NCLEX EXAMINATION 2024/2025 GURANTEED PASS WITH 100% VERIFIED ANSWERS., Exams of Health sciences

Download NCLEX EXAMINATION 2024/2025 GURANTEED PASS WITH 100% VERIFIED ANSWERS. and more Exams Health sciences in PDF only on Docsity! NCLEX EXAMINATION 2024/2025 GURANTEED PASS WITH 100% VERIFIED ANSWERS. A client is in the eighth month of pregnancy. To enhance cardiac output and renal function, the nurse should advise her to use which body position? Left lateral During her fourth clinic visit, a client who's 5 months pregnant tells the nurse she was exposed to rubella during the past week and asks whether she can be immunized now. How should the nurse respond? No. Because the live viral vaccine is contraindicated during pregnancy. A client and her spouse, both 25 years old, are having trouble conceiving. Infertility in this couple is defined as: inability to conceive after 1year of unprotected attempts. When evaluating a pregnant client's fundal height, the nurse should measure in which way? from symphysis pubis notch to highest level of fundus. Which of the following client statements indicates the need for further teaching about percutaneous umbilical blood sampling (PUBS) to assess fetal hemoglobin and hematocrit? "I will lie on my back in a cylinder-type machine." When explaining the risk for having a child with cystic fibrosis to a husband and wife, the nurse should tell them: the risk is greatest when both clients have the recessive gene. A nurse is caring for a client whose membranes ruptured prematurely 12 hours ago. When assessing this client, the nurse's highest priority is to evaluate: maternal vital signs and fetal heart rate (FHR). A 34-year-old multiparous client at 16 weeks' gestation who received regular prenatal care for all of her previous pregnancies tells the nurse that she has already felt the baby move. How does the nurse interpret this finding? normal because multiparous clients can experience quickening between 14 and 20 weeks' gestation When developing the plan of care for a multigravid client with class III heart disease, the nurse should expect to assess the client frequently for which problem? Tachycardia A client at 37 weeks gestation is at a prenatal visit and states that she sometimes feels dizzy when lying directly on her back. Which of the following is the nurse's best response? "This may be due to the uterus putting pressure on a blood vessel." A client is a 43-year-old G2 P1 at 16 weeks' gestation that has completed prenatal testing for chromosomal abnormalities. The results reveal the infant is a female with Down syndrome. The parents are seeking information about this syndrome. What should the nurse tell the parents? Select all that apply. • Down syndrome can occur in mothers of any age. • Down syndrome occurs more frequently with advanced maternal age. • Down syndrome results from a trisomy of chromosome 21. Which task may a nurse delegate to a nursing assistant? Assisting a client who had surgery to ambulate in the hallway A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects: respiratory alkalosis. A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: a positive edrophonium test. A nurse is caring for a client admitted to the unit with a seizure disorder. The client seems upset and asks the nurse, "What will they do to me? I'm scared of the tests and of what they'll find out." The nurse should focus her teaching plans on which diagnostic tests? EEG, blood cultures, and neuroimaging studies A client with schizophrenia comes to the outpatient mental health clinic 5 days after being discharged from the hospital. The client was given a 1-week supply of clozapine. The client tells the nurse that she has too much saliva and frequently needs to spit. The nurse interprets the client's statement as being consistent with which factor? expected adverse effect of clozapine Which of the following statements indicates that a new graduate nurse understands central venous pressure (CVP) measurement when used on a client? "It will assess pressure and volume changes in the right atrium." of accumulated base bicarbonate or decreased hydrogen ion concentrations. The result is retention of sodium bicarbonate and increased base bicarbonate. A client is receiving fluid replacement with lactated Ringer's after 40% of the body was burned 10 hours ago. The assessment reveals temperature 97.1° F (36.2° C), heart rate 122 bpm, blood pressure 84/42 mm Hg, central venous pressure (CVP) 2 mm Hg, and urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL/h. Using the SBAR (Situation-Background-Assessment- Recommendation) technique for communication, the nurse calls the health care provider (HCP) with a recommendation for: IV rate increase. The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given due to the existing fluid volume deficit. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding. Fluid replacement used for burns is Lactated Ringer's solution, normal saline, or albumin. (less The nurse is caring for a client admitted with pyloric stenosis. A nasogastric tube placed upon admission is on low intermittent suction. Upon review of the morning's blood work, the nurse observes that the patient's potassium is below reference range. The nurse should recognize that the patient may be at risk for what imbalance? Metabolic alkalosis. Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This client would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the client's respiratory status. Which of the following clients is at greatest risk for Buerger's disease? A 29-year-old male with a 14-year history of cigarette smoking. Thromboangiitis obliterans (Buerger's disease) is a nonatherosclerotic, inflammatory vasoocclusive disorder. The disorder occurs predominantly in younger men < 40 years of age and there is a very strong relationship with tobacco use. Diagnosis is based on age of onset, history of tobacco use, symptoms, and exclusion of diabetes mellitus. While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The primary health care provider is notified because the nurse suspects which of the following? Hypospadias. The condition in which the urinary meatus is located on the ventral surface of the penis, termed hypospadias, occurs in 1 of every 500 male infants. Circumcision is delayed until the condition is corrected surgically, usually between 6 and 12 months of age. Phimosis is an inability to retract the prepuce at an age when it should be retractable or by age 3 years. Phimosis may necessitate circumcision or surgical intervention. Hydrocele is a painless swelling of the scrotum that is common in neonates. It is not a contraindication for circumcision. Epispadias occurs when the urinary meatus is located on the dorsal surface of the penis. It is extremely rare and is commonly associated with bladder extrophy. The nurse is caring for a client experiencing panic post fireworks display over the holiday weekend. The client routinely takes a prescribed dose of alprazolam 1.5 mg PO TID. A PRN dosage is also prescribed as 1.5 mg PO every four hours. The maximum daily dose is 8 mg. How many doses of the PRN medication might the client take safely?" 2 . The client would have a regularly prescribed dose of 1.5mg X 3 (tid)= 4.5mg. The client only has 2 doses or 3 mg possible to remain under the maximum dosage cap. A nurse is evaluating a client's auditory function. To compare air conduction to bone conduction, the nurse should conduct which test? Rinne test. The Rinne test compares air conduction to bone conduction in both ears. A client with a suspected diagnosis of lung cancer has a bronchoscopy with biopsy. Following the procedure the nurse should: monitor the client for signs of pneumothorax. After a bronchoscopy with a biopsy, as well as hemorrhage. The client should not gargle with oral lidocaine; this will not allow the gag reflex to return. The client should not have any mediastinal discomfort after a bronchoscopy; if pain does occur, it should be reported promptly to the health care provider (HCP). It is not necessary to tell the client not to talk until the gag reflex returns. A client who is at 38 weeks gestation has been admitted to the hospital for meconium stained rupture of membranes. The nurse inserts an internal fetal scalp electrode (FSE). The client appears anxious and asks why she requires the FSE. What is the nurse's most appropriate response? "The baby needs to be observed more closely. It is not ethical to tell this woman that her baby is "fine." The passage of meconium indicates that the fetus has experienced a stressor in the intrauterine environment, but the severity of the distress cannot be confirmed. The well being of the fetus is not yet known and requires further observation and evaluation with the internal FSE. (less) The nurse assesses a client who is receiving a tube feeding. Which situation would require prompt intervention from the nurse? The feeding that is infusing has been hanging for 8 hours. Feeding solutions that have not been infused after hanging for 8 hours should be discarded because of the increased risk of bacterial growth. Sitting the client upright during the feeding helps prevent aspiration of the feeding. A gastric residual of 25 mL is considered acceptable. A gastric residual of 100 to 150 mL, or a residual greater than 100% of the previous hour's intake, indicates delayed emptying. The feeding solution should be at room or body temperature. The nurse is educating a client on diabetes management. The client is asking questions that cause the nurse to be concerned about the client's ability to retain the information. Which of the following would be the best technique for the nurse to use to enhance the retention of information by the client? Repeat important information during the presentation. Repetition is an effective means of reinforcing critical information and enhancing content retention. The other options will not increase the client's ability to retain information and may decrease the client's concentration and ability to retain critical information. The nurse finds a client lying on the floor next to the bed. After returning the client to bed, assessing for injury, and notifying the health care provider (HCP), the nurse fills out an incident report. What should the nurse do next? Give the incident report to the nurse-manager. A client with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client's hypertension is caused by excessive hormone secretion from which gland? Adrenal cortex. Excessive secretion of aldosterone in the adrenal cortex is responsible for the client's hypertension. This hormone acts on the renal tubule, where it promotes reabsorption of sodium and excretion of potassium and hydrogen ions. The pancreas mainly secretes hormones involved in fuel metabolism. The adrenal medulla secretes the catecholamines — epinephrine and norepinephrine. The parathyroids secrete parathyroid hormone. The mother of a client who has a radium implant asks why so many nurses are involved in her daughter's care. She states, "The doctor said I can be in the room for up to 2 hours each day, but the nurses say they are restricted to 30 minutes." The nurse explains that this variation is based on the fact that nurses: Work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. The three factors related to radiation safety are time, distance, and shielding. Nurses on radiation oncology units work with radiation frequently and so must limit their contact. Nurses are physically closer to clients than are visitors, who are often asked to sit 6 feet (182.9 cm) away from the client. Touching the client does not increase the amount of radiation exposure. Aseptic technique and isolation prevent the spread of infection. Age is a risk factor for people in their reproductive years. During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates: cranial nerves IX and X. Swallowing is a motor function of cranial nerves IX and X. Cranial nerves I, II, and VIII don't possess motor functions. The motor functions of cranial nerve III include extraocular eye movement, eyelid elevation, and pupil constriction. The motor function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement. and do not experience complications. However, hypopituitarism can cause growth hormone, gonadotropin, thyroid-stimulating hormone, and adrenocorticotropic hormone deficits. The client should be taught to monitor for change in mental status, energy level, muscle strength, and cognitive function. Acromegaly and Cushing's disease are conditions of hypersecretion. A 10-year-old child hospitalized with acute poststreptococcal glomerulonephritis during the acute stage has elevated blood pressure and low urine output for 14 hours. The nurse should next: assess the child's neurologic status. The nurse should assess the child's neurologic status because hypertensive encephalopathy is a major potential complication of the acute phase of glomerulonephritis. Seizure precautions also should be instituted. Hypertensive encephalopathy can result in transient loss of vision, hemiparesis, disorientation, and grand mal seizures. Encouraging the child to drink more water is inappropriate because the child has had a low urine output for 14 hours. Typically, in this situation, fluids would be restricted. Although a low-sodium diet is encouraged, it is not the priority action at this time. Initially, bed rest, not ambulation, is advocated during the acute phase of glomerulonephritis. A boy, age 2, is diagnosed with hemophilia, an X-linked recessive disorder. His parents and newborn sister are healthy. The nurse explains how the gene for hemophilia is transmitted. Which statement by the father indicates an understanding of X-linked recessive disorders? Our newborn daughter may be a carrier of the trait." The father stating that his newborn daughter may be a carrier of the trait demonstrates understanding of X-linked recessive disorders. X-linked recessive genes behave like other recessive genes. A normal dominant gene hides the effects of an abnormal recessive gene. However, the gene is expressed primarily in male offspring because it's located on the X chromosome. Male offspring of a carrier mother and an unaffected father have a 50% chance of expressing the trait whereas female offspring are more likely to carry the trait than express it. These parents may produce offspring who neither express nor carry the trait for hemophilia. A client is 37 weeks gestation and is experiencing preeclampsia. The physician has ordered magnesium sulfate, increased fetal surveillance, and increased nursing interventions. The nightshift charge nurse is preparing the patient-nurse assignment before the morning shift begins. Which of the following factors should be the primary factor in the decision surrounding who should care for this client? Complexity of care requirements Registered nurses are responsible for exhibiting critical thinking skills and caring for clients with fluctuating changes in their condition. This client requires extensive nursing care because she has experienced a change in health status and requires enhanced surveillance. It is critical that the nurse caring for her recognizes if her condition further deteriorates. While it is appropriate to consider senior nursing staff, client wishes and continuity of care, it is the responsibility of nurses to provide safe and ethical care. Therefore, in this context, client safety is the priority and requires that the charge nurse considers the complexity of her care requirements when assigning the appropriate care provider. A laboring client's membranes rupture, and the nurse notes that the amniotic fluid is meconium stained. Which of the following activities should the nurse immediately perform? Begin continuous fetal heart rate monitoring. Meconium staining in the amniotic fluid is not always a sign of fetal distress but is correlated with its occurrence. It reveals that the fetus has had an episode of loss of sphincter control. This clinical situation requires further investigation with fetal heart rate monitoring. There is no indication that birth is imminent. Changing the client to left lateral position may enhance uteroplacental exchange, allowing more oxygen to reach the fetus; however, it is most critical to assess the fetal heart rate, as this provides immediate information surrounding the health and safety of the fetus. A nurse in a psychiatric care unit finds that a client with psychosis has become violent and has struck another client in the unit. What action should the nurse take in this case? Restrain the client, as he is harmful to the other clients in the psychiatric care unit. Restraints should be used as a last resort and their use should be justified. Unnecessary restraining can lead to allegations of false imprisonment and battery; both are not applicable in this case, however. The nurse should inform the physician about the client, but sometimes it may not be logical to wait for orders to restrain a violent client. A multigravid laboring client has an extensive documented history of drug addiction. Her last reported usage was 5 hours ago. She is 2 cm dilated with contractions every 3 minutes of moderate intensity. The health care provider (HCP) prescribes nalbuphine 15 mg slow IV push for pain relief followed by an epidural when the client is 4 cm dilated. Within 10 minutes of receiving the nalbuphine, the client states she thinks she is going to have her baby now. Of the drugs available at the time of the birth, which should the nurse avoid using with this client in this situation? Naloxone. Naloxone would not be used in a client who has a history of drug addiction. Naloxone would abruptly withdraw this woman from the drug she is addicted to as well as the nalbuphine. The withdrawal would occur within a few minutes of injection and, if severe enough, could jeopardize the mother and fetus. Interferon alfa-2b has been prescribed to treat a client with chronic hepatitis B. The nurse should assess the client for which common adverse effects? Flulike symptoms. Interferon alfa-2b most commonly causes flulike adverse effects, such as myalgia, arthralgia, headache, nausea, fever, and fatigue. The client with breast cancer is prescribed tamoxifen 20 mg daily. The client states she does not like taking medicine and asks the nurse if the tamoxifen is really worth taking. The nurse should tell the client: "This drug has been found to decrease metastatic breast cancer and to improve the survival rate. The drug causes hot flashes as an adverse effect. A client with asthma who has wheezing and shortness of breath asks the nurse if it is all right to use the salmeterol inhaler during exercise. What is the nurse's best response? "No, this drug is a maintenance drug, not a rescue inhaler." Salmeterol is a beta2-agonist, a maintenance drug that the asthmatic client uses twice daily, every 12 hours. Albuterol is used as the "rescue inhaler" for bronchospasms. Salmeterol can be used to prevent exercise-induced bronchospasms, but it should be taken 30 to 60 minutes before exercise. If the client is taking salmeterol twice daily, it should not be used in additional doses before exercise; twice daily is the maximum dosage. Indications for salmeterol include only asthma and bronchospasm induced by chronic obstructive pulmonary disease. The nurse is monitoring a client who appears to be hallucinating. The client displays paranoid speech content, seems agitated, and gestures at a figure on the television. Which of the following nursing interventions is appropriate? Select all that apply. Reinforce that the client is not in any danger. • Acknowledge the presence of the hallucinations. • Use a calm voice and simple commands. Using a calm voice, the nurse should reassure that the client is safe. The nurse should not challenge the client; rather, he or she should acknowledge the hallucinatory experience. It is not appropriate to request that the client stop the behavior. Implementing restraints is not warranted at this time. Although the client is agitated, no evidence exists that the client is at risk for harming self or others. The nurse is caring for a client receiving digoxin who has begun vomiting and reports seeing colorful halos around the lights in the room. Which of the following actions should the nurse implement? Select all that apply. 1. D/C digoxin. 2. Begin continuous ECG monitoring for cardiac dysrhythmias. 3. Determine serum digoxin and electrolyte levels. Symptoms of digoxin toxicity include severe sinus bradycardia, colorful halos around lights, nausea, anorexia, and vomiting. A client is diagnosed with myocardial infarction. Which data collection findings indicate that the client has developed left-sided heart failure? Select all that apply. Cough Crackles Orthopnea Left-sided heart failure produces primarily pulmonary signs and symptoms, such as orthopnea, cough, and crackles. Right-sided heart failure primarily produces systemic signs and symptoms, such as ascites, jugular vein distention, and hepatomegaly. A nurse is conducting a teaching session with a group of parents on infant care and safety to assist parents in appropriately preparing to take their neonates home. Which statement about automobile restraints made by one of the parents would indicate to the nurse that learning has taken place?