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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 53 )

Updated On: 12-Jan-2026
Page 53 of 345
PDF with 862 Questions

As the nurse assesses a male adolescent with chlamydia, the nurse determines that a sign of chlamydia is:

  1. Enlarged penis
  2. Secondary lymphadenitis
  3. Epididymitis
  4. Hepatomegaly

Answer(s): C

Explanation:

(A) An enlarged penis is not a sign of chlamydia. (B) Secondary lymphadenitis is a complication of lymphogranuloma venereum. (C) Untreated chlamydial infection can spread from the urethra, causing epididymitis, which presents as a tender, scrotal swelling. (D) Hepatomegaly is not a complication.



Which of the following findings would be abnormal in a postpartal woman?

  1. Chills shortly after delivery
  2. Pulse rate of 60 bpm in morning on first postdelivery day
  3. Urinary output of 3000 mL on the second day after delivery
  4. An oral temperature of 101F (38.3C) on the third day after delivery

Answer(s): D

Explanation:

(A) Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous response or to vasomotor changes. If not followed by a fever, it is clinically innocuous. (B) The pulse rate during the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt to the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. (C) Urinary output increases during the early postpartal period (12­24 hours) owing to diuresis. The kidneys must eliminate an estimated 2000­3000 mL of extracellular fluid associated with a normal pregnancy. (D) A temperature of 100.4F (38C) may occur after delivery as a result of exertion and dehydration of labor. However, any temperature greater than 100.4F needs further investigation to identify any infectious process.



Which of the following medications requires close observation for bronchospasm in the client with chronic obstructive pulmonary disease or asthma?

  1. Verapamil (Isoptin)
  2. Amrinone (Inocor)
  3. Epinephrine (Adrenalin)
  4. Propranolol (Inderal)

Answer(s): D

Explanation:

(A) Verapamil has the respiratory side effect of nasal or chest congestion, dyspnea, shortness of breath (SOB), and wheezing. (B) Amrinone has the effect of increased contractility and dilation of the vascular smooth muscle. It has no noted respiratory side effects. (C) Epinephrine has the effect of bronchodilation through stimulation. (D) Propranolol, esmolol, and labetalol are all - blocking agents, which can increase airway resistance and cause bronchospasms.



The nurse would expect to include which of the following when planning the management of the client with Lyme disease?

  1. Complete bed rest for 6­8 weeks
  2. Tetracycline treatment
  3. IV amphotericin B
  4. High-protein diet with limited fluids

Answer(s): B

Explanation:

(A) The client is not placed on complete bed rest for 6 weeks. (B) Tetracycline is the treatment of choice for children with Lyme disease who are over the age of 9. (C) IV amphotericin B is the treatment for histoplasmosis. (D) The client is not restricted to a high-protein diet with limited fluids.



A client with bipolar disorder taking lithium tells the nurse that he has ringing in his ears, blurred vision, and diarrhea. The nurse notices a slight tremor in his left hand and a slurring pattern to his speech. Which of the following actions by the nurse is appropriate?

  1. Administer a stat dose of lithium as necessary.
  2. Recognize this as an expected response to lithium.
  3. Request an order for a stat blood lithium level.
  4. Give an oral dose of lithium antidote.

Answer(s): C

Explanation:

(A) These symptoms are indicative of lithium toxicity. A stat dose of lithium could be fatal. (B) These are toxic effects of lithium therapy. (C) The client is exhibiting symptoms of lithium toxicity, which may be validated by lab studies. (D) There is no known lithium antidote.



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