Sample NCLEX Questions l Nursing Board Exam Question Part 5

1.) An eleven-month-old infant is brought to the pediatric clinic. The nurse suspects that the child has iron deficiency anemia. Because iron deficiency anemia is suspected, which of the following is the most important information to obtain from the infant’s parents?
1.Normal dietary intake.
2.Relevant sociocultural, economic, and educational background of the family.
3.Any evidence of blood in the stools.
4.A history of maternal anemia during pregnancy.

Answer no. 1
Rationale:
Iron deficiency anemia occurs commonly in children 6 to 24 months of age. For the first 4 to 5 months of infancy iron stores laid down for the baby during pregnancy are adequate. When fetal iron stores are depleted, supplemental dietary iron needs to be supplied to meet the infant’s rapid growth needs. Iron deficiency may occur in the infant who drinks mostly milk, which contains no iron, and does not receive adequate dietary iron or supplemental iron.

2.) Ms.Ericka has hyperthyroidism and is scheduled for a thyroidectomy. The physician has ordered Lugol’s solution for the client. The nurse understands that the primary reason for giving Lugol’s solution preoperatively is to
1.Decrease the risk of agranulocytosis postoperatively.
2.Prevent tetany while the client is under general anesthesia.
3.Reduce the size and vascularity of the thyroid and prevent hemorrhage.
4.Potentiate the effect of the other preoperative medication so less medicine can be given while the client is under anesthesia.

Answer no. 3
Rationale:
The client may receive iodine solution (Lugol’s solution) for 10 to 14 days before surgery to decrease vascularity of the thyroid and thus prevent excess bleeding.

3.) A four-year-old girl was in a car accident with her family. Upon arrival in the emergency room, she is noted to have lacerations on her head and arms, a temperature of 39° C, BP 158/102, pulse 60, and sluggish pupil reactions. She is crying and does not recognize her family. The nurse recognizes these manifestations as possible evidence of
1.Elevated intracranial pressure.
2.Reye’s syndrome.
3.Guillain-Barré syndrome.
4.Anxiety attack related to being in a strange environment.

Answer no. 1
Rationale:
Head injury is one situation that may cause elevated intracranial pressure. Clinical manifestations include the ones listed in the question.

4.) A client has been trying for several months to become pregnant. At long last, the nurse receives the results of the laboratory tests that confirm the pregnancy, and, at the request of the physician, telephones the client to tell her the good news. The client’s husband answers the phone, stating that his wife is not home. The nurse congratulates him on his impending fatherhood, and asks that his wife call as soon as she returns. When the wife calls later that day, she is distant and cool to the nurse. How can the nurse best interpret this behavior?
1.The wife may be having second thoughts about the pregnancy.
2.Depression is common in early stages of pregnancy due to hormonal changes.
3.The stresses of long-awaited pregnancy often place a strain on a marriage.
4.The nurse violated the client’s privacy by telling her husband the test results.

Answer no. 4
Rationale:
The ethical principle of autonomy is the basis for the client’s right to expect that the nurse will hold personal information in confidence, even when the news is good.

5.) The nurse is evaluating the infection control procedures on the unit. Which finding indicates a break in technique and the need for education of staff?
1.The nurse aide is not wearing gloves when feeding an elderly client.
2.A client with active tuberculosis is asked to wear a mask when he leaves his room to go to another department for testing.
3.A nurse with open, weeping lesions of the hands puts on gloves before giving direct client care.
4.The nurse puts on a mask, a gown, and gloves before entering the room of a client on strict isolation.

Answer no. 3
Rationale:
Persons with exudative lesions or weeping dermatitis should not give direct client care or handle client-care equipment until the condition resolves.