NCLEX # 601-650 || Questions and 100% Verified Answers.
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NCLEX # 601-650
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NCLEX # 601-650
NO.601 A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical examination are normal. How does the nurse interpret the effectiveness of the instruction about diet and weight control?
A. She is compliant with her diet as previously taught.
B...
NCLEX # 601-650 || Questions and 100% Verified Answers.
NO.601 A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The
results of her physical examination are normal. How does the nurse interpret the effectiveness of
the instruction about diet and weight control?
A. She is compliant with her diet as previously taught.
B. She needs further instruction and reinforcement.
C. She needs to increase her caloric intake.
D. She needs to be placed on a restrictive diet immediately. Correct Answer: B Explanation:
(A) She is probably not compliant with her diet and exercise program. Recommended weight
gain during second and third trimesters is approximately 12 lb. (B) Because of her excessive
weight gain of 10 lb in 2 months, she needs re-evaluation of her eating habits and reinforcement
of proper dietary habits for pregnancy. A 2200-calorie diet is recommended for most pregnant
women with a weight gain of 27-30 lb over the 9-month period. With rapid and excessive
weightgain, PIH should also be suspected. (C) She does not need to increase her caloric intake,
but she does need to re-evaluate dietary habits. Ten pounds in 2 months is excessive weight gain
during pregnancy, and health teaching is warranted. (D) Restrictive dieting is not recommended
during pregnancy.
NO.602 A 47-year-old client comes to the emergency department complaining of moderate
flank, abdominal, and testicular pain with nausea of 4 hours' duration. After physical
examination and obtaining the client's history, the physician suspects urethral obstruction by
calculi. The nurse realizes that the physician will order which one of the following diagnostic
studies to best confirm the diagnosis?
A. Cystoscopy
B. Kidneys, ureter, bladder, x-ray of abdomen
C. Intravenous pyelogram with excretory urogram
D. Ureterolithotomy Correct Answer: C Explanation:
(A) Cystoscopy is an endoscopic procedure that uses an instrument (a cystoscope) to visualize
the internal bladder and ureter structures and to capture and remove an obstructing stone. (B)
Kidney,
ureter, bladder x-ray is used to outline gross structural changes in the kidneys, ureter, and bladder
and will determine the general location of a stone. (C) An intravenous pyelogram with excretory
urogram is used to visualize the kidneys, kidney pelvis, ureters, and bladder. This procedure is
used specifically to determine whether urethral obstruction is partial or complete; it shows the
exact location of the stone and dilation of the ureter above the stone. (D) Ureterolithotomy is a
surgical procedure in which the ureter is incised and the stone is manually removed because the
stone is unable to pass through the ureter independently.
NO.603 A child has a nursing diagnosis of fluid volume excess related to compromised
regulatory mechanisms. Which of the following nursing interventions is the most accurate
measure to include in his care?
A. Weigh the child twice daily on the same scale.
B. Monitor intake and output.
C. Check urine specific gravity of each voiding.
,D. Observe for edema. Correct Answer: A Explanation:
(A) Although all of these interventions are important aspects of care, weight is the most sensitive
indicator of fluid balance. (B) Although monitoring intake and output is important, weight is a
more accurate indicator of fluid status. (C) Urine specific gravity does not necessarily
indicatefluid volume excess. (D) Edema may not be apparent, yet the client may have fluid
volume excess.
NO.604 A client is being discharged from the hospital today. The discharge teaching for care of
her colostomy included which of the following basic principles for protecting the skin around her
stoma:
A. Taping a pouch that is leaking
B. Cutting the skin barrier 112 inches larger than the stoma
C. Changing the pouch only when leakage occurs
D. Using a skin sealant under pouch adhesives Correct Answer: D Explanation:
(A) When a pouch seal leaks, the pouch should be immediately changed, not taped. Stool held
against the skin can quickly result in severe irritation. (B) The skin barrier should be cut only
slightly larger than the stoma (one-half inch). (C) The client should be taught to change pouches
whenever possible before leakage occurs. (D) When skin sealant is used under the tape, the
outermost layer of the epidermis remains intact. When no skin sealant
is used, this layer is removed when the tape is removed.
NO.605 A 22-year-old client who is being seen in the clinic for a possible asthma attack stops
wheezing suddenly as the nurse is doing a lung assessment. Which one of the following nursing
interventions is most important?
A. Place the client in a supine position.
B. Draw a blood sample for arterial blood gases.
C. Start O2 at 4 L/min.
D. Establish a patent airway. Correct Answer: D Explanation:
(A) During impending respiratory failure or asthmatic complications, the client is placed in the
high- Fowler position to facilitate comfort and promote optimal gas exchange. (B) Arterial blood
gases are monitored in the treatment of respiratory failure during an asthma attack, but it is not
an initial intervention. (C) O2 therapy is used during an asthma attack, but it is not the initial
intervention. The usual prescribed amount is a cautiously low flow rate of 1-2 L/min. (D)
Wheezing is a characteristic clinical finding during an asthma attack. If wheezing
suddenlyceases, it usually indicates a complete airway obstruction and requires immediate
treatment for respiratory failure or arrest.
NO.606 The physician orders fluoxetine (Prozac) for a depressed client. Which of the following
should the nurse remember about fluoxetine?
A. Because fluoxetine is a tricyclic antidepressant, it may precipitate a hypertensive crisis.
B. The therapeutic effect of the drug occurs 2-4 weeks after treatment is begun.
C. Foods such as aged cheese, yogurt, soy sauce, and bananas should not be eaten with this drug.
D. Fluoxetine may be administered safely in combination with monoamine oxidase (MAO)
inhibitors. Correct Answer: B Explanation:
(A) Fluoxetine is not a tricyclic antidepressant. It is an atypical antidepressant. (B) This
statement is true. (C) These foods are high in tyramine and should be avoided when the client is
, taking MAO inhibitors. Fluoxetine is not an MAO inhibitor. (D) Fatal reactions have been
reported in clients receiving fluoxetine in combination with MAO inhibitors.
NO.607 The following medications were noted on review of the client's home medication
profile. Which of the medications would most likely potentiate or elevate serum digoxin levels?
A. KCl
B. Thyroid agents
C. Quinidine
D. Theophylline Correct Answer: C Explanation:
(A) Hypokalemia can cause digoxin toxicity. Administration of KCl would prevent this. (B)
Thyroid agents decrease digoxin levels. (C) Quinidine increases digoxin levels dramatically. (D)
Theophylline is not noted to have an effect on digoxin levels.
NO.608 In discussing the plan of care for a child with chronic nephrosis with the mother, the
nurse identifies that the purpose of weighing the child is to:
A. Measure adequacy of nutritional management
B. Check the accuracy of the fluid intake record
C. Impress the child with the importance of eating well
D. Determine changes in the amount of edema Correct Answer: D
Explanation:
(A) Weighing a child with nephrosis is to assess for edema, not nutrition. (B, C) This is not the
purpose for weighing the child. (D) Weight and measurement are the primary ways of evaluating
edema and fluid shifts.
NO.609 The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It
would be correct for the nurse to explain that with cigarette smoking there is increased risk that
the baby will have:
A. Nicotine withdrawal
B. A birth defect
C. Anemia
D. A low birth weight Correct Answer: D Explanation:
(A) Women who smoke during pregnancy are at increased risk for miscarriage, preterm labor,
and IUGR in the fetus. (B) Although smoking produces harmful effects on the maternal vascular
system and the developing fetus, it has not been directly linked to fetal anomalies. (C) Smoking
during pregnancy has not been directly linked to anemia in the fetus. (D) Smoking during
pregnancy has not been linked to nicotine withdrawal symptoms in the newborn.
NO.610 The primary reason for sending a burn client home with a pressure garment, such as a
Jobst garment, is that the garment:
A. Decreases hypertrophic scar formation
B. Assists with ambulation
C. Covers burn scars and decreases the psychological impact during recovery
D. Increases venous return and cardiac output by normalizing fluid status Correct Answer: A
Explanation:
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