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NCLEX National Council Licensure Examination(NCLEX-RN) Sample Questions (Q652-Q657):

NEW QUESTION # 652
A client with severe PIH receiving MgSO4 is placed in a quiet, darkened room. The nurse bases this action on the following understanding:

A. Noise or bright lights may precipitate a convulsion.
B. The elevated blood pressure causes photophobia.
C. External stimuli are annoying to the client with PIH.
D. The client is restless.

Answer: A

Explanation:
Explanation/Reference:
Explanation:
(A) The client may be anxious and hyperresponsive to stimuli but not necessarily restless. (B) This is not a physiological response to an elevated blood pressure in PIH. (C) The nurse must know the nursing measures that decrease the potential for convulsions. A quiet, darkened room decreases stimuli and promotes rest. (D) External stimuli might induce a convulsion but are not annoying to the client with PIH.

NEW QUESTION # 653
A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 lb from her 7th to 8th month; her face and hands indicate edema. She is diagnosed as having PIH and referred to the high-risk prenatal clinic. The client's weight increase is most likely due to:

A. Obesity prior to conception
B. Fluid retention
C. Overeating and subsequent obesity
D. Hypertension due to kidney lesions

Answer: B

Explanation:
(A) Overeating can lead to obesity, but not to edema. (B) There is no indication of obesity prior to pregnancy. PIH is more prevalent in the underweight than in the obese in this age group. (C) Hypertension can be due to kidney lesions, but it would have been apparent earlier in the pregnancy. (D) The weight gain in PIH is due to the retention of sodium ions and fluid and is one of the three cardinal symptoms of PIH.

NEW QUESTION # 654
During a client's first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus.
This may be due to:

A. Displacement due to bowel distention
B. Endometritis
C. Fibroid tumor on the uterus
D. Urine retention or a distended bladder

Answer: D

Explanation:
(A, B) Endometritis, urine retention, or bladder distention provide good distractors because they may delay involution but do not usually cause the uterus to be lateral. (C) Bowel
distention and constipation are common in the postpartum period but do not displace the uterus laterally. (D) Urine retention or bladder distention commonly displaces the uterus to the right and may delay involution.

NEW QUESTION # 655
Medication is administered to a client who has been placed in restraints after a sudden violent episode, and his EPSs subside. Restraints can be removed when:

A. The physician orders it
B. The violent behavior subsides, and the client agrees to behave
C. A therapeutic alliance has been established, and violent behavior subsides
D. The nurse deems that removal of restraints is necessary

Answer: C

Explanation:
(A) The physicianmayorder release of restraints, but prior to that, the client must meet criteria for release. (B) While the client is still restrained, but after violent behavior has subsided, a therapeutic bridge is built. This alliance encourages dialogue between nurse and client, allowing the client to determine causative factors, feelings prior to loss of control, and adaptive alternatives to violence. (C) If the client only "agrees to behave" after violent behavior subsides, he has developed no insight into cause and effect of violence or his response to stress. (D)Removal of restraints occurs only when the client meets the criteria for release, not just because the nurse says it is necessary.

NEW QUESTION # 656
Which nursing implication is appropriate for a client undergoing a paracentesis?

A. Keep the client NPO.
B. Place the client on the right side following the procedure.
C. Observe the client for hypertension following the procedure.
D. Have the client void before the procedure.

Answer: D

Explanation:
Section: Questions Set B
Explanation:
(A) A full bladder would impede withdrawal of ascitic fluid. (B) Keeping the client NPO is not necessary. (C) The client may exhibit signs and symptoms of shock and hypertension. (D) No position change is needed after the procedure.

NEW QUESTION # 657
......

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Sam Martin Sam Martin

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