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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 4 )

Updated On: 12-Jan-2026
Page 4 of 345
PDF with 862 Questions

A 6-year-old child is attending a pediatric clinic for a routine examination. What should the nurse assess for while conducting a vision screening?

  1. Hearing test
  2. Gait
  3. Strabismus
  4. Papilledema

Answer(s): C

Explanation:

(A) Hearing should be assessed separately. (B) Gait should be assessed separately. Client usually remains in one place for vision screening. Gait is part of neurological assessment. (C) Strabismus is crossing of eyes or outward deviation, which may cause diplopia or ambylopia. It is easily assessed during vision screening. (D) Papilledema is assessed by an ophthalmoscopic examination, which follows vision screening. It is part of neurological assessment.



The nurse working with a client who is out of control should follow a model of intervention that includes which of the following?

  1. Approach the client on a continuum of least restrictive care.
  2. Challenge client's behavior immediately with steps to prevent injury to self or others.
  3. Leave the aggressive client to himself or herself, and take other clients away.
  4. To ensure safety of other clients, place client in seclusion immediately when he or she begins shouting.

Answer(s): A

Explanation:

(A) Approaching a client's aggressive behavior on a continuum of least restrictive care is in agreement with his or her rights (i.e., verbal methods to help maintain control, medication, seclusion, and restraints, as necessary). (B) Approaching a client in a challenging manner is threatening and inappropriate. A nonchallenging and calm approach reflects staff in control and may increase client's internal control. (C) It is inappropriate to leave an aggressive client who is acting out alone. The nurse should acquire qualified help to prevent client from harm or injury to self or others. (D) Moving a client to seclusion immediately for shouting is inappropriate. The nurse should offer the client an opportunity to control self with limit setting. The client should understand that the staff will assist with control if necessary (i.e., quietly accompany out of environment to decrease stimulation and allow for verbalization) employing the least restrictive care model of intervention.



At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her physician orders that an IV be started with 500 mL D5W mixed with 150 mg of ritodrine stat. The RN prepares the IV solution with the medication. The RN knows that clients receiving the medication ritodrine IV should be observed closely for which one of the following side effects:

  1. Hypoglycemia
  2. Hyperkalemia
  3. Tachycardia
  4. Increase in hematocrit and hemoglobin

Answer(s): C

Explanation:

(A) Ritodrine is a sympathomimetic 2-adrenergic agonist that can cause an elevation of blood glucose and plasma insulin in pregnant women. Hyperglycemia can occur in women with abnormal carbohydrate metabolism because of their inability to release more insulin. (B) Hypokalemia can occur resulting from the action of the _-mimetics. It results from a displacement of the extracellular potassium into the intracellular space. (C) Ritodrine causes vasodilation of vessel walls, which can lead to hypotension. The body compensates by increasing heart rate and pulse pressure. (D) There is a lowering of serum iron resulting from the action of _-mimetics to activate hematopoiesis.



A 16-year-old client with anorexia nervosa is on an inpatient psychiatric unit. She has a fear of gaining weight and is refusing to eat sufficient amounts to maintain body weight for her age, height, and stature. To assist with the problem of powerlessness and plan for the client to no longer need to withhold food to feel in control, the nurse uses the following strategy:

  1. Establish a structured environment with routine tasks and activities. Also, serve meals at the same time each day.
  2. Distract the client during meals to get her to eat because she must take in sufficient amounts to keep from starving.
  3. Do frequent room checks to be sure that the client is not hiding food or throwing it away.
  4. Listen attentively and participate in in-depth discussions about food, because these actions may encourage her to eat.

Answer(s): A

Explanation:

(A) Anorexia nervosa clients feel out of control. Providing a structured environment offers safety and comfort and can help them to develop internal control, thus reducing their need to control by self-starvation. (B) Distraction does not focus on the client's need for control. (C) Doing frequent room checks reinforces feelings of powerlessness and the need to continue with the dysfunctional behavior. (D) Participating in long discussions about food does not make the client want to eat, but rather this strategy allows her to indulge in her preoccupation and to continue with the dysfunctional behavior.



A 4-year-old child has Down syndrome. The community health nurse has coordinated a special preschool program. The nurse's primary goal is to:

  1. Provide respite care for the mother
  2. Facilitate optimal development
  3. Provide a demanding and challenging educational program
  4. Prepare child to enter mainstream education

Answer(s): B

Explanation:

(A) Respite care for the family may be needed, but it is not the primary goal of a preschool program. (B) Facilitation of optimal growth and development is essential for every child. (C) A demanding and challenging educational program may predispose the child to failure. Children with retardation should begin with simple and challenging educational programs. (D) Mental retardation associated with Down syndrome may not permit mainstream education. A preschoolprogram's primary goal is not preparation for mainstream education but continuation of optimal development.



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