NCLEX RN ACTUAL EXAM TEST BANK OF REAL QUESTIONS & ANSWERS NCLEX 2024/2025, Exams of Nursing

Download NCLEX RN ACTUAL EXAM TEST BANK OF REAL QUESTIONS & ANSWERS NCLEX 2024/2025 and more Exams Nursing in PDF only on Docsity! NCLEX RN ACTUAL EXAM TEST BANK OF REAL QUESTIONS & ANSWERS NCLEX 2024/2025 QUESTION 1 Which classification of drugs is contraindicated for the client with hypertrophic cardiomyopathy? A. Positive inotropes B. Vasodilators C. Diuretics D. Antidysrhythmics Answer: A Explanatio n: (A) Positive inotropic agents should not be administered owing to their action of increasing myocardial contractility. Increased ventricular contractility would increase outflow tract obstruction in the client with hypertrophic cardiomyopathy. (B) Vasodilators are not typically prescribed but are not contraindicated. (C) Diuretics are used with caution to avoid causing hypovolemi A. (D) Antidysrhythmics are typically needed to treat both atrial and ventricular dysrhythmias. QUESTION 2 Signs and symptoms of an allergy attack include which of the following? A. Wheezing on inspiration B. Increased respiratory rate C. Circumoral cyanosis D. Prolonged expiration Answer: D Explanatio n: (A) Wheezing occurs during expiration when air movement is impaired because of constricted edematous bronchial lumin A. (B) Respirations are difficult, but the rate is frequently normal. (C) The circumoral area is usually pale. Cyanosis is not an early sign of hypoxi A. (D) Expiration is prolonged because the alveoli are greatly distended and air trapping occurs. QUESTION 3 A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of hallucination? A. Auditory NCLEX RN ACTUAL EXAM TEST BANK OF REAL QUESTIONS & ANSWERS NCLEX 2024/2025 B. Gustatory C. Olfactory D. Visceral Answer: B Explanatio n: (A) Auditory hallucinations involve sensory perceptions of hearing. (B) Gustatory hallucinations involve sensory perceptions of taste. (C) Olfactory hallucinations involve sensory perceptions of smell. (D) Visceral hallucinations involve sensory perceptions of sensation. NCLEX RN ACTUAL EXAM TEST BANK OF REAL QUESTIONS & ANSWERS NCLEX 2024/2025 finger foods allow him to eat during periods of activity. (B) This type of therapy should be implemented when other methods have been exhausted. (C) The manic client should not be in control of his treatment plan. This type of client may forget to eat. (D) The manic client is unable to sit down to eat full meals. QUESTION 7 A client with bipolar disorder taking lithium tells the nurse that he has ringing in his ears, blurred vision, and diarrhe A. The nurse notices a slight tremor in his left hand and a slurring pattern to his speech. Which of the following actions by the nurse is appropriate? A. Administer a stat dose of lithium as necessary. B. Recognize this as an expected response to lithium. C. Request an order for a stat blood lithium level. D. Give an oral dose of lithium antidote. Answer: C Explanatio n: (A) These symptoms are indicative of lithium toxicity. A stat dose of lithium could be fatal. (B) These are toxic effects of lithium therapy. (C) The client is exhibiting symptoms of lithium toxicity, which may be validated by lab studies. (D) There is no known lithium antidote. QUESTION 8 A diagnosis of hepatitis C is confirmed by a male client‘s physician. The nurse should be knowledgeable of the differences between hepatitis A, B, and C. Which of the following are characteristics of hepatitis C? A. The potential for chronic liver disease is minimal. B. The onset of symptoms is abrupt. C. The incubation period is 2–26 weeks. D. There is an effective vaccine for hepatitis B, but not for hepatitis C. Answer: C Explanatio n: (A) Hepatitis C and B may result in chronic liver disease. Hepatitis A has a low potential for chronic liver disease. (B) Hepatitis C and B have insidious onsets. Hepatitis A has an abrupt onset. (C) Incubation periods are as follows: hepatitis C is 2–26 weeks, hepatitis B is 6–20 weeks, and hepatitis A is 2–6 weeks. (D) Only hepatitis B has an effective vaccine. QUESTION 9 Hypoxia is the primary problem related to near-drowning victims. The first organ that sustains irreversible damage after submersion in water is the: A. Kidney (urinary system) B. Brain (nervous system) C. Heart (circulatory system) D. Lungs (respiratory system) NCLEX RN ACTUAL EXAM TEST BANK OF REAL QUESTIONS & ANSWERS NCLEX 2024/2025 Answer: B Explanatio n: NCLEX RN ACTUAL EXAM TEST BANK OF REAL QUESTIONS & ANSWERS NCLEX 2024/2025 (A) The kidney can survive after 30 minutes of water submersion. (B) The cerebral neurons sustain irreversible damage after 4–6 minutes of water submersion. (C) The heart can survive up to 30 minutes of water submersion. (D) The lungs can survive up to 30 minutes of water submersion. QUESTION 10 Which of the following activities would be most appropriate during occupational therapy for a client with bipolar disorder? A. Playing cards with other clients B. Working crossword puzzles C. Playing tennis with a staff member D. Sewing beads on a leather belt Answer: C Explanatio n: (A) This activity is too competitive, and the manic client might become abusive toward the other clients. (B) During mania, the client‘s attention span is too short to accomplish this task. (C) This activity uses gross motor skills, eases tension, and expands excess energy. A staff member is better equipped to interact therapeutically with clients. (D) This activity requires the use of fine motor skills and is very tedious. QUESTION 11 A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2 months, his family describes him as being ―on the move,‖ sleeping 3–4 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial assessment with the client, the nurse would expect him to exhibit which of the following? A. Short, polite responses to interview questions B. Introspection related to his present situation C. Exaggerated self-importance D. Feelings of helplessness and hopelessness Answer: C Explanatio n: (A) During the manic phase of bipolar disorder, clients have short attention spans and may be abusive toward authority figures. (B) Introspection requires focusing and concentration; clients with mania experience flight of ideas, which prevents concentration. (C) Grandiosity and an inflated sense of self-worth are characteristic of this disorder. (D) Feelings of helplessness and hopelessness are symptoms of the depressive stage of bipolar disorder. QUESTION 12 Diabetes during pregnancy requires tight metabolic control of glucose levels to prevent perinatal mortality. When evaluating the pregnant client, the nurse knows the recommended serum glucose range during pregnancy is: NCLEX RN ACTUAL EXAM TEST BANK OF REAL QUESTIONS & ANSWERS NCLEX 2024/2025 QUESTION 15 A schizophrenic client has made sexual overtures toward her physician on numerous occasions. During lunch, the client tells the nurse, ―My doctor is in love with me and wants to marry me.‖ This client is using which of the following defense mechanisms? NCLEX RN ACTUAL EXAM TEST BANK OF REAL QUESTIONS & ANSWERS NCLEX 2024/2025 A. Displacement B. Projection C. Reaction formation D. Suppression Answer: B Explanatio n: (A) Displacement involves transferring feelings to a more acceptable object. (B) Projection involves attributing one‘s thoughts or feelings to another person. (C) Reaction formation involves transforming an unacceptable impulse into the opposite behavior. (D) Suppression involves the intentional exclusion of unpleasant thoughts or experiences. QUESTION 16 When teaching a sex education class, the nurse identifies the most common STDs in the United States as: A. Chlamydia B. Herpes genitalis C. Syphilis D. Gonorrhea Answer: A Explanatio n: (A) Chlamydia trachomatis infection is the most common STD in the United States. The Centers for Disease Control and Prevention recommend screening of all high-risk women, such as adolescents and women with multiple sex partners. (B) Herpes simplex genitalia is estimated to be found in 5–20 million people in the United States and is rising in occurrence yearly. (C) Syphilis is a chronic infection caused by Treponema pallidum. Over the last several years the number of people infected has begun to increase. (D) Gonorrhea is a bacterial infection caused by the organism Neisseria gonorrhoeae. Although gonorrhea is common, chlamydia is still the most common STD. QUESTION 17 The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should: A. Increase his nasal O2 to 6 L/min B. Place him in a lateral Sims‘ position C. Encourage pursed-lip breathing D. Have him breathe into a paper bag Answer: C Explanatio n: (A) Giving too high a concentration of O2 to a client with em-physema may remove his stimulus to breathe. (B) The client should sit forward with his hands on his knees or an overbed table and with shoulders elevated. (C) Pursed-lip breathing helps the client to blow off CO2 and to keep air passages open. (D) Covering the face of a client extremely short of breath may cause anxiety and NCLEX RN ACTUAL EXAM TEST BANK OF REAL QUESTIONS & ANSWERS NCLEX 2024/2025 further increase dyspnea. NCLEX RN ACTUAL EXAM TEST BANK OF REAL QUESTIONS & ANSWERS NCLEX 2024/2025 QUESTION 21 An 8-year-old child comes to the physician‘s office complaining of swelling and pain in the knees. His mother says, ―The swelling occurred for no reason, and it keeps getting worse.‖ The initial diagnosis is Lyme disease. When talking to the mother and child, questions related to which of the following would be important to include in the initial history? A. A decreased urinary output and flank pain B. A fever of over 103F occurring over the last 2–3 weeks C. Rashes covering the palms of the hands and the soles of the feet D. Headaches, malaise, or sore throat Answer: D Explanatio n: (A) Urinary tract symptoms are not commonly associated with Lyme disease. (B) A fever of 103F is not characteristic of Lyme disease. (C) The rash that is associated with Lyme diseasedoes not appear on the palms of the hands and the soles of the feet. (D) Classic symptoms of Lyme disease include headache, malaise, fatigue, anorexia, stiff neck, generalized lymphadenopathy, splenomegaly, conjunctivitis, sore throat, abdominal pain, and cough. QUESTION 22 When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is: A. Stephens-Johnson syndrome B. Folate deficiency C. Leukopenic aplastic anemia D. Granulocytosis and nephrosis Answer: A Explanatio n: (A) Stephens-Johnson syndrome is a toxic effect of phenytoin. (B) Folate deficiency is a side effect of phenytoin, but not a toxic effect. (C) Leukopenic aplastic anemia is a toxic effect of carbamazepine (Tegretol). (D) Granulocytosis and nephrosis are toxic effects of trimethadione (Tridione). QUESTION 23 The nurse should know that according to current thinking, the most important prognostic factor for a client with breast cancer is: A. Tumor size B. Axillary node status C. Client‘s previous history of disease D. Client‘s level of estrogen-progesterone receptor assays Answer: B Explanatio n: NCLEX RN ACTUAL EXAM TEST BANK OF REAL QUESTIONS & ANSWERS NCLEX 2024/2025 (A) Although tumor size is a factor in classification of cancer growth, it is not an indicator of lymph node spread. (B) Axillary node status is the most important indicator for predicting how far the cancer has spread. If the lymph nodes are positive for cancer cells, the prognosis is poorer. (C) The client‘s previous history of cancer NCLEX RN ACTUAL EXAM TEST BANK OF REAL QUESTIONS & ANSWERS NCLEX 2024/2025 puts her at an increased risk for breast cancer recurrence, especially if the cancer occurred in the other breast. It does not predict prognosis, however. (D) The estrogen-progesterone assay test is used to identify present tumors being fedfrom an estrogen site within the body. Some breast cancers grow rapidly as long as there is an estrogen supply such as from the ovaries. The estrogen- progesterone assay test does not indicate the prognosis. QUESTION 24 Three weeks following discharge, a male client is readmitted to the psychiatric unit for depression. His wife stated that he had threatened to kill himself with a handgun. As the nurse admits him to the unit, he says, ―I wish I were dead because I am worthless to everyone; I guess I am just no good.‖ Which response by the nurse is most appropriate at this time? A. ―I don‘t think you are worthless. I‘m glad to see you, and we will help you.‖ B. ―Don‘t you think this is a sign of your illness?‖ C. ―I know with your wife and new baby that you do have a lot to live for.‖ D. ―You‘ve been feeling sad and alone for some time now?‖ Answer: D Explanatio n: (A) This response does not acknowledge the client‘s feelings. (B) This is a closed question and does not encourage communication. (C) This response negates the client‘s feelings and does not require a response from the client. (D) This acknowledges the client‘s implied thoughts and feelings and encourages a response. QUESTION 25 Which of the following should be included in discharge teaching for a client with hepatitis C? A. He should take aspirin as needed for muscle and joint pain. B. He may become a blood donor when his liver enzymes return to normal. C. He should avoid alcoholic beverages during his recovery period. D. He should use disposable dishes for eating and drinking. Answer: C Explanatio n: (A) Aspirin is hepatotoxic, may increase bleeding, and should be avoided. (B) Blood should not be donated by a client who has had hepatitis C because of the possibility of transmission of disease. (C) Alcohol is detoxified in the liver. (D) Hepatitis C is not spread through the oral route. QUESTION 26 The initial treatment for a client with a liquid chemical burn injury is to: A. Irrigate the area with neutralizing solutions B. Flush the exposed area with large amounts of water C. Inject calcium chloride into the burned area D. Apply lanolin ointment to the area NCLEX RN ACTUAL EXAM TEST BANK OF REAL QUESTIONS & ANSWERS NCLEX 2024/2025 B. Tetracycline treatment C. IV amphotericin B D. High-protein diet with limited fluids NCLEX RN ACTUAL EXAM TEST BANK OF REAL QUESTIONS & ANSWERS NCLEX 2024/2025 Answer: B Explanatio n: (A) The client is not placed on complete bed rest for 6 weeks. (B) Tetracycline is the treatment of choice for children with Lyme disease who are over the age of 9. (C) IV amphotericin B is the treatment for histoplasmosis. (D) The client is not restricted to a high-protein diet with limited fluids. QUESTION 30 The physician recommends immediate hospital admission for a client with PIH. She says to the nurse, ―It‘s not so easy for me to just go right to the hospital like that.‖ After acknowledging her feelings, which of these approaches by the nurse would probably be best? A. Stress to the client that her husband would want her to do what is best for her health. B. Explore with the client her perceptions of why she is unable to go to the hospital. C. Repeat the physician‘s reasons for advising immediate hospitalization. D. Explain to the client that she is ultimately responsible for her own welfare and that of her baby. Answer: B Explanatio n: (A) This answer does not hold the client accountable for her own health. (B) The nurse should explore potential reasons for the client‘s anxiety: are there small children at home, is the husband out of town? The nurse should aid the client in seeking support or interventions to decrease the anxiety of hospitalization. (C) Repeating the physician‘s reason for recommending hospitalization may not aid the client in dealing with her reasons for anxiety. (D) The concern for self and welfare of baby may be secondary to a woman who is in a crisis situation. The nurse should explore the client‘s potential reasons for anxiety. For example, is there another child in the home who is ill, or is there a husband who is overseas and not able to return on short notice? QUESTION 31 The child with iron poisoning is given IV deforoxamine mesylate (Desferal). Following administration, the child suffers hypotension, facial flushing, and urticari A. The initial nursing intervention would be to: A. Discontinue the IV B. Stop the medication, and begin a normal saline infusion C. Take all vital signs, and report to the physician D. Assess urinary output, and if it is 30 mL an hour, maintain current treatment Answer: B Explanatio n: (A) The IV line should not be discontinued because other IV medications will be needed. (B) Stop the medication and begin a normal saline infusion. The child is exhibiting signs of an allergic reaction and could go into shock if the medication is not stopped. The line should be kept opened for other medication. (C) Taking vital signs and reporting to the physician is not an adequate intervention because the IV NCLEX RN ACTUAL EXAM TEST BANK OF REAL QUESTIONS & ANSWERS NCLEX 2024/2025 medication continues to flow. (D) Assessing urinary output and, if it is 30 mL an hour, maintaining current treatment is an inappropriate intervention owing to the child‘s obvious allergic reaction. NCLEX RN ACTUAL EXAM TEST BANK OF REAL QUESTIONS & ANSWERS NCLEX 2024/2025 QUESTION 37 A client with a C-3–4 fracture has just arrived in the emergency room. The primary nursing intervention is: NCLEX RN ACTUAL EXAM TEST BANK OF REAL QUESTIONS & ANSWERS NCLEX 2024/2025 A. Stabilization of the cervical spine B. Airway assessment and stabilization C. Confirmation of spinal cord injury D. Normalization of intravascular volume Answer: B Explanatio n: (A) If cervical spine injury is suspected, the airway should be maintained using the jaw thrust method that also protects the cervical spine. (B) Primary intervention is protection of the airway and adequate ventilation. (C, D) All other interventions are secondary to adequate ventilation. QUESTION 38 To ensure proper client education, the nurse should teach the client taking SL nitroglycerin to expect which of the following responses with administration? A. Stinging, burning when placed under the tongue B. Temporary blurring of vision C. Generalized urticaria with prolonged use D. Urinary frequency Answer: A Explanatio n: (A) Stinging or burning when nitroglycerin is placed under the tongue is to be expected. This effect indicates that the medication is potent and effective for use. Failure to have this response means that the client needs to get a new bottle of nitroglycerin. (B, C, D) The other responses are not expected in this situation and are not even side effects. QUESTION 39 Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes: A. Maintaining seizure precautions B. Restricting fluid intake C. Increasing sensory stimuli D. Applying ankle and wrist restraints Answer: A Explanatio n: (A) These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. (B) Fluid intake should be increased to prevent dehydration. (C) Environmental stimuli should be decreased to prevent precipitation of seizures. (D) Application of restraints may cause the client to increase his or her physical activity and may eventually lead to exhaustion. QUESTION 40 The day following his admission, the nurse sits down by a male client on the sofa in the dayroom. He was admitted for depression and thoughts of suicide. He looks at the nurse and says, ―My life is NCLEX RN ACTUAL EXAM TEST BANK OF REAL QUESTIONS & ANSWERS NCLEX 2024/2025 so bad no one can do anything to help me.‖ The most helpful initial response by the nurse would be: NCLEX NCLEX-RN QUESTION 46 A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical A. Determine gross abnormal motor function B. Obtain a baseline for comparison with the infant‘s future adaptation to the environment C. Evaluate the infant‘s vital functions D. Determine the extent of congenital malformations Answer: C Explanatio n: (A) Apgar scores are not related to the infant‘s care, but to the infant‘s physical condition. (B) Apgar scores assess the current physical condition of the infant and are not related to future environmental adaptation. (C) The purpose of the Apgar system is to evaluate the physical condition of the newborn at birth and to determine if there is an immediate need for resuscitation. (D) Congenital malformations are not one of the areas assessed with Apgar scores. QUESTION 44 Hematotympanum and otorrhea are associated with which of the following head injuries? A. Basilar skull fracture B. Subdural hematoma C. Epidural hematoma D. Frontal lobe fracture Answer: A Explanatio n: (A) Basilar skull fractures are fractures of the base of the skull. Blood behind the eardrum or blood or cerebrospinal fluid (CSF) leaking from the ear are indicative of a dural laceration. Basilar skull fractures are the only type with these symptoms. (B, C, D) These do not typically cause dural lacerations and CSF leakage. QUESTION 45 Which of the following risk factors associated with breast cancer would a nurse consider most significant in a client‘s history? A. Menarche after age 13 B. Nulliparity C. Maternal family history of breast cancer D. Early menopause Answer: C Explanatio n: (A) Women who begin menarche late (after 13 years old) have a lower risk of developing breast NCLEX NCLEX-RN QUESTION 46 A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical cancer than women who have begun earlier. Average age for menarche is 12.5 years. (B) Women who have never been pregnant have an increased risk for breast cancer, but a positive family history poses an even greater risk. (C) A positive family history puts a woman at an increased risk of developing breast cancer. It is recommended that mammography screening begin 5 years before the age at which an immediate female relative was diagnosed with breast cancer. (D) Early menopause decreases the risk of developing breast cancer. NCLEX NCLEX-RN decreased peripheral perfusion and bradycardi A. (B) Dobutamine‘s side effects include increased heart rate and blood pressure, ventricular ectopy, nausea, examination are normal. How does the nurse interpret the effectiveness of the instruction about diet and weight control? A. She is compliant with her diet as previously taught. B. She needs further instruction and reinforcement. C. She needs to increase her caloric intake. D. She needs to be placed on a restrictive diet immediately. Answer: B Explanatio n: (A) She is probably not compliant with her diet and exercise program. Recommended weight gain during second and third trimesters is approximately 12 lb. (B) Because of her excessive weight gain of 10 lb in 2 months, she needs re-evaluation of her eating habits and reinforcement of proper dietary habits for pregnancy. A 2200-calorie diet is recommended for most pregnant women with a weight gain of 27–30 lb over the 9-month period. With rapid and excessive weightgain, PIH should also be suspected. (C) She does not need to increase her caloric intake, but she does need to re-evaluate dietary habits. Ten pounds in 2 months is excessive weight gain during pregnancy, and health teaching is warranted. (D) Restrictive dieting is not recommended during pregnancy. QUESTION 47 The priority nursing goal when working with an autistic child is: A. To establish trust with the child B. To maintain communication with the family C. To promote involvement in school activities D. To maintain nutritional requirements Answer: A Explanatio n: (A) The priority nursing goal when working with an autistic child is establishing a trusting relationship. (B) Maintaining a relationship with the family is important but having the trust of the child is a priority. (C) To promote involvement in school activities is inappropriate for a child who is autistic. (D) Maintaining nutritional requirements is not the primary problem of the autistic child. QUESTION 48 The nurse would need to monitor the serum glucose levels of a client receiving which of the following medications, owing to its effects on glycogenolysis and insulin release? A. Norepinephrine (Levophed) B. Dobutamine (Dobutrex) C. Propranolol (Inderal) NCLEX NCLEX-RN D. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus Answer: C Answer: A Explanatio n: (A) This is a high-risk factor for potential suicide. (B) A previous suicide attempt is a definite risk factor for subsequent attempts. (C) Every threat of suicide should be taken seriously. (D) The client should be asked directly about his or her intent to do bodily harm. The client is never hurt by direct, respectful questions. QUESTION 52 When assessing a child with diabetes insipidus, the nurse should be aware of the cardinal signs of: A. Anemia and vomiting B. Polyuria and polydipsia C. Irritability relieved by feeding formula D. Hypothermia and azotemia Answer: B Explanatio n: (A) Anemia and vomiting are not cardinal signs of diabetes insipidus. (B) Polyuria and polydipsia are the cardinal signs of diabetes insipidus. (C) Irritability relieved by feeding water, not formula, is a common sign, but not the cardinal sign, of diabetes insipidus. (D) Hypothermia and azotemia are signs, but not cardinal signs, of diabetes insipidus. QUESTION 53 The physician orders fluoxetine (Prozac) for a depressed client. Which of the following should the nurse remember about fluoxetine? A. Because fluoxetine is a tricyclic antidepressant, it may precipitate a hypertensive crisis. B. The therapeutic effect of the drug occurs 2–4 weeks after treatment is begun. C. Foods such as aged cheese, yogurt, soy sauce, and bananas should not be eaten with this drug. D. Fluoxetine may be administered safely in combination with monoamine oxidase (MAO) inhibitors. Answer: B Explanatio n: (A) Fluoxetine is not a tricyclic antidepressant. It is an atypical antidepressant. (B) This statement is true. (C) These foods are high in tyramine and should be avoided when the client is taking MAO inhibitors. Fluoxetine is not an MAO inhibitor. (D) Fatal reactions have been reported in clients receiving fluoxetine in combination with MAO inhibitors. QUESTION 54 NCLEX NCLEX-RN D. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus Answer: C A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include: A. Bleeding, bruising, and hemorrhage B. Increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase C. Pain, pallor, pulselessness, paresthesia, and paralysis NCLEX NCLEX-RN D. Decreased tidal volume and tachypnea Answer: C Explanation: (A) Bleeding, bruising, and hemorrhage may occur due to injury but are not classic signs of ischemi A. (B) An increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase is related to the disruption of muscle integrity. (C) Classic signs of ischemia related to vascular injury secondary to long bone fractures include the five ―P‘s‖: pain, pallor, pulselessness, paresthesia, and paralysis. (D) Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus are common clinical manifestations of a fracture but not ischemia. QUESTION 55 A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report: A. Dizziness and tachypnea B. Circumoral pallor and lightheadedness C. Headache and facial flushing D. Pallor and itching of the face and neck Answer: C Explanatio n: (A) Tachypnea is not a symptom. (B) Circumoral pallor is not a symptom. (C) Autonomic dysreflexia is an uninhibited and exaggerated reflex of the autonomic nervous system to stimulation, which results in vasoconstriction and elevated blood pressure. (D) Pallor and itching are not symptoms. QUESTION 56 A client with emphysema is placed on diuretics. In order to avoid potassium depletion as a side effect of the drug therapy, which of the following foods should be included in his diet? A. Celery B. Potatoes C. Tomatoes D. Liver Answer: B Explanatio n: (A) Celery is high in sodium. (B) Potatoes are high in potassium. (C) Tomatoes are high in sodium. (D) Liver is high in iron. QUESTION 57 Which of the following signs and symptoms indicates a tension pneumothorax as compared NCLEX NCLEX-RN level Answer: A NCLEX NCLEX-RN B. Exacerbation of depressive symptoms Explanation: (A) Polymerase chain reaction is the laboratory technique specific for Lyme disease. (B) Heterophil antibody test is used to diagnose mononucleosis. (C) Lyme disease does not decrease the serum calcium level. (D) Lyme disease does not increase the serum potassium level. QUESTION 61 The cardiac client who exhibits the symptoms of disorientation, lethargy, and seizures may be exhibiting a toxic reaction to: A. Digoxin (Lanoxin) B. Lidocaine (Xylocaine) C. Quinidine gluconate or sulfate (Quinaglute, Quinidex) D. Nitroglycerin IV (Tridil) Answer: B Explanatio n: (A) Side effects of digoxin include headache, hypotension, AV block, blurred vision, and yellow-green halos. (B) Side effects of lidocaine include heart block, headache, dizziness, confusion, tremor, lethargy, and convulsions. (C) Side effects of quinidine include heart block, hepatotoxicity, thrombocytopenia, and respiratory depression. (D) Side effects of nitroglycerin include postural hypotension, headache, dizziness, and flushing. QUESTION 62 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. Give him 3 tbsp of sugar dissolved in 4 oz of grape juice to drink B. Ask him to dissolve three pieces of hard candy in his mouth C. Have him drink 4 oz of orange juice D. Monitor him closely until dinner arrives Answer: C Explanatio n: (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. NCLEX NCLEX-RN B. Exacerbation of depressive symptoms QUESTION 63 After 3 weeks of treatment, a severely depressed client suddenly begins to feel better and starts interacting appropriately with other clients and staff. The nurse knows that this client has an increased risk for: A. Suicide NCLEX NCLEX-RN C. Phenylephrine (Neo-Synephrine) D. Sodium bicarbonate Answer: A Explanatio n: (A) Phentolamine is given to counteract the-adrenergic effects that cause ischemia and necrosis of local tissue. (B) Epinephrine is an endogenous catecholamine that produces vasoconstriction and increases heart rate and contractility. (C) Phenylephrine causes constriction of arterioles of skin, mucous membranes, and viscera, which in turn can cause ischemia and necrosis. (D) Sodium bicarbonate is an alkalinizing agent that is incompatible with dopamine. QUESTION 67 A male client receives 10 U of regular human insulin SC at 9:00 AM. The nurse would expect peak action from this injection to occur at: A. 9:30 AM B. 10:30 AM C. 12 noon D. 4:00 PM Answer: C Explanatio n: (A) This is too early for peak action to occur. (B) This is too early for peak action to occur. (C) Regular insulin peak action occurs 2–4 hours after administration. (D) This is too late for peak action to occur. QUESTION 68 As the nurse assesses a male adolescent with chlamydia, the nurse determines that a sign of chlamydia is: A. Enlarged penis B. Secondary lymphadenitis C. Epididymitis D. Hepatomegaly Answer: C Explanatio n: (A) An enlarged penis is not a sign of chlamydi A. (B) Secondary lymphadenitis is a complication of lymphogranuloma venereum. (C) Untreated chlamydial infection can spread from the urethra, causing epididymitis, which presents as a tender, scrotal swelling. (D) Hepatomegaly is not a complication. QUESTION 69 One of the most dramatic and serious complications associated with bacterial meningitis is NCLEX NCLEX-RN Waterhouse- Friderichsen syndrome, which is: A. Peripheral circulatory collapse B. Syndrome of inappropriate antiduretic hormone C. Cerebral edema resulting in hydrocephalus NCLEX NCLEX-RN D. Auditory nerve damage resulting in permanent hearing loss Answer: A Explanatio n: (A) Waterhouse-Friderichsen syndrome is peripheral circulatory collapse, which may result in extensive and diffuse intravascular coagulation and thrombocytopenia resulting in death. (B) Syndrome of inappropriate antidiuretic hormone is a complication of meningitis, but it is not Waterhouse- Friderichsen syndrome. (C) Cerebral edema resulting in hydrocephalus is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. (D) Auditory nerve damage resulting in permanent hearing loss is a complication of meningitis, but it is not Waterhouse- Friderichsen syndrome. QUESTION 70 Priapism may be a sign of: A. Altered neurological function B. Imminent death C. Urinary incontinence D. Reproductive dysfunction Answer: A Explanatio n: (A) Priapism in the trauma client is due to the neurological dysfunction seen in spinal cord injury. Priapism is an abnormal erection of the penis; it may be accompanied by pain and tenderness. This may disappear as spinal cord edema is relieved. (B) Priapism is not associated with death. (C) Urinary retention, rather than incontinence, may occur. (D) Reproductive dysfunction may be a secondary problem. QUESTION 71 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. Continue monitoring because this is a normal occurrence. B. Turn client on right side. C. Decrease IV fluids. D. Report to physician or midwife. Answer: D Explanatio n: (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. NCLEX NCLEX-RN A. Distant breath sounds B. Increased heart sounds C. Decreased anteroposterior chest diameter D. Collapsed neck veins NCLEX NCLEX-RN Answer: A Explanatio n: (A) Distant breath sounds are found in clients with emphysema owing to increased anteroposterior chest diameter, overdistention, and air trapping. (B) Deceased heart sounds arepresent because of the increased anteroposterior chest diameter. (C) A barrel-shaped chest is characteristic of emphysem A. (D) Increased distention of neck veins is found owing to right-sided heart failure, which may be present in advanced emphysema. QUESTION 76 Which of the following would have the physiological effect of decreasing intracranial pressure (ICP)? A. Increased core body temperature B. Decreased serum osmolality C. Administration of hypo-osmolar fluids D. Decreased PaCO2 Answer: D Explanatio n: (A) An increase in core body temperature increases metabolism and results in an increase in ICP. (B) Decreased serum osmolality indicates a fluid overload and may result in an increase in ICP. (C) Hypo-osmolar fluids are generally voided in the neurologically compromised. Using IV fluids such as D5W results in the dextrose being metabolized, releasing free water that is absorbed by the brain cells, leading to cerebral edem A. (D) Hypercapnia and hypoventilation, which cause retention of CO2 and lead to respiratory acidosis, both increase ICP. CO2 is the most potent vasodilator known. QUESTION 77 When teaching a mother of a 4-month-old with diarrhea about the importance of preventing dehydration, the nurse would inform the mother about the importance of feeding her child: A. Fruit juices B. Diluted carbonated drinks C. Soy-based, lactose-free formula D. Regular formulas mixed with electrolyte solutions Answer: C Explanatio n: (A) Diluted fruit juices are not recommended for rehydration because they tend to aggravate the diarrhe A. (B) Diluted soft drinks have a high-carbohydrate content, which aggravates the diarrhe A. (C) Soy-based, lactose-free formula reduces stool output and duration of diarrhea in most infants. (D) Regular formulas contain lactose, which can increase diarrhea. QUESTION 78 The nurse is aware that nutrition is an important aspect of care for a client with hepatitis. Which of NCLEX NCLEX-RN the following diets would be most therapeutic? A. High protein and low carbohydrate B. Low calorie and low protein NCLEX NCLEX-RN D. The nurse should administer an alcohol backrub at bedtime. Answer: A Explanatio n: (A) The source of infection with hepatitis C is contaminated blood products. (B) Modified bed rest should be maintained while the client is symptomatic. Routine activities can be slowly resumed once the client is asymptomatic. (C) Nausea and vomiting occur frequently with hepatitis C. A high Fowler position may decrease the tendency to vomit. (D) The buildup of bilirubin in the client‘s skin may cause pruritus. Alcohol is a drying agent. QUESTION 82 When inspecting a cardiovascular client, the nurse notes that he needs to sit upright to breathe. This behavior is most indicative of: A. Pericarditis B. Anxiety C. Congestive heart failure D. Angina Answer: C Explanatio n: (A) Pericarditis can cause dyspnea but primarily causes chest pain. (B) Anxiety can cause dyspnea resulting in SOB, yet it is not typically influenced by degree of head elevation. (C) The inability to oxygenate well without being upright is most indicative of congestive heart failure, due to alveolar drowning. (D) Angina causes primarily chest pain; any SOB associated with angina is not influenced by body position. QUESTION 83 The physician has ordered that a daily exercise program be instituted by a client with type I diabetes following his discharge from the hospital. Discharge instructions about exercise should include which of the following? A. Exercise should be performed 30 minutes before meals. B. A snack may be needed before and/or during exercise. C. Hyperglycemia may occur 2–4 hours after exercise. D. The blood glucose level should be 100 mg or below before exercise is begun. Answer: B Explanatio n: (A) Exercise should not be performed before meals because the blood sugar is usually lower just prior to eating; therefore, there is an increased risk for hypoglycemi A. (B) Exercise lowers blood sugar levels; therefore, a snack may be needed to maintain the appropriate glucose level. (C) Exercise lowers blood sugar levels. (D) Exercise lowers blood sugar levels. If the blood glucose level is 100 mg or below at the start of exercise, the potential for hypoglycemia is greater. NCLEX NCLEX-RN QUESTION 84 The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be a reaction to which of the following medications if applied in large amounts? A. Neosporin sulfate NCLEX NCLEX-RN B. Mafenide acetate C. Silver sulfadiazine D. Povidone-iodine Answer: B Explanatio n: (A) The side effects of neomycin sulfate include rash, urticaria, nephrotoxicity, and ototoxicity. (B) The side effects of mafenide acetate include bone marrow suppression, hemolytic anemia, eosinophilia, and metabolic acidosis. The hyperventilation is a compensatory response to the metabolic acidosis. (C) The side effects of silver sulfadiazine include rash, itching, leukopenia, and decreased renal function. (D) The primary side effect of povidone- iodine is decreased renal function. QUESTION 85 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. Nausea and vomiting B. Quickening C. A 6–8 lb weight gain D. Abdominal enlargement Answer: A Explanatio n: (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. QUESTION 86 Which of the following medications requires close observation for bronchospasm in the client with chronic obstructive pulmonary disease or asthma? A. Verapamil (Isoptin) B. Amrinone (Inocor) C. Epinephrine (Adrenalin) D. Propranolol (Inderal) Answer: D Explanatio n: (A) Verapamil has the respiratory side effect of nasal or chest congestion, dyspnea, shortness of NCLEX NCLEX-RN Answer: B Explanatio n: NCLEX NCLEX-RN (A) This choice would provide more unwanted fat and sugar than protein. (B) Skim milk would add protein. Eggs are good sources of protein while low in fat and calories. (C) The benefit of protein from ice cream would be outweighed by the fat content. Chocolate syrup has caffeine, which is contraindicated or limited in pregnancy. (D) Although most animal proteins are higher in protein than plant proteins, gelatin is not. It loses protein during the processing for food consumption. QUESTION 90 A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child? A. Blood pressure B. Serum potassium level C. Urine output D. Pulse rate Answer: C Explanatio n: (A) Blood pressure can remain normotensive even in a state of hypovolemi A. (B) Serum potassium is not reliable for determining adequacy of fluid resuscitation. (C) Urine output, alteration in sensorium, and capillary refill are the most reliable indicators for assessing adequacy of fluid resuscitation. (D) Pulse rate may vary for many reasons and is not a reliable indicator for assessing adequacy of fluid resuscitation. QUESTION 91 The medication that best penetrates eschar is: A. Mafenide acetate (Sulfamylon) B. Silver sulfadiazine (Silvadene) C. Neomycin sulfate (Neosporin) D. Povidone-iodine (Betadine) Answer: A Explanatio n: (A) Mafenide acetate is bacteriostatic against gram-positive and gram-negative organisms and is the agent that best penetrates eschar. (B) Silver sulfadiazine poorly penetrates eschar. (C) Neomycin sulfate does not penetrate eschar. (D) Povidoneiodine does not penetrate eschar. QUESTION 92 A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Nägele‘s rule is: A. March 27 B. February 1 C. February 27 D. January 3 NCLEX NCLEX-RN Answer: C Explanatio n: (A)March 27 is a miscalculation. (B) February 1 is a miscalculation. (C) February 27 is the correct answer. To calculate the estimated date of confinement using Nagele‘s rule, subtract 3 months from the date that the last menstrual cycle began and then add 7 days to the result. (D) January 3 is a miscalculation. QUESTION 93 The therapeutic blood-level range for lithium is: A. 0.25–1.0 mEq/L B. 0.5–1.5 mEq/L C. 1.0–2.0 mEq/L D. 2.0–2.5 mEq/L Answer: B Explanatio n: (A) This range is too low to be therapeutic. (B) This is the therapeutic range for lithium. (C) This range is above the therapeutic level. (D) This range is toxic and may cause severe side effects. QUESTION 94 Which of the following ECG changes would be seen as a positive myocardial stress test response? A. Hyperacute T wave B. Prolongation of the PR interval C. ST-segment depression D. Pathological Q wave Answer: C Explanatio n: (A) Hyperacute T waves occur with hyperkalemi A. (B) Prolongation of the P R interval occurs with first-degree AV block. (C) Horizontal ST-segment depression of>1 mm during exercise isdefinitely a positive criterion on the exercise ECG test. (D) Patho-logical Q waves occur with MI. QUESTION 95 A psychotic client who believes that he is God and rules all the universe is experiencing which type of delusion? A. Somatic B. Grandiose C. Persecutory D. Nihilistic Answer: B Explanatio NCLEX NCLEX-RN (A) Basilar skull fracture may cause dural lacerations, which result in CSF leaking from the ears or nose. Insertion of a tube could lead to CSF going into the brain tissue or sinuses. (B) Tamponading flow could worsen the problem and increase ICP. (C) Suction could increase brain damage NCLEX NCLEX-RN and dislocate tissue. (D) Testing the fluid from the nares would determine the presence of CSF. Elevation of the head, notification of the medical staff, and prophylactic antibiotics are appropriate therapy. QUESTION 99 To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and O2 demand will occur with which of the following? A. Positive inotropic therapy B. Negative chronotropic therapy C. Increase in balance of myocardial O2 supply and demand D. Afterload reduction therapy Answer: A Explanatio n: (A) Inotropic therapy will increase contractility, which will increase myocardial O2 demand. (B) Decreased heart rate to the point of bradycardia will increase coronary artery filling time. This should be used cautiously because tachycardia may be a compensatory mechanism to increase cardiac output. (C) The goal in the care of the MI client with angina is to maintain a balance between myocardial O2 supply and demand. (D) Decrease in systemic vascular resistance by drug therapy, such as IV nitroglycerin or nitroprusside, or intra- aortic balloon pump therapy, would decrease myocardial work and O2 demand. QUESTION 100 The most important reason to closely assess circumferential burns at least every hour is that they may result in: A. Hypovolemia B. Renal damage C. Ventricular arrhythmias D. Loss of peripheral pulses Answer: D Explanatio n: (A) Hypovolemia could be a result of fluid loss from thermal injury, but not as a result of the circumferential injury. (B) Renal damage is typically seen because of prolonged hypovolemia or myoglobinuri A. (C) Electrical injuries and electrolyte changes typically cause arrhythmias in the burn client. (D) Full- thickness circumferential burns are nonelastic and result in an internal tourniquet effect that compromises distal blood flow when the area involved is an extremity.Circumferential full-thickness torso burns compromise respiratory motion and, when extreme, cardiac return. QUESTION 101 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 NCLEX NCLEX-RN record: A. 3-2-0-0-2 B. 2-2-0-2-2 C. 3-1-1-0-2 NCLEX NCLEX-RN auscultated just: A. Below the umbilicus toward left side of mother‘s abdomen B. Below the umbilicus toward right side of mother‘s abdomen C. At the umbilicus D. Above the umbilicus to the left side of mother‘s abdomen Answer: A Explanatio n: (A) LOA identifies a fetus whose back is on its mother‘s left side, whose head is the presenting part, and whose back is toward its mother‘s anterior. It is easiest to auscultate fetal heart tones (FHTs) through the fetus‘s back. (B) The identified fetus‘s back is on its mother‘s left side, not right side. It is easiest to auscultate FHTs through the fetus‘s back. (C) In an LOA position, the fetus‘s head is presenting with the back to the left anterior side of the mother. The umbilicus is too high of a landmark for auscultating the fetus‘s heart rate through its back. (D) This is the correct auscultation point for a fetus in the left sacroanterior position, where the sacrum is presenting, not LOA. QUESTION 105 A mother came to the pediatric clinic with her 17- month-old child. The mother would like to begin toilet training. What should the nurse teach her about implementing toilet training? A. Take two or three favorite toys with the child. B. Have a child-sized toilet seat or training potty on hand. C. Explain to the child she is going to ―void‖ and ―defecate.‖ D. Show disapproval if she does not void or defecate. Answer: B Explanatio n: (A) Giving her toys will distract her and interfere with toilet training because of inappropriate reinforcement. (B) A child-sized toilet seat or training potty gives a child a feeling of security. (C) She should use words that are age appropriate for the child. (D) Children should be praised for cooperative behavior and/or successful evacuation. QUESTION 106 Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who suffered partial- and fullthickness burns to 25% of her body? A. Urine output B. Edema C. Hypertension D. Bulging fontanelle Answer: A Explanatio n: (A) Urinary output is a reliable indicator of renal perfusion, which in turn indicates that fluid NCLEX NCLEX-RN resuscitation is adequate. IV fluids are adjusted based on the urinary output of the child during fluid resuscitation. (B) Edema is an indication of increased capillary permeability following a burn injury. (C) Hypertension is an indicator of fluid volume excess. (D) Fontanelles close by 18 months of age. NCLEX NCLEX-RN QUESTION 107 The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because: A. Immediate treatment of mild PIH includes the administration of a variety of medications B. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation C. Self-discipline is required to control caloric intake throughout the pregnancy D. The client may not recognize the early symptoms of PIH Answer: D Explanatio n: (A) Mild PIH is not treated with medications. (B) Emotional stress is not the cause of blood pressure elevation in PIH. (C) Excessive caloric intake is not the cause of weight gain in PIH. (D) The client most frequently is not aware of the signs and symptoms in mild PIH. QUESTION 108 A client is admitted to the labor unit. On vaginal examination, the presenting part in a cephalic presentation was at station plus two. Station 12 means that the: A. Presenting part is 2 cm above the level of the ischial spines B. Biparietal diameter is at the level of the ischial spines C. Presenting part is 2 cm below the level of the ischial spines D. Biparietal diameter is 5 cm above the ischial spines Answer: C Explanatio n: (A) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is above the ischial spines, the station is negative. (B) When the biparietal diameter is at the level of the ischial spines, the presenting part is generally at a +4 or +5 station. (C) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is below the ischial spines, the station is positive. Thus, 2 cm below the ischial spines is the station +2. (D) When the biparietal diameter is above the ischial spines by 5 cm, the presenting part is usually engaged or at station 0. QUESTION 109 To prevent fungal infections of the mouth and throat, the nurse should teach clients on inhaled steroids to: A. Rinse the plastic holder that aerosolizes the drug with hydrogen peroxide every other day B. Rinse the mouth and gargle with warm water after each use of the inhaler C. Take antacids immediately before inhalation to neutralize mucous membranes and prevent infection D. Rinse the mouth before each use to eliminate colonization of bacteria Answer: B Explanatio n: NCLEX NCLEX-RN D. ―I‘ll be sure not to take any more aspirin while I am NCLEX NCLEX-RN on this drug.‖ Answer: A Explanatio n: (A) This response will help to prevent the occurrence of postural hypotension, a common side effect of this drug and a common reason for falls. (B) Although walking is an excellent exercise, it is not specific to the reduction of risks associated with diuretic therapy. (C) Clients on diuretic therapy are generally taught to ensure that their fluid intake is at least 2000–3000 mL daily, unless contraindicated. (D) Aspirin is a safe drug to take along with furosemide. QUESTION 113 A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin. The nurse‘s first intervention should be to: A. Check FHT B. Notify the attending physician C. Turn off the IV oxytocin D. Prepare for the delivery because the client is probably in transition Answer: C Explanatio n: (A) FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. (B) The physician should be notified, but this is not the first intervention the nurse should do. (C) The standard of care for an induction according to the Association of Women‘s Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. (D) Contractions lasting 60–90 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor. QUESTION 114 A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should: A. Explain that he will be kept NPO for 24 hours before the exam B. Practice with him so he will be able to hold his breath for 1 minute C. Explain that he will be receiving a laxative to prevent a distended bowel from applying pressure on the liver D. Explain that his vital signs will be checked frequently after the test Answer: D Explanatio n: (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. NCLEX NCLEX-RN QUESTION 115 After a liver biopsy, the best position for the client is: NCLEX NCLEX-RN A. Partial thromboplastin time B. Hemoglobin C. Red blood cell (RBC) count D. Prothrombin time Answer: A Explanatio n: (A) Partial thromboplastin time is used to monitor the effects of heparin, and dosage is adjusted depending on test results. It is a screening test used to detect deficiencies in all plasma clotting factors except factors VII and XIII and platelets. (B) Hemoglobin is the main component of RBCs. Its main function is to carry O2from the lungs to the body tissues and to transport CO2back to the lungs. (C) RBC count is the determination of the number of RBCs found in each cubic millimeter of whole blood. (D) PT is used to monitor the effects of oral anticoagulants, e.g., coumarintype anticoagulants. QUESTION 119 A 16-year-old student has a long history of bronchial asthma and has experienced several severe asthmatic attacks during the school year. The school nurse is required to administer 0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How does the school nurse evaluate the effectiveness of this intervention? A. Increased pulse rate B. Increased expectorate of secretions C. Decreased inspiratory difficulty D. Increased respiratory rate Answer: C Explanatio n: (A) A side effect of epinephrine is fatal ventricular fibrillation owing to its effects on cardiac stimulation. (B) Medications used to treat asthma are designed to decrease bronchospasm, not to increase expectorate of secretions. (C) Epinephrine decreased inspiratory difficulty by stimulating -, 1, and 2-receptors causing sympathomimetic stimulation (e.g., bronchodilation). (D) The person with asthma fights to inspire sufficient air thus increasing respiratory rate. QUESTION 120 Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include: A. Cleanse area around the meatus twice a day B. Empty the catheter drainage bag at least daily C. Change the catheter tubing and bag every 48 hours D. Maintain fluid intake of 1200–1500 mL every day Answer: A Explanatio n: (A) Catheter site care is to be done at least twice daily to prevent pathogen growth at the catheter insertion site. NCLEX NCLEX-RN (B) Catheter drainage bags are usually emptied every 8 hours to prevent urine stasis and pathogen growth. (C) Tubing and collection bags are not changed this often, because research studies have not demonstrated the efficacy of this practice. NCLEX NCLEX-RN (D) Fluid intake needs to be in the 2000–2500 mL range if possible to help irrigate the bladder and prevent infection. QUESTION 121 A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self- mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by: A. Placing her in seclusion until the behavior is under control B. Walking up to the client and touching her on the arm to get her attention C. Communicating a desire to assist the client to regain control, offering a one-to-one session in a quiet area D. Confronting the client, letting her know the consequences for getting angry and disrupting the unit Answer: C Explanatio n: (A) Threatening a client with punitive action is violating a client‘s rights and could escalate the client‘s anger. (B) Angry clients need respect for personal space, and physical contact may be perceived as a threatening gesture escalating anger. (C) Client lacks sufficient self-control to limit own maladaptive behavior; she may need assistance from staff. (D) Confronting an angry client may escalate her anger to further acting out, and consequences are for acting out anger aggressively, not for getting angry or feeling angry. QUESTION 122 A client is being discharged with albuterol (Proventil) and beclomethasone dipropionate (Vanceril) to be administered via inhalation three times a day and at bedtime. Client teaching regarding the sequential order in which the drugs should be administered includes: A. Glucocorticoid followed by the bronchodilator B. Bronchodilator followed by the glucocorticoid C. Alternate successive administrations D. According to the client‘s preference Answer: B Explanatio n: (A) The client would not receive therapeutic effects of the glucocorticoid when it is inhaled through constricted airways. (B) Bronchodilating the airways first allows for the glucocorticoid to be inhaled through open airways and increases the penetration of the steroid for maximum effectiveness of the drug. (C) Inac- Inaccurate use of the inhalers will lead to decreased effectiveness of the treatment. (D) Client teaching regarding the use and effects of inhalers will promote client understanding and compliance. QUESTION 123 A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to NCLEX NCLEX-RN 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. Place a tongue blade in the child‘s mouth. NCLEX NCLEX-RN B. Restrain the child so he will not injure himself. C. Go to the nurses station and call the physician. D. Move furniture out of the way and place a blanket under his head. Answer: D Explanatio n: (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. QUESTION 127 A mother frantically calls the emergency room (ER) asking what to do about her 3-year-old girl who was found eating pills out of a bottle in the medicine cabinet. The ER nurse tells the mother to: A. Give the child 15 mL of syrup of ipecac. B. Give the child 10 mL of syrup of ipecac with a sip of water. C. Give the child 1 cup of water to induce vomiting. D. Bring the child to the ER immediately. Answer: D Explanatio n: (A) Before giving any emetic, the substance ingested must be known. (B) At least 8 oz of water should be administered along with ipecac syrup to increase volume in the stomach and facilitate vomiting. (C) Water alone will not induce vomiting. An emetic is necessary to facilitate vomiting. (D) Vomiting should never be induced in an unconscious client because of the risk of aspiration. QUESTION 128 A mother continues to breast-feed her 3-month-old infant. She tells the nurse that over the past 3 days she has not been producing enough milk to satisfy the infant. The nurse advises the mother to do which of the following? A. ―Start the child on solid food.‖ B. ―Nurse the child more frequently during this growth spurt.‖ C. ―Provide supplements for the child between breastfeeding so you will have enough milk.‖ D. ―Wait 4 hours between feedings so that your breasts will fill up.‖ Answer: B Explanatio n: (A) Solid foods introduced before 4–6 months of age are not compatible with the abilities of the GI tract and the nutritional needs of the infant. (B) Production of milk is supply and demand. A common growth spurt occurs at 3 months of age, and more frequent nursing will increase the milk supply to satisfy the infant. (C) Supplementation will decrease the infant‘s appetite and in turn decrease the milk supply. When the infant nurses less often or with less vigor, the amount of milk produced decreases. (D) Rigid feeding schedules lead to a decreased milk supply, NCLEX NCLEX-RN whereas frequent nursing signals the mother‘s body to produce a correspondingly increased amount of milk. NCLEX NCLEX-RN water would not have an impact on the risk of falls. (D) This option would result in the need to get up during the night to urinate and would thus increase the risk of falls. QUESTION 132 The nurse observes that a client has difficulty chewing and swallowing her food. A nursing response designed to reduce this problem would include: A. Ordering a full liquid diet for her B. Ordering five small meals for her C. Ordering a mechanical soft diet for her D. Ordering a puréed diet for her Answer: C Explanatio n: (A) Full liquids would be difficult to swallow if the muscle control of the swallowing act is affected; this is a probable reason for her difficulties, given her medical diagnosis of multiple sclerosis. (B) Five small meals would do little if anything to decrease her swallowing difficulties, other than assure that she tires less easily. (C) A mechanical soft diet should be easier to chew and swallow, because foods would be more evenly consistent. (D) A pureed diet would cause her to regress more than might be needed; the mechanical soft diet should be tried first. QUESTION 133 In performing the initial nursing assessment on a client at the prenatal clinic, the nurse will know that which of the following alterations is abnormal during pregnancy? A. Striae gravidarum B. Chloasma C. Dysuria D. Colostrum Answer: C Explanatio n: (A) Striae gravidarum are the normal stretch marks that frequently occur on the breasts, abdomen, and thighs as pregnancy progresses. (B) Chloasma is the ―mask of pregnancy‖ that normally occurs in many pregnant women. (C) Dysuria is an abnormal danger sign during pregnancy and may indicate a urinary tract infection. (D) Colostrum is a yellow breast secretion that is normally present during the last trimester of pregnancy. QUESTION 134 Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client‘s depression alert the nurse to prioritize problems and care by addressing which of the following problems first: A. Nutritional status NCLEX NCLEX-RN B. Impaired thinking C. Possible harm to self D. Rest and activity impairment NCLEX NCLEX-RN Answer: C Explanatio n: (A) Anorexia and weight loss are problems that need attention in severe depression, but they can be addressed secondary to immediate concerns. (B) Impaired thinking and confusion are problems in severe depression that are addressed with administration of medication, through group and individual psychotherapy, and through activity therapy as motivation and interest increase. (C) Possible harm to self as with suicidal ideation; a suicide plan, means to execute plan; and/or overt gestures or an attempt must be addressed as an immediate concern and safety measures implemented appropriate to the risk of suicide. (D) Rest and activity impairment may take time and further assessment to determine client‘s sleep pattern and amount of psychomotor retardation with the more immediate concern for safety present. QUESTION 135 The nurse is teaching a mother care of her child‘s spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be: A. ―Blowing air under the cast using a hair dryer on cool setting often relieves itching.‖ B. ―Slide a ruler under the cast and scratch the area.‖ C. ―Guide a towel under and through the cast and move it back and forth to relieve the itch.‖ D. ―Gently thump on cast to dislodge dried skin that causes the itching.‖ Answer: A Explanatio n: (A) Cool air will often relieve pruritus without damaging the cast or irritating the skin. (B) The nurse should never force anything under the cast, because the cast may become damaged and skin breakdown may occur. (C) Forcing an object under the cast could lead to cast damage and skin breakdown. The object may become lodged under the cast necessitating cast removal. (D) This technique does not dislodge skin cells. It could damage the cast and cause skin breakdown. QUESTION 136 A 56-year-old psychiatric inpatient has had recurring episodes of depression and chronic low self- esteem. She feels that her family does not want her around, experiences a sense of helplessness, and has a negative view of herself. To assist the client in focusing on her strengths and positive traits, a strategy used by the nurse would be to: A. Tell the client to attend all structured activities on the unit B. Encourage or direct client to attend activities that offer simple methods to attain success C. Increase the client‘s self-esteem by asking that she make all decisions regarding attendance in group activities D. Not allow any dependent behaviors by the client because she must learn independence and will have to ask for any assistance from staff Answer: B Explanatio n: (A) The nurse should encourage activities gradually, as client‘s energy level and tolerance for shared NCLEX NCLEX-RN A. 136/88 to 144/93 B. 132/78 to 124/76 C. 114/70 to 140/88 NCLEX NCLEX-RN D. 140/90 to 148/98 Answer: C Explanatio n: (A) These blood pressure changes reflect only an 8 mm Hg systolic and a 5 mm Hg diastolic increase, which is insufficient for blood pressure changes indicating PIH. (B) These blood pressure changes reflect a decrease in systolic pressure of 8 mm Hg and diastolic pressure of 2 mm Hg; these values are not indicative of blood pressure increases reflecting PIH. (C) The definition of PIH is an increase in systolic blood pressure of 30 mm Hg and/or diastolic blood pressure of 15 mm Hg. These blood pressures reflect a change of 26 mm Hg systolically and 18mm Hg diastolically. (D) These blood pressures reflect a change of only 8 mm Hg systolically and 8 mm Hg diastolically, which is insufficient for blood pressure changes indicating PIH. QUESTION 140 An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction? A. Boardlike, rigid abdomen B. Loss of the urge to defecate C. Liquid stool D. Abdominal pain Answer: C Explanatio n: (A) A boardlike, rigid abdomen would point to a perforated bowel, not a fecal impaction. (B) When a client is fecally impacted, a common symptom is the urge to defecate but the inability to do so. (C) When an impaction is present, only liquid stool will be able to pass around the impacted site. (D) Abdominal pain without distention is not a sign of a fecal impaction. QUESTION 141 A postpartum client complains of rectal pressure and severe pain in her perineum; this may be indicative of: A. Afterbirth pains B. Constipation C. Cystitis D. A hematoma of the vagina or vulva Answer: D Explanatio n: (A) Afterbirth pains are a common complaint in the postpartum client, but they are located in the uterus. (B) Constipation may cause rectal pressure but is not usually associated with ―severe pain.‖ (C) Cystitis may cause pain, but the location is different. (D) Hematomas are frequently associated with severe pain and pressure. Further assessments are indicated for this client. NCLEX NCLEX-RN QUESTION 142 Iron dextran (Imferon) is a parenteral iron preparation. The nurse should know that it: