[2021] Pass NCLEX NCLEX-RN Exam Updated 865 Questions
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NEW QUESTION 166
An alcoholic client who is completing the inpatient segment of a substance abuse program was placed on disulfiram (Antabuse) drug therapy. What should the nurse include in the discharge instructions?
- A. The effects of disulfiram can be triggered by alcohol 5 days to 2 weeks after the drug is discontinued.
- B. Disulfiram works on the desensitization principle.
- C. Disulfiram is most effective when prescribed as late as possible in a recovery program.
- D. If disulfiram is taken and alcohol ingested, the client experiences nausea, vomiting and elevated blood pressure.
Answer: A
Explanation:
(A) When alcohol is ingested with disulfiram therapy, the client experiences nausea, vomiting, and a potentially serious drop in blood pressure. (B) Disulfiram is most successful when used early in the recovery process while the individual makes major lifestyle changes necessary for long-term recovery. (C) Disulfiram works on the classical conditioning principle. (D) The effects of disulfiram can be felt when alcohol is ingested 1-2 weeks after disulfiram is discontinued.
NEW QUESTION 167
A client had a ruptured abdominal aortic aneurysm that was repaired surgically. Her postoperative recovery progressed without complications, and she is ready for discharge. Client education in preparation for discharge began 7 days ago on her admission to the nursing unit. Evaluation of nursing care related to client education is based on evaluation of expected outcomes. Which statement made by the client would indicate that she is ready for discharge?
- A. "Teach my husband about the diet. He'll be doing all the cooking now."
- B. "I will not drive but ride in the front seat of the car with a seat belt on for my first doctor's appointment."
- C. "When I bathe tomorrow morning, I will be very careful not to get soap on my incision."
- D. "I am allowed to exercise by walking for short periods."
Answer: D
Explanation:
(A) Postoperatively, clients with major abdominal surgery are instructed to avoid driving, riding in the front seat, and wearing seat belts because any sudden impact may injure a fresh incision. She should ride in back seat without a seat belt. (B) Clients should not sit in the tub and allow the incision to soak in water because this may predispose the client to infection. A short, cool shower would be preferable. Allowing soap to come in contact with the incision would not harm it and is frequently used as postoperative wound care at home on discharge from the hospital. (C) Activity instructions include: avoid sitting for long periods and get exercise by walking. Lifting more than 5 lb of weight is also prohibited. (D) The client must also learn her diet. Her husband cooking is probably a temporary measure unless he did the cooking prior to her hospitalization.A statement such as this may indicate the need for further exploration of feelings regarding her illness, dependence, and self-care expectations.
NEW QUESTION 168
A client has received digoxin 0.25 mg po daily for 2 weeks. Which of the following digoxin levels indicates toxicity?
- A. 0.5 ng/mL
- B. 1.0 ng/mL
- C. 2.0 ng/mL
- D. 3.0 ng/mL
Answer: D
Explanation:
(A) 0.5 ng/mL of digoxin is a subtherapeutic level, not a toxic one. (B) 1.0 ng/mL is a therapeutic level. (C) 2.0 ng/mL is a therapeutic level. (D) Digoxin's therapeutic level is 0.8-2.0 ng/mL. Digoxin's toxic level is >2.0 ng/mL.
NEW QUESTION 169
A 35-year-old client is admitted to the hospital with diabetic ketoacidosis. Results of arterial blood gases are pH 7.2, PaO2 90, PaCO2 45, and HCO3 16. The nursing assessment of arterial blood gases indicate the presence of:
- A. Metabolic alkalosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Respiratory acidosis
Answer: B
Explanation:
Explanation
(A) Respiratory alkalosis is determined by elevated pH and low PaCO2. (B) Respiratory acidosis is determined by low pH and elevated PaCO2. (C) Metabolic alkalosis is determined by elevated pH and HCO3.(D) Metabolic acidosis is determined by low pH and HCO3.
NEW QUESTION 170
A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse's best response is:
- A. "There's really no need to stay with her. She's going to sleep for several hours after the treatment."
- B. "Visitors are not allowed. We will telephone you to inform you of her progress."
- C. "Yes, you may visit. She may experience temporary drowsiness, confusion, or memory loss after each treatment."
- D. "You'll have to get permission from the physician to visit. Clients are pretty sick after the first treatment."
Answer: C
Explanation:
Explanation
(A) It is within the nurse's realm of practice to grant visiting privileges according to hospital policy. ECT treatments do not make clients sick. (B) Visitors are allowed and encouraged, particularly family members.
(C) Clients are usually awake within 1 hour posttreatment. Drowsiness wanes as the anesthetic wears off. (D) A family member is encouraged to stay with the client after return to the unit. The nurse has used an opportunity to do family teaching and allay fears by explaining temporary side effects of the treatment.
NEW QUESTION 171
The client tells the nurse, "I have pain in my left shoulder."
This is considered:
- A. Evaluation process
- B. Subjective information
- C. Objective information
- D. Complaining
Answer: B
Explanation:
Explanation
(A) Evaluation process follows a nursing intervention. (B) Objective information can be measured. (C) Subjective information is provided by a person. (D) Client is reporting a symptom that needs to be assessed.
NEW QUESTION 172
A client's membranes have just ruptured spontaneously. Which of the following nursing actions should take priority?
- A. Assess color and odor of fluid.
- B. Assess quantity of fluid.
- C. Document on fetal monitor strip and chart.
- D. Assess fetal heart rate (FHR).
Answer: D
Explanation:
Section: Questions Set F
Explanation:
(A) Assessing the quantity of amniotic fluid is important as an indication of maternal fetal well-being, but it does not take priority over assessment of FHR. (B) Greenish-brown discoloration of amniotic fluid indicates presence of meconium. Foul odor may indicate presence of infection. Both of these are important assessment data, but they do not take priority over possible lifethreatening compression of the umbilical cord. (C) Documentation is important, but it does not take priority over the possible life-threatening compression of the umbilical cord. (D) If changes in the FHR are noted, the nurse should check for umbilical cord prolapse. This intervention has priority over the other actions. The danger of a prolapsed cord is increased once membranes have ruptured, especially if the presenting part of the fetus does not fit firmly against the cervix.
NEW QUESTION 173
A client has renal failure. Today's lab values indicate he has an elevated serum potassium. What additional priority information does the nurse need to obtain?
- A. Serum potassium lab values for the last several days
- B. Evaluation of his level of consciousness
- C. Evaluation of an electrocardiogram
- D. Measurement of his urine output for the past 8 hours
Answer: C
Explanation:
(A) The level of consciousness is not affected by elevated potassium levels. (B) An electrocardiogram (EKG) can tell the nurse whether this client is experiencing any cardiac dysfunction or arrhythmias related to the elevated potassium level. (C) Measurement of the urine output is not a priority nursing action at this time. (D) The client's serum potassium values for the past several days may provide information about his renal function, but they are not a priority at this time.
NEW QUESTION 174
The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take?
- A. Restrain the child so he will not injure himself.
- B. Move furniture out of the way and place a blanket under his head.
- C. Go to the nurses station and call the physician.
- D. Place a tongue blade in the child's mouth.
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) The nurse should not put anything in the child's mouth during a seizure; this action could obstruct the airway. (B) Restraining the child's movements could cause constrictive injury. (C) Staying with the child during a seizure provides protection and allows the nurse to observe the seizure activity. (D) The nurse should provide safety for the child by moving objects and protecting the head.
NEW QUESTION 175
A 5-year-old child was recently diagnosed as having acute lymphoid leukemia. She is hospitalized for additional tests and to begin a course of chemotherapy designed to induce a remission. She is scheduled to have a bone marrow aspiration tomorrow. She has had a bone marrow test previously and is apprehensive about having another. Which of the following interventions will be most effective in relieving her anxiety?
- A. Remind her that she has had this procedure before and that it is nothing to be afraid of.
- B. Explain what will take place and what she will see, feel, and hear.
- C. Give her a big hug and tell her that she is a big girl now and that she will do just fine.
- D. Tell her not to worry about it, that it will be over soon and she can join her friends in the playroom.
Answer: B
Explanation:
Explanation
(A) Even though the child has had the procedure before, she will probably need additional explanations and emotional support. (B) The fact that the child has had the procedure before and possibly found it painful or uncomfortable may increase, not relieve, her stress. (C) This intervention does nothing to reassure the child and may well prevent her from expressing her feelings. (D) This does not prepare the child for the test and burdens her with the expectation that she act bigger and braver than she is.
NEW QUESTION 176
A client presents to the emergency room with cyanosis, coughing, tachypnea, and tachycardia. She has a history of asthma. Arterial blood gas values are pH 7.28, PaO2 54, PaCO2 60, and HCO3 24. The nursing assessment of arterial blood gases indicate the presence of:
- A. Metabolic alkalosis
- B. Respiratory acidosis
- C. Respiratory alkalosis
- D. Metabolic acidosis
Answer: B
Explanation:
Explanation
(A) Respiratory alkalosis is determined by elevated pH and low PaCO2. (B) Respiratory acidosis is determined by low pH and elevated PaCO2. (C) Metabolic alkalosis is determined by elevated pH and HCO3.
(D) Metabolic acidosis is determined by low pH and HCO3.
NEW QUESTION 177
Assessment of a client reveals a 30% loss of preillness weight, lanugo, and cessation of menses for 3 months.
Her vital signs are BP 90/50, P 96 bpm, respirations 30, and temperature 97 οF. She admits to the nurse that she has induced vomiting 3 times this morning, but she had to continue exercising to lose "just 5 more lb." Her symptoms are consistent with:
- A. Bulimia
- B. Anorexia nervosa
- C. Pregnancy
- D. Gastritis
Answer: B
Explanation:
Section: Questions Set F
Explanation:
(A) Presenting behaviors collectively are inconsistent with depression. (B) A preillness weight loss of 30%, lanugo, and cessation of menses are inconsistent with bulimia. (C) Symptoms and vital signs do not indicate the presence of infection. (D) All symptoms and vital signs are consistent with anorexia nervosa.
NEW QUESTION 178
Plans for the care of a client with an ulcer caused by emotional problems need to take into consideration that:
- A. His priority needs are limited to medical management
- B. There is no real psychological basis for his illness
- C. He is unable to participate in planning his care
- D. The disorder is a threat to his physical well-being
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) There may be a medical emergency that takes top priority; however, the basis of the problem is emotional. (B) The problem is a physical manifestation of an emotional conflict. (C) The bleeding ulcer can be life threatening. (D) For lifestyle change to occur, the client must participate in the planning of his care so that he is committed to changes that will have positive results.
NEW QUESTION 179
In assessing the nature of the stool of a client who has cystic fibrosis, what would the nurse expect to see?
- A. Steatorrhea stools
- B. Blood-tinged stools
- C. Clay-colored stools
- D. Dark brown stools
Answer: A
Explanation:
(A) Clay-colored stools indicate dysfunction of the liver or biliary tract. (B) In the early stages of cystic fibrosis, fat absorption is primarily affected resulting in fat, foul, frothy, bulky stools. (C) Dark brown stools indicate normal passage through the colon. (D) Blood-tinged stools indicate dysfunction of the gastrointestinal (GI) tract.
NEW QUESTION 180
A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?
- A. Give fluids if the client requests them.
- B. Measure vital signs at least every 4 hours.
- C. Release restraints every 2 hours for client to exercise.
- D. Assess skin integrity and circulation of extremities before applying restraints and as they are removed.
Answer: C
Explanation:
Explanation
(A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly while the client is restrained, not only before restraints are applied and after they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains agitated in restraints, vital signs should be monitored even more closely, perhaps every 1-2 hours. (D) Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation.
NEW QUESTION 181
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