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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 61 )

Updated On: 25-Jan-2026
Page 61 of 345
PDF with 862 Questions

In a client with chest trauma, the nurse needs to evaluate mediastinal position. This can best be done by:

  1. Auscultating bilateral breath sounds
  2. Palpating for presence of crepitus
  3. Palpating for trachial deviation
  4. Auscultating heart sounds

Answer(s): C

Explanation:

(A) No change in the breath sounds occurs as a direct result of the mediastinal shift. (B) Crepitus can occur owing to the primary disorder, not to the mediastinal shift. (C) Mediastinal shift occurs primarily with tension pneumothorax, but it can occur with very large hemothorax or pneumothorax. Mediastinal shift causes trachial deviation and deviation of the heart's point of maximum impulse. (D) No change in the heart sounds occurs as a result of the mediastinal shift.



Which of the following statements relevant to a suicidal client is correct?

  1. The more specific a client's plan, the more likely he or she is to attempt suicide.
  2. A client who is unsuccessful at a first suicide attempt is not likely to make future attempts.
  3. A client who threatens suicide is just seeking attention and is not likely to attempt suicide.
  4. Nurses who care for a client who has attempted suicide should not make any reference to the word "suicide" in order to protect the client's ego.

Answer(s): A

Explanation:

(A) This is a high-risk factor for potential suicide. (B) A previous suicide attempt is a definite risk factor for subsequent attempts. (C) Every threat of suicide should be taken seriously. (D) The client should be asked directly about his or her intent to do bodily harm. The client is never hurt by direct, respectful questions.



A diagnosis of hepatitis C is confirmed by a male client's physician. The nurse should be knowledgeable of the differences between hepatitis A, B, and C. Which of the following are characteristics of hepatitis C?

  1. The potential for chronic liver disease is minimal.
  2. The onset of symptoms is abrupt.
  3. The incubation period is 2­26 weeks.
  4. There is an effective vaccine for hepatitis B, but not for hepatitis C.

Answer(s): C

Explanation:

(A) Hepatitis C and B may result in chronic liver disease. Hepatitis A has a low potential for chronic liver disease. (B) Hepatitis C and B have insidious onsets. Hepatitis A has an abrupt onset. (C) Incubation periods are as follows: hepatitis C is 2­26 weeks, hepatitis B is 6­20 weeks, and hepatitis A is 2­6 weeks. (D) Only hepatitis B has an effective vaccine.



The primary reason that an increase in heart rate (100 bpm) detrimental to the client with a myocardial infarction (MI) is that:

  1. Stroke volume and blood pressure will drop proportionately
  2. Systolic ejection time will decrease, thereby decreasing cardiac output
  3. Decreased contractile strength will occur due to decreased filling time
  4. Decreased coronary artery perfusion due to decreased diastolic filling time will occur, which will increase ischemic damage to the myocardium

Answer(s): D

Explanation:

(A) Decreased stroke volume and blood pressure will occur secondary to decreased diastolic filling. (B) Tachycardia primarily decreases diastole; systolic time changes very little. (C) Contractility decreases owing to the decreased filling time and decreased time for fiber lengthening. (D) Decreased O2 supply due to decreased time for filling of the coronary arteriesincreases ischemia and infarct size. Tachycardia primarily robs the heart of diastolic time, which is the primary time for coronary artery filling.



A six-month-old infant has been admitted to the emergency room with febrile seizures. In the teaching of the parents, the nurse states that:

  1. Sustained temperature elevation over 103F is generally related to febrile seizures
  2. Febrile seizures do not usually recur
  3. There is little risk of neurological deficit and mental retardation as sequelae to febrile seizures
  4. Febrile seizures are associated with diseases of the central nervous system

Answer(s): C

Explanation:

(A) The temperature elevation related to febrile seizures generally exceeds 101F, and seizures occur during the temperature rise rather than after a prolonged elevation. (B) Febrile seizures may recur and are more likely to do so when the first seizure occurs in the 1st year of life. (C) There is little risk of neurological deficit, mental retardation, or altered behavior secondary to febrile seizures. (D) Febrile seizures are associated with disease of the central nervous system.



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