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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 8 )

Updated On: 12-Jan-2026
Page 8 of 345
PDF with 862 Questions

When assessing residual volume in tube feeding, the feeding should be delayed if the amount of gastric contents (residual) exceeds:

  1. 20 mL
  2. 25 mL
  3. 30 mL
  4. 50 mL

Answer(s): D

Explanation:

(A) A residual volume of 20 mL is not excessive. (B) A residual volume of 25 mL is not excessive. (C) A residual volume of 30 mL is not excessive. (D) Tube feedings should be withheld and physician notified for residual volumes of 50­100 mL.



One week ago, a 21-year-old client with a diagnosis of bipolar disorder was started on lithium 300 mg po qid. A lithium level is ordered. The client's level is 1.3 mEq/L. The nurse recognizes that this level is considered to be:

  1. Within therapeutic range
  2. Below therapeutic range
  3. Above therapeutic range
  4. At a level of toxic poisoning

Answer(s): A

Explanation:

(A) This answer is correct. The therapeutic range is 1.0­1.5 mEq/L in the acute phase. Maintenance control levels are 0.6­1.2 mEq/L. (B, C) This answer is incorrect. A level of 1.3 mEq/L is within therapeutic range. (D) This answer is incorrect. Toxic poisoning is usually at the 2.0 level or higher.



An 8-year-old child is admitted to the hospital for surgery. She has had no previous hospitalizations, and both she and her family appear anxious and fearful. It will be most helpful for the nurse to:

  1. Take the child to her room and calmly and matter-offactly begin to get her ready to go to the operating room
  2. Take time to orient the child and her family to the hospital and the forthcoming events
  3. Explain that as soon as the child goes to the operating room she will have time to answer any questions the family has
  4. Tell the child and her family that there is nothing to worry about, that the operation will not take long, and she will soon be as "good as new"

Answer(s): B

Explanation:

(A) This action does nothing to prepare the child and her family for what will happen or to relieve their anxiety and fear. (B) This action provides security by preparing the child and the family for what will happen and will help to relieve fear and anxiety. (C) This action does nothing to help prepare the child for what will happen and does not give the parents permission to ask questions until later. (D) This action provides possibly false reassurance and may prevent the child and/or the family from asking pressing questions.



A 4-year-old child with a history of sickle cell anemia is admitted to the nursing unit with dizziness, shortness of breath, and pallor. Nursing assessment findings reveal tenderness in the abdomen. The child is most likely experiencing a/an:

  1. Aplastic crisis
  2. Vaso-occlusive crisis
  3. Dactylitis crisis
  4. Sequestration crisis

Answer(s): D

Explanation:

(A) Aplastic anemia is characterized by a lack of reticulocytes in the blood. Platelet and white blood cell counts are usually not depressed. It is usually self-limiting, lasting 5­10 days. (B) Vaso-occlusive crisis is the most common type of crisis in sickle cell anemia. Sickled cells become clogged, leading to distal tissue hypoxia and infarction. Joints and extremities are the most commonly affected areas. (C) Dactylitis crisis, or "hand-foot syndrome," causes symmetrical infarction of the bones in the hands and feet, resulting in painful swelling in the soft tissues of the hands and feet. (D) Sequestration crisis occurs as enormous volumes of blood pool within the spleen. The spleen enlarges, causing tenderness. Signs of shock including pallor, tachypnea, and faintness result, related to the deficient intravascular volume. This type of crisis is potentially fatal.



A 74-year-old client seen in the emergency room is exhibiting signs of delirium. His family states that he has not slept, eaten, or taken fluids for the past 24 hours. The planning of nursing care for a delirious client is based on which of the following premises?

  1. The delirious client is capable of returning to his previous level of functioning.
  2. The delirious client is incapable of returning to his previous level of functioning.
  3. Delirium entails progressive intellectual and behavioral deterioration.
  4. Delirium is an insidious process.

Answer(s): A

Explanation:

(A) This answer is correct. If the cause is removed, the delirious client will recover completely. (B) This answer is incorrect. The demented client is incapable of returning to previous level of functioning. The delirious client is capable of returning to previous functioning. (C) This answer is incorrect. The demented client, not the delirious client, has progressive intellectual and behavioral deterioration. (D) This answer is incorrect. Delirium develops rapidly, whereas dementia is insidious.



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