NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024, Exams of Nursing

Download NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 and more Exams Nursing in PDF only on Docsity! NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 1 NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 NO.1 A depressed client is seen at the mental health center for follow-up after an attempted suicide 1 week ago. She has taken phenelzine sulfate (Nardil), a monoamine oxidase ( MAO) inhibitor, for 7 straight days. She states that she is not feeling any better. The nurse explains that the drug must accumulate to an effective level before symptoms are totally relieved. Symptom relief is expected to occur within: A. 10 days B. 2-4 weeks C. 2 months D. 3 months Answer: B Explanation: ( A) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication. ( B) This answer is correct. Because MAO inhibitors are slow to act, it takes 2-4 weeks before improvement of symptoms is noted. ( C) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication. ( D) This answer is incorrect. Therapeutic effects of the medication are noted within 1 month of drug therapy. NO.2 Cystic fibrosis is transmitted as an autosomal recessive trait. This means that: A. Mothers carry the gene and pass it to their sons B. Fathers carry the gene and pass it to their daughters C. Both parents must have the disease for a child to have the disease D. Both parents must be carriers for a child to have the disease Answer: D Explanation: ( A) Cystic fibrosis is not an X-linked or sex-linked disease. (B) The only characteristic on the Y chromosome is the trait for hairy ears. (C) Both parents do not need to have the disease but must be carriers. (D) If a trait is recessive, two genes (one from each parent) are necessary to produce an affected child. NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 2 NO.3 A 24-year-old client presents to the emergency department protesting "I am God." The nurse identifies this as a: A. Delusion B. Illusion C. Hallucination D. Conversion Answer: A Explanation: ( A) Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion is the expression of intrapsychic conflict through sensory or motor manifestations. NO.4 In acute episodes of mania, lithium is effective in 1-2 weeks, but it may take up to 4 weeks, or even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms. In addition to the lithium, which one of the following medications might the physician prescribe? A. Diazepam (Valium) B. Haloperidol (Haldol) C. Sertraline (Zoloft) D. Alprazolam (Xanax) Answer: B Explanation: ( A) Diazepam is an antianxiety medication and is not designed to reduce psychotic symptoms. (B ) Haloperidol is an antipsychotic medication and may be used until the lithium takes effect. (C) Sertraline is an antidepressant and is used primarily to reduce symptoms of depression. (D) Alprazolam is an antianxiety medication and is not designed to reduce psychotic symptoms. NO.5 A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints? A. Give fluids if the client requests them. B. Assess skin integrity and circulation of extremities before applying restraints and as they are removed. C. Measure vital signs at least every 4 hours. D. Release restraints every 2 hours for client to exercise. Answer: D Explanation: ( A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 5 ( A) Normal pH of arterial blood gases for an infant is 7.35-7.45. (B) Normal white blood cell count in an infant is 6,000-17,500 WBCs/mm3. (C) Normal hematocrit in infant is 28%-42%. A 60% hematocrit may indicate polycythemia, a common complication of cyanotic heart disease. (D) Normal bleeding time is 2-7 minutes. NO.11 A male client is experiencing extreme distress. He begins to pace up and down the corridor. What nursing intervention is appropriate when communicating with the pacing client? A. Ask him to sit down. Speak slowly and use short, simple sentences. B. Help him to recognize his anxiety. C. Walk with him as he paces. D. Increase the level of his supervision. Answer: C Explanation: ( A) The nurse should not ask him to sit down. Pacing is the activity he has chosen to deal with his anxiety. The nurse dealing with this client should speak slowly and with short, simplesentences. (B) The client may already recognize the anxiety and is attempting to deal with it. (C) Walk with the client as he paces. This gives support while he uses anxiety-generated energy. (D) Increasing the level of supervision may be appropriate after he stops pacing. It would minimize self-injury and/or loss of control. NO.12 Prior to an amniocentesis, a fetal ultrasound is done in order to: A. Evaluate fetal lung maturity B. Evaluate the amount of amniotic fluid C. Locate the position of the placenta and fetus D. Ensure that the fetus is mature enough to perform the amniocentesis Answer: C Explanation: ( A) Amniocentesis can be performed to assess for lung maturity. Fetal ultrasound can be used for gestational dating, although it does not separately determine lung maturity. (B) Ultrasound can evaluate amniotic fluid volume, which may be used to determine congenital anomalies. (C) Amniocentesis involves removal of amniotic fluid for evaluation. The needle, inserted through the abdomen, is guided by ultrasound to avoid needle injuries, and the test evaluates the position of the placenta and the fetus. (D) Amniocentesis can be performed as early as the 15th-17th week of pregnancy. NO.13 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. NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 6 Her last menstrual period began May 20, and her estimated date of confinement using Nagele's rule is: A. March 27 B. February 1 C. February 27 D. January 3 Answer: C Explanation: ( 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. NO.14 A client is now pregnant for the second time. Her first child weighed 4536 g at delivery. The client's glucose tolerance test shows elevated blood sugar levels. Because she only shows signs of diabetes when she is pregnant, she is classified as having: A. Insulin-dependent diabetes B. Type II diabetes mellitus C. Type I diabetes mellitus D. Gestational diabetes mellitus Answer: D Explanation: ( A) Insulin-dependent diabetes mellitus, also known as type I diabetes, usually appears before the age of 30 years with an abrupt onset of symptoms requiring insulin for management. It is not related to onset during pregnancy. (B) Non-insulin-dependent diabetes (type II diabetes) usually appears in older adults. It has a slow onset and progression of symptoms. (C) This type of diabetes is the same as insulin-dependent diabetes. (D) Gestational diabetes mellitus has its onset of symptoms during pregnancy and usually disappears after delivery. These symptoms are usually mild and not life threatening, although they are associated with increased fetal morbidity and other fetal complications. NO.15 A 44-year-old female client is receiving external radiation to her scapula for metastasis of breast cancer. Teaching related to skin care for the client would include which of the following? A. Teach her to completely clean the skin to remove all ointments and markings after each treatment . B. Teach her to cover broken skin in the treated area with a medicated ointment. NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 7 C. Encourage her to wear a tight-fitting vest to support her scapula. D. Encourage her to avoid direct sunlight on the area being treated. Answer: D Explanation: ( A) The skin in a treatment area should be rinsed with water and patted dry. Markings should be left intact, and the skin should not be scrubbed. (B) Clients should avoid putting any creams or lotions on the treated area. This could interfere with treatment. (C) Radiation therapy clients should wear loosefitting clothes and avoid tight, irritating fabrics. (D) The area of skin being treated is sensitive to sunlight, and the client should take care to prevent sun damage by avoiding direct sunlight and covering the area when she is in the sun. NO.16 The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue healing? A. Vitamin C B. Vitamin B1 C. Vitamin D D. Vitamin A Answer: A Explanation: ( A) Vitamin C (ascorbic acid) is essential in promoting wound healing and collagen formation. (B ) Vitamin B1 (thiamine) maintains normal gastrointestinal (GI) functioning, oxidizes carbohydrates, and is essential for normal functioning of nervous tissue. (C) Vitamin D regulates absorption of calcium and phosphorus from the GI tract and helps prevent rickets. (D) Vitamin A is necessary for the formation and maintenance of skin and mucous membranes. It is also essential for normal growth and development of bones and teeth. NO.17 A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony. Which of the following nursing implementations would be most effective in helping him cope with immobility? A. Providing him with books, challenging puzzles, and games as diversionary activities B. Allowing him to do as much for himself as he is able, including learning to do pin-site care under supervision C. Having a volunteer come in to sit with the client and to read him stories D. Stimulating rest and relaxation by gentle rubbing with lotion and changing the client's position frequently Answer: B Explanation: ( A) These activities could be frustrating for the client if he is having difficulty with problem solving and concentration. (B) Selfcare is usually well received by the child, and it is one of the most useful interventions to help the child cope with immobility. (C) This may be helpful to the client if he has no visitors, but it does little to help him develop coping skills. (D) This will helpto prevent skin irritation or breakdown related to immobility but will not help to prevent behavioral changes related to immobility. NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 10 family's need to grieve in their own manner. (C) The nurse should leave the room and allow the family privacy in their grief. (D) The family's wish to conduct a religious ceremony in the client's room is part of the grief process. The request is based on specific cultural and religious differences dictating social customs. NO.23 A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will teach her to: A. Limit activities which require focusing (close vision) B. Take more frequent naps C. Use artificial tears D. Wear a patch over one eye Answer: D Explanation: ( A ) Limiting activities requiring close vision will not alleviate the discomfort of double vision. ( B ) Frequent naps may be comforting, but they will not prevent double vision. (C) Artificial tears are necessary in the absence of a corneal reflex, but they have no effect on diplopia. ( D ) An eye patch over either eye will eliminate the effects of double vision during the time the eye patch is worn. An eye patch is safe for a person with an intact corneal reflex. NO.24 One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is: A. Blood pressure B. Level of consciousness C. Skin turgor D. Fluid intake Answer: B Explanation: ( A ) Blood pressure can remain normotensive in a state of hypovolemia. (B) Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. (C) Skin turgor is not a reliable indicator for assessing hydration in a burn client. ( D ) Fluid intake does not indicate adequacy of fluid resuscitation in a burn client. NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 11 NO.25 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 Explanation: ( A) Urinary output is a reliable indicator of renal perfusion, which in turn indicates that fluid 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. NO.26 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 Explanation: ( 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. NO.27 A client states to his nurse that "I was told by the doctor not to take one of my drugs because it seems to have caused decreasing blood cells." Based on this information, which drug might the nurse expect to be discontinued? A. Prednisone B. Timolol maleate (Blocadren) C. Garamycin (Gentamicin) D. Phenytoin (Dilantin) Answer: D Explanation: NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 12 ( A) Prednisone is not linked with hematological side effects. (B) Timolol, a -adrenergic blocker is metabolized by the liver. It has not been linked to blood dyscrasia. (C) Gentamicin is ototoxic and nephrotoxic. (D) Phenytoin usage has been linked to blood dyscrasias such as aplastic anemia. The drug most commonly linked to aplastic anemia is chloramphenicol (Chlormycetin). NO.28 A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should: A. Notify the physician immediately B. Hold the morning lithium dose and continue to observe the client C. Administer the morning lithium dose as scheduled D. Obtain an order for benztropine (Cogentin) Answer: C Explanation: ( A) There is no need to phone the physician because the lithium level is within therapeutic range and because there are no indications of toxicity present. (B) There is no reason to withhold the lithium because the blood level is within therapeutic range. Also, it is necessary to give the medication as scheduled to maintain adequate blood levels. (C) The lab results indicate that the client's lithium level is within therapeutic range (0.2-1.4 mEq/L), so the medication should be given as ordered. (D) Benztropine is an antiparkinsonism drug frequently given to counteractextrapyramidal symptoms associated with the administration of antipsychotic drugs (not lithium). NO.29 The primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed toward: A. Maintaining an adequate level of hydration B. Providing pain relief C. Preventing infection D. O2 therapy Answer: A Explanation: ( A) Maintaining the hydration level is the focus for nursing intervention because dehydration enhances the sickling process. Both oral and parenteral fluids are used. (B) The pain is a result of the sickling process. Analgesics or narcotics will be used for symptom relief, but the underlying cause of the pain will be resolved with hydration. (C) Serious bacterial infections may result owing to splenic dysfunction. This is true at all times, not just during the acute period of a crisis. (D) O2 therapy is used for symptomatic relief of the hypoxia resulting from the sickling process. Hydration is the primary intervention to alleviate the dehydration that enhances the sickling process. NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 15 D. 12-Lead ECG Answer: A Explanation: ( A) Furosemide, a potassium-depleting diuretic, inhibits the reabsorption of sodium and chloride from the loop of Henle and the distal renal tubules. Serum electrolytes are monitored for hypokalemia. (B) Severe acid-base imbalances influence the movement of potassium into and out of the cells, but arterial blood gases to not measure the serum potassium level. (C) Furosemide is a potassium-depleting diuretic. A complete blood count does not reflect potassium levels. (D) Abnormalities in potassium (both hyperkalemia and hypokalemia) are reflected in ECG changes, but these changes do not occur until the abnormality is severe. NO.35 A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements? A. "When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices." B. "If I have any side effects from my medicines, I will take an extra dose of Cogentin." C. "When I get home, I should be able to taper myself off the Haldol because the voices are gone now." D. "As soon as I leave here, I'm throwing away my medicines. I never thought I needed them anyway." Answer: A Explanation: ( A ) The client verbalizes that he is responsible for compliance and keeping the treatment team member informed of progress. This behavior puts him at the lowest risk for relapse. ( B ) Noncompliance is a major cause of relapse. This statement reflects lack of responsibility for his own health maintenance. (C) This statement reflects lack of insight into the importance of compliance. (D) This statement reflects no insight into his illness or his responsibility in health maintenance. NO.36 A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful? A. Examine the 4 year old first. B. Provide time for play and becoming acquainted. C. Have the mother leave the room with one child, and examine the other child privately. D. Examine painful areas first to get them "over with." Answer: B Explanation: NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 16 ( A ) The 6 month old should be examined first. If several children will be examined, begin with the most cooperative and less anxious child to provide modeling. (B) Providing time for play and getting acquainted minimizes stress and anxiety associated with assessment of body parts. (C) Children generally cooperate best when their mother remains with them. ( D ) Painful areas are best examined last and will permit maximum accuracy of assessment. NO.37 Diagnostic assessment findings for an infant with possible coarctation of the aorta would include: A. A third heart sound B. A diastolic murmur C. Pulse pressure difference between the upper extremities D. Diminished or absent femoral pulses Answer: D Explanation: ( A) S1 and S2 in an infant with coarctation of the aorta are usually normal. S3 and S4 do not exist with this diagnosis. (B) Either no murmur will be heard or a systolic murmur from an associated cardiac defect will be heard along the left upper sternal border. A diastolic murmur is not associated with coarctation of the aorta. (C) Pulse pressure differences of>20 mm Hg exist between the upper extremities and the lower extremities. It is important to evaluate the upper and lower extremities with the appropriate- sized cuffs. (D) Femoral and pedal pulses will be diminished or absent in infants with coarctation of the aorta. NO.38 During a client's first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus. This may be due to: A. Endometritis B. Fibroid tumor on the uterus C. Displacement due to bowel distention D. Urine retention or a distended bladder Answer: D Explanation: ( A, B) Endometritis, urine retention, or bladder distention provide good distractors because they may delay involution but do not usually cause the uterus to be lateral. (C) Bowel distention and constipation are common in the postpartum period but do not displace the uterus laterally. (D) Urine retention or bladder distention commonly displaces the uterus to the right and may delay involution. NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 17 NO.39 An 80-year-old widow is living with her son and daughter- in-law. The home health nurse has been making weekly visits to draw blood for a prothrombin time test. The client is taking 5 mg of coumadin per day. She appears more debilitated, and bruises are noted on her face. Elder abuse is suspected. Which of the following are signs of persons who are at risk for abusing an elderly person? A. A family member who is having marital problems and is regularly abusing alcohol B. A person with adequate communication and coping skills who is employed by the family C. A friend of the family who wants to help but is minimally competent D. A lifelong friend of the client who is often confused Answer: A Explanation: ( A ) This answer is correct. Two risk factors are identified in this answer. (B) This answer is incorrect. Persons at risk tend to lack communication skills and effective coping patterns. ( C ) This answer is incorrect. Persons at risk are usually family members or those reluctant to provide care. (D) This answer is incorrect. This individual has a vested interest in providing care. NO.40 A 32-year-old female client is being treated for Guillain- Barre syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation? A. Complaints of a headache B. Loss of superficial and deep tendon reflexes C. Complaints of shortness of breath D. Facial paralysis Answer: C Explanation: ( A) Headaches are not associated with Guillain-Barre syndrome. (B) Loss of superficial and deep tendon reflexes is expected with this diagnosis. (C) Complaints of shortness of breath must be further evaluated. Forty percent of all clients have some detectable respiratory weakness and should be prepared for a possible tracheostomy. Pneumonia is also a common complication of this syndrome. ( D) Facial paralysis is expected and is not considered abnormal. NO.41 Plans for the care of a client with an ulcer caused by emotional problems need to take into consideration that: A. His priority needs are limited to medical management B. There is no real psychological basis for his illness NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 20 C. Above therapeutic range D. At a level of toxic poisoning Answer: A Explanation: ( A) This answer is correct. The therapeutic range is 1.0-1.5 mEq/L in the acute phase. Maintenance control levels are 0.6-1.2 mEq/L. (B, C) This answer is incorrect. A level of 1.3 mEq/L is within therapeutic range. (D) This answer is incorrect. Toxic poisoning is usually at the 2.0 level or higher. NO.47 When discussing the relationship between exercise and insulin requirements, a 26-year-old client with IDDM should be instructed that: A. When exercise is increased, insulin needs are increased B. When exercise is increased, insulin needs are decreased C. When exercise is increased, there is no change in insulin needs D. When exercise is decreased, insulin needs are decreased Answer: B Explanation: ( A) If the client's insulin is increased when activity level is increased, hypoglycemia may result. (B ) Exercise decreased the blood sugar by promoting uptake of glucose by the muscles. Consequently, less insulin is needed to metabolize ingested carbohydrates. Extra food may be required for extra activity. (C) This statement directly contradicts the correct answer and is inaccurate. (D) When exercise is decreased, the client's insulin dose does not need to be altered unless the blood sugar becomes unstable. NO.48 A client had a hemicolectomy performed 2 days ago. Today, when the nurse assesses the incision, a small part of the abdominal viscera is seen protruding through the incision. This complication of wound healing is known as: A. Excoriation B. Dehiscence C. Decortication D. Evisceration Answer: D Explanation: ( A) Excoriation is abrasion of the epidermis or of the coating of any organ of the body by trauma, chemicals, burns, or other causes. (B) Dehiscence is a partial or complete separation of the wound edges with no protrusion of abdominal tissue. (C) Decortication is removal of the surface layer of an organ or structure. It is a type of surgery, such as removing the fibrinous peel from the visceral pleura NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 21 in thoracic surgery. (D) Evisceration occurs when the incision separates and the contents of the cavity spill out. NO.49 A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure? A. Bulging fontanelles B. Seizure C. Headache D. Ataxia Answer: C Explanation: ( A) Bulging fontanelles are a symptom of increased intracranial pressure in infants. (B) Seizure is a late sign of increased intracranial pressure. (C) Headache is a very early symptom of increased intracranial pressure in the child. (D) Ataxia is a late sign of increased intracranial pressure. NO.50 Which nursing implication is appropriate for a client undergoing a paracentesis? A. Have the client void before the procedure. B. Keep the client NPO. C. Observe the client for hypertension following the procedure. D. Place the client on the right side following the procedure. Answer: A Explanation: ( A) A full bladder would impede withdrawal of ascitic fluid. (B) Keeping the client NPO is not necessary. (C) The client may exhibit signs and symptoms of shock and hypertension. (D) No position change is needed after the procedure. NO.51 A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, "The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart." The nurse's best response is: A. "I know you're feeling frightened right now, but I want you to know that I don't see anyone in the corner." B. "You'll probably see strange things for a while until the PCP wears off." C. "Try to sleep. When you wake up, the devil will be gone." D. "You're probably feeling guilty because you used illegal drugs tonight." Answer: A Explanation: NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 22 ( A) The nurse is the client's link to reality. This response validates the authenticity of the client's experience by casting doubt on his belief and reinforcing reality. (B) Although this statement may be literally correct, it is nontherapeutic because it lacks validation. (C) This response encourages the client to attempt to do something that may be impossible at this time, offers false reassurance, and reinforces delusional content. (D) The nurse is making an incorrect assumption about the client's feelings by offering a nontherapeutic interpretation of the motivation for the client's actions. NO.52 To facilitate maximum air exchange, the nurse should position the client in: A. High Fowler B. Orthopneic C. Prone D. Flat-supine Answer: B Explanation: ( A) The high Fowler position does increase air exchange, but not to the extent of orthopneic position. ( B) The orthopneic position is a sitting position that allows maximum lung expansion. (C) The prone position places pressure on diaphragm and does not promote maximum air exchange. (D) The flatsupine position places pressure on diaphragm by abdominal organs and does not promote maximum air exchange. NO.53 A 48-year-old client is in the surgical intensive care unit after having had three-vessel coronary artery bypass surgery yesterday. She is extubated, awake, alert and talking. She is receiving digitalis for atrial arrhythmias. This morning serum electrolytes were drawn. Which abnormality would require immediate intervention by the nurse after contacting the physician? A. Serum osmolality is elevated indicating hemoconcentration. The nurse should increase IV fluid rate. B. Serum sodium is low. The nurse should change IV fluids to normal saline. C. Blood urea nitrogen is subnormal. The nurse should increase the protein in the client's diet as soon as possible. D. Serum potassium is low. The nurse should administer KCl as ordered. Answer: D Explanation: ( A ) An elevated serum osmolality poses no immediate danger and is not corrected rapidly. ( B ) A low serum sodium alone does not warrant changing IV fluids to normal saline. Other assessment parameters, such as hydration status, must be considered. (C) A low serum blood urea nitrogen is not necessarily indicative of protein deprivation. It may also be the result of overhydration. (D)A low NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 25 Answer: A Explanation: ( A) A lower postoperative infection has been documented as a result of laser therapy versus routine surgery. (B) Clients will still need preoperative sedation to facilitate anxiety reduction. (C) Operating time may actually increase in some laser surgeries. (D) The client must still be observed for postoperative complications. NO.59 Based on your knowledge of genetic inheritance, which of these statements is true for autosomal recessive genetic disorders? A. Heterozygotes are affected. B. The disorder is always carried on the X chromosome. C. Only females are affected. D. Two affected parents always have affected children. Answer: D Explanation: ( A) The term heterozygote refers to an individual with one normal and one mutant allele at a given locus on a pair of homologous chromosomes. An individual who is heterozygous for the abnormal gene does not manifest obvious symptoms. (B) Disorders carried on either the X or Y sex chromosome are referred to as sex-linked recessive. (C) Either sex may be affected by autosomal recessive genetic disorders because the responsible allele can be on any one of the 46 chromosomes. ( D) If both parents are affected by the disorder and are not just carriers, then all their children would manifest the same disorder. NO.60 The pediatric nurse charts that the parents of a 4-yearold child are very anxious. Which observation would indicate to the nurse unhealthy coping by these parents: A. Discussing their needs with the nursing staff B. Discussing their needs with other family members C. Seeking support from their minister D. Refusing to participate in the child's care Answer: D Explanation: ( A, B, C) These methods are healthy ways of dealing with anxiety. (D) Participation minimizes feelings of helplessness and powerlessness. It is important that parents have accurate information and that they seek support from sources available to them. NO.61 The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury. Normal fluid intake for a child of 2 years is: A. 900 mL/24 hr B. 1300 mL/24 hr C. 1600 mL/24 hr NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 26 D. 2000 mL/24 hr Answer: C Explanation: ( A, B, D) These values are incorrect. Normal intake for a child of 2 years is about 1600 mL in 24 hours. ( C) This value is correct. Normal intake for a child of 2 years is about 1600 mL in 24 hours. NO.62 A couple is planning the conception of their first child. The wife, whose normal menstrual cycle is 34 days in length, correctly identifies the time that she is most likely to ovulate if she states that ovulation should occur on day: A. 14+2 days B. 20+2 days C. 16+2 days D. 22+2 days Answer: B Explanation: ( A) Ovulation is dependent on average length of menstrual cycle, not standard 14 days. (B) Ovulation occurs 14+2 days before next menses (34 minus 14 does not equal 16). (C) Ovulation occurs 14+2 days before next menses (34 minus 14 equals 20). (D) Ovulation occurs 14+2 days before next menses (34 minus 14 does not equal 22). NO.63 The nurse is collecting a nutritional history on a 28- year-old female client with iron-deficiency anemia and learns that the client likes to eat white chalk. When implementing a teaching plan, the nurse should explain that this practice: A. Will bind calcium and therefore interfere with its metabolism B. Will cause more premenstrual cramping C. Interferes with iron absorption because the iron precipitates as an insoluble substance D. Causes competition at iron-receptor sites between iron and vitamin B1 Answer: C Explanation: ( A) Eating chalk is not related to calcium and its absorption. (B) Poor nutritional habits may result in increased discomfort during premenstrual days, but this is not a primary reason for the client to stop eating chalk. Premenstrual discomfort has not been mentioned. (C) Iron is rendered insoluble and is excreted through the gastrointestinal tract. (D) There is no competition between the two nutrients. NO.64 A child becomes neutropenic and is placed on protective isolation. The purpose of protective isolation is to: A. Protect the child from infection B. Provide the child with privacy NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 27 C. Protect the family from curious visitors D. Isolate the child from other clients and the nursing staff Answer: A Explanation: ( A) The child no longer has normal white blood cells and is extremely susceptible to infection. (B ) There are more appropriate ways to provide privacy, and there is no need to protect the child from healthy visitors. (C) Visitors and visiting hours may be at the client's and/or family's request without regard to the isolation precaution. (D) The child may have strong positive relationships with other clients or staff. As long as proper precautions are observed, there is no reason to isolate her from them. NO.65 A schizophrenic client who is experiencing thoughts of having special powers states that "I am a messenger from another planet and can rule the earth." The nurse assesses this behavior as: A. Ideas of reference B. Delusions of persecution C. Thought broadcasting D. Delusions of grandeur Answer: D Explanation: ( A) Clients experiencing ideas of reference believe that information from the environment (e.g., the television) is referring to them. (B) Clients experiencing delusions of persecution believe that others in the environment are plotting against them. (C) Clients experiencing thought broadcasting perceive that others can hear their thoughts. (D) Clients experiencing delusions of grandeur think that they are omnipotent and have superhuman powers. NO.66 Following a gastric resection, which of the following actions would the nurse reinforce with the client in order to alleviate the distress from dumping syndrome? A. Eating three large meals a day B. Drinking small amounts of liquids with meals C. Taking a long walk after meals D. Eating a low-carbohydrate diet Answer: D Explanation: ( A) Six small meals are recommended. (B) Liquids after meals increase the time food empties from the stomach. (C) Lying down after meals is recommended to prevent gravity from producing dumping. (D) A low-carbohydrate diet will prevent a hypertonic bolus, which causes dumping. NO.67 A 6-year-old child is attending a pediatric clinic for a routine examination. What should the nurse assess for while conducting a vision screening? NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 30 Bed rest will be ordered for 8-12 hours postprocedure. Flexing of the leg at the arterial puncture site will occur if the client gets out of bed, and this is contraindicated after arteriography. (B) The client will be able to eat as soon as he is alert enough to swallow safely and that will depend on what medications areused for sedation during the procedure. ( C ) Oozing at the arterial puncture site is not normal and should be closely evaluated. (D) The leg where the arterial puncture occurred must be kept straight for 8-12 hours to minimize the risk of bleeding. NO.73 The nurse is assessing breath sounds in a bronchovesicular client. She should expect that: A. Inspiration is longer than expiration B. Breath sounds are high pitched C. Breath sounds are slightly muffled D. Inspiration and expiration are equal Answer: D Explanation: ( A) Inspiration is normally longer in vesicular areas. (B) Highpitched sounds are normal in bronchial area. (C) Muffled sounds are considered abnormal. (D) Inspiration and expiration are equal normally in this area, and sounds are medium pitched. NO.74 Parents should be taught not to prop the bottle when feeding their infants. In addition to the risk of choking, it puts the infant at risk for: A. Otitis media B. Asthma C. Conjunctivitis D. Tonsillitis Answer: A Explanation: ( A ) Because the eustachian tube is short and straight in the infant, formula that pools in the back of the throat attacks bacteria which can enter the middle ear and cause an infection. ( B ) Asthma is not associated with propping the bottle. (C) Conjunctivitis is an eye infection and not associated with propping the bottle. (D) Tonsillitis is usually a result of pharyngitis and not propping the bottle. NO.75 A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent: NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 31 A. Bladder spasms B. Clot formation C. Scrotal edema D. Prostatic infection Answer: B Explanation: ( A) The purpose of bladder irrigation is not to prevent bladder spasms, but to drain the bladder and decrease clot formation and obstruction. (B) A three-way system of bladder irrigation will cleanse the bladder and prevent formation of blood clots. A catheter obstructed by clots or other debris will cause prostatic distention and hemorrhage. (C) Scrotal edema seldom occurs after TURP. Bladder irrigation will not prevent this complication. (D) Prostatic infection seldom occurs after TURP. Bladder irrigation will not prevent this complication. NO.76 Priapism may be a sign of: A. Altered neurological function B. Imminent death C. Urinary incontinence D. Reproductive dysfunction Answer: A Explanation: ( 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. NO.77 The healthcare team determines that an elderly client has had progressive changes in memory over the last 2 years that have interfered with her personal, social, or occupational functioning. Her memory, learning, attention, and judgment have all been affected in some way. These symptoms describe which of the following conditions? A. Dementia B. Parkinsonism C. Delirium D. Mania Answer: A Explanation: ( A ) These changes are common characteristics of dementia. (B) Parkinson's disease affects the muscular system. Progressive memory changes are not presenting symptoms. NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 32 ( C ) Delirium includes an altered level of consciousness, which is not found in dementia. (D) Mania includes symptoms of hyperactivity, flight of ideas, and delusions of grandeur. NO.78 After instructing a female client on circumcision care, the nursery nurse asks her to restate some of the key points covered. Which statement shows that the client will properly care for her son's circumcision? A. "I'll make sure I soak the gauze with warm water first, before I take it off each time." B. "I'll make sure that I report any drainage around where they operated." C. "I'll apply alcohol to the area daily to clean it and prevent any infection." D. "I'll keep a close watch on it for a day or two." Answer: A Explanation: ( A) Before petrolatum gauze is removed, it should be soaked with warm water to prevent trauma to adherent tissues. (B) A yellow exudate often forms normally over the surgical site. Only if it becomes foul-smelling and purulent would it need to be reported. (C) Alcohol should never be used on the site; this would be extremely painful to the infant. (D) Special care and observance should continue until the site is completely covered with clean, pink granulation tissue, which could take 7-10 days. NO.79 The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have: A. A low birth weight B. A birth defect C. Anemia D. Nicotine withdrawal Answer: A Explanation: ( A) Women who smoke during pregnancy are at increased risk for miscarriage, preterm labor, and IUGR in the fetus. (B) Although smoking produces harmful effects on the maternal vascular system and the developing fetus, it has not been directly linked to fetal anomalies. (C) Smoking during pregnancy has not been directly linked to anemia in the fetus. (D) Smoking during pregnancy has not been linked to nicotine withdrawal symptoms in the newborn. NO.80 Respiratory function is altered in a 16-year-old asthmatic. Which of the following is the cause of this alteration? A. Altered surfactant production B. Paradoxical movements of the chest wall NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 35 C. He should avoid alcoholic beverages during his recovery period. D. He should use disposable dishes for eating and drinking. Answer: C Explanation: ( 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. NO.86 A physician's order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a microdrip tubing set. How many drops per minute should the nurse administer? A. 1 gtt/min B. 5 gtt/min C. 50 gtt/min D. 100 gtt/min Answer: C Explanation: ( A) This answer is a miscalculation. (B) This answer is a miscalculation. (C)50 gtt/min. (D) This answer is a miscalculation. NO.87 A 48-year-old male client is hospitalized with mild ascites, bruising, and jaundice. He has a 20year history of alcohol abuse. The client is diagnosed with cirrhosis. His serum ammonia level is high, indicating hepatic encephalopathy. He has esophageal varices. Which of the following may cause the varices to rupture? A. Lifting heavy objects B. Walking briskly C. Ingestion of barbiturates D. Ingestion of antacids Answer: A Explanation: ( A) Lifting heavy objects will increase intrathoracic pressure, thus placing the client at risk for rupturing esophageal varices. (B, C, D) This activity will not cause an increase in intrathoracic pressure. NO.88 The nurse is admitting an infant with bacterial meningitis and is prepared to manage the following possible effects of meningitis: A. Constipation B. Hypothermia C. Seizure NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 36 D. Sunken fontanelles Answer: C Explanation: ( A) Constipation may occur if the child is dehydrated, but it is not directly associated with meningitis. ( B) It is more likely the child will have fever. (C) Seizure is often the initial sign of meningitis in children and could become frequent. (D) It is more likely the child will have bulging fontanelles. NO.89 A male client received a heart-lung transplant 1 month ago at a local transplant center. While visiting the nursing center to have his blood pressure taken, he complains of recent weakness and fatigue. He also tells the nurse that he is considering stopping his cyclosporine because it is expensive and is causing his face to become round. He fears he will catch viruses and be more susceptible to infections. The nurse responds to this last statement by explaining that cyclosporine: A. Is given to prevent rejection and makes him less susceptible to infection than other oral corticosteroids B. Is available at discount pharmacies for a reduced price C. Is usually not necessary after the first year following transplantation D. May initially cause weakness, dizziness, and fatigue, but these side effects will gradually resolve themselves Answer: A Explanation: ( A) Cyclosporine is the immunosuppressive drug of choice. It provides immunosuppression but does not lower the white blood cell count; therefore, the client is less susceptible to infection. (B) Cyclosporine is available at discount pharmacies. The cost may be absorbed by health insurance, or Medicare, if the client is eligible. However, this statement does not address the entire problem verbalized by the client. (C) Immunosuppressive agents will be taken for the client's entire life because rejection can occur at any time. (D) These side effects do not necessarily resolve in time; however, the client may adapt. NO.90 After the RN is finished the initial assessment of a newborn baby and after the initial bonding between the newborn and the mother has taken place in the delivery room, the RN will bring the newborn to the well-baby nursery. Before the newborn is taken from the delivery room and brought to the well-baby nursery, the RN makes sure that which of the following interventions was completed? A. The physician verifies the exact time of birth. B. The nurse counts the instruments and sponges with the scrub nurse. C. The nurse instills prophylactic ointment in the conjunctival sacs of the newborn's eyes. D. The nurse makes sure the mother and her newborn have been tagged with identical bands. Answer: D Explanation: NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 37 ( A) The delivery room personnel are responsible for verifying time of birth. (B) The scrub and circulating nurses count sponges and instruments. (C) This intervention is done in the nursery. (D) Tagging the mother and infant with identical bands is of utmost importance. The mother wears one band, and the newborn wears two. Identical numbers on the three bands provide identification for the newborn and the birth mother. Every time the newborn is brought to the mother after delivery, those bands are checked to be sure that the numbers are identical. NO.91 A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction. One comfort measure the nurse can employ is to: A. Place her in knee-chest position during the contraction B. Use effleurage during the contraction C. Apply strong sacral pressure during the contraction D. Have her push with each contraction Answer: C Explanation: ( A) This measure is inappropriate. The knee-chest position is employed to take pressure off the cord. ( B) Effleurage is a comfort measure but not the one that will contribute most to the relief of backache caused by a posterior position. (C) Sacral pressure will counteract the pressure created by the position of the fetal head. (D) The client is not completely dilated. Pushing is contraindicated until the second stage of labor. NO.92 A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first: A. Reinforce the dressing. B. Continue to monitor the dressing. C. Notify the physician. D. Note the time and amount of blood. Answer: C Explanation: ( A) The dressing should not be reinforced without first notifying the physician. The decision may be made by the physician to reinforce the dressing after assessing the amount of bleeding. (B) Blood on the dressing is unusual and should make the nurse aware that something more than continuing to monitor the dressing should be done. (C) The physician should be notified immediately, because if the bleeding persists, the client may have to be taken back to surgery. (D) The time and amount of blood do need to be recorded after the physician is notified. NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 40 Answer: A Explanation: ( A) Based on the client's history, presence of bright red vaginal bleeding, and hemoglobin value on admission, the priority nursing diagnosis would be decreased cardiac output related to excessive bleeding. (B) This nursing diagnosis is a potential problem that does not exist at the present time, and therefore is not the priority problem. (C) The client's expressed anxiety is for her child. The fetus will remain physiologically safe if the decreased cardiac output is resolved. (D) Initial spontaneous bleeding with placenta previa is rarely life threatening to the mother or the fetus. Delivery of the fetus will be postponed until fetal maturity is achieved and survival is likely. NO.98 A client has chronic obstructive pulmonary disease. She is slowly losing weight, and her daughter is very concerned about increasing her nutrition. The nurse helps the daughter devise a plan of care for her mother. The plan of care should include which of the following interventions to promote nutrition? A. Offer her oral hygiene before and after meals. B. Encourage her to consume milk products. C. Encourage her to engage in an activity before a meal to stimulate her appetite. D. Restrict her fluid intake to three glasses of water a day. Answer: A Explanation: ( A) Clients with respiratory diseases are generally mouth breathers. Cleaning the oral cavity may improve the client's appetite, increase her feelings of well-being, and remove the taste and odor of sputum. (B) Milk causes thick sputum; therefore, milk products would not be beneficial for this client. ( C) Exercise prior to a meal would require increased O2 consumption and most likely would decrease the client's ability to eat. (D) Clients with respiratory diseases need increased fluid to liquefy secretions. NO.99 In admitting a client to the psychiatric unit, the nurse must explain the rules and regulations of the unit. A client with antisocial personality disorder makes the following remark, "Forget all those rules. I always get along well with the nurses." Which nursing response to him would be most effective? A. "OK, don't listen to the rules. See where you end up." B. "I'm pleased that you get along so well with the staff. You must still know and abide by the rules." C. "It is irrelevant whether you get along with the nurses." D. "I'm not the other nurses. You better read the rules yourself." Answer: B Explanation: NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 41 ( A) This answer is incorrect. A nurse should be an appropriate role model. Threats are not appropriate. No limit setting was stated. (B) This answer is correct. The nurse made a positive statement followed by a simple, clear, concise setting of limits. (C) This answer is incorrect. It appears to have a negative connotation. There was no limit setting. (D) This answer is incorrect. The nurse obviously responded in a negative manner. Learning takes place more readily when one is accepted, not rejected. No limits were set. NO.100 A 14-year-old teenager is demonstrating behavior indicative of an obsessive-compulsive disorder. She is obsessed with her appearance. She will not leave her room until her hair, clothes, and makeup are perfect. She always dresses immaculately. Recently, she expressed disgust over her appearance after she gained 5 lb. After observing a marked weight loss over a 2-week period, her mother suspects that she is experiencing bulimia. She eats everything on her plate, then runs to the bathroom. In interviewing the teenager, she discusses in great detail all of the events leading to her bulimia, but not her feelings. What defense mechanism is she using? A. Dissociation B. Intellectualization C. Rationalization D. Displacement Answer: B Explanation: ( A) Dissociation is separating a group of mental processes from consciousness or identity, such as multiple personalities. That is not evident in this situation. (B) Intellectualization is excessive use of reasoning, logic, or words usually without experiencing associated feelings. This is the defense mechanism that this client is using. (C) Rationalization is giving a socially acceptable reason for behavior rather than the actual reason. She is discussing events, not reasons. (D) Displacement is a shift of emotion associated with an anxiety-producing person, object, or situation to a less threatening object. NO.101 A 27-year-old healthy primigravida is brought to the labor and birthing room by her husband at 32 weeks' gestation. She experienced a sudden onset of painless vaginal bleeding. Following an ultrasound examination, the diagnosis of bleeding secondary to complete placenta previa is made. Expected assessment findings concerning the abdomen would include: A. A rigid, boardlike abdomen B. Uterine atony C. A soft relaxed abdomen D. Hypertonicity of the uterus Answer: C Explanation: NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 42 ( A) A rigid, boardlike abdomen is an assessment finding indicative of placenta abruptio. (B) A cause of postbirth hemorrhage is uterine atony. With placenta previa, uterine tone is within normal range. (C) The placenta is located directly over the cervical os in complete previa. Blood will escape through the os, resulting in the uterus and abdomen remaining soft and relaxed. (D) In placenta abruptio, hypertonicity of the uterus is caused by the entrapment of blood between the placenta and uterine wall, a retroplacental bleed. This does not exist in placenta previa. NO.102 The nurse assesses a client on the second postpartum day and finds a dark red discharge on the peripad. The stain appears to be about 5 inches long. Which of the following correctly describes the character and amount of lochia? A. Lochia alba, light B. Lochia serosa, heavy C. Lochia granulosa, heavy D. Lochia rubra, moderate Answer: D Explanation: ( A) Lochia alba occurs approximately 10 days after birth and is yellow to white. A discharge is classified as light when less than a 4-inch stain exists. (B) Lochia serosa is pink to brown and occurs 34 days after delivery. A stain is classified as heavy when a peripad is saturated in 1 hour. (C) Lochia granulosa is not a proper classification. (D) Lochia rubra is red, consisting mainly of blood, debris, and bacteria, and lasts from the time of delivery to 3-4 days afterward. A stain is classified as moderate when less than a 6-inch stain exists. NO.103 Which of the following blood values would require further nursing action in a newborn who is 4 hours old? A. Hemoglobin 17.2 g/dL B. Platelets 250,000/mm3 C. Serum glucose 30 mg/dL D. White blood cells 18,000/mm3 Answer: C Explanation: ( A) The normal range for hemoglobin in the newborn is 17-19 g/dL; 17.2 g/dL is within normal limits. ( B) A normal value range for platelets in the newborn is 150,000-400,000 mm3; 250,000/mm3 is within normal range. (C) A serum glucose of 30 mg/dL in the first 72 hours of life is indicative of hypoglycemia and warrants further intervention. (D) On the day of birth, a white blood cell count of 18 ,000-40,000/mm3 is normal in the newborn. NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 45 C. A large toy with movable parts to improve pincer grasp D. Various large colored blocks to teach visual discrimination Answer: A Explanation: ( A ) Increased locomotive skills make push-pull toys appropriate for the energetic toddler. ( B ) Infants progress from reflex activity through simple repetitive behaviors to imitative behavior. Handeye coordination forms the foundation of other movements. (C) At age 8 months, infants begin to have pincer grasp. Toys that help infants develop the pincer grasp are recommended for this age group. (D) Various large colored blocks are suggested toys for infants 6-12 months of age to help visual stimulation. NO.110 During an examination, the nurse notes that an infant has diaper rash on the convex surfaces of his buttocks, inner thighs, and scrotum. Which of the following nursing interventions will be most effective in resolving the condition? A. Coating the inflamed areas with zinc oxide B. Using talcum powder on the inflamed areas to promote drying C. Removing the diaper entirely for extended periods of time D. Cleaning the inflamed area thoroughly with disposable wet "wipes" at each diaper change Answer: C Explanation: ( A) Zinc oxide is not usually applied to inflamed areas because it contributes to sweat retention. (B ) Talcum powder is of questionable benefit and poses a hazard of accidental inhalation. (C) Removing the diaper and exposing the area to air and light facilitate drying and healing. (D) Infants may be sensitive to one or more agents in the wet "wipes." It is better to simply clean with a wet cloth. NO.111 The nurse is admitting a client with folic acid deficiency anemia. Which of the following questions is most important for the nurse to ask the client? A. "Do you take aspirin on a regular basis?" B. "Do you drink alcohol on a regular basis?" C. "Do you eat red meat?" D. "Have your stools been normal?" Answer: B Explanation: ( A) Aspirin does not affect folic acid absorption. (B) Folic acid deficiency is strongly associated with alcohol abuse. (C) Because folic acid is a coenzyme for single carbon transfer purines, calves liver or other purines are the meat sources. (D) Folic acid does not affect stool character. NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 46 NO.112 A client is receiving IV morphine 2 days after colorectal surgery. Which of the following observations indicate that he may be becoming drug dependent? A. The client requests pain medicine every 4 hours. B. He is asleep 30 minutes after receiving the IV morphine. C. He asks for pain medication although his blood pressure and pulse rate are normal. D. He is euphoric for about an hour after each injection. Answer: D Explanation: ( A) Frequent requests for pain medication do not necessarily indicate drug dependence after complex surgeries such as colorectal surgery. (B) Sleeping after receiving IV morphine is not an unexpected effect because the pain is relieved. (C) A person may be in pain even with normal vital signs. (D) A subtle sign of drug dependency is the tendency for the person to appear more euphoric than relieved of pain. NO.113 When preparing insulin for IV administration, the nurse identifies which kind of insulin to use? A. NPH B. Human or pork C. Regular D. Long acting Answer: C Explanation: ( A, B, D) Intermediate-acting and long-acting preparations contain materials that increase length of absorption time from the subcutaneous tissues but cause the preparation to be cloudy and unsuitable for IV use. Human insulin must be given SC. (C) Only regular insulin can be given IV. NO.114 A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, "Oh dear, I feel like I have to urinate again!" Which of the following is the most appropriate initial nursing response? A. Assure her that this is most likely the result of bladder spasms. B. Check the collection bag and tubing to verify that the catheter is draining properly. C. Instruct her to do Kegel exercises to diminish the urge to void. D. Ask her if she has felt this way before. Answer: B Explanation: ( A) Although this may be an appropriate response, the initial response would be to assure the patency of the catheter. (B) The most frequent reason for an urge to void with an indwelling catheter NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 47 is blocked tubing. This response would be the best initial response. (C) Kegel exercises while a retention catheter is in place would not help to prevent a voiding urge and could irritate the urethral sphincter. (D) Though the nurse would want to ascertain whether the client has felt the same urge to void before, the initial response should be to assure the patency of the catheter. NO.115 Following TURP, which of the following instructions would be appropriate to prevent or alleviate anxiety concerning the client's sexual functioning? A. "You may resume sexual intercourse in 2 weeks." B. "Many men experience impotence following TURP." C. "A transurethral resection does not usually cause impotence." D. "Check with your doctor about resuming sexual activity." Answer: C Explanation: ( A) Sexual activity should be delayed until cleared by the client's physician. (B) Although many men experience retrograde ejaculation following prostate surgery, potency is seldom affected. (C) Although the client may experience retrograde ejaculation, it will not limit his ability to engage in sexual intercourse. (D) Although the client should obtain clearance from his physician before resuming sexual activity, this statement does not give the client any information or reassurance about future sexual activity or potency that could decrease his anxiety. NO.116 The most frequent cause of early postpartum hemorrhage is: A. Hematoma B. Coagulation disorders C. Uterine atony D. Retained placental fragments Answer: C Explanation: ( A) Hematomas, which are the result of damage to a vessel wall without laceration of the tissue, are a cause, though not the most frequent cause. (B) Coagulation disorders are among the causes of postpartal hemorrhage, but they are less common. (C) The most frequent causes of hemorrhage in the postpartal period are related to an interference with involution of the uterus. Uterine atony is the most frequent cause, occurring in the first 24 hours after delivery. (D) Retained placental fragments are also a cause, although these bleeds usually occur 7-14 days after delivery. NO.117 A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse's best response is: A. "You'll have to get permission from the physician to visit. Clients are pretty sick after the first treatment." B. "Visitors are not allowed. We will telephone you to inform you of her progress." NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 50 NO.122 A 9-year-old child was in the garage with his father, who was repairing a lawnmower. Some gasoline ignited and caused an explosion. His father was killed, and the child has split- thickness and full-thickness burns over 40% of his upper body, face, neck, and arms. All of the following nursing diagnoses are included on his care plan. Which of these nursing diagnoses should have top priority during the first 24-48 hours postburn? A. Pain related to tissue damage from burns B. Potential for infection related to contamination of wounds C. Fluid volume deficit related to increased capillary permeability D. Potential for impaired gas exchange related to edema of respiratory tract Answer: D Explanation: ( A, B, C) These answers are all correct; however, maintenance of airway is the top priority. ( D) Persons burned about the face and neck during an explosion are also likely to suffer burns of the respiratory tract, which can lead to edema and respiratory arrest. NO.123 A 35-year-old client is admitted to the hospital with diabetic ketoacidosis. Results of arterial blood gases are pH 7.2, PaO2 90, PaCO2 45, and HCO3 16. The nursing assessment of arterial blood gases indicate the presence of: A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis Answer: D Explanation: ( A) Respiratory alkalosis is determined by elevated pH and low PaCO2. (B) Respiratory acidosis is determined by low pH and elevated PaCO2. (C) Metabolic alkalosis is determined by elevated pH and HCO3.(D) Metabolic acidosis is determined by low pH and HCO3. NO.124 A client is dilated 8 cm and entering the transition phase of labor. Common behaviors of the laboring woman during transition are: A. Frustration, vague in communication B. Seriousness, some difficulty following directions C. Calmness, follows directions easily D. Excitement, openness to instructions Answer: A Explanation: ( A) During the transition phase, the mother may become frustrated and unclear in her communication owing to severe pain and fear of loss of control. (B) These behaviors are common in NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 51 the active phase of labor. (C) These behavioral clues are seen in the latent phase of labor. (D) These characteristics are observed in the latent phase of labor. NO.125 A 30-year-old client has a history of several recent traumatic experiences. She presents at the physician's office with a complaint of blindness. Physical exam and diagnostic testing reveal no organic cause. The nurse recognizes this as: A. Delusion B. Illusion C. Hallucination D. Conversion Answer: D Explanation: ( A) The client's blindness is real. Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion is the expression of intrapsychic conflict through sensory or motor manifestations. NO.126 One afternoon 3 weeks into his alcohol treatment program, a client says to the nurse, "It's really not all my fault that I have a drinking problem. Alcoholism runs in my family. Both my grandfather and father were heavy drinkers." The nurse's best response would be: A. "That might be a problem. Tell me more about them." B. "Risk factors can often be controlled by self-responsibility." C. "It sounds like you're intellectualizing your drinking problem." D. "Your grandfather and father were both alcoholics?" Answer: B Explanation: ( A) Focusing is an effective therapeutic strategy. This response, however, allows the client to "defocus" off the topic of learning how to accept responsibility for his behavior and future growth. ( B) The nurse can educate the client about both the "genetic risk" for the development of alcoholism and ways to make long-term healthy lifestyle changes. (C) This response is inappropriately confrontational and condescending to the client. (D) Reflection of content can be an effective verbal therapeutic technique. It is used inappropriately here. NO.127 A female client at 36 weeks' gestation has been treated successfully for premature labor for 4 weeks. She has begun having uterine contractions today and has been admitted to the labor and delivery suite. Her amniocentesis results reveal a lecithin/sphingomyelin (L/S) ratio of 2 and positive phosphatidylglycerol (PG). These lab values indicate: A. Placental maturity B. Suspected chronic asphyxia NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 52 C. Cord compression D. Fetal lung maturity Answer: D Explanation: ( A) Placental maturity is assessed by a biophysical profile. (B) L/S ratio and presence of phosphatidylglycerol are not used to determine fetal asphyxia. A biophysical profile score of6 may indicate this condition. (C) Cord compression is not reflected by the L/S ratio or presence of phosphatidylglycerol. Variable decelerations observed through electronic fetal monitoring could reflect umbilical cord compression. (D) An L/S ratio>2 and the presence of phosphatidylglycerol in amniotic fluid indicate fetal lung maturity. NO.128 Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients? A. Vitamin C and zinc B. Folic acid and niacin C. Vitamin A and biotin D. Thiamine and pyroxidine Answer: D Explanation: ( A) Chronic alcoholism can lead to deficiencies of B complex vitamins including thiamine and pyroxidine. (B) Chronic alcoholism can lead to deficiencies of vitamins A, D, K, and B complex. (C) Chronic alcoholism can lead to deficiencies of vitamins A, D, K, and B complex. (D) Vitamins A, D, K, and B require bile salts to be absorbed from the gastrointestinal tract. A damaged liver does not form bile salts. NO.129 A complication for which the nurse should be alert following a liver biopsy is: A. Hepatic coma B. Jaundice C. Ascites D. Shock Answer: D Explanation: ( A) Hepatic coma may occur in liver disease due to the increased NH3levels, not due to liver biopsy. ( B) Jaundice may occur due to increased bilirubin levels, not due to liver biopsy. (C) Ascites would occur due to portal hypertension, not due to liver biopsy. (D) Hemorrhage and shock are the most likely complications after liver biopsy because of already existing bleeding tendencies in the vascular makeup of the liver. NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 55 A. Palpate these pulses again in 15 minutes. B. Use a Doppler to determine presence and strength of these pulses. C. Document the finding that the pulses are not palpable. D. Call the physician and notify the physician of this finding. Answer: B Explanation: ( A) Palpating these pulses again in 15 minutes may only result in the same findings. (B) Any time during an assessment that the nurse is unable to palpate pulses, the nurse should then obtain a Doppler and assess for presence or absence of the pulse and pulse strength, if a pulse is present. (C) Pulses may be present and assessed through use of a Doppler. Absence of palpable pulses does not indicate absence of blood flow unless pulses cannot be located with a Doppler. (D) The nurse would only call the physician after determining that the pulses are absent by both palpation and Doppler. NO.136 A 33-year-old client is diagnosed with bipolar disorder, acute phase. This is her first psychiatric hospitalization, and she is being evaluated for treatment with lithium. Which of the following diagnostic tests are essential prior to the initiation of lithium therapy with this client? A. Hematocrit, hemoglobin, and white blood cell (WBC) count B. Blood urea nitrogen, electrolytes, and creatinine C. Glucose, glucose tolerance test, and random blood sugar D. X-rays, electroencephalogram, and electrocardiogram (ECG) Answer: B Explanation: ( A) These are general diagnostic blood studies (usually done on admission), but they are not reliable indicators of lithium therapy clearance. (B) These are the primary diagnostic tests to determine kidney functioning. Because lithium is excreted through the kidneys and because it can be very toxic, adequate renal function must be ascertained before therapy begins. (C) These are diagnostic blood tests used to determine the presence of endocrine (not renal) dysfunction. (D) These are other types of diagnostic procedures used to determine musculoskeletal, neural, and cardiac (rather than renal) functioning. NO.137 A 60-year-old woman exhibits forgetfulness, emotional lability, confusion, and decreased concentration. She has been unable to perform activities of daily living without assistance. After a thorough medical evaluation, a diagnosis of Alzheimer's disease was made. An appropriate nursing intervention to decrease the anxiety of this client would include: A. Allowing the client to perform activities of daily living as much as possible unassisted B. Confronting confabulations C. Reality testing D. Providing a highly stimulating environment NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 56 Answer: A Explanation: ( A) This answer is correct. The more the client is able to control her daily routine, the less anxiety she will experience. (B) This answer is incorrect. Confrontation tends to increase anxiety. (C) This answer is incorrect. Reality testing is an assessment tool. It does not decrease anxiety. (D) This answer is incorrect. A highly stimulating environment increases distractibility and anxiety. NO.138 On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle feeding. The nurse should initially recommend to her to: A. Take 2 ibuprofen (Motrin) tablets by mouth now because the baby will be returning for feeding in 20 minutes B. Allow the infant to breast-feed at the next feeding time to empty the breasts C. Apply ice packs to the breasts and wear a supportive, well-fitting bra D. Take a warm shower and express milk from both breasts until empty Answer: C Explanation: ( A) Judicious use of analgesics is appropriate with breast engorgement; however, mechanical suppression would be the initial recommendation. (B) Breast-feeding every 112-3 hours will reduce and/or prevent breast engorgement. Breast-feeding will promote milk production, which will compound the distention and stasis of the venous circulation of engorgement in a bottlefeeding mother. (C) Ice packs reduce milk flow while the snug, supportive bra provides mechanical suppression and decreases pulling on Cooper's ligament. In addition, breast binders or ace bandages may be used for some women. (D) Warmth promotes milk production and may stimulate the letdown reflex. These measures would contribute to the venous congestion of engorgement. NO.139 While changing the dressing on a client's central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be appropriate to implement based on this finding? A. Discontinue the central line. B. Begin a peripheral IV. C. Document in the nurse's notes and notify the physician after redressing the site. D. Clean the site well and redress. Answer: C Explanation: ( A) The nurse may never discontinue a central line without a physician's order. (B) The nurse may never initiate a peripheral IV without a physician's order except in an emergency situation. (C) The nurse should always document findings and alert the physician to the findings as well. The physician NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 57 may then initiate a new central line and order the current central line to be discontinued. (D) Besides cleaning and redressing, the nurse should always document the findings. NO.140 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 record: A. 3-2- 00-2 B. 2-2-0-2-2 C. 3-1-1-0-2 D. 2-1-1-0-2 Answer: C Explanation: ( A) This answer is an incorrect application of the GTPAL method. One prior pregnancy was a preterm birth at 36 weeks (T =1, P= 1; not T = 2). (B) This answer is an incorrect application of the GTPAL method. The client is currently pregnant for the third time (G = 3, not 2), one prior pregnancy was preterm (T= 1, P= 1; not T= 2), and she has had no prior abortions (A =0). (C) This answer is the correct application of GTPAL method. The client is currently pregnant for the third time (G =3), her first pregnancy ended at term (>37 weeks) (T = 1), her second pregnancy ended preterm 20-33 weeks) (P = 1), she has no history of abortion (A=0), and she has two living children (L = 2). (D) This answer is an incorrect application of the GTPAL method. The client is currently pregnant for the third time (G =3, not 2). NO.141 A 60-year-old male client was hospitalized 3 days ago with the diagnosis of acute anterior wall myocardial infarction. Today he has been complaining of increasing weakness and shortness of breath. Crackles in both lung bases are audible on auscultation. He is developing: A. An extension of his myocardial infarction B. Pneumonia C. Pulmonary edema D. Pulmonary emboli Answer: C Explanation: ( A) Extensions of his myocardial infarction would be chest pain unrelieved with nitroglycerin, cardiac enzyme elevations, and electrocardiographic changes. (B) Persons with pneumonia may complain of weakness and shortness of breath and have crackles in their lung bases. However, they would also have sputum production and leukocytosis. (C) Persons who have had myocardial infarctions ( especially anterior wall) are at risk of developing left ventricular heart failure, which is a major cause of pulmonary edema. Pulmonary edema is manifest by shortness of breath, weakness, and crackles on auscultation of the lung fields. (D) Pulmonary emboli may be accompanied by shortness of breath, NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 60 protect the myocardium from the adverse effects of hyperkalemia. Serum levels reflect hyperkalemia. (C) Rapid catabolism releases potassium from the body tissue into the bloodstream. Infection and hyperthermia increase the process of catabolism. (D) The administration of dextrose and regular insulin IV forces potassium back into the cells decreasing the potassium in the serum. NO.147 A 26-year-old female client presents at 10 weeks' gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her grandmother also has insulin-dependent diabetes. The client's previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches tall and her current weight is 130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following factors places her at risk for gestational diabetes? A. Age>25 years B. Maternal weight C. Previous birth of an infant weighing>9 lb D. Family history of heart disease Answer: C Explanation: ( A ) Maternal age older than 30 years is an identified risk factor for diabetes. Age younger than 30 years is insignificant for diabetes unless there is a familial history of diabetes. (B) The client's weight is appropriate for her height. Obesity or pregnancy weight >20% of the ideal weight is a contributing factor to the development of gestational diabetes. (C) The birth of an infant weighing >9 lb (4000 g) is an identified risk factor for gestational diabetes. ( D ) A familial history of heart disease is insignificant in the development of diabetes. However, a familial history of type II diabetes mellitus is identified as a risk factor in the development of diabetes during pregnancy. NO.148 When assessing residual volume in tube feeding, the feeding should be delayed if the amount of gastric contents (residual) exceeds: A. 20 mL B. 25 mL C. 30 mL D. 50 mL Answer: D Explanation: ( A) A residual volume of 20 mL is not excessive. (B) A residual volume of 25 mL is not excessive. (C) A residual volume of 30 mL is not excessive. (D) Tube feedings should be withheld and physician notified for residual volumes of 50-100 mL. NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 61 NO.149 A 5-year-old child was recently diagnosed as having acute lymphoid leukemia. She is hospitalized for additional tests and to begin a course of chemotherapy designed to induce a remission. She is scheduled to have a bone marrow aspiration tomorrow. She has had a bone marrow test previously and is apprehensive about having another. Which of the following interventions will be most effective in relieving her anxiety? A. Explain what will take place and what she will see, feel, and hear. B. Remind her that she has had this procedure before and that it is nothing to be afraid of. C. Tell her not to worry about it, that it will be over soon and she can join her friends in the playroom. D. Give her a big hug and tell her that she is a big girl now and that she will do just fine. Answer: A Explanation: ( A ) Even though the child has had the procedure before, she will probably need additional explanations and emotional support. (B) The fact that the child has had the procedure before and possibly found it painful or uncomfortable may increase, not relieve, her stress. ( C ) This intervention does nothing to reassure the child and may well prevent her from expressing her feelings. (D) This does not prepare the child for the test and burdens her with the expectation that she act bigger and braver than she is. NO.150 A female client was employed as a client care technician in a hemodialysis unit. She recently began to experience extreme fatigue, being able to sleep for 16-20 hours at a time. She also noted that her urine was tea colored, which she rationalized was a result of the vitamins she began taking to alleviate fatigue. She was diagnosed with hepatitis B. After a brief hospital stay, she is discharged to her parent's home. Her mother asks the nurse if any precautions are necessary to prevent transmission to the client's family. The nurse explains necessary precautions, which include: A. Isolation of the client from the remainder of the family B. Separate bathroom facilities if possible; if not, then cleansing daily of the facilities with a chloride solution C. No necessary precautions because she is beyond the contagious phase D. Laundering clothes separately in cold water with a chloride solution Answer: B Explanation: ( A) Isolation is not necessary, even in the acute phase. (B) Separate bathroom facilities are recommended. If unavailable, daily cleansing with a chloride solution is recommended. (C) Precautions continue to be necessary while the client is in the active phase of hepatitis. (D) Clothes are to be laundered separately in hot water with a chloride solution. NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 62 NO.151 A 29-year-old client delivered her fifth child by the Lamaze method and developed a postpartal hemorrhage in the recovery room. What are the initial symptoms of shock that she may experience? A. Marked elevation in blood pressure, respirations, and pulse B. Decreased systolic pressure, cold skin, and anuria C. Rapid pulse; narrowed pulse pressure; cool, moist skin D. No urinary output, tachycardia, and restlessness Answer: C Explanation: ( A) Early shock does not exhibit the symptom of marked elevation in blood pressure. A narrowing of the pulse pressure is indicative of early shock. (B) Anuria is a clinical finding in late shock. (C) All of these clinical findings are congruent with early shock. (D) Absence of urinary output is a clinical finding in the late phase of shock. NO.152 A successful executive left her job and became a housewife after her marriage to a plastic surgeon. She started doing volunteer work for a charity organization. She developed pain in her legs that advanced to the point of paralysis. Her physicians can find no organic basis for the paralysis. The client's behavior can be described as: A. Housework phobia B. Malingering C. Conversion reaction D. Agoraphobia Answer: C Explanation: ( A) A typical phobia does not result in physical symptoms (i.e., paralysis). (B) Malingering is pretending to be ill. This person has a true paralysis. (C) A conversion reaction is a physical expression of an emotional conflict. It has no organic basis. (D) Agoraphobia is fear of public places. NO.153 A pregnant client experiences spontaneous rupture of membranes. The first nursing action is to: A. Assess the client's respirations B. Notify the physician C. Auscultate fetal heart rate D. Transfer to delivery suite Answer: C Explanation: NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 65 Answer: D Explanation: ( A ) Describing pain is an important aspect of the assessment; however, assessing activity preceding muscle spasms is equally important. (B) Edema may occur with peripheral vascular disease, but it is not of particular importance in assessing intermittent claudication. ( C ) Lesions may be present with peripheral vascular disease, but they are not an indication of intermittent claudication. (D) With intermittent claudication, muscle spasms occur intermittently, mainly with walking and after exercising. Rest may relieve muscle spasms. NO.159 A client's behavior is annoying other clients on the unit. He is meddling with their belongings and dominating the group. The best approach by the nurse is to: A. Seclude him in his room. B. Set limits on his behavior. C. Have his medication increased. D. Ignore him and tell the other clients that these behaviors are due to his illness and that they should understand. Answer: B Explanation: ( A) This action by the nurse would be punitive. (B) Consistent limit setting will help the client to know what is acceptable behavior. (C) This action is not within the nurse's scope of practice. (D) This could be dangerous to the client and to others and violates other clients' rights. NO.160 A behavioral modification program is recommended by the multidisciplinary team working with a 15-year-old client with anorexia nervosa. A nursing plan of care based on this modality would include: A. Role playing the client's eating behaviors B. Restriction to the unit until she has gained 2 lb C. Encouraging her to verbalize her feelings concerning food and food intake D. Provision for a high-calorie, high-protein snack between meals Answer: B Explanation: ( A) This answer is incorrect. Role playing is based on learning but is not based on the behavioral modification model. (B) This answer is correct. The behavioral modification model is based on negative and positive reinforcers to change behavior. (C) This answer is incorrect. Verbal catharsis is not an intervention based on behavioral modification. (D) This answer is incorrect. Although an acceptable nursing intervention, it is not based on behavioral modification. NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 66 NO.161 An alcoholic client who is completing the inpatient segment of a substance abuse program was placed on disulfiram (Antabuse) drug therapy. What should the nurse include in the discharge instructions? A. If disulfiram is taken and alcohol ingested, the client experiences nausea, vomiting and elevated blood pressure. B. Disulfiram is most effective when prescribed as late as possible in a recovery program. C. Disulfiram works on the desensitization principle. D. The effects of disulfiram can be triggered by alcohol 5 days to 2 weeks after the drug is discontinued. Answer: D Explanation: ( A) When alcohol is ingested with disulfiram therapy, the client experiences nausea, vomiting, and a potentially serious drop in blood pressure. (B) Disulfiram is most successful when used early in the recovery process while the individual makes major lifestyle changes necessary for long-term recovery. (C) Disulfiram works on the classical conditioning principle. (D) The effects of disulfiram can be felt when alcohol is ingested 1-2 weeks after disulfiram is discontinued. NO.162 The postpartum nurse should include which of the following instructions to breast-feeding mothers? A. Limit feeding times for several days to avoid nipple soreness. B. Wash the nipples with soap and water before and after each feeding. C. Daily caloric intake should be increased by 500 cal. D. Breast milk is totally digestible by the baby because it contains lactose. Answer: C Explanation: ( A) Limiting initial feeding times will only delay nipple soreness as well as the establishment of the letdown reflex, thus encouraging engorgement from clogged ducts and ductules. (B) Soap should be avoided because it may be excessively drying, predisposing nipples to cracking. (C) For optimal milk production, an additional 500 kcal over maintenance levels are needed daily. (D) Lipase, not lactose, emulsifies the fat in breast milk, making it almost totally digestible by infants. NO.163 At her monthly prenatal visit, a client reports experiencing heartburn. Which nursing measure should be included in her plan of care to help alleviate it? A. Restrict fluid intake. B. Use Alka-Seltzer as necessary. C. Eat small, frequent bland meals. D. Lie down after eating. Answer: C Explanation: NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 67 ( A) At least eight glasses of fluid per day are encouraged to help dilute stomach contents, thereby decreasing irritation. (B) Alka Seltzer contains aspirin, which is irritating to gastric mucosa, and therefore should be avoided. (C) Small, frequent bland meals help to decrease gastric pressure and to prevent reflux. (D) Lying down after meals may cause gastric reflux and prevents optimal gastric emptying. NO.164 A type I diabetic client is diagnosed with cellulitis in his right lower extremity. The nurse would expect which of the following to be present in relation to his blood sugar level? A. A normal blood sugar level B. A decreased blood sugar level C. An increased blood sugar level D. Fluctuating levels with a predawn increase Answer: C Explanation: ( A) Blood sugar levels increase when the body responds to stress and illness. (B) Blood sugar levels increase when the body responds to stress and illness. (C) Hyperglycemia occurs because glucose is produced as the body responds to the stress and illness of cellulitis. (D) Blood sugar levels remain elevated as long as the body responds to stress and illness. NO.165 An 8-year-old boy has been diagnosed with hemophilia. Which of the following diagnostic blood studies is characteristically abnormal in this disorder? A. Partial thromboplastin time B. Platelet count C. Complete blood count D. Bleeding time Answer: A Explanation: ( A) Partial thromboplastic time measures activity of thromboplastin, which depends on the intrinsic clotting factors deficient in children who are hemophiliacs. (B) Platelet counts are normal in hemophilia. (C) Hemophilia does not affect the complete blood count. (D) Bleeding times are normal in hemophiliacs. They measure the time interval for the bleeding from small superficial wounds to cease. NO.166 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 B. Mafenide acetate C. Silver sulfadiazine NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 70 C. Ask the client to go to an activity once. If she gives no response right away, change the question around, asking the same thing. D. Give the client two or three choices to decide what she wants to do. Answer: A Explanation: ( A) Alzheimer's clients cope poorly with changes in routine because of memory deficits. Schedule changes cause confusion and frustration, whereas adhering to schedules is helpful and supports orientation. (B) Insisting that the client go to all unit activities may antagonize her and increase her agitation because of cognitive impairments. It may be better to allow the client time for calming down or distraction rather than to insist that she attend every activity. (C) When repeating a question, allow time first for a response; then use the same words the second time to avoid further confusion. (D) The nurse should avoid giving several choices at once. Cognitively impaired clients will become more frustrated with making decisions. NO.172 The initial focus when providing nursing care for a child with rheumatic fever during the acute phase of the illness should be to: A. Maintain contact with her parents B. Provide for physical and psychological rest C. Provide a nutritious diet D. Maintain her interest in school Answer: B Explanation: ( A ) This goal is helpful, but rest is essential during the acute phase. (B) Rest is essential for healing to occur and for pain to be relieved. (C) This goal is important, but rest is essential. ( D ) This goal should be part of the plan of care, but it is not the priority during the acute phase. NO.173 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 Explanation: NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 71 ( 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. NO.174 A female client is concerned that she is in a "high-risk" group for the development of acquired immunodeficiency syndrome (AIDS). She wants to know about the advisability of donating blood. Which of the following responses is correct? A. "Individuals who donate blood are at risk of getting the AIDS virus. You should not donate." B. "It's OK for you to donate because the blood bank has a test that is 100% effective." C. "You should not donate since it takes time to develop antibodies to the AIDS virus. If you donate blood before you develop the antibody, you could pass it on in the blood." D. "It is not a good idea for you to donate. If you have AIDS, the information is made public and could destroy your personal life." Answer: C Explanation: ( A) The AIDS virus cannot be transmitted to the donor through the blood donation procedure. (B) The test for the AIDS virus is not absolutely foolproof; therefore, it is not wise for a person with known risk factors to donate blood. (C) It takes time for antibodies to the AIDS virus to develop. An infected individual could donate contaminated blood without it testing positive for the virus. (D) For reasons of confidentiality, information about individuals infected with AIDS is not made public. NO.175 A 56-year-old client is admitted to the psychiatric unit in a state of total despair. She feels hopeless and worthless, has a flat affect and very sad appearance, and is unable to feel pleasure from anything. Her husband has been assisting her at home with the housework and cooking; however, she has not been eating much, lies around or sits in a chair most of the day, and is becoming confused and thinks her family does not want her around anymore. In assessing the client, the nurse determines that her behavior is consistent with: A. Transient depression B. Mild depression C. Moderate depression D. Severe depression Answer: D Explanation: ( A) Transient depression manifests as sadness or the "blues" as seen with everyday disappointments and is not necessarily dysfunctional. (B) Mild depression manifests as symptoms seen with grief response, such as denial, sadness, withdrawal, somatic symptoms, and frequent or continuous NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 72 thoughts of the loss. (C) Moderate depression manifests as feelings of sadness, negativism; low selfesteem; rumination about life's failures; decreased interest in grooming and eating; and possibly sleep disturbances. These symptoms are consistent with dysthymia. (D) Severe depression manifests as feelings of total despair, hopelessness, emptiness, inability to feel pleasure; possibly extreme psychomotor retardation; inattention to hygiene; delusional thinking; confusion; self-blame; and suicidal thoughts. These symptoms are consistent with major depression. NO.176 A client had a ruptured abdominal aortic aneurysm that was repaired surgically. Her postoperative recovery progressed without complications, and she is ready for discharge. Client education in preparation for discharge began 7 days ago on her admission to the nursing unit. Evaluation of nursing care related to client education is based on evaluation of expected outcomes. Which statement made by the client would indicate that she is ready for discharge? A. "I will not drive but ride in the front seat of the car with a seat belt on for my first doctor's appointment." B. "When I bathe tomorrow morning, I will be very careful not to get soap on my incision." C. "I am allowed to exercise by walking for short periods." D. "Teach my husband about the diet. He'll be doing all the cooking now." Answer: C Explanation: ( A) Postoperatively, clients with major abdominal surgery are instructed to avoid driving, riding in the front seat, and wearing seat belts because any sudden impact may injure a fresh incision. She should ride in back seat without a seat belt. (B) Clients should not sit in the tub and allow the incision to soak in water because this may predispose the client to infection. A short, cool shower would be preferable. Allowing soap to come in contact with the incision would not harm it and is frequently used as postoperative wound care at home on discharge from the hospital. (C) Activity instructions include: avoid sitting for long periods and get exercise by walking. Lifting more than 5 lb of weight is also prohibited. (D) The client must also learn her diet. Her husband cooking is probably a temporary measure unless he did the cooking prior to her hospitalization.A statement such as this may indicate the need for further exploration of feelings regarding her illness, dependence, and self-care expectations. NO.177 In caring at home for a child who just ingested a caustic alkali, the nurse would immediately tell the mother to: A. Give vinegar, lemon juice, or orange juice B. Phone the doctor C. Take the child to the emergency room D. Induce vomiting Answer: A Explanation: NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 75 B. Hypokalemia C. Hypernatremia D. Hyponatremia Answer: D Explanation: ( A) Early signs of hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, and diaphoresis. (B) Early signs of potassium depletion include muscular weakness or paralysis, tetany, postural hypotension, weak pulse, shallow respirations, apathy, weak voice, and electrocardiographic changes. (C) Early signs of an elevated sodium level include dry oral mucous membranes, marked thirst, hypertension, tachycardia, oliguria or anuria, anxiety, and agitation. (D) This answer is correct. Important early clinical findings of a decreased sodium concentration include confusion and disorientation. Hyponatremia can occur after a TURP because absorption during surgery through the prostate veins can increase circulating blood volume and decrease sodium concentration. NO.184 A 6-month-old infant who was diagnosed at 4 weeks of age with a ventricular septal defect, was admitted today with a diagnosis of failure to thrive. His mother stated that he had not been eating well for the past month. A cardiac catheterization reveals congestive heart failure. All of the following nursing diagnoses are appropriate. Which nursing diagnosis should have priority? A. Altered nutrition: less than body requirements related to inability to take in adequate calories B. Altered growth and development related to decreased intake of food C. Activity intolerance related to imbalance between oxygen supply and demand D. Decreased cardiac output related to ineffective pumping action of the heart Answer: D Explanation: ( A) Altered nutrition occurs owing to the fatigue from decreased cardiac output associated with congestive heart failure. (B) The decreased intake occurs due to fatigue from the altered cardiac output. (C) Fatigue occurs due to the decreased cardiac output. (D) The ineffective action of the myocardium leads to inadequate O2 to the tissues, which produces activity intolerance, altered nutrition, and altered growth and development. NO.185 A 35-year-old client has returned to her room following surgery on her right femur. She has an IV of D5 in onehalf normal saline infusing at 125 mL/hr and is receiving morphine sulfate 10-15 mg IM q4h prn for pain. She last voided 51/2 hours ago when she was given her preoperative medication. In monitoring and promoting return of urinary function after surgery, the nurse would: A. Provide food and fluids at the client's request B. Maintain IV, increasing the rate hourly until the client voids C. Report to the surgeon if the client is unable to void within 8 hours of surgery D. Hold morphine sulfate injections for pain until the client voids, explaining to her that morphine sulfate can cause urinary retention NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 76 Answer: C Explanation: ( A) Provision of food and fluid promotes bowel elimination. Nutritional needs postoperatively are determined by the physician, not the client. (B) Increasing IV fluids postoperatively will not cause a client to void. Any change in rate of administration of IV fluids should be determined by the physician. (C) The postoperative client with normal kidney function who cannot void 8 hours after surgery is retaining urine. The client may need catheterization or medication. The physician must provide orders for both as necessary. (D) Although morphine sulfate can cause urinary retention, withholding pain medication will not ensure that the client will void. The client with uncontrolled pain will probably not be able to void. NO.186 The physician decides to prescribe both a short-acting insulin and an intermediate-acting insulin for a newly diagnosed 8-year-old diabetic client. An example of a short-acting insulin is: A. Novolin Regular B. Humulin NPH C. Lente Beef D. Protamine zinc insulin Answer: A Explanation: ( A ) Novolin is a short-acting insulin. (B, C) NPH and Lente are intermediate-acting insulins. ( D ) Protamine zinc insulin is a long-acting insulin preparation. NO.187 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 pureed diet for her Answer: C Explanation: ( 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. NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 77 NO.188 A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains of severe abdominal pain. Assessment reveals abdominal rigidity and distention, increased temperature, and tachycardia. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has developed: A. Gastritis B. Evisceration C. Peritonitis D. Pulmonary embolism Answer: C Explanation: ( A) Assessment findings for gastritis would reveal anorexia, nausea and vomiting, epigastric fullness and tenderness, and discomfort. (B) Evisceration is the extrusion of abdominal viscera as a result of trauma or sutures failing in a surgical incision. (C) Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and fluid into the abdominal cavity. This causes infection and irritation. (D) Assessment findings of pulmonary embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath, anxiety or panic, and wheezing and coughing often accompanied by blood-tinged sputum. NO.189 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) Answer: B Explanation: ( 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. NO.190 A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period was February 16, with 3 days of spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to be: A. November 23rd B. December 26th C. September 14th D. December 9th NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 80 D. Decreased secretion of catecholamines secondary to anxiety Answer: A Explanation: ( A) Anaerobic metabolism results because the decreased blood supply to the myocardium causes a release of lactic acid. Lactic acid is an irritant to the myocardial neural receptors, producing chest pain. (B) Chest pain is caused by a decrease in the O2 supply to the myocardial cells. Treatment modalities for chest pain are aimed toward increasing the blood flow through coronary arteries. (C) Chest pain causes an increase in the stimulation of the sympathetic nervous system. This stimulation increases the heart rate and blood pressure, causing an increase in myocardial workload aggravating the chest pain. (D) Chest pain and anxiety cause increased secretion of catecholamines by stimulating the sympathetic nervous system. This stimulation increases chest pain by increasing the workload of the heart. NO.196 The nurse working with a client who is out of control should follow a model of intervention that includes which of the following? A. Approach the client on a continuum of least restrictive care. B. Challenge client's behavior immediately with steps to prevent injury to self or others. C. Leave the aggressive client to himself or herself, and take other clients away. D. To ensure safety of other clients, place client in seclusion immediately when he or she begins shouting. Answer: A Explanation: ( A) Approaching a client's aggressive behavior on a continuum of least restrictive care is in agreement with his or her rights (i.e., verbal methods to help maintain control, medication, seclusion, and restraints, as necessary). (B) Approaching a client in a challenging manner is threatening and inappropriate. A nonchallenging and calm approach reflects staff in control and may increase client's internal control. (C) It is inappropriate to leave an aggressive client who is acting out alone. The nurse should acquire qualified help to prevent client from harm or injury to self or others. (D) Moving a client to seclusion immediately for shouting is inappropriate. The nurse should offer the client an opportunity to control self with limit setting. The client should understand that the staff will assist with control if necessary (i.e., quietly accompany out of environment to decrease stimulation and allow for verbalization) employing the least restrictive care model of intervention. NO.197 A 2-year-old toddler is hospitalized with epiglottitis. In assessing the toddler, the nurse would expect to find: A. A productive cough B. Expiratory stridor C. Drooling D. Crackles in the lower lobes NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 81 Answer: C Explanation: ( A) A productive cough is not associated with epiglottitis. (B) Children with epiglottitis seldom have expiratory stridor. Inspiratory stridor is more common due to edema of the supraglottic tissues. (C) Because of difficulty with swallowing, drooling often accompanies epiglottitis. (D) Crackles are not heard in the lower lobes with epiglottitis because the infection is usually confined to the supraglottic structures. NO.198 A 24-year-old graduate student recognizes that he has a phobia. He suffers severe anxiety when he is in darkness. It has altered his lifestyle because he is unable to go to a movie theater, concert, and other events that may require absence of light. The client is seeking assistance because he is no longer able to socialize with friends due to his phobia. The psychologist working with him is using desensitization. He has asked the nursing staff to assist the client in muscle relaxation techniques. What result would indicate client education has been successful? A. He enters a movie theater, sits in his chair, and replaces anxiety with relaxation as the theater darkens. B. He enters a concert, but as the lights dim, he does not experience anxiety. C. He states that he no longer fears dark places. D. He takes a part-time job as a photographic assistant. His job necessitates his working in a darkroom. Answer: A Explanation: ( A) This situation provides specific evidence that the client is able to integrate muscle relaxation technique into his lifestyle to alleviate anxiety. (B) The client may not experience anxiety at the concert, but there is no evidence regarding the technique that he used to alleviate anxiety. (C) The client may state he no longer experiences anxiety, but there is no evidence demonstrating this. He may be denying anxiety to discontinue therapy prematurely. (D) Does he experience anxiety in the darkroom? He may have taken this job to force himself to deal with the phobia directly. NO.199 When planning care for the passive-aggressive client, the nurse includes the following goal: A. Allow the client to use humor, because this may be the only way this client can express self. B. Allow the client to express anger by using "I" messages, such as "I was angry when . . .," etc. C. Allow the client to have time away from therapeutic responsibilities. D. Allow the client to give excuses if he forgets to give staff information. Answer: B Explanation: ( A) Ceasing to use humor and sarcasm is a more appropriate goal, because this client uses these behaviors covertly to express aggression instead of being open with anger. (B) Use of "I" messages demonstrates proper use of assertive behavior to express anger instead of passive-aggressive NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 82 behavior. (C) Client is expected to complete share of work in therapeutic community because he has often obstructed other's efforts by failing to do his share. (D) Client has used conveniently forgetting or withholding information as a passive-aggressive behavior, which is not acceptable. NO.200 A 26-year-old client is in a treatment center for aprazolam (Xanax) abuse and continues to manifest moderate levels of anxiety 3 weeks into the rehabilitation program, often requesting medication for "his nerves." Included in the client's plan of care is to identify alternate methods of coping with stress and anxiety other than use of medication. After intervening with assistance in stress reduction techniques, identifying feelings and past coping, the nurse evaluates the outcome as being met if: A. Client promises that he will not abuse aprazolam after discharge B. Client demonstrates use of exercise or physical activity to handle nervous energy following conflicts of everyday life C. Client is able to verbalize effects of substance abuse on the body D. Client has remained substance free during hospitalization and is discharged Answer: B Explanation: ( A) This client response does not address stress reduction techniques. Verbal response focuses only on the problem. (B) Exercise or physical activity is a common strategy or coping technique used to reduce stress and anxiety. (C) Verbalizing effects of substance abuse on the body may help with insight and break through denial, but it is not a strategy to reduce anxiety. (D)Remaining substancefree does indicate motivation to change lifestyle of substance abuse or dependence, and it is not a stress reduction strategy in itself. NO.201 A child receiving chemotherapeutic drugs experiences a loss of appetite directly related to the therapy. Which of the following strategies should be most effective in encouraging the child to eat? A. Provide a well-balanced diet at usual times, and restrict dessert if the child fails to eat well. B. Schedule procedures immediately after eating so that the child will not be tired or in pain at mealtime. C. Offer the child a diet with a wider variety of foods and with more seasoning than her usual diet. D. Offer the child smaller meals more frequently than usual, and include as many of her favorite foods as possible. Answer: D Explanation: ( A) Because the child's appetite is capricious at best, regular servings may be overwhelming. Praise the child for what is eaten. (B) The child will soon learn that procedures follow meals and may play with food rather than eat it to avoid or delay the procedure. (C) Young children usually do not like highly seasoned foods and may need the security of usual foods. Such a change may actually increase NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 85 ( A) RhoGAM is given to Rh-negative mothers to prevent the maternal Rh immune response to fetal Rh-positive antigens. (B) If the infant is Rh positive, the mother will receive another dose postdelivery to prevent maternal sensitization. (C) Prevention of maternal sensitization will protect future pregnancies because the mother's blood will be free of antibodies against her fetus. (D) RhoGAM prevents maternal sensitization to Rh-positive blood. NO.207 A client who has gout is most likely to form which type of renal calculi? A. Struvite stones B. Staghorn calculi C. Uric acid stones D. Calcium stones Answer: C Explanation: ( A ) The presence of urinary tract infection is a factor in the formation of struvite stones. (B) Staghorn calculi is the other name for struvite stones associated with urinary tract infection. ( C ) Clients who have gout form uric acid stones. (D) Clients who have increased urinary excretion of calcium form calcium stones. NO.208 A 55-year-old man is admitted to the hospital with complaints of fatigue, jaundice, anorexia, and clay-colored stools. His admitting diagnosis is "rule out hepatitis." Laboratory studies reveal elevated liver enzymes and bilirubin. In obtaining his health history, the nurse should assess his potential for exposure to hepatitis. Which of the following represents a high-risk group for contracting this disease? A. Heterosexual males B. Oncology nurses C. American Indians D. Jehovah's Witnesses Answer: B Explanation: ( A ) Homosexual males, not heterosexual males, are at high risk for contracting hepatitis. ( B ) Oncology nurses are employed in high-risk areas and perform invasive procedures that expose them to potential sources of infection. (C) The literature does not support the idea that any ethnic groups are at higher risk. (D) There is no evidence that any religious groups are at higher risk. NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 86 NO.209 A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching concerning the warfarin therapy? A. "If you forget to take your morning dose, double the night time dose." B. "You should take aspirin instead of acetaminophen (Tylenol) for headaches." C. "Carry a medications alert card with you at all times." D. "You should use a straight-edge razor when shaving your arms and legs." Answer: C Explanation: ( A) Warfarin must always be taken exactly as directed. Clients should be instructed never to skip or double up on their dosage. (B) Aspirin decreases platelet aggregation, which would potentiate the effects of the coumadin. (C) Healthcare providers need to be aware of persons on warfarin therapy prior to the initiation of any diagnostic tests and/or surgery to help prevent bleeding complications. ( D) An electric razor should be used to prevent accidental cutting, which can lead to bleeding. NO.210 A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to: A. Be comforted when he is held B. Cry C. Not notice that his mother has left D. Withdraw and become listless Answer: B Explanation: ( A) It will be difficult to comfort a 2 year old with a headache without his mother. (B) This baby probably will cry, which should be prevented because it will increase his intracranial pressure (ICP). Asking the mother to wait until the baby is asleep may help. (C) An awake 2 year old will notice when his mother leaves. (D) An older child may withdraw when feeling afraid, but a 2 year old will probably show more aggressive behavior. NO.211 A laboring client presents with a prolapsed cord. The nurse should immediately place the client in what position? A. Reverse Trendelenburg B. Fowler's C. Trendelenburg D. Sims' Answer: C Explanation: NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 87 ( A) Reverse Trendelenburg position increases pressure on the perineum. This position will not relieve cord pressure. (B) Fowler's position increases perineal pressure. Cord pressure would not be relieved. ( C) Trendelenburg position will decrease perineal pressure. Cord compression will be decreased and increase in fetal blood flow occurs. (D) Sims' position does not relieve pressure on cord or perineum. NO.212 Parents of children receiving chemotherapy should be warned that alopecia is a side effect and that: A. Children seldom show concern about losing their hair B. The hair will come out gradually, and the loss will not be noticeable for some time C. It is best for girls to choose a wig similar to their hair style and color before the hair falls out D. The parents will soon get used to seeing their children without hair, and it will no longer bother them Answer: C Explanation: ( A) Children may become depressed with a changed appearance and not want to look at themselves or have others see them. (B) The hair will fall out in clumps, causing patchy baldness that is quite noticeable and traumatic to children and their families. (C) Having a wig that looks like a girl's own hair can be a psychological boost to children and is helpful in fostering later adjustments to hair loss. ( D) Families may become accustomed to seeing their children without hair, but the loss is traumatic to them and will continue to bother them. NO.213 A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 lb from her 7th to 8th month; her face and hands indicate edema. She is diagnosed as having PIH and referred to the high-risk prenatal clinic. The client's weight increase is most likely due to: A. Overeating and subsequent obesity B. Obesity prior to conception C. Hypertension due to kidney lesions D. Fluid retention Answer: D Explanation: ( A) Overeating can lead to obesity, but not to edema. (B) There is no indication of obesity prior to pregnancy. PIH is more prevalent in the underweight than in the obese in this age group. (C) Hypertension can be due to kidney lesions, but it would have been apparent earlier in the pregnancy. ( D) The weight gain in PIH is due to the retention of sodium ions and fluid and is one of the three cardinal symptoms of PIH. NO.214 The nurse is caring for a 3-month-old girl with meningitis. She has a positive Kernig's sign. The nurse expects her to react to discomfort if she: A. Dorsiflexes her ankle B. Flexes her spine NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 90 NO.219 The nurse is caring for a 2-year-old girl with a subdural hematoma of the temporal area as a result of falling out of bed and notices that she has a runny nose. The nurse should: A. Call the doctor immediately B. Help her to blow her nose carefully C. Test the discharge for sugar D. Turn her to her side Answer: C Explanation: ( A) The nasal discharge could be due to a cold. It is necessary to gather additional assessment data to identify a possible cerebrospinal fluid leak. (B) If the discharge is cerebrospinal fluid, it would not be safe to encourage the girl to blow her nose. (C) Cerebrospinal fluid is positive for sugar; mucus is not. ( D) Turning her to her side will have no effect on her "runny nose." It is necessary to gather further assessment data. NO.220 Which of the following menu choices would indicate that a client with pressure ulcers understands the role diet plays in restoring her albumin levels? A. Broiled fish with rice B. Bran flakes with fresh peaches C. Lasagna with garlic bread D. Cauliflower and lettuce salad Answer: A Explanation: ( A) Broiled fish and rice are both excellent sources of protein. (B) Fresh fruits are not a good source of protein. (C) Foods in the bread group are not high in protein. (D) Most vegetables are not high in protein; peas and beans are the major vegetables higher in protein. NO.221 The nurse would be sure to instruct a client on the signs and symptoms of an eye infection and hemorrhage. These signs and symptoms would include: A. Blurred vision and dizziness B. Eye pain and itching C. Feeling of eye pressure and headache D. Eye discharge and hemoptysis Answer: B Explanation: ( A) Although blurred vision may occur, dizziness would not be associated with an infection or hemorrhage. (B) Eye pain is a symptom of hemorrhage within the eye, and itching is associated with infection. (C) Nausea and headache would not be usual symptoms of eye hemorrhage or NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 91 infection. ( D) Some eye discharge might be anticipated if an infection is present; hemoptysis would not. NO.222 A client has ascites, which is caused by: A. Decreased plasma proteins B. Electrolyte imbalance C. Decreased renal function D. Portal hypertension Answer: A Explanation: ( A) A decrease in plasma proteins causes a decrease in intravascular osmotic pressure resulting in leakage of fluid into peritoneal cavity. (B) Fluid and electrolyte imbalance may occur as a result of the ascites. (C) Ascites is a result of hepatic malfunction, not renal malfunction. (D) Portal hypertension causes esophageal varices, not ascites. NO.223 A 19-year-old primigravida is admitted to the labor and delivery suite of the hospital. Her husband is accompanying her. The couple tells the nurse that this is the first hospital admission for her. The client's vaginal exam indicates she is 3 cm dilated, 80% effaced, and at _0 station. Based on the vaginal exam, she is in: A. Stage 2, latent phase B. Stage 1, active phase C. Stage 3, transition phase D. Stage 1, latent phase Answer: D Explanation: ( A) The second stage of labor is from full cervical dilation through birth of the baby. The three phases of this stage include latency or resting, descent, and final transition. The client is less than fully dilated so she is not in stage 2. (B) The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor. (C) The third stage of labor is from the birth of the baby until the delivery of the placenta. The client is less than fully dilated. (D) The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early orlatent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor. NO.224 A 48-year-old client presents with a long history of severedepression unrelieved by medication. He is admitted to the hospital for electroconvulsive therapy. Familymembers are very concerned about this therapy and are requesting information about aftereffects of the treatment. NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 92 The nurse informs the family that he will: A. Have transient memory loss, confusion, andheadache B. Be alert and oriented immediately after the treatment C. Have insomnia for the first few days D. Require no special care after the procedure Answer: A Explanation: ( A) This answer is correct. The client will be confused and have a memory loss, which is usually temporary, after electroconvulsive shock therapy. (B) This answer is incorrect. The client will experience transient memory loss, look bewildered, and be confused initially. (C) This answer is incorrect. The client will sleep immediately following the treatment. (D) This answer is incorrect. Vital signs are taken at least hourly after treatment. The client is monitored for hypotension, tachycardia, respiratory problems, and possible seizure activity. NO.225 Which of the following procedures is necessary to establish a definitive diagnosis of breast cancer? A. Diaphanography B. Mammography C. Thermography D. Breast tissue biopsy Answer: D Explanation: ( A) Diaphanography, also known as transillumination, is a painless, noninvasive imaging technique that involves shining a light source through the breast tissue to visualize the interior. It must be used in conjunction with a mammogram and physical examination. (B) Mammography is a useful tool for screening but is not considered a means of diagnosing breast cancers. (C) Thermography is a pictorial representation of heat patterns on the surface of the breast. Breast cancers appear as a "hot spot" owing to their higher metabolic rate. (D) Biopsy either by needle aspiration or by surgical incision is the primary diagnostic technique for confirming the presence of cancer cells. NO.226 Following a vaginal delivery, the postpartum nurse should observe for: A. Dystocia, kraurosis B. Chadwick's sign C. Fatigue, hemorrhoids D. Hemorrhage and infection Answer: D Explanation: NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 95 B. Increase in serum HCO3 C. Decrease in serum potassium D. Decrease in serum calcium Answer: C Explanation: ( A) Sodium polystyrene sulfonate administration will not increase serum magnesium. Hypermagnesemia is virtually unknown except for clients in renal failure. (B) Sodium polystyrene sulfonate administration is not known to increase serum bicarbonate. (C) Decrease in serum potassium, the expected response of sodium polystyrene sulfonate, is secondary to the binding of this drug and potassium in the colon, and potassium is removed through the feces. (D) Serum calcium may actually increase with sodium polystyrene sulfonate administration, especially if calcium chloride is administered concurrently with this drug. NO.233 At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her contractions are every 5 minutes and last 60 seconds, her cervix is closed, and the suture placed around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is still intact. She is very concerned about delivering prematurely. She asks the RN, "What is the greatest risk to my baby if it is born prematurely?" The RN's answer should be: A. Hyperglycemia B. Hypoglycemia C. Lack of development of the intestines D. Lack of development of the lungs Answer: D Explanation: ( A ) Any infant would be at risk for hyperglycemia because the infant's liver is missing the islets of Langerhans, which secrete insulin to break down glucose for cellular use. Prematurity is not an added risk for hyperglycemia. (B) Both premature and mature infants can be at risk for hypoglycemia if their mother had gestational diabetes during pregnancy or entered the pregnancy with diabetes mellitus. These infants are exposed to high levels of maternal glucose while in utero, which causes the islets of Langerhans in the infant's liver to produce insulin. After birth when the umbilical cord is severed, the generous amount of maternal blood glucose is eliminated; however, there is continued islet cell hyperactivity in the infant's liver, which can lead to excessive insulin levels and depleted blood glucose. ( C ) Mature infants are born with an immature GI system. The nervous control of the stomach is incomplete at birth, salivary glands are immature at birth, and the intestinal tract is sterile. This is not the greatest risk to the premature infant. (D) Infants born before 37 weeks' gestation are at greatest NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 96 risk for an insufficient amount of surfactant in the alveoli system of the lungs. Surfactant helps to prevent lung collapse and ensures stability of the respiratory system so that the infant can maintain his own respirations once the umbilical cord is severed at birth. NO.234 The nurse caring for a client who has pneumonia, which is caused by a gram-positive bacteria, inspects her sputum. Because the client's pneumonia is caused by a gram-positive bacteria, the nurse experts to find the sputum to be: A. Bright red with streaks B. Rust colored C. Green colored D. Pink-tinged and frothy Answer: B Explanation: ( A ) Bright red sputum with streaks is associated with pneumonia caused by gram-negative bacteria, such asKlebsiellapneumonia. (B) Pneumococcal pneumonia, caused by gram-positive bacteria, has a characteristic productive cough with green or rust-colored sputum. ( C ) Green-colored sputum is more characteristic ofPseudomonasthan of gram-positive bacterial pneumonia. (D) Pink-tinged and frothy sputum is more characteristic of pulmonary edema than of gram-positive bacterial pneumonia. NO.235 Primary nursing diagnoses for the antisocial client are: A. Alteration in perception and altered self-concept B. Impaired social interaction, ineffective individual coping, and altered self-concept C. Altered communication processes and altered recreational patterns D. Altered body image and altered thought processes Answer: B Explanation: ( A ) This answer is incorrect. Perception is not altered because the client is not psychotic. ( B ) This answer is correct. The antisocial client lacks responsibility, accountability, and social commitment; has impaired problem-solving ability; tends to overuse defense mechanisms; lies and steals; and is often grandiose concerning self. (C) This answer is incorrect. Altered communication processes do not characterize this client. The antisocial person communicates well and tends to have NCLEX RN EXAM LATEST 865 REAL EXAM QUESTIONS AWITH 100% CORRECT ANSWERS LATEST UPDATE 2024 97 a charming personality. (D) This answer is incorrect. Altered thought processes refer to delusional thinking, which is bizarre and fixed, and do not characterize this client. NO.236 The mother of a preschooler reports to the nurse that he frequently tells lies. The admission assessment of the child indicates possible child abuse. The nurse knows that his: A. Behavior is not normal, and a child psychiatrist should be consulted. B. Mother is lying to protect herself. C. Lying is normal behavior for a preschool child who is learning to separate fantasy from reality. D. Behavior indicates a developmental delay, because preschoolers should be able to tell right from wrong. Answer: C Explanation: ( A) Because preschoolers often tell "stories" as they learn to differentiate fantasy from reality, the child's behavior is normal. (B) The nurse has no reason to believe the child's mother is lying, because children of his age often tell lies. (C) The child's lying is actually "storytelling" as he learns to separate fantasy from reality, a normal developmental task for his age group. (D) The child's behavior is consistent with his age and does not indicate a developmental delay. NO.237 A 30-year-old client has just been treated in the ER for bruises and abrasions to her face and a broken arm from domestic violence, which has been increasing in frequency and intensity over the last few months. The nurse assesses her as being very anxious, fearful, bewildered, and feeling helpless as she states, "I don't know what to do, I'm afraid to go home." The best response by the nurse to the client would be: A. "I wouldn't want to go home either; call a friend who could help you." B. "Did you do something that could have made him so angry?" C. "Let's talk about people and resources available to you so that you don't have to go home." D. "I'll call the police and they will take care of him, and you can go home and get some rest." Answer: C Explanation: ( A) A person in crisis needs support, assistance, and direction from a caregiver rather than just an instruction. (B) A battered person may feel guilt and think that they cause the abuser's behavior; however, the abuser has the problem and goes through phases of violence. (C) The nurse should provide support and guidance to the client in crisis by offering alternatives and assist in referrals. (D) Focusing on help from law enforcement may be a very temporary solution, because the victim may be fearful of pressing charges. This answer does not address the crisis of going home. NO.238 The 4th of July holiday comes while a client is in the hospital being treated for schizophrenia. She is taking chlorpromazine and has improved to the point of being allowed to go with a group to the park for a picnic. The side effect of chlorpromazine that the nurse needs to keep in mind during this outing is: A. Hypotension