[Oct-2021] Pass NCLEX-RN Exam in First Attempt UpdatedNCLEX-RN DumpsQuestion Exam Question
NCLEX Certification Dumps NCLEX-RN Exam for Full Questions - Exam Study Guide
NEW QUESTION 211
When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the nurse take?
- A. Turn client on right side.
- B. Report to physician or midwife.
- C. Decrease IV fluids.
- D. Continue monitoring because this is a normal occurrence.
Answer: B
Explanation:
Explanation
(A) This is not a normal occurrence. Late decelerations need prompt intervention for immediate infant recovery. (B) To increase O2 perfusion to the unborn infant, the mother should be placed on her left side. (C) IV fluids should be increased, not decreased. (D) Immediate action is warranted, such as reporting findings, turning mother on left side, administering O2, discontinuing oxytocin (Pitocin), assessing maternal blood pressure and the labor process, preparing for immediate cesarean delivery, and explaining plan of action to client.
NEW QUESTION 212
A 22-year-old single woman was admitted to the psychiatric hospital by her mother, who reported bizarre behavior. Except for going to work, she spends all her time in her room and expresses concern over neighbors spying on her. She has fears of the telephone being "bugged." Her diagnosis is schizophrenia. One nurse per shift is assigned to work with the client. The primary reason for this plan would be to:
- A. Protect her from suicide
- B. Enable her to develop trust
- C. Supervise her medication regimen
- D. Involve her in groups for social interaction
Answer: B
Explanation:
(A) Suicide is a greater risk in depression than in schizophrenia. (B) The client is suspicious and needs help to develop trust, which is basic to her improvement. (C) Although she will be taking medication, drug therapy would not necessitate consistency in the nurses assigned. (D) A suspicious client should have limited exposure to groups, because group participation increases discomfort.
NEW QUESTION 213
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. If disulfiram is taken and alcohol ingested, the client experiences nausea, vomiting and elevated blood pressure.
- B. Disulfiram is most effective when prescribed as late as possible in a recovery program.
- C. Disulfiram works on the desensitization principle.
- D. The effects of disulfiram can be triggered by alcohol 5 days to 2 weeks after the drug is discontinued.
Answer: D
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 214
In healthcare settings, nurses must be familiar with primary, secondary, and tertiary levels of care. As a nurse in the community, which of the following interventions might be a primary prevention strategy?
- A. Referring a client who has been on a detoxification unit to a rehabilitation center
- B. Teaching fifth-grade children the harmful effects of substance abuse
- C. Crisis intervention with an intoxicated teenager whose mother just committed suicide
- D. Counseling a client with post-traumatic stress disorder
Answer: B
Explanation:
Section: Questions Set F
Explanation:
(A) The teenager is already coping ineffectively and requires early detection and treatment, which is secondary prevention. (B) The client must be sent to a rehabilitation unit, which requires tertiary prevention. (C) Reducing the incidence of disease through education supports primary prevention. (D) A client with identified symptoms of post-traumatic stress disorder requires intervention by treatment.
NEW QUESTION 215
On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle feeding. The nurse should initially recommend to her to:
- A. Take a warm shower and express milk from both breasts until empty
- B. Apply ice packs to the breasts and wear a supportive, well-fitting bra
- C. Allow the infant to breast-feed at the next feeding time to empty the breasts
- D. Take 2 ibuprofen (Motrin) tablets by mouth now because the baby will be returning for feeding in 20 minutes
Answer: B
Explanation:
Explanation
(A) Judicious use of analgesics is appropriate with breast engorgement; however, mechanical suppression would be the initial recommendation. (B) Breast-feeding every 112-3 hours will reduce and/or prevent breast engorgement. Breast-feeding will promote milk production, which will compound the distention and stasis of the venous circulation of engorgement in a bottlefeeding mother. (C) Ice packs reduce milk flow while the snug, supportive bra provides mechanical suppression and decreases pulling on Cooper's ligament. In addition, breast binders or ace bandages may be used for some women. (D) Warmth promotes milk production and may stimulate the let-down reflex. These measures would contribute to the venous congestion of engorgement.
NEW QUESTION 216
The mother of a child taking phenytoin will need to plan appropriate mouth care and gingival stimulation. When tooth-brushing is contraindicated, the next most effective cleansing and gingival stimulation technique would be:
- A. Rinsing with hydrogen peroxide
- B. Rinsing with baking soda
- C. Rinsing with water
- D. Using a water pik
Answer: D
Explanation:
Section: Questions Set G
Explanation:
(A) This technique provides effective rinsing and gingival stimulation. (B) This technique does not provide gingival stimulation. (C) This technique provides effective rinsing but not gingival stimulation. Using peroxide is not pleasant for the child. (D) This technique provides effective rinsing but not gingival stimulation.
NEW QUESTION 217
A 19-year-old client has sustained a C-7 fracture, which resulted in his spinal cord being partially transected. By 2 weeks' postinjury, his neck has been surgically stabilized, and he has been transferred from the intensive care unit. A potential life-threatening complication the nurse monitors the client for is:
- A. Central cord syndrome
- B. Autonomic dysreflexia
- C. Bradycardia
- D. Spinal shock
Answer: B
Explanation:
(A) Autonomic dysreflexia is the exaggerated sympathetic nervous system response to various stimuli in the anesthetized area. Sympathetic stimulation results in severe, uncontrolled hypertension, which may result in myocardial infarction or cerebral hemorrhage. (B) Bradycardia occurs as a result of sympathetic blockade in the immediate postinjury period. After spinal shock recedes, cardiovascular stability returns, but the client will be bradycardiac for life. (C) Central cord syndrome is a specific type of spinal cord injury that occurs as a result of either hyperextension injuries or disrupted blood flow to the spinal cord. (D) Spinal shock occurs in the immediate postinjury phase and usually resolves in approximately 72 hours.
NEW QUESTION 218
A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody drainage on his surgical dressing. The nurse would document this as what type of drainage?
- A. Purulent
- B. Serosanguinous
- C. Catarrhal
- D. Sanguinous
Answer: D
Explanation:
(A)
Drainage from a surgical incision usually proceeds from sanguinous to serosanguinous.
(B)
Purulent drainage usually indicates infection and should not be seen initially from a surgical incision. (C) Drainage from a surgical incision is initially sanguinous, proceeding to serosanguinous, and then to serous. (D) Catarrhal is a type of exudate seen in upper respiratory infections, not in surgical incisions.
NEW QUESTION 219
A family is experiencing changes in their lifestyle in many ways. The invalid grandmother has moved in with them. The couple have a 2-year-old son by their marriage, and the wife has two children by her previous marriage. The older children are in high school. In applying systems theory to this family, it is important for the nurse to remember which of the following principles?
- A. Dysfunction in one part affects every other part.
- B. Healthy families are enmeshed.
- C. A family system has no boundaries.
- D. The parts of a system are only minimally related.
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) The parts of a system are interrelated. (B) Any change in any part of the system affects all other parts.
(C) A family system, like any other system, has boundaries. (D) Healthy families are neither enmeshed nor disengaged.
NEW QUESTION 220
A 35-weeks-pregnant client is undergoing a nonstress test (NST). During the 20-minute examination, the nurse notes three fetal movements accompanied by accelerations of the fetal heart rate, each 15 bpm, lasting
15 seconds. The nurse interprets this test to be:
- A. Nonreactive
- B. Positive
- C. Negative
- D. Reactive
Answer: D
Explanation:
Explanation
(A) In a nonreactive NST, the criteria for reactivity are not met. (B) A reactive NST shows at least two accelerations of FHR with fetal movements, each 15 bpm, lasting 15 seconds or more, over 20 minutes. (C, D) This term is used to interpret a contraction stress test (CST), or oxytocin challenge test, not an NST.
NEW QUESTION 221
The physician of an alcoholic client places him on a low-protein, high-carbohydrate diet. When choosing his menu, the client's best choice from the items below would be:
- A. Baked chicken, baked potato with bacon bits, milk
- B. Cheese omelette with ham and mushrooms, milk
- C. Liver and onions, macaroni and cheese, tea with sugar
- D. Waffles with butter and honey, orange juice
Answer: D
Explanation:
(A, B, D) These foods are high in protein, which needs to be restricted. (C) Serum ammonia levels can be decreased by restricting dietary protein intake. Waffles, honey, and orange juice are high in carbohydrate and low or completely lacking in protein. Butter, a concentrated fat, will provide extra calories.
NEW QUESTION 222
After instructing a female client on circumcision care, the nursery nurse asks her to restate some of the key points covered. Which statement shows that the client will properly care for her son's circumcision?
- A. "I'll keep a close watch on it for a day or two."
- B. "I'll apply alcohol to the area daily to clean it and prevent any infection."
- C. "I'll make sure I soak the gauze with warm water first, before I take it off each time."
- D. "I'll make sure that I report any drainage around where they operated."
Answer: C
Explanation:
(A) Before petrolatum gauze is removed, it should be soaked with warm water to prevent trauma to adherent tissues. (B) A yellow exudate often forms normally over the surgical site. Only if it becomes foul-smelling and purulent would it need to be reported. (C) Alcohol should never be used on the site; this would be extremely painful to the infant. (D) Special care and observance should continue until the site is completely covered with clean, pink granulation tissue, which could take 7-10 days.
NEW QUESTION 223
A 27-year-old primigravida at 32 weeks' gestation has been diagnosed with complete placenta previa. Conservative management including bed rest is the proper medical management. The goal for fetal survival is based on fetal lung maturity. The test used to determine fetal lung maturity is:
- A. Metachromatic stain
- B. Lecithin-sphingomyelin ratio
- C. Blood serum phenylalanine test
- D. Dinitrophenylhydrazine
Answer: B
Explanation:
(A) Dinitrophenylhydrazine is a laboratory test used to detect phenylketonuria, maple syrup urine disease, and Lowe's syndrome. (B) Metachromatic stain is a laboratory test that may be used to diagnose Tay-Sachs and other lipid diseases of the central nervous system. (C) The blood serum phenylalanine test is diagnostic of phenylketonuria and can be used for wide-scale screening. (D) A lecithin-sphingomyelin ratio of at least 2:1 is indicative of fetal lung maturity, and survival of the fetus is likely.
NEW QUESTION 224
A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurse instructs the client to:
- A. Clean the sutured laceration twice a day with povidone- iodine (Betadine)
- B. Take meperidine 50 mg po q4-6h prn for headache
- C. Return to the hospital immediately if he develops confusion, nausea, or vomiting
- D. Remove his scalp sutures after 5 days
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Povidone-iodine is very irritating to skin and should not be routinely used. (B) Sutures should not be removed by the client. (C) Confusion, nausea, vomiting, and behavioral changes may indicate increasing intracranial pressure as a result of intracerebral bleeding. (D) Use of a narcotic opiate such as meperidine is not recommended in clients with a possible head injury because it may produce sedation, pupil changes, euphoria, and respiratory depression, which may mask the signs of increasing intracranial pressure.
NEW QUESTION 225
A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, "The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart." The nurse's best response is:
- A. "Try to sleep. When you wake up, the devil will be gone."
- B. "I know you're feeling frightened right now, but I want you to know that I don't see anyone in the corner."
- C. "You're probably feeling guilty because you used illegal drugs tonight."
- D. "You'll probably see strange things for a while until the PCP wears off."
Answer: B
Explanation:
(A) The nurse is the client's link to reality. This response validates the authenticity of the client's experience by casting doubt on his belief and reinforcing reality. (B) Although this statement may be literally correct, it is nontherapeutic because it lacks validation. (C) This response encourages the client to attempt to do something that may be impossible at this time, offers false reassurance, and reinforces delusional content. (D) The nurse is making an incorrect assumption about the client's feelings by offering a nontherapeutic interpretation of the motivation for the client's actions.
NEW QUESTION 226
Which stage of labor lasts from delivery of the baby to delivery of the placenta?
- A. Second
- B. Fifth
- C. Third
- D. Fourth
Answer: C
Explanation:
Section: Questions Set G
Explanation:
(A) This stage is from complete dilatation of the cervix to delivery of the fetus. (B) This is the correct stage for the definition. (C) This stage lasts for about 2 hours after the delivery of the placenta. (D) There is no fifth stage of labor.
NEW QUESTION 227
Goal setting for a client with Meniere's disease should include which of the following?
- A. Prevention of a fall injury
- B. Frequent ambulation
- C. Prevention of infection
- D. Consumption of three meals per day
Answer: A
Explanation:
(A) Although not contraindicated, initially ambulation may be difficult because of vertigo and is recommended only with assistance. (B) Vertigo resulting in balance problems is one of
the most common manifestations of Meniere's disease. (C) Adequate nutrition is important, but the emphasis in Meniere's disease is not the number of meals per day but a decrease in intake of sodium. (D) Infection is not an anticipated problem.
NEW QUESTION 228
A 33-year-old client is diagnosed with bipolar disorder, acute phase. This is her first psychiatric hospitalization, and she is being evaluated for treatment with lithium. Which of the following diagnostic tests are essential prior to the initiation of lithium therapy with this client?
- A. Hematocrit, hemoglobin, and white blood cell (WBC) count
- B. X-rays, electroencephalogram, and electrocardiogram (ECG)
- C. Glucose, glucose tolerance test, and random blood sugar
- D. Blood urea nitrogen, electrolytes, and creatinine
Answer: D
Explanation:
(A) These are general diagnostic blood studies (usually done on admission), but they are not reliable indicators of lithium therapy clearance. (B) These are the primary diagnostic tests to determine kidney functioning. Because lithium is excreted through the kidneys and because it can be very toxic, adequate renal function must be ascertained before therapy begins. (C) These are diagnostic blood tests used to determine the presence of endocrine (not renal) dysfunction. (D) These are other types of diagnostic procedures used to determine musculoskeletal, neural, and cardiac (rather than renal) functioning.
NEW QUESTION 229
When preparing insulin for IV administration, the nurse identifies which kind of insulin to use?
- A. Regular
- B. Long acting
- C. Human or pork
- D. NPH
Answer: A
Explanation:
Section: Questions Set G
Explanation:
(A, B, D) Intermediate-acting and long-acting preparations contain materials that increase length of absorption time from the subcutaneous tissues but cause the preparation to be cloudy and unsuitable for IV use. Human insulin must be given SC. (C) Only regular insulin can be given IV.
NEW QUESTION 230
A child becomes neutropenic and is placed on protective isolation. The purpose of protective isolation is to:
- A. Isolate the child from other clients and the nursing staff
- B. Protect the family from curious visitors
- C. Protect the child from infection
- D. Provide the child with privacy
Answer: C
Explanation:
Explanation
(A) The child no longer has normal white blood cells and is extremely susceptible to infection. (B) There are more appropriate ways to provide privacy, and there is no need to protect the child from healthy visitors. (C) Visitors and visiting hours may be at the client's and/or family's request without regard to the isolation precaution. (D) The child may have strong positive relationships with other clients or staff. As long as proper precautions are observed, there is no reason to isolate her from them.
NEW QUESTION 231
A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain. She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the following findings in the client's nursing assessment demand immediate nursing action?
- A. Associated symptoms of indigestion and nausea
- B. Restlessness and apprehensiveness
- C. History of hypertension treated with pharmacological therapy
- D. Inability to tolerate assessment session with the admitting nurse
Answer: B
Explanation:
Explanation
(A) Indigestion or nausea may accompany angina or myocardial infarction, but they do not indicate imminent danger for the client. (B) Restlessness and apprehensiveness require immediate nursing action because they are indicative of very low oxygenation of body tissues and are frequently the first indication of impending cardiac or respiratory arrest. (C) It is common for the cardiac client to experience fatigue and inability to physically tolerate long assessment sessions. (D) A history of hypertension requires no immediate nursing intervention.
In the situation described, the blood pressure is not given and therefore cannot be assumed to be elevated.
NEW QUESTION 232
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