NCLEX REVIEW QUESTIONS
Summer 2010 Set 3
(Answers follow all questions)
Fundamentals of Nursing
1. A 92-year-old client with emphysema is experiencing chest pain. The nurse determines with a pulse oximetry that the oxygen saturation is 83%. The nurse understands that it is essential that oxygen be administered by nasal cannula at which of the following rates?
A. 8 L/minute
B. 2 L/minute
C. 5 L/minute
D. 12 L/minute
Maternity
2. A client asks the nurse about the purpose of the placenta. Based on the understanding of the metabolic functions of the placenta, which of the following would be the most appropriate response by the nurse? The purposes of the placenta for the baby include:
Select all that apply
A. Cushion
B. Protects the skin
C. Respiration
D. Excretion
E. Pancreatic function
F. Nutrition
Pediatrics
3. An adolescent experiences recurrent aphthous stomatitis. Which of the following should the nurse include in the instructions for a client with aphthous ulcers?
A. Encourage fluids through a straw and soft diet while the ulcers are present
B. Recommend the use of a hard-bristle toothbrush to remove affected tissue
C. Administer antiviral drugs such as acyclovir (Zovirax) to shorten course
D. Inform the client that the ulcers will last one to two days

Neurological Disorders (Adult)
4. The nurse’s plan of care for a client with Guillain-Barre syndrome is based on an understanding of which of the following disease processes?
A. Decreased secretion of acetylcholine and an increase of cholinesterase at the myoneural junction
B. Segmental demyelination of the ventral and dorsal nerve roots in the spinal cord and medulla
C. Chronic inflammation, demyelination, and scarring of the CNS
D. Decreased secretion of the neurotransmitter dopamine with an anticholinergic effect
Musculoskeletal/Integumentary Disorders (Adult)
5. Which of the following neurovascular complications should the nurse assess for after a fracture?
Select all that apply:
A. Petechiae over all extremities
B. Pallor
C. Exaggerated extremity movement
D. Decreased sensation distal to the fracture site
E. Purulent drainage at the site of an open fracture
F. Pulselessness
Oncological/Immune Disorders (Adult)
6. The nurse is caring for a client who received chemotherapy for leukemia 24 hours ago and is now complaining of flank pain. The client’s urinary output has decreased to less than 30 ml/hour. The nurse evaluates which of the following conditions as the most likely cause of the client’s clinical manifestations?
A. Syndrome of inappropriate antidiuretic hormone (SIADH)
B. Tumor lysis syndrome
C. Superior vena cava syndrome
D. Hypercalcium

Cardiovascular Disorders (Adult)
7. The nurse is caring for a client admitted with severe rectal bleeding who is receiving warfarin (Coumadin) therapy. Which of the following interventions should have priority in the plan of care?
A. Accurate intake and output
B. Discontinue the warfarin
C. Assure a patent 18-gauge IV
D. Administer vitamin K
Respiratory Disorders (Adult)
8. Which of the following is the priority for the nurse to monitor in a client who has been on a ventilator and on 70% FIO2 for the past 72 hours?
A. Atelectasis
B. Pulmonary fibrosis
C. Expense to client
D. Oxygen dependence
Endocrine Disorders (Adult)
9. The nurse would report which of the following laboratory results as consistent with a diagnosis of primary aldosteronism?
A. Serum potassium of 3 mEq/L
B. Serum phosphorus of 3 mg/dL
C. Serum sodium of 130 mEq/L
D. Serum calcium of 12 mg/dL
GI/GU Disorders (Adult)
10. The registered nurse is making out the clinical assignments for the day. Which of the following nursing tasks is appropriate to delegate to a licensed practical nurse?
A. Plan an activity schedule for a client following a Billroth I
B. Develop a plan of care for a client following a total proctocolectomy
C. Assess the client’s understanding of the care following an ileostomy
D. Assist the client to select a low-fat diet following a cholecystectomy

Sensory Disorders (Adult)
11. For the client who sustained a chemical burn from battery acid, the nurse should include which of the following in the emergency procedures?
A. Assess the visual acuity
B. Irrigate the eye with sterile normal saline
C. Swab the eye with antibiotic ointment
D. Cover the affected eye with an eye patch
Psychiatric and Mental Health (Adult)
12. The nurse evaluates which of the following disorders to contribute to the severity of a sexual disorder?
A. Schizophrenia
B. Bipolar disorder
C. Diabetes
D. Anorexia

Answers
1. B: In emphysema, the drive to breathe will be decreased or eliminated if oxygen is administered at a high rate. The best and safest initial rate of oxygen flow is 2 L to 3
L/minute. If higher flow rates are administered, the client may need artificial ventilation.
2. C, D, F: The placenta is responsible for the gas exchange (respiration), for nutrients that actively and passively cross the placental membrane for the fetus (nutrition), and for removal of metabolic waste for the fetus (excretion).
3. A: Aphthous stomatitis is canker sores. Eating a soft diet and using a straw will help avoid additional trauma and contact with painful lesions allowing the child to eat. A softbristle toothbrush is recommended to avoid further trauma and irritation of the ulcers.
Antiviral drugs such as acyclovir (Zovirax) are helpful to treat herpetic lesions but are not used in the treatment of aphthous ulcers. Aphthous ulcers typically last 4 to 12 days.
4. B: Guillain-Barre syndrome, often referred to as postinfectious polyneuropathy, is a segmental demyelination of the ventral and dorsal nerve roots in the spinal cord and medulla. A decrease in acetylcholine at the neuromuscular junction is myasthenia gravis.
Parkinson’s disease is a decrease in the secretion of dopamine. Chronic inflammation, demyelination, and scarring of the CNS is characteristic of multiple sclerosis.
5. B, D, F: Neurovascular complications are assessed by a neurovascular check. Clinical manifestations of a possible neurovascular problem include pain with passive motion, pallor, pulselessness, paresthesia, pressure, and paralysis. Loss of sensation is an indication of paresthesia.
6. B: Tumor lysis is most common in clients who have received chemotherapy for leukemia lymphoma, or small cell lung cancer, within 24 to 48 hours of administration.
Flank pain is a clinical manifestation of renal failure associated with tumor lysis syndrome. Flank pain is not a typical clinical manifestation of syndrome of inappropriate antidiuretic hormone (SIADH), superior vena cava syndrome, or hypercalcium.
7. C: Although maintaining an accurate intake and output, discontinuing the Coumadin, and administering vitamin K may be anticipated, the priority intervention is to assure an
18-gauge IV needed for potential transfusion of blood, if bleeding causes hypovolemia and low hemoglobin.
8. B: Clients on an FIO2 of 50% or greater for 24 to 48 hours have a higher incidence of pulmonary fibrosis and oxygen toxicity. Atelectasis can occur but is generally reversible and therefore not the greatest concern. Expense is considered, but treatment requirements for the client take priority. Oxygen dependence is related to pulmonary disease.
9. A: Excessive production of aldosterone from the adrenal cortex (primary aldosteronism) is characterized by a severe decline in serum potassium levels causing muscle weakness and fatigue and decline in serum hydrogen ions leading to alkalosis.

Hypertension is the major sign of primary aldosteronism with serum sodium levels that are normal or elevated. Serum calcium levels are low, as the hypokalemic alkalosis may decrease the ionized serum calcium levels leading to tetany. A serum phosphorus level of
3 mg/dL is with the normal range.
10. D: A licensed practical nurse may assist a client in selecting the specific foods on a selected diet. Only a registered nurse may develop, assess, and plan interventions.
11. B: Emergency care following a chemical burn to the eye includes irrigating the eye immediately with a sterile saline or ocular solution. The irrigation should be continued for at least 10 minutes. After the irrigation, visual acuity will be assessed. Ointment or patching would retain the burn solution on the eye and cause further damage.
12. C: Diabetes is a physical illness that interferes with sexual functioning.
Schizophrenia, bipolar disorder, and anorexia do not contribute to the severity of a sexual disorder.
References
Gauwitz, D. (2007). Complete Review for the NCLEX-RN Examination. Clifton, NY: Thomson Delmar
Learning.