[Jan-2022 Newly Released] NCLEX-RN Dumps for NCLEX Certification Certified
Updated Verified NCLEX-RN dumps Q&As - 100% Pass
NEW QUESTION 79
The initial focus when providing nursing care for a child with rheumatic fever during the acute phase of the illness should be to:
- A. Provide a nutritious diet
- B. Provide for physical and psychological rest
- C. Maintain her interest in school
- D. Maintain contact with her parents
Answer: B
Explanation:
(A)
This goal is helpful, but rest is essential during the acute phase. (B) Rest is essential for healing to occur and for pain to be relieved. (C) This goal is important, but rest is essential.
(D)
This goal should be part of the plan of care, but it is not the priority during the acute phase.
NEW QUESTION 80
A male client is being treated in the burn unit for thirddegree burns on his head, neck, and upper chest received in the last 24 hours. The nurse is evaluating the effectiveness of fluid resuscitation. Which of the following indicates effective fluid balance?
- A. His weight increases from 165 to 175 lb.
- B. His urine output is equal to his total fluid intake.
- C. His urine output has been>35 mL/hr for the past 12 hours.
- D. His blood pressure is 94/62.
Answer: C
Explanation:
(A) A weight gain of 10 lb represents a state of overhydration. (B) He is losing fluids through insensible losses; a urine output equal to his intake indicates that he is receiving too little fluids. (C) A urine output greater than his intake indicates that he is receiving adequate fluid resuscitation to account for urinary and insensible losses. (D) A blood pressure of 94/62 indicates a state of underhydration and inadequate circulatory volume.
NEW QUESTION 81
A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2-week period. Her husband asks, "Isn't that a lot?" The nurse's best response is:
- A. "You'll have to talk to the doctor about that. The physician knows what's best for the client."
- B. "Yes, that does seem like a lot."
- C. "Don't worry. Some clients have lots more than that."
- D. "Six to 10 treatments are common. Are you concerned about permanent effects?"
Answer: D
Explanation:
Explanation
(A) This response indicates that the nurse is unsure of herself and not knowledgeable about ECT. It also reinforces the husband's fears. (B) This response is "passing the buck" unnecessarily. The information needed to appropriately answer the husband's question is well within the nurse's knowledge base. (C) The most common range for affective disorders is 6-10 treatments. This response confirms and reinforces the physician's plan for treatment. It also opens communicationwith the husband to identify underlying fears and knowledge deficits. (D) This response offers false reassurance and dismisses the husband's underlying concerns about his wife.
NEW QUESTION 82
The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue healing?
- A. Vitamin A
- B. Vitamin C
- C. Vitamin B1
- D. Vitamin D
Answer: B
Explanation:
Section: Questions Set D
Explanation:
(A) Vitamin C (ascorbic acid) is essential in promoting wound healing and collagen formation. (B) Vitamin B1 (thiamine) maintains normal gastrointestinal (GI) functioning, oxidizes carbohydrates, and is essential for normal functioning of nervous tissue. (C) Vitamin D regulates absorption of calcium and phosphorus from the GI tract and helps prevent rickets. (D) Vitamin A is necessary for the formation and maintenance of skin and mucous membranes. It is also essential for normal growth and development of bones and teeth.
NEW QUESTION 83
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. Reactive
- B. Positive
- C. Negative
- D. Nonreactive
Answer: A
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 84
A child is admitted with severe headache, fever, vomiting, photophobia, drowsiness, and stiff neck associated with viral meningitis. She will be more comfortable if the nurse:
- A. Dims the lights in her room
- B. Places a large, soft pillow under her head
- C. Offers sips of warm liquids
- D. Encourages her to breathe slowly and deeply
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) The discomfort of photophobia is alleviated by dimming the lights. (B) Helping the child to breathe slowly and deeply may help to reduce anxiety, but it will not alleviate other discomforts of viral meningitis.
(C) It is important to maintain fluid balance, but sips of warm liquids do not alleviate the discomforts of meningitis. (D) A large, soft pillow under her head causing neck flexion is likely to increase her discomfort owing to stretching of the meninges.
NEW QUESTION 85
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 acidosis
- B. Respiratory alkalosis
- C. Respiratory acidosis
- D. Metabolic alkalosis
Answer: C
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 86
A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:
- A. Blood pressure increase from 100/80 to 115/85 after lunch
- B. Headache that is unresponsive to acetaminophen (Tylenol)
- C. Temperature rise to 102_F rectally
- D. Pulse rate ranges between 68 bpm and 76 bpm
Answer: C
Explanation:
(A) This change in blood pressure may not be significant and does not indicate a widening pulse pressure, a late sign of increased ICP. It is important to continue to monitor for change in blood pressure. (B) Acetaminophen may be ineffective in relieving headache after head injury. Stronger analgesics are contraindicated because they mask neurological signs and may depress the CNS. (C) Pulse rates between 68 bpm and 76 bpm are within normal limits for a 14-year-old child. It is important to monitor for a consistent drop in pulse rate, which is a late sign of increasing ICP. (D) An elevated temperature is abnormal and requires further assessment and medical intervention. The temperature may be unrelated to the head injury, but CNS infection is serious and difficult to control.
NEW QUESTION 87
A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from:
- A. Rolling from his back to his tummy
- B. Crying
- C. Sucking his thumb
- D. Falling asleep
Answer: B
Explanation:
(A) A child with a subdural hematoma has increased ICP. Crying may significantly increase this pressure. (B) Adequate sleep is essential, but it is important that the child can be aroused from sleep after head injury. (C) This child is free to roll from his back to his abdomen. (D) Thumb-sucking serves to reduce anxiety and should not be prevented at this time.
NEW QUESTION 88
MgSO4 blood levels are monitored and the nurse would be prepared to administer the following antidote for MgSO4 side effects or toxicity:
- A. Naloxone (Narcan)
- B. Calcium hydroxide
- C. Calcium gluconate
- D. Magnesium oxide
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A, B) These drugs are not antidotes for MgSO4. (C) This drug is the standard antidote and should always be readily available when MgSO4is being administered. (D) This drug is an antidote for narcotics, not MgSO4.
NEW QUESTION 89
A client's behavior is annoying other clients on the unit. He is meddling with their belongings and dominating the group. The best approach by the nurse is to:
- A. Set limits on his behavior.
- B. Seclude him in his room.
- C. Have his medication increased.
- D. Ignore him and tell the other clients that these behaviors are due to his illness and that they should understand.
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) This action by the nurse would be punitive. (B) Consistent limit setting will help the client to know what is acceptable behavior. (C) This action is not within the nurse's scope of practice. (D) This could be dangerous to the client and to others and violates other clients' rights.
NEW QUESTION 90
A 19-year-old primigravida is admitted to the labor and delivery suite of the hospital. Her husband is accompanying her. The couple tells the nurse that this is the first hospital admission for her. The client's vaginal exam indicates she is 3 cm dilated, 80% effaced, and at 0 station. Based on the vaginal exam, she is in:
- A. Stage 3, transition phase
- B. Stage 1, latent phase
- C. Stage 2, latent phase
- D. Stage 1, active phase
Answer: B
Explanation:
Section: Questions Set E
Explanation:
(A) The second stage of labor is from full cervical dilation through birth of the baby. The three phases of this stage include latency or resting, descent, and final transition. The client is less than fully dilated so she is not in stage 2. (B) The first stage of labor begins with regular uterine contractions and continues until the woman is
10 cm dilated. The three phases of this stage include the early or latent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is < 4 cm dilated so she is in the latent phase of the first stage of labor. (C) The third stage of labor is from the birth of the baby until the delivery of the placenta. The client is less than fully dilated. (D) The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0-
3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor.
NEW QUESTION 91
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. Serosanguinous
- B. Catarrhal
- C. Purulent
- 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 92
A client had a cardiac catheterization with angiography and thrombolytic therapy with streptokinase. The nurse should initiate which of the following interventions immediately after he returns to his room?
- A. Place him in a high Fowler position.
- B. Ambulate him to the bathroom to void.
- C. Place him on NPO restriction for 4 hours.
- D. Monitor the catheterization site every 15 minutes.
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) A contrast dye, iodine, is used in this procedure. This dye is nephrotoxic. The client must be encouraged to drink plenty of liquids to assist the kidneys in eliminating the dye. (B) Streptokinase activates plasminogen, dissolving fibrin deposits. To prevent bleeding, pressure is applied at the insertion site. The client is assessed for both internal and external bleeding. (C) The extremity used for the insertion site must be kept straight and be immobilized because of the potential for bleeding. (D) The client is kept on bed rest for 8-12 hours following the procedure because of the potential for bleeding.
NEW QUESTION 93
A 24-year-old graduate student recognizes that he has a phobia. He suffers severe anxiety when he is in darkness. It has altered his lifestyle because he is unable to go to a movie theater, concert, and other events that may require absence of light. The client is seeking assistance because he is no longer able to socialize with friends due to his phobia. The psychologist working with him is using desensitization. He has asked the nursing staff to assist the client in muscle relaxation techniques. What result would indicate client education has been successful?
- A. He enters a movie theater, sits in his chair, and replaces anxiety with relaxation as the theater darkens.
- B. He enters a concert, but as the lights dim, he does not experience anxiety.
- C. He states that he no longer fears dark places.
- D. He takes a part-time job as a photographic assistant. His job necessitates his working in a darkroom.
Answer: A
Explanation:
(A) This situation provides specific evidence that the client is able to integrate muscle relaxation technique into his lifestyle to alleviate anxiety. (B) The client may not experience anxiety at the concert, but there is no evidence regarding the technique that he used to alleviate anxiety. (C) The client may state he no longer experiences anxiety, but there is no evidence demonstrating this. He may be denying anxiety to discontinue therapy
prematurely. (D) Does he experience anxiety in the darkroom? He may have taken this job
to force himself to deal with the phobia directly.
NEW QUESTION 94
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 hypocalcemia to prevent seizures
- B. Evidence of depression
- C. Detection of tetany
- D. Detection of premature cataract formation
Answer: C
Explanation:
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 95
A 26-year-old female client presents at 10 weeks' gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her grandmother also has insulin-dependent diabetes. The client's previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches tall and her current weight is
130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following factors places her at risk for gestational diabetes?
- A. Maternal weight
- B. Family history of heart disease
- C. Age >25 years
- D. Previous birth of an infant weighing>9 lb
Answer: D
Explanation:
Section: Questions Set F
Explanation:
(A) Maternal age older than 30 years is an identified risk factor for diabetes. Age younger than 30 years is insignificant for diabetes unless there is a familial history of diabetes. (B) The client's weight is appropriate for her height. Obesity or pregnancy weight >20% of the ideal weight is a contributing factor to the development of gestational diabetes. (C) The birth of an infant weighing >9 lb (4000 g) is an identified risk factor for gestational diabetes. (D) A familial history of heart disease is insignificant in the development of diabetes. However, a familial history of type II diabetes mellitus is identified as a risk factor in the development of diabetes during pregnancy.
NEW QUESTION 96
After an infant is delivered by cesarean delivery and placed on the warmer, the RN dries and assesses the infant. At 1 and 5 minutes after birth, the RN does the Apgar scoring of the infant. The RN knows that because this infant was delivered by cesarean section, he is at increased risk for having which one of the following:
- A. Seizures
- B. Respiratory distress syndrome
- C. Cold stress
- D. Cyanosis
Answer: B
Explanation:
(A) The infant is placed on the warmer and dried after birth. Cold stress occurs when the infant is not dried and kept warm. (B) The fact that this infant was born by cesarean delivery does not place him at a greater risk for cyanosis than an infant delivered vaginally. Cyanosis occurs when infants cannot oxygenate their blood after the umbilical cord is severed. (C) Infants born by cesarean delivery are at a higher risk for developing respiratory distress syndrome because these infants do not pass through the pelvis, where the chest is compressed and fluid is able to escape from the lungs. (D) Cesarean-delivered infants are not at greater risk for seizures than infants delivered vaginally.
NEW QUESTION 97
A 7-year-old girl has been diagnosed with juvenile arthritis and has been placed on daily aspirin. Which statement made by the parent indicates a need for further teaching?
- A. "Her gums have been bleeding frequently. Maybe she is brushing too hard."
- B. "One sign of aspirin toxicity can be ringing in the ears."
- C. "I give her aspirin on a regular schedule every day."
- D. "My daughter takes her aspirin with her meals."
Answer: A
Explanation:
Explanation
(A) Aspirin should not be given on an empty stomach because it is irritating to the mucosa. (B) Bleeding from decreased clotting capacity may be caused by aspirin toxicity. (C) A regular schedule of aspirin administration is important to maintain a satisfactory drug level in the body. (D) Aspirin toxicity may affect cranial nerve VIII, leading to tinnitus (ringing in the ears).
NEW QUESTION 98
A client is now pregnant for the second time. Her first child weighed 4536 g at delivery. The client's glucose tolerance test shows elevated blood sugar levels. Because she only shows signs of diabetes when she is pregnant, she is classified as having:
- A. Gestational diabetes mellitus
- B. Type II diabetes mellitus
- C. Type I diabetes mellitus
- D. Insulin-dependent diabetes
Answer: A
Explanation:
(A) Insulin-dependent diabetes mellitus, also known as type I diabetes, usually appears before the age of 30 years with an abrupt onset of symptoms requiring insulin for management. It is not related to onset during pregnancy. (B) Non-insulin-dependent diabetes (type II diabetes) usually appears in older adults. It has a slow onset and progression of symptoms. (C) This type of diabetes is the same as insulin-dependent diabetes. (D) Gestational diabetes mellitus has its onset of symptoms during pregnancy and usually disappears after delivery. These symptoms are usually mild and not life threatening, although they are associated with increased fetal morbidity and other fetal complications.
NEW QUESTION 99
Pregnant women with diabetes often have problems related to the effectiveness of insulin in controlling their glucose levels during their second half of pregnancy. The nurse teaches the client that this is due to:
- A. Decreased glomerular filtration and increased tubular absorption
- B. Decreased estrogen levels
- C. Increased human placental lactogen levels
- D. Decreased progesterone levels
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) There is a rise in glomerular filtration rate in the kidneys in conjunction with decreased tubular glucose reabsorption, resulting in glycosuria. (B) Insulin is inhibited by increased levels of estrogen. (C) Insulin is inhibited by increased levels of progesterone. (D) Human placental lactogen levels increase later in pregnancy. This hormonal antagonist reduces insulin's effectiveness, stimulates lipolysis, and increases the circulation of free fatty acids.
NEW QUESTION 100
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