explanation:

(A) Describing pain is an important aspect of the assessment; however, assessing activity preceding muscle spasms is equally important. (B) Edema may occur with peripheral vascular disease, but it is not of particular importance in assessing intermittent claudication. (C) Lesions may be present with peripheral vascular disease, but they are not an indication of intermittent claudication. (D) With intermittent claudication, muscle spasms occur intermittently, mainly with walking and after exercising. Rest may relieve muscle spasms.



A 48-year-old female client is going to have a cholecystectomy in the morning. In planning for her postoperative care, the nurse is aware that a priority nursing diagnosis for her will be high risk for:

  1. Knowledge deficit
  2. Urinary retention
  3. Impaired physical mobility
  4. Ineffective breathing pattern

Answer(s): D

Explanation:

(A) The client may have a knowledge deficit, but reducing the risk for knowledge deficit is not a priority nursing diagnosis postoperatively. (B) The client will have a Foley catheter for a day or two after surgery. Urinary retention is usually not a problem once the Foley catheter is removed. (C) A client having a cholecystectomy should not be physically impaired. In fact, the client is encouraged to begin ambulating soon after surgery. (D) Because of the location of the incision, the client having a cholecystectomy is reluctant to breathe deeply and is at risk for developing pneumonia. These clients have to be reminded and encouraged to take deep breaths.



A 15-year-old client was diagnosed as having cystic fibrosis at 8 months of age. He is in the hospital for a course of IV antibiotic therapy and vigorous chest physiotherapy. He has a poor appetite. The nurse can best help him to meet the desired outcome of consuming a prescribed number of calories by:

  1. Including the client in planning sessions to select the type of meal plan and foods for his diet
  2. Working with the nutritionist to devise a diet with significantly increased calories
  3. Selecting foods for the client's diet that are high in calories and instituting a strict calorie count
  4. Constantly providing him with chips, dips, and candies, because the number of calories consumed is more important than the quality of foods

Answer(s): A

Explanation:

(A) The adolescent knows what he likes and will be more likely to eat if he has some control over his diet. (B) The nurses and nutritionist can plan an excellent diet, but it will not help the adolescent unless he eats it. (C) Eating is already a chore for this client. Adding a strict calorie count could make it even more burdensome. (D) Fats are particularly difficult for the cystic fibrosis client to digest. He does need a healthful diet, not just more calories.



A client with cystic fibrosis exhibits activity intolerance related to the pulmonary problems associated with his disease. However, he needs to be encouraged to participate in daily physical exercise. The ultimate aim of exercise is to:

  1. Create a sense of well-being and self-worth
  2. Help him overcome respiratory infections
  3. Establish an effective, habitual breathing pattern
  4. Promote normal growth and development

Answer(s): C

Explanation:

(A) Regular exercise does promote a sense of well-being and selfworth, but this is not the ultimate goal of exercise for this client. (B) Regular chest physiotherapy, not exercise per se, helps to prevent respiratory infections. (C) Physical exercise is an important adjunct to chest physiotherapy. It stimulates mucus secretion, promotes a feeling of well-being, and helps to establish a habitual breathing pattern. (D) Along with adequate nutrition and minimization of pulmonary complications, exercise does help promote normal growth and development. However, exercise is promoted primarily to help establish a habitual breathing pattern.



The primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed toward:

  1. Maintaining an adequate level of hydration
  2. Providing pain relief
  3. Preventing infection
  4. O2 therapy

Answer(s): A

Explanation:

(A) Maintaining the hydration level is the focus for nursing intervention because dehydration enhances the sickling process. Both oral and parenteral fluids are used. (B) The pain is a result of the sickling process. Analgesics or narcotics will be used for symptom relief, but the underlying cause of the pain will be resolved with hydration. (C) Serious bacterial infections may result owing to splenic dysfunction. This is true at all times, not just during the acute period of a crisis. (D) O2 therapy is used for symptomatic relief of the hypoxia resulting from the sickling process. Hydration is the primary intervention to alleviate the dehydration that enhances the sickling process.



Viewing page 34 of 345
Viewing questions 166 - 170 out of 862 questions



Post your Comments and Discuss NCLEX NCLEX-RN exam prep with other Community members:

Join the NCLEX-RN Discussion