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 44 )

Updated On: 12-Jan-2026
Page 44 of 345
PDF with 862 Questions

Home-care instructions for the child following a cardiac catheterization should include:

  1. Notify the physician if a slight bruise develops around the insertion site.
  2. Use sponge bathing until stitches are removed.
  3. Give aspirin if the child complains of pain at the insertion site.
  4. Keep a clean, dry dressing on the insertion site for 2 days.

Answer(s): B

Explanation:

(A) A small bruise may develop around the insertion site and is not a reason for alarm. (B) It is best to keep the child out of the bathtub until the sutures are removed. (C) Acetaminophen, not aspirin, is the drug of choice if there is pain at the insertion site. (D) The insertion site should be kept clean and dry and open to air.



A client who was started on antipsychotic medication 2 weeks ago is preparing for discharge from the hospital. Compliance with the medication regimen is important despite the mild side effects encountered. In order to increase the likelihood of medication compliance, the nurse would:

  1. Discuss the disease process and the importance of the medication in prevention of symptoms.
  2. Inform the client that additional side effects are to be expected and need not be reported.
  3. Discuss the importance of getting blood drawn weekly to determine medication therapeutics.
  4. Inform the client to cease taking the medication when all psychotic symptoms have cleared.

Answer(s): A

Explanation:

(A) This answer is correct. If the client is well informed about what reactions to expect from her medication, she is more likely to follow the treatment regimen. (B) This answer is incorrect. There are many side effects that are reversible by medication, and these must be reported to the nurse or physician. There are also more severe side effects, such as neuroleptic malignant syndrome, characterized by fever, tachycardia, and diaphoresis, which can be life threatening. (C) This answer is incorrect. There is no need for weekly blood tests if the drug regimen has been followed properly. (D) This answer is incorrect. The client should continue the medicationuntil the physician recommends any change in the drug regimen. Symptoms will usually reappear if medication is discontinued.



A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain his personal hygiene without assistance. Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of:

  1. Loss of ability to speak and communicate effectively
  2. Aspiration and weight loss
  3. Secondary infection resulting from poor oral hygiene
  4. Drooling

Answer(s): B

Explanation:

(A) Loss of ability to speak is not dysphasia. Although the client may have difficulty communicating, alternative measures can be developed to enhance communication. This goal, while important, is of a lesser priority. (B) Dysphasia is difficulty swallowing, which could result in aspiration of food and inability to eat, causing weight loss. (C) A secondary infection could result from poor oral hygiene, which could enhance the client's inability to eat, but this goal is of a lesser priority. (D) Drooling normally occurs in clients with amyotrophic lateral sclerosis and may require suctioning. Drooling, while aggravating for the client, does not pose an immediate danger.



A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the left side of the chest of a newly intubated client is probably due to:

  1. A left hemothorax
  2. A right hemothorax
  3. Intubation of the right mainstem bronchus
  4. An inadequate mechanical ventilator

Answer(s): C

Explanation:

(A) Although a left hemothorax could cause diminished and distant breath sounds, it is irrelevant to this situation. (B) A right hemothorax will not cause diminished and distant breath sounds on the left side of the chest. (C) The right mainstem bronchus is most frequently intubated in error because the angle of the right mainstem bronchus is very small as compared with that of the left mainstem bronchus. Because ventilation is only occurring on the right side, the nurse would auscultate diminished and distant breath sounds on the left. (D) An inadequate mechanical ventilator has no relationship to this situation.



What is the appropriate nursing action for a child with increased intracranial pressure?

  1. Head of bed elevated 45 degrees with child's head maintained in a neutral position
  2. Child lying flat
  3. Head turned to side
  4. Frequent visitation for stimulation

Answer(s): A

Explanation:

(A) Elevation of head of bed and neutral head position promote drainage of cerebrospinal fluid. (B) Flat position increases intracranial pressure and impedes cerebrospinal fluid drainage. (C) Head turned to either side impedes cerebrospinal fluid drainage. (D) Child should be in a calm, quiet environment with minimal stimulation.



Viewing page 44 of 345
Viewing questions 216 - 220 out of 862 questions



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

Join the NCLEX-RN Discussion