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 38 )

Updated On: 12-Jan-2026
Page 38 of 345
PDF with 862 Questions

A client is being discharged from the hospital tomorrow following a colon resection with a left colostomy. The nurse knows that the client understands the discharge teaching about care of her colostomy when she says:

  1. "I know that I am not supposed to irrigate my colostomy."
  2. "My stool will be soft like paste."
  3. "My stoma should be red and slightly raised."
  4. "The skin around my stoma may become irritated from the enzymes in my stool."

Answer(s): C

Explanation:

(A) A left colostomy indicates an ascending colon resection. This type of colostomy can be irrigated. (B) The stool from an ascending colon resection should be formed. (C) The healthy stoma should be red and slightly raised. If it begins to turn dark or blue, the client should see the physician immediately. (D) The stool in the ascending colon does not usually have many enzymes in it. Stool from an ileostomy has more enzymes and is more irritating to the skin.



The physician has prescribed metoclopramide (Reglan). When assessing the client, the nurse would expect to find which of the following responses?

  1. Increase in gastric secretions
  2. Increase in peristalsis
  3. Disorientation
  4. Drowsiness

Answer(s): B

Explanation:

(A) Metoclopramide does not stimulate gastric secretions. (B) This response is expected with metoclopramide, in addition to increasing gastric emptying. (C) Disorientation is a symptom of metoclopramide overdose. The drug should be discontinued. (D) Drowsiness is a symptom of metoclopramide overdose and the drug should be discontinued.



Nursing care for the parents of a child with a congenital heart defect would include:

  1. Encouraging the parents not to tell the child about the seriousness of the congenital heart defect, so the child will function as normally as possible
  2. Acknowledging the fear and concern surrounding their child's health and assisting the parents through the grieving process as they mourn the loss of their fantasized healthy child
  3. Identifying anger and resentment as destructive emotions that serve no purpose
  4. Expressing to the parents after the corrective surgery has been completed successfully that all their grief feelings will resolve

Answer(s): B

Explanation:

(A) It is important to discuss with parents the need to treat the child as they would any other children, but they must be truthful and honest with the child about the heart defect. As the child grows older, Explanation can go into greater depth. (B) Parents of children with congenital heart defects go through a grieving process over the loss of their "healthy" child. The nurse needs to recognize these feelings and give the parents a role in the child's care when they are ready. (C) Anger and resentment are normal feelings that must be dealt with appropriately. (D) Parents may go through a second grieving process after the repair of the cardiac defect. During this grieving period, they mourn the loss of the "defective" child who now may be essentially "normal."



A 9-month-old infant was diagnosed with nonorganic failure to thrive. During her hospitalization, primary nurses were assigned to initiate all infant feedings. The infant's parents question why they cannot feed their own child. Which of the following responses would be most appropriate by the nurse?

  1. By assigning the same nurses to the child, the nurses can begin to learn the infant's cues and feeding behaviors.
  2. The same nurses will prevent parental fatigue and frustration.
  3. The same nurses will prevent infant fatigue and frustration.
  4. Primary nurses will ensure privacy.

Answer(s): A

Explanation:

(A) Consistent primary care nurses can better interpret infant cues and note feeding behaviors. (B) In nonorganic failure to thrive the parent-infant dyad has already experienced difficulties in the relationship. These parents may already feel dissatisfied and frustrated. The primary nurse would be unable to prevent this. (C) Assigning a primary nurse does not ensure that infant fatigue and frustration will not occur or can be prevented. (D) Providing privacy does not ensure a change in feeding behavior.



A child becomes neutropenic and is placed on protective isolation. The purpose of protective isolation is to:

  1. Protect the child from infection
  2. Provide the child with privacy
  3. Protect the family from curious visitors
  4. Isolate the child from other clients and the nursing staff

Answer(s): A

Explanation:

(A) The child no longer has normal white blood cells and is extremely susceptible to infection. (B) There are more appropriate ways to provide privacy, and there is no need to protect the child from healthy visitors. (C) Visitors and visiting hours may be at the client's and/or family's request without regard to the isolation precaution. (D) The child may have strong positive relationships with other clients or staff. As long as proper precautions are observed, there is no reason to isolate her from them.



Viewing page 38 of 345
Viewing questions 186 - 190 out of 862 questions



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

Join the NCLEX-RN Discussion