NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 45 )

Updated On: 12-Jan-2026

A client had a vaginal delivery 3 days ago and is discharged from the hospital on the 2nd day postpartum. She told the RN, "I need to start exercising so that I can get back into shape. Could you suggest an exercise I could begin with?'' The RN could suggest which one of the following?

  1. Push-ups
  2. Jumping jacks
  3. Leg lifts
  4. Kegel exercises

Answer(s): D

Explanation:

(A, B, C) This exercise is too strenuous at this time. (D) This exercise is recommended for the first few days after delivery. It helps to stimulate muscle tonus in the area of the perineum and the area around the urinary meatus and vagina.



When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is:

  1. Stephens-Johnson syndrome
  2. Folate deficiency
  3. Leukopenic aplastic anemia
  4. Granulocytosis and nephrosis

Answer(s): A

Explanation:

(A) Stephens-Johnson syndrome is a toxic effect of phenytoin. (B) Folate deficiency is a side effect of phenytoin, but not a toxic effect. (C) Leukopenic aplastic anemia is a toxic effect of carbamazepine (Tegretol). (D) Granulocytosis and nephrosis are toxic effects of trimethadione (Tridione).



A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of hallucination?

  1. Auditory
  2. Gustatory
  3. Olfactory
  4. Visceral

Answer(s): B

Explanation:

(A) Auditory hallucinations involve sensory perceptions of hearing. (B) Gustatory hallucinations involve sensory perceptions of taste. (C) Olfactory hallucinations involve sensory perceptions of smell. (D) Visceral hallucinations involve sensory perceptions of sensation.



Which of the following procedures is necessary to establish a definitive diagnosis of breast cancer?

  1. Diaphanography
  2. Mammography
  3. Thermography
  4. Breast tissue biopsy

Answer(s): D

Explanation:

(A) Diaphanography, also known as transillumination, is a painless, noninvasive imaging technique that involves shining a light source through the breast tissue to visualize the interior. It must be used in conjunction with a mammogram and physical examination. (B) Mammography is a useful tool for screening but is not considered a means of diagnosing breast cancers. (C) Thermography is a pictorial representation of heat patterns on the surface of the breast. Breast cancers appear as a "hot spot" owing to their higher metabolic rate. (D) Biopsy either by needle aspiration or by surgical incision is the primary diagnostic technique for confirming the presence of cancer cells.



A 27-year-old man was diagnosed with type I diabetes 3 months ago. Two weeks ago he complained of pain, redness, and tenderness in his right lower leg. He is admitted to the hospital with a slight elevation of temperature and vague complaints of "not feeling well." At 4:30 PM on the day of his admission, his blood glucose level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to:

  1. Give him 3 tbsp of sugar dissolved in 4 oz of grape juice to drink
  2. Ask him to dissolve three pieces of hard candy in his mouth
  3. Have him drink 4 oz of orange juice
  4. Monitor him closely until dinner arrives

Answer(s): C

Explanation:

(A) The combination of sugar and juice will increase the blood sugar beyond the normal range. (B) Concentrated sweets are not absorbed as fast as juice; consequently, they elevate the blood sugar beyond the normal limit. (C) Four ounces of orange juice will act immediately to raise the blood sugar to a normal level and sustain it for 30 minutes until supper is served. (D) There is an increased potential for the client's blood sugar to decrease even further, resulting in diabetic coma.



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