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NCLEX-RN dumps review - Professional Quiz Study Materials
NCLEX-RN exam consists of a minimum of 75 questions and a maximum of 265 questions, with a time limit of six hours. The questions are computer-adaptive, which means that the difficulty level of the questions will increase or decrease based on the test taker's performance. NCLEX-RN exam covers a wide range of topics, including patient care, health promotion, pharmacology, and nursing practice. The NCLEX-RN exam is a challenging and rigorous test, but passing it is a critical step for aspiring nurses to begin their careers in nursing.
NEW QUESTION # 74
The nurse enters the room of a client on which a "do not resuscitate" order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, "please save her!" The nurse's action would be:
- A. Call a code and proceed with cardiopulmonary resuscitation.
- B. Discuss with the husband that these orders are written only on clients who are not likely to recover with resuscitative efforts.
- C. Remind the husband that the physician wrote an order not to resuscitate.
- D. Call the physician and inform him that the client has expired.
Answer: A
Explanation:
Section: Questions Set G
Explanation:
(A, B, C) The last request from the husband overrides the decision not to initiate resuscitation efforts. (D) The nurse should begin cardiopulmonary resuscitation unless a living will and durable power of attorney are in force. In the meantime, the nurse should talk with the husband and notify the doctor.
NEW QUESTION # 75
The nurse working with a client who is out of control should follow a model of intervention that includes which of the following?
- A. To ensure safety of other clients, place client in seclusion immediately when he or she begins shouting.
- B. Challenge client's behavior immediately with steps to prevent injury to self or others.
- C. Approach the client on a continuum of least restrictive care.
- D. Leave the aggressive client to himself or herself, and take other clients away.
Answer: C
Explanation:
Explanation
(A) Approaching a client's aggressive behavior on a continuum of least restrictive care is in agreement with his or her rights (i.e., verbal methods to help maintain control, medication, seclusion, and restraints, as necessary). (B) Approaching a client in a challenging manner is threatening and inappropriate. A nonchallenging and calm approach reflects staff in control and may increase client's internal control. (C) It is inappropriate to leave an aggressive client who is acting out alone. The nurse should acquire qualified help to prevent client from harm or injury to self or others. (D) Moving a client to seclusion immediately for shouting is inappropriate. The nurse should offer the client an opportunity to control self with limit setting. The client should understand that the staff will assist with control if necessary (i.e., quietly accompany out of environment to decrease stimulation and allow for verbalization) employing the least restrictive care model of intervention.
NEW QUESTION # 76
A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony. Which of the following nursing implementations would be most effective in helping him cope with immobility?
- A. Allowing him to do as much for himself as he is able, including learning to do pin-site care under supervision
- B. Providing him with books, challenging puzzles, and games as diversionary activities
- C. Stimulating rest and relaxation by gentle rubbing with lotion and changing the client's position frequently
- D. Having a volunteer come in to sit with the client and to read him stories
Answer: A
Explanation:
(A) These activities could be frustrating for the client if he is having difficulty with problem solving and concentration. (B) Selfcare is usually well received by the child, and it is one of the most useful interventions to help the child cope with immobility. (C) This may be helpful to the client if he has no visitors, but it does little to help him develop coping skills. (D) This will helpto prevent skin irritation or breakdown related to immobility but will not help to prevent behavioral changes related to immobility.
NEW QUESTION # 77
A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL system to record her obstetrical history, the nurse should record:
- A. 2-2-0-2-2
- B. 2-1-1-0-2
- C. 3-1-1-0-2
- D. 3-2-0-0-2
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) This answer is an incorrect application of the GTPAL method.
One prior pregnancy was a preterm birth at 36 weeks (T =1, P= 1; not T = 2). (B) This answer is an incorrect application of the GTPAL method. The client is currently pregnant for the third time (G = 3, not 2), one prior pregnancy was preterm (T= 1, P= 1; not T= 2), and she has had no prior abortions (A =0). (C) This answer is the correct application of GTPAL method. The client is currently pregnant for the third time (G =3), her first pregnancy ended at term (>37 weeks) (T = 1), her second pregnancy ended preterm 20-
33 weeks) (P = 1), she has no history of abortion (A=0), and she has two living children (L = 2). (D) This answer is an incorrect application of the GTPAL method. The client is currently pregnant for the third time (G =3, not 2).
NEW QUESTION # 78
A client is resting comfortably after delivering her first child. When assessing her pulse rate, the nurse would recognize the following finding to be typical:
- A. Thready pulse
- B. Bradycardia
- C. Irregular pulse
- D. Tachycardia
Answer: B
Explanation:
(A)
A thready pulse is indicative of hypotension and excessive blood loss and is often rapid.
(B)
Pulse irregularities or dysrhythmias do not occur in the normal postpartal woman. (C) Tachycardia occurs less frequently than bradycardia and is related to increased blood loss or prolonged difficult labor and/or birth. (D) Puerperal bradycardia with rates of 50-70 bpm commonly occurs during the first 6-10 days of the postpartal period. It may be related to decreased cardiac strain, decreased blood volume, contraction of the uterus, and increased stroke volume.
NEW QUESTION # 79
A registered nurse is trying to determine the appropriate care that she should provide for her obstetrical clients. Which of the following documents is considered the legal standard of practice?
- A. International Council of Nurses' Code
- B. American Nurses' Association Standards of Maternal- Child Health Nursing
- C. AWHONN Standards for the Nursing Care of Women and Newborns
- D. State nursing practice act
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) The state nursing practice act determines the standard of care for the professional nurse. (B) AWHONN Standards are published as recommendations and guidelines for maternal-newborn nursing. (C) American Nurses' Association Standards are published as recommendations and guidelines for maternalchild health nursing. (D) The International Council of Nurses' Code emphasizes the nurse's obligations to the client rather than to the physician. It is published as recommendations and guidelines by the international organization for professional nursing.
NEW QUESTION # 80
A 6-year-old girl is visiting the outpatient clinic because she has a fever and a rash. The doctor diagnoses chickenpox. Her mother asks the nurse how many baby aspirins her daughter can have for fever. The nurse should:
- A. Assess the function of the client's cranial nerve VIII
- B. Ask if the client is allergic to aspirin before giving further information
- C. Check the aspirin bottle label to determine milligrams per tablet
- D. Advise the mother not to give her aspirin
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Aspirin taken during a viral infection has been implicated as a predisposing factor to Reye's syndrome in children and adolescents. Children and adolescents should not be given aspirin. (B) Allergy to aspirin is not related to Reye's syndrome. (C) Tinnitus, caused by damage to the acoustic nerve, occurs with aspirin toxicity, but this is not related to Reye's syndrome. (D) A 6-year-old child should not be given any baby aspirin.
NEW QUESTION # 81
A male client is diagnosed with hypoparathyroidism. He has been on dialysis for several years. He is experiencing symptoms such as numbness of the lips, muscle weakness, carpopedal spasms, and wheezing.
Given the client's symptoms, nursing assessment would focus on:
- A. Detection of tetany
- B. Evidence of depression
- C. Detection of premature cataract formation
- D. Detection of hypocalcemia to prevent seizures
Answer: A
Explanation:
Section: Questions Set D
Explanation:
(A) Assessment should focus on detection of tetany, which is the most common symptom of hypoparathyroidism. Left undetected and untreated, tetany resulting from hypocalcemia can progress to seizures. (B) Hypocalcemia is difficult to detect on nursing assessment alone. Abdominal cramping may be an indication of hypocalcemia, but laboratory data are required to confirm diagnosis. (C) Depression can be a symptom of hypoparathyroidism, but it is not definitive. (D) Premature cataract formation can occur, but it also is not specific to parathyroidism and poses no immediate danger to the client.
NEW QUESTION # 82
A parent told the public health nurse that her 6-year-old son has been taking tetracycline for a chronic skin condition. The parent asked if this could cause any problems for the child. What should the nurse explain to the parent?
- A. If you give tetracycline with milk, it may be absorbed readily.
- B. Secondary infections of chronic skin disorders do not respond to antibiotics.
- C. The medication should be given to adults, not children.
- D. Giving tetracycline to a child younger than 8 years may cause permanent staining of his teeth.
Answer: D
Explanation:
(A) Tetracycline should be avoided during tooth development because it interferes with enamel formation and dental pigmentation. (B) Milk interferes with the absorption of tetracyclines. (C) Children older than 9 years or past the tooth development stage may be given tetracycline. (D) Secondary infections of chronic skin disorders may respond to antibiotics such as penicillin or tetracyclines.
NEW QUESTION # 83
A male client has been hospitalized with congestive heart failure. Medical management of heart failure focuses on improving myocardial contractility. This can be achieved by administering:
- A. Furosemide (Lasix) 40 mg po every morning
- B. Nitroglycerin (Nitrol) 1 inch topically every 4 hours
- C. O22 L/min via nasal cannula
- D. Digoxin (Lanoxin) 0.25 mg po every day
Answer: D
Explanation:
Explanation
(A) Digoxin is a cardiac glycoside given to clients in heart failure to improve their myocardial contractility.
(B) Furosemide is a loop diuretic given to clients in heart failure to promote diuresis. (C) O2is given to clients in heart failure to increase oxygenation and to prevent or treat hypoxemia. (D) Nitroglycerin is a nitrate given to clients in heart failure to increase their cardiac output by decreasing the peripheral resistance that the left ventricle must pump against.
NEW QUESTION # 84
A 45-year-old client diagnosed with major depression is scheduled for electroconvulsive therapy (ECT) in the morning. Which of the following medications are routinely administered either before or during ECT?
- A. Atropine, sodium brevitol, and succinylcholine chloride (Anectine)
- B. Sodium, potassium, and magnesium
- C. Thioridazine (Mellaril), lithium, and benztropine
- D. Carbamazepine (Tegretol), haloperidol, and trihexyphenidyl (Artane)
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Thioridazine (an antipsychotic drug), lithium (an antimanic drug), and benztropine (an antiparkinsonism agent) are generally administered to treat schizophrenic and bipolar disorders. (B) Atropine (a cholinergic blocker), sodium brevitol (a shortacting anesthetic), and succinylcholine (a neuromuscular blocker) are administered either before or during ECT to coun teract bradycardia and to provide anesthesia and total muscle relaxation. (C) These are electrolyte substances administered to correct fluid and electrolyte imbalances in the body. (D) Carbamazepine (an anticonvulsant), haldoperidol (an antipsychotic), and trihexyphenydyl (an antiparkinsonism agent) are usually administered in psychiatric settings to control problems associated with psychotic behavior.
NEW QUESTION # 85
After 7 hours in restraints and a total of 30-mg haloperidol in divided doses, a client complains of stiffness in his neck and his tongue "pulling to one side." These extrapyramidal symptoms (EPS) will most likely be relieved by the administration of:
- A. Benztropine (Cogentin)
- B. Thiothixene (Navane)
- C. Flurazepan (Dalmane)
- D. Lorazepam (Ativan)
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Lorazepam is an antianxiety agent that produces muscle relaxation and inhibits cortical and limbic arousal. It has no action in the basal ganglia of the brain. (B) Benztropine acts to reduce EPS by blocking excess CNS cholinergic activity associated with dopamine deficiency in the basal ganglia by displacing acetylcholine at the receptor site. (C) Thiothixene is an antipsychotic known to block dopamine in the limbic system, thereby causing EPS. (D) Flurazepan is a hypnotic that acts in the limbic system, thalamus, and hypothalamus of the CNS to produce sleep. It has no known action in the vasal ganglia.
NEW QUESTION # 86
The nurse working with a client who is out of control should follow a model of intervention that includes which of the following?
- A. To ensure safety of other clients, place client in seclusion immediately when he or she begins shouting.
- B. Challenge client's behavior immediately with steps to prevent injury to self or others.
- C. Approach the client on a continuum of least restrictive care.
- D. Leave the aggressive client to himself or herself, and take other clients away.
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Approaching a client's aggressive behavior on a continuum of least restrictive care is in agreement with his or her rights (i.e., verbal methods to help maintain control, medication, seclusion, and restraints, as necessary). (B) Approaching a client in a challenging manner is threatening and inappropriate. A nonchallenging and calm approach reflects staff in control and may increase client's internal control. (C) It is inappropriate to leave an aggressive client who is acting out alone. The nurse should acquire qualified help to prevent client from harm or injury to self or others. (D) Moving a client to seclusion immediately for shouting is inappropriate. The nurse should offer the client an opportunity to control self with limit setting.
The client should understand that the staff will assist with control if necessary (i.e., quietly accompany out of environment to decrease stimulation and allow for verbalization) employing the least restrictive care model of intervention.
NEW QUESTION # 87
A premature infant needs supplemental O2 therapy. A nursing intervention that reduces the risk of retrolental fibroplasia is to:
- A. Maintain O2at>40%
- B. Maintain O2at <40%
- C. Give moist O2at>40%
- D. Maintain on 100% O2
Answer: B
Explanation:
Explanation
(A) Retrolental fibroplasia is the result of prolonged exposure to high levels of O2in premature infants.
Complications are hemorrhage and retinal detachment. (B, C, D) O2concentration is too high.
NEW QUESTION # 88
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. Anemia
- B. A birth defect
- C. Nicotine withdrawal
- D. A low birth weight
Answer: D
Explanation:
Explanation/Reference:
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.
NEW QUESTION # 89
When giving discharge instructions to a 24-year-old client who had a short-arm cast applied for a fractured right ulna, the nurse recognizes the importance of telling him that the drying time for a plaster of Paris cast is approximately:
- A. 24-72 hours
- B. 1-4 hours
- C. 12-24 hours
- D. 30 minutes
Answer: A
Explanation:
Explanation
(A) Synthetic cast materials harden in 3-15 minutes. Weight bearing is permitted in 15-30 minutes. Drying time for plaster of Paris is about 24-72 hours. (B, C) Plaster of Paris cast materials are heavier than synthetic materials and require a drying time of 24-72 hours. Synthetic materials dry within 30 minutes. (D) Plaster of Paris cast materials are heavier thansynthetic materials and require a longer period to set and dry. Even though setting time (hardening) is only 3-15 minutes, the drying time for plaster of Paris is 24-72 hours. This depends on the size and thickness of the cast, exposure to air, and humidity in the air.
NEW QUESTION # 90
A baby who was diagnosed with pyloric stenosis has continued to have projectile vomiting. With prolonged vomiting, the infant is prone to:
- A. Respiratory alkalosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Metabolic acidosis
Answer: B
Explanation:
Explanation
(A) Respiratory acidosis is the result of problematic ventilation. Plasma pH decreases, while plasma PCO2 and plasma HCO3 increase. (B) Respiratory alkalosis results from increased respiratory rate and depth. Plasma pH increases, while plasma PCO2 and plasma HCO3 decrease. (C) Metabolic acidosis occurs when there is strong acid gain in the body. Plasma pH, PCO2, and HCO3 decrease. (D) Increased risk for metabolic alkalosis is due to a loss of hydrogen ions; depletion of potassium, sodium, and chloride when vomiting occurs. Plasma pH and plasma PCO2 increase; plasma HCO3 may decrease and then increase to compensate.
NEW QUESTION # 91
A 58-year-old client on a general surgery unit is scheduled for transurethral resection of the prostate (TURP) in 2 hours. The nurse explains to the client that this procedure means:
- A. Removal of the prostate tissue by an open surgical approach through an incision between the ischial tuberosities, the scrotum, and the rectum
- B. Removal of prostate tissue by a resectoscope that is inserted through the penile urethra
- C. Removal of the prostate tissue by way of a lower abdominal midline incision through the bladder and into the prostate gland
- D. Removal of prostate tissue by an open surgical approach through a low horizontal incision, bypassing the bladder, to the prostate gland
Answer: B
Explanation:
(A) This describes a suprapubic (transvesical) prostatectomy procedure. (B) This is the correct description of a TURP procedure. (C) This describes a perineal prostatectomy procedure. (D) This describes a retropubic (extravesical) prostatectomy procedure.
NEW QUESTION # 92
A 27-year-old man was diagnosed with type I diabetes 3 months ago. Two weeks ago he complained of pain, redness, and tenderness in his right lower leg. He is admitted to the hospital with a slight elevation of temperature and vague complaints of "not feeling well." At 4:30 PM on the day of his admission, his blood glucose level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to:
- A. Have him drink 4 oz of orange juice
- B. Ask him to dissolve three pieces of hard candy in his mouth
- C. Give him 3 tbsp of sugar dissolved in 4 oz of grape juice to drink
- D. Monitor him closely until dinner arrives
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) The combination of sugar and juice will increase the blood sugar beyond the normal range. (B) Concentrated sweets are not absorbed as fast as juice; consequently, they elevate the blood sugar beyond the normal limit. (C) Four ounces of orange juice will act immediately to raise the blood sugar to a normal level and sustain it for 30 minutes until supper is served. (D) There is an increased potential for the client's blood sugar to decrease even further, resulting in diabetic coma.
NEW QUESTION # 93
A burn victim's immunization history is assessed by the nurse. Which immunization is of priority concern?
- A. Inactivated poliovirus vaccine
- B. Hepatitis B vaccine
- C. Oral poliovirus vaccine
- D. Tetanus toxoid
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Oral poliovirus vaccine is given to prevent polio. Polio is transmitted by direct contact with an infected person. (B) Inactivated poliovirus vaccine is given to adults and immunosuppressed individuals. Polio is transmitted by direct contact with an infected person. (C) Tetanus toxoid prevents tetanus. Tetanus is transmitted through contaminated wounds. (D) Hepatitis B vaccine prevents hepatitis B infection. Hepatitis B is transmitted through contact with infected blood or body fluids.
NEW QUESTION # 94
A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements?
- A. "If I have any side effects from my medicines, I will take an extra dose of Cogentin."
- B. "When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices."
- C. "When I get home, I should be able to taper myself off the Haldol because the voices are gone now."
- D. "As soon as I leave here, I'm throwing away my medicines. I never thought I needed them anyway."
Answer: B
Explanation:
Explanation
(A) The client verbalizes that he is responsible for compliance and keeping the treatment team member informed of progress. This behavior puts him at the lowest risk for relapse. (B) Noncompliance is a major cause of relapse. This statement reflects lack of responsibility for his own health maintenance. (C) This statement reflects lack of insight into the importance of compliance. (D) This statement reflects no insight into his illness or his responsibility in health maintenance.
NEW QUESTION # 95
The nurse practitioner determines that a client is approximately 9 weeks' gestation. During the visit, the practitioner informs the client about symptoms of physical changes that she will experience during her first trimester, such as:
- A. A 6-8 lb weight gain
- B. Quickening
- C. Nausea and vomiting
- D. Abdominal enlargement
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Nausea and vomiting are experienced by almost half of all pregnant women during the first 3 months of pregnancy as a result of elevated human chorionic gonadotropin levels and changed carbohydrate metabolism. (B) Quickening is the mother's perception of fetal movement and generally does not occur until 18-20 weeks after the last menstrual period in primigravidas, but it may occur as early as 16 weeks in multigravidas. (C) During the first trimester there should be only a modest weight gain of 2-4 lb. It is not uncommon for women to lose weight during the first trimester owing to nausea and/or vomiting. (D) Physical changes are not apparent until the second trimester, when the uterus rises out of the pelvis.
NEW QUESTION # 96
A gravida 2 para 1 client is hospitalized with severe preeclampsia. While she receives magnesium sulfate (MgSO4) therapy, the nurse knows it is safe to repeat the dosage if:
- A. MgSO4 serum levels are > 15 mg/dL
- B. Urine output is 20 mL/hr
- C. Deep tendon reflexes are absent
- D. Respirations are > 16 breaths/min
Answer: D
Explanation:
Section: Questions Set B
Explanation:
(A) MgSO4 is a central nervous system depressant. Loss of reflexes is often the first sign of developing toxicity.
(B) Urinary output at < 25 mL/hr or 100 mL in 4 hours may result in the accumulation of toxic levels of magnesium. (C) The therapeutic serum range for MgSO4 is 6-8 mg/dL. Higher levels indicate toxicity. (D) Respirations of >16 breaths/min indicate that toxic levels of magnesium have not been reached. Medication administration would be safe.
NEW QUESTION # 97
A client had a renal transplant 3 months ago. He has suddenly developed graft tenderness, an increased white blood cell count, and malaise. The client is experiencing which type of rejection?
- A. Chronic
- B. Hyperacute
- C. Hyperchronic
- D. Acute
Answer: D
Explanation:
Explanation
(A) The sudden development of fever, graft tenderness, increased white blood count, and malaise are signs and symptoms of an acute rejection that commonly occurs at 3 months. (B) Chronic rejection occurs slowly over a period of months to years and mimics chronic renal failure. (C) Hyperacute rejection occurs immediately after surgery up to 48 hours postoperatively. (D) Hyperchronic rejection is not a type of rejection.
NEW QUESTION # 98
A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should:
- A. Explain that his vital signs will be checked frequently after the test
- B. Explain that he will be kept NPO for 24 hours before the exam
- C. Explain that he will be receiving a laxative to prevent a distended bowel from applying pressure on the liver
- D. Practice with him so he will be able to hold his breath for 1 minute
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) There is no NPO restriction prior to a liver biopsy. (B) The client would need to hold his breath for 5-10 seconds. (C) There is no pretest laxative given. (D) Following the test, the client is watched for hemorrhage and shock.
NEW QUESTION # 99
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