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NCLEX NCLEX-RN Exam Questions
National Council Licensure Examination - NCLEX-RN (Page 43 )

Updated On: 10-Mar-2026
Page 43 of 345
PDF with 862 Questions

A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should:

  1. Explain that he will be kept NPO for 24 hours before the exam
  2. Practice with him so he will be able to hold his breath for 1 minute
  3. Explain that he will be receiving a laxative to prevent a distended bowel from applying pressure on the liver
  4. Explain that his vital signs will be checked frequently after the test

Answer(s): D

Explanation:

(A) There is no NPO restriction prior to a liver biopsy. (B) The client would need to hold his breath for 5­10 seconds. (C) There is no pretest laxative given. (D) Following the test, the client is watched for hemorrhage and shock.



A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching?

  1. "If he develops diarrhea lasting for more than 2­3 days, I will contact the doctor or nurse."
  2. "I should anticipate that he will gain about 1 lb/day now that he is on continuous feedings."
  3. "It is important to keep the head of his bed elevated or sit him in the chair during feedings."
  4. "I should use prepared or open formula within 24 hours and store unused portions in the refrigerator."

Answer(s): B

Explanation:

(A) Diarrhea is a complication of tube feedings that can lead to dehydration. Diarrhea may be the result of hypertonic formulas that can draw fluid into the bowel. Other causes of diarrhea may be bacterial contamination, fecal impaction, medications, and low albumin. (B) A consistent weight gain of more than 0.22 kg/day (12 lb/day) over several days should be reported promptly. The client should be evaluated for fluid volume excess. (C) Elevating the client's head prevents reflux and thus formula from entering the airway. (D) Bacteria proliferate rapidly in enteral formulas and can cause gastroenteritis and even sepsis.



A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching?

  1. "If he develops diarrhea lasting for more than 2­3 days, I will contact the doctor or nurse."
  2. "I should anticipate that he will gain about 1 lb/day now that he is on continuous feedings."
  3. "It is important to keep the head of his bed elevated or sit him in the chair during feedings."
  4. "I should use prepared or open formula within 24 hours and store unused portions in the refrigerator."

Answer(s): B

Explanation:

(A) Diarrhea is a complication of tube feedings that can lead to dehydration. Diarrhea may be the result of hypertonic formulas that can draw fluid into the bowel. Other causes of diarrhea may be bacterial contamination, fecal impaction, medications, and low albumin. (B) A consistent weight gain of more than 0.22 kg/day (12 lb/day) over several days should be reported promptly. The client should be evaluated for fluid volume excess. (C) Elevating the client's head prevents reflux and thus formula from entering the airway. (D) Bacteria proliferate rapidly in enteral formulas and can cause gastroenteritis and even sepsis.



A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 lb from her 7th to 8th month; her face and hands indicate edema. She is diagnosed as having PIH and referred to the high-risk prenatal clinic. The client's weight increase is most likely due to:

  1. Overeating and subsequent obesity
  2. Obesity prior to conception
  3. Hypertension due to kidney lesions
  4. Fluid retention

Answer(s): D

Explanation:

(A) Overeating can lead to obesity, but not to edema. (B) There is no indication of obesity prior to pregnancy. PIH is more prevalent in the underweight than in the obese in this age group. (C) Hypertension can be due to kidney lesions, but it would have been apparent earlier in the pregnancy. (D) The weight gain in PIH is due to the retention of sodium ions and fluid and is one of the three cardinal symptoms of PIH.



A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 lb from her 7th to 8th month; her face and hands indicate edema. She is diagnosed as having PIH and referred to the high-risk prenatal clinic. The client's weight increase is most likely due to:

  1. Overeating and subsequent obesity
  2. Obesity prior to conception
  3. Hypertension due to kidney lesions
  4. Fluid retention

Answer(s): D

Explanation:

(A) Overeating can lead to obesity, but not to edema. (B) There is no indication of obesity prior to pregnancy. PIH is more prevalent in the underweight than in the obese in this age group. (C) Hypertension can be due to kidney lesions, but it would have been apparent earlier in the pregnancy. (D) The weight gain in PIH is due to the retention of sodium ions and fluid and is one of the three cardinal symptoms of PIH.



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