PART = 3 Now 


  [Q.NO.201 -250 ]

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📖Read NCLEX Practice Questions Answer part 3 Give Below -

201. A client has cancer of the liver. The nurse should be most concerned about which nursing diagnosis? 
❍ A. Alteration in nutrition 
❍ B. Alteration in urinary elimination 

❍ C. Alteration in skin integrity 

❍ D. Ineffective coping

202. The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites? 
❍ A. Inspection of the abdomen for enlargement 
❍ B. Bimanual palpation for hepatomegaly 
❍ C. Daily measurement of abdominal girth 
❍ D. Assessment for a fluid wave 

203. The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 68/34, pulse rate 130, and respirations 18. Which is the client’s most appropriate priority nursing diagnosis? 

❍ A. Alteration in cerebral tissue perfusion 
❍ B. Fluid volume deficit 
❍ C. Ineffective airway clearance 
❍ D. Alteration in sensory perception 

204. The home health nurse is visiting a 15-year-old with sickle cell disease. Which information obtained on the visit would cause the most concern? The client: 
❍ A. Likes to play baseball 
❍ B. Drinks several carbonated drinks per day 
❍ C. Has two sisters with sickle cell trait 
 D. Is taking Tylenol to control pain 

205. The nurse on oncology is caring for a client with a white blood count of 600. During evening visitation, a visitor brings a potted plant. What action should the nurse take? 

❍ A. Allow the client to keep the plant 
❍ B. Place the plant by the window 
❍ C. Water the plant for the client 
❍ D. Tell the family members to take the plant home 

206. The nurse is caring for the client following a thyroidectomy when suddenly the client becomes nonresponsive and pale, with a BP of 60 systolic. The nurse’s initial action should be to: 

❍ A. Lower the head of the bed 
❍ B. Increase the infusion of normal saline 
❍ C. Administer atropine IV 
❍ D. Obtain a crash cart

207. The client pulls out the chest tube and fails to report the occurrence to the nurse. When the nurse discovers the incidence, he should take which initial action? 

❍ A. Order a chest x-ray 
❍ B. Reinsert the tube 
❍ C. Cover the insertion site with a Vaseline gauze 
❍ D. Call the doctor 

208. A client being treated with sodium warfarin has an INR of 8.0. Which intervention would be most important to include in the nursing care plan? 

❍ A. Assess for signs of abnormal bleeding 

❍ B. Anticipate an increase in the Coumadin dosage 
❍ C. Instruct the client regarding the drug therapy 
❍ D. Increase the frequency of neurological assessments 

209. Which snack selection by a client with osteoporosis indicates that the client understands the dietary management of the disease? 

❍ A. A granola bar 
❍ B. A bran muffin 
❍ C. Yogurt 
❍ D. Raisins 

210. The client with preeclampsia is admitted to the unit with an order for magnesium sulfate IV. Which action by the nurse indicates a lack of understanding of magnesium sulfate? 

❍ A. The nurse places a sign over the bed not to check blood pressures in the left arm. 
❍ B. The nurse obtains an IV controller. 
❍ C. The nurse inserts a Foley catheter. 
❍ D. The nurse darkens the room. 

211. The nurse is caring for a 12-year-old client with appendicitis. The client’s mother is a Jehovah’s Witness and refuses to sign the blood permit. What nursing action is most appropriate? 

❍ A. Give the blood without permission 
❍ B. Encourage the mother to reconsider 
❍ C. Explain the consequences without treatment 
❍ D. Notify the physician of the mother’s refusal

212. A client is admitted to the unit 2 hours after an injury with second-degree burns to the face, trunk, and head. The nurse would be most concerned with the client developing what? 

❍ A. Hypovolemia 
❍ B. Laryngeal edema 
❍ C. Hypernatremia 
❍ D. Hyperkalemia 

213. The nurse is evaluating nutritional outcomes for an elderly client with anorexia nervosa. Which data best indicates that the plan of care is effective

❍ A. The client selects a balanced diet from the menu. 
❍ B. The client’s hematocrit improves. 
❍ C. The client’s tissue turgor improves. 

❍ D. The client gains weight. 
214. The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor? 
❍ A. Pain beneath the cast 
❍ B. Warm toes 
❍ C. Pedal pulses weak and rapid 
❍ D. Paresthesia of the toes 

215. The client is having a cardiac catheterization. During the procedure, the client tells the nurse, “I’m feeling really hot.” Which response would be best? 
❍ A. “You are having an allergic reaction. I will get an order for Benadryl.” 
❍ B. “That feeling of warmth is normal when the dye is injected.” 
❍ C. “That feeling of warmth indicates that the clots in the coronary vessels are dissolving.” 
❍ D. “I will tell your doctor and let him explain to you the reason for the hot feeling that you are experiencing.” 

216. Which action by the healthcare worker indicates a need for further teaching? 

❍ A. The nursing assistant wears gloves while giving the client a bath. 
❍ B. The nurse wears goggles while drawing blood from the client. 
❍ C. The doctor washes his hands before examining the client. 
❍ D. The nurse wears gloves to take the client’s vital signs.
217. The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective? 

❍ A. The client loses consciousness. 
❍ B. The client vomits. 
❍ C. The client’s ECG indicates tachycardia. 
❍ D. The client has a grand mal seizure

218. The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to: 

❍ A. Place tape on the child’s perianal area before putting the child to bed 

❍ B. Scrape the skin with a piece of cardboard and bring it to the clinic 
❍ C. Obtain a stool specimen in the afternoon 
❍ D. Bring a hair sample to the clinic for evaluation 

219. The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication? 

❍ A. Treatment is not recommended for children less than 10 years of age. 
❍ B. The entire family should be treated. 
❍ C. Medication therapy will continue for 1 year. 
❍ D. Intravenous antibiotic therapy will be ordered

220. The registered nurse is making assignments for the day. Which client should not be assigned to the pregnant nurse?

❍ A. The client receiving linear accelerator radiation therapy for lung cancer 
❍ B. The client with a radium implant for cervical cancer 
❍ C. The client who has just been administered soluble brachytherapy for thyroid cancer 
❍ D. The client who returned from an intravenous pyelogram 

221. Which client is at risk for opportunistic diseases such as pneumocystis pneumonia? 

❍ A. The client with cancer who is being treated with chemotherapy 
❍ B. The client with Type I diabetes 
❍ C. The client with thyroid disease 
❍ D. The client with Addison’s disease

222. The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with: 

❍ A. Negligence 
❍ B. Tort 
❍ C. Assault 
❍ D. Malpractice 

223. Which assignment should not be performed by the registered nurse? 

❍ A. Inserting a Foley catheter 
❍ B. Inserting a nasogastric tube 
❍ C. Monitoring central venous pressure 
❍ D. Inserting sutures and clips in surgery 

224. The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority? 

❍ A. Document the finding. 
❍ B. Contact the physician. 
❍ C. Elevate the head of the bed. 
❍ D. Administer a pain medication. 

225. Which nurse should be assigned to care for the postpartal client with preeclampsia? 

❍ A. The RN with 2 weeks of experience in postpartum 
❍ B. The RN with 3 years of experience in labor and delivery 
❍ C. The RN with 10 years of experience in surgery 
❍ D. The RN with 1 year of experience in the neonatal intensive care unit 

226. Which medication is used to treat iron toxicity? 

❍ A. Narcan (naloxane) 
❍ B. Digibind (digoxin immune Fab) 
❍ C. Desferal (deferoxamine) 
❍ D. Zinecard (dexrazoxane) 

227. The nurse is suspected of charting medication administration that he did not give. The nurse can be charged with: 

❍ A. Fraud 
❍ B. Malpractice 
❍ C. Negligence 
❍ D. Tort

228. The home health nurse is planning for the day’s visits. Which client should be seen first? 

❍ A. The client with renal insufficiency 
❍ B. The client with Alzheimer’s 
❍ C. The client with diabetes who has a decubitus ulcer 
❍ D. The client with multiple sclerosis who is being treated with IV cortisone 

229. The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?

❍ A. A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis 
❍ B. The client who is six months pregnant with abdominal pain and the client with facial lacerations and a broken arm 
❍ C. A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury 
❍ D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain 

230. The nurse is caring for a 6-year-old client admitted with the diagnosis of conjunctivitis. Before administering eyedrops, the nurse should recognize that it is essential to consider which of the following? 

❍ A. The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops. 
❍ B. The child should be allowed to instill his own eyedrops. 
❍ C. Allow the mother to instill the eyedrops. 
❍ D. If the eye is clear from any redness or edema, the eyedrops should be held.

231. To assist with the prevention of urinary tract infections, the teenage girl should be taught to:
❍ A. Drink citrus fruit juices 
❍ B. Avoid using tampons 
❍ C. Take showers instead of tub baths per 
❍ D. Clean the perineum from front to back

232. A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect? 

❍ A. Ask the parent/guardian to leave the room when assessments are being performed. 
❍ B. Ask the parent/guardian to take the child’s favorite blanket home because anything from the outside should not be brought into the hospital. 
❍ C. Ask the parent/guardian to room-in with the child. 
❍ D. If the child is screaming, tell him this is inappropriate behavior. 

233. Which instruction should be given to the client who is fitted for a behindthe-ear hearing aid? 

❍ A. Remove the mold and clean every week. 
❍ B. Store the hearing aid in a warm place. 
❍ C. Clean the lint from the hearing aid with a toothpick. 
❍ D. Change the batteries weekly

234. A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is: 

❍ A. Body image disturbance 
❍ B. Impaired verbal communication 
❍ C. Risk for aspiration 
❍ D. Pain 

235. A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal? 

❍ A. High fever 
❍ B. Nonproductive cough 
❍ C. Rhinitis 
❍ D. Vomiting and diarrhea 

236. The nurse is caring for a client admitted with acute laryngotracheobronchitis (LTB). Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available? 

❍ A. Intravenous access supplies 
❍ B. Emergency intubation equipment 
❍ C. Intravenous fluid-administration pump 
❍ D. Supplemental oxygen

237. A 5-year-old client with hyperthyroidism is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal? 

❍ A. Bradycardia 
❍ B. Decreased appetite 
❍ C. Exophthalmos 
❍ D. Weight gain 

238. The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions? 

❍ A. Whole-wheat bread 
❍ B. Spaghetti 
❍ C. Hamburger on wheat bun with ketchup 
❍ D. Cheese omelet 

239. The nurse is caring for a 9-year-old child admitted with asthma. Upon the morning rounds, the nurse finds an O2 sat of 78%. Which of the following actions should the nurse take first? 

❍ A. Notify the physician 
❍ B. Do nothing; this is a normal O2 sat for a 9-year-old 
❍ C. Apply oxygen 
❍ D. Assess the child’s pulse 

240. A gravida II para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse expect to make immediately after the amniotomy? 

❍ A. Fetal heart tones 160 beats per minute 
❍ B. A moderate amount of clear fluid 
❍ C. A small amount of greenish fluid 
❍ D. A small segment of the umbilical cord 

241. The client is admitted to the unit. A vaginal exam reveals that she is 3cm dilated. Which of the following statements would the nurse expect her to make? 

❍ A. “I can’t decide what to name the baby.” 
❍ B. “It feels good to push with each contraction.” 
❍ C. “Don’t touch me. I’m trying to concentrate.” 
❍ D. “When can I get my epidural?”

242. The client is having fetal heart rates of 100–110 beats per minute during the contractions. The first action the nurse should take is to: 

❍ A. Apply an internal monitor 
 B. Turn the client to her side 
❍ C. Get the client up and walk her in the hall 
❍ D. Move the client to the delivery room 

243. In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect: 

❍ A. A rapid delivery 
❍ B. Cervical effacement 
❍ C. Infrequent contractions 
❍ D. Progressive cervical dilation 

244. A vaginal exam reveals a breech presentation in a newly admitted client. The nurse should take which of the following actions at this time? 

❍ A. Prepare the client for a caesarean section 
❍ B. Apply the fetal heart monitor 
❍ C. Place the client in the Trendelenburg position 
❍ D. Perform an ultrasound exam 

245. The nurse is caring for a client admitted to labor and delivery. The nurse is aware that the infant is in distress if she notes: 

❍ A. Contractions every three minutes 
❍ B. Absent variability 
❍ C. Fetal heart tone accelerations with movement 
❍ D. Fetal heart tone 120–130bpm 

246. The following are all nursing diagnoses appropriate for a gravida 4 para 3 in labor. Which one would be most appropriate for the client as she completes the latent phase of labor? 

❍ A. Impaired gas exchange related to hyperventilation 
❍ B. Alteration in placental perfusion related to maternal position 
❍ C. Impaired physical mobility related to fetal-monitoring equipment 
❍ D. Potential fluid volume deficit related to decreased fluid intake

247. As the client reaches 8cm dilation, the nurse notes a pattern on the fetal monitor that shows a drop in the fetal heart rate of 30bpm beginning at the peak of the contraction and ending at the end of the contraction. The FHR baseline is 165–175bpm with variability of 0–2bpm. What is the most likely explanation of this pattern? 

❍ A. The baby is asleep. 
❍ B. The umbilical cord is compressed. 
❍ C. There is a vagal response. 
❍ D. There is uteroplacental insufficiency. 

248. The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to: 

❍ A. Notify her doctor 

❍ B. Increase the rate of IV fluid 

❍ C. Reposition the client 

❍ D. Readjust the monitor 

249. Which of the following is a characteristic of a reassuring fetal heart rate pattern? 

❍ A. A fetal heart rate of 180bpm 

❍ B. A baseline variability of 35bpm 

❍ C. A fetal heart rate of 90 at the baseline 

❍ D. Acceleration of FHR with fetal movements 

250. The nurse asks the client with an epidural anesthesia to void every hour during labor. The rationale for this intervention is: 

❍ A. The bladder fills more rapidly because of the medication used for the epidural. 

❍ B. Her level of consciousness is altered. 

❍ C. The sensation of the bladder filling is diminished or lost. 

❍ D. She is embarrassed to ask for the bedpan that frequently 




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