100% Reliable Microsoft NCLEX-RN Exam Dumps Test Pdf Exam Material
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Passing the NCLEX-RN exam is essential for aspiring nurses to become licensed nurses in the United States. NCLEX-RN exam is designed to ensure that nurses have the necessary knowledge and skills to provide safe and effective patient care. The NCLEX-RN exam is recognized by all U.S. state and territorial nursing boards, and passing NCLEX-RN exam is a requirement for obtaining a nursing license in any state in the U.S.
NEW QUESTION # 127
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. Conversion
- B. Delusion
- C. Hallucination
- D. Illusion
Answer: A
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.
NEW QUESTION # 128
A 12-year-old girl has been diagnosed with insulindependent diabetes mellitus. Which of these principles would best guide her nutritional management?
- A. Caloric distribution should be calculated to fit activity patterns.
- B. Fat requirements are increased owing to the possibility of ketoacidosis.
- C. Food restriction is imposed to reduce weight.
- D. Concentrated sweets are taken during increased activity.
Answer: A
Explanation:
Explanation
(A) Concentrated sweets are eliminated from diet planning. Complex carbohydrates may be taken at the time of increased activity. (B) Food restriction is not used for diabetic control of growing children. Caloric restriction may be imposed for weight control if necessary. (C) Total caloric intake and proportions of basic nutrients should be consistent from day to day. Distribution of these calories should fit the activity pattern.
Extra food is needed for increased activity. A balance of food, exercise, and insulin should be maintained. (D) Because of the increased risk of atherosclerosis, the fat percentage of the total caloric intake is reduced.
NEW QUESTION # 129
A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:
- A. Reporting any signs of crepitus immediately to the physician
- B. Avoiding manipulation of the tracheostomy including cuff deflation
- C. Changing tracheostomy dressing only as necessary using one-half strength hydrogen peroxide to cleanse the site
- D. Deflating the cuff for 10 minutes every other hour instead of 5 minutes every hour
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) The tracheal cuff should not be deflated within the first 24 hours following surgery. (B) To minimize bleeding, any manipulation, including cuff deflation, should be avoided. (C) Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician. (D) The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.
NEW QUESTION # 130
The usual treatment for diabetes insipidus is with IM or SC injection of vasopressin tannate in oil. Nursing care related to the client receiving IM vasopressin tannate would include:
- A. Hold the vial under warm water for 10-15 minutes and shake vigorously before drawing medication into the syringe.
- B. Store the medication in a refrigerator and allow to stand at room temperature for 30 minutes prior to administration.
- C. Limit fluid intake to 500 mL/day.
- D. Weigh once a week and report to the physician any weight gain of10 lb.
Answer: A
Explanation:
Section: Questions Set A
Explanation:
(A) Weight should be obtained daily. (B) Fluid is not restricted but is given according to urine output. (C) The medication does not have to be stored in a refrigerator. (D) Holding the vial under warm water for 10-15 minutes or rolling between your hands and shaking vigorously before drawing medication into the syringe activates the medication in the oil solution.
NEW QUESTION # 131
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. Check the collection bag and tubing to verify that the catheter is draining properly.
- B. Ask her if she has felt this way before.
- C. Instruct her to do Kegel exercises to diminish the urge to void.
- D. Assure her that this is most likely the result of bladder spasms.
Answer: A
Explanation:
Section: Questions Set 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 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.
NEW QUESTION # 132
A client has been diagnosed with thrombophlebitis. She asks, "What is the most likely cause of thrombophlebitis during my pregnancy?" The nurse explains:
- A. Increased levels of the coagulation factors and a decrease in fibrinolysis
- B. An inadequate production of platelets
- C. An increase in fibrinolysis and a decrease in coagulation factors
- D. An inadequate intake of folic acid during pregnancy
Answer: A
Explanation:
Explanation
(A) During pregnancy, the potential for thromboses increases owing to the increased levels of coagulation factors and a decrease in the breakdown of fibrin. (B) An inadequate production of platelets would result in thrombocytopenia with resulting signs and symptoms of bleeding such as petechiae, hematuria, or hematemesis. (C) A deficiency of folic acid during pregnancy produces a megaloblastic anemia. It is usually found in combination with iron deficiency. (D) This combination would result in bleeding disorders because more fibrin would be broken down and fewer clotting factors would be available.
NEW QUESTION # 133
The FHR pattern in a laboring client begins to show early decelerations. The nurse would best respond by:
- A. Administering O2 at 8 L/min via face mask
- B. Notifying the physician
- C. Changing the client to the left lateral position
- D. Continuing to monitor the FHR closely
Answer: D
Explanation:
Explanation
(A) Early decelerations are reassuring and do not warrant notification of the physician. (B) Because early decelerations is a reassuring pattern, it would not be necessary to change the client's position. (C) Early decelerations warrant the continuation of close FHR monitoring to distinguish them from more ominous signs.
(D) O2 is not warranted in this situation, but it is warranted in situations involving variable and/or late decelerations.
NEW QUESTION # 134
A male client is scheduled to have angiography of his left leg. The nurse needs to include which of the following when preparing the client for this procedure?
- A. Validate that he is not allergic to iodine or shellfish.
- B. Instruct him to start active range of motion of his left leg immediately following the procedure.
- C. Inform him that he will not be able to eat or drink anything for 4 hours after the procedure.
- D. Inform him that vital signs will be taken every hour for 4 hours after the procedure.
Answer: A
Explanation:
Section: Questions Set G
Explanation:
(A) Angiography, an invasive radiographic examination, involves the injection of a contrast solution (iodine) through a catheter that has been inserted into an artery. (B) The client is kept on complete bed rest for 6-12 hours after the procedure. The extremity in which the catheter was inserted must be immobilized and kept straight during this time. (C) The contrast dye, iodine, is nephrotoxic. The client must be instructed to drink a large quantity of fluids to assist the kidneys in excreting this contrast media. (D) The major complication of this procedure is hemorrhage. Vital signs are assessed every 15 minutes initially for signs of bleeding.
NEW QUESTION # 135
On admission to the postpartal unit, the nurse's assessment identifies the client's fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right. This is most likely an indication of:
- A. Normal involution
- B. A hemorrhage
- C. A full bladder
- D. An infection pain
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Immediately after expulsion of the placenta, the fundus should be in the midline and remain firm. (B) A boggy displaced uterus in the immediate postpartum period is a sign of urinary distention. Because uterine ligaments are stretched, a full bladder can displace the uterus. (C) Symptoms of infection may include unusual uterine discomfort, temperature elevation, and foul-smelling lochia. The stem of this question does not address any of these factors. (D) While excessive bleeding is associated with a soft, boggy uterus, the stem of this question includes displacement of the uterus, which is more commonly associated with bladder distention.
NEW QUESTION # 136
Which of the following nursing actions is essential to prevent drug-resistant tuberculosis?
- A. Monitor liver function.
- B. Monitor renal function.
- C. Monitor compliance with drug therapy.
- D. Assess knowledge of respiratory isolation.
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Monitoring liver function will not prevent the development of drug-resistant organisms. (B) Monitoring renal function will not prevent the development of drug-resistant organisms. (C) Knowledge of respiratory isolation will reduce transmission of tuberculosis but will not prevent development of drug-resistant organisms. (D) Noncompliance with prescribed antituberculosis drug regimen is the primary cause of drug- resistant organisms. Noncompliance permits the mutation of organisms.
NEW QUESTION # 137
A 66-year-old female client has smoked 2 packs of cigarettes per day for 20 years. Her arterial blood gases on room air are as follows: pH 7.35; PO2 70 mm Hg; PCO2 55 mm Hg; HCO3 32 mEq/L. These blood gases reflect:
- A. Compensated metabolic acidosis
- B. Compensated respiratory acidosis
- C. Uncompensated respiratory acidosis
- D. Compensated respiratory alkalosis
Answer: B
Explanation:
Section: Questions Set C
Explanation:
(A) In compensated metabolic acidosis, the pH level is normal, the PCO2 level is decreased, and the HCO3 level is decreased. The client's primary alteration is an inability to remove excess acid via the kidneys. The lungs compensate by hyperventilating and decreasing PCO2. (B) In compensated respiratory acidosis, the pH level is normal, the PCO2 level is elevated, and the HCO3 level is elevated. The client's primary alteration is an inability to remove CO2 from the lungs, so over time, the kidneys increase reabsorption of HCO3 to buffer the CO2. (C) In compensated respiratory alkalosis, the pH level is normal, the PCO2 level is decreased, and the HCO3level is decreased. The client's primary alteration is hyperventilation, which decreases PCO2. The client compensates by increasing the excretion of HCO3 from the body. (D) In uncompensated respiratory acidosis, the pH level is decreased, the PCO2 level is increased, and the HCO3 level is normal. The client's primary alteration is an inability to remove CO2 from the lungs. The kidneys have not compensated by increasing HCO3 reabsorption.
NEW QUESTION # 138
A client has received digoxin 0.25 mg po daily for 2 weeks. Which of the following digoxin levels indicates toxicity?
- A. 1.0 ng/mL
- B. 2.0 ng/mL
- C. 3.0 ng/mL
- D. 0.5 ng/mL
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) 0.5 ng/mL of digoxin is a subtherapeutic level, not a toxic one. (B) 1.0 ng/mL is a therapeutic level. (C)
2.0 ng/mL is a therapeutic level. (D) Digoxin's therapeutic level is 0.8-2.0 ng/mL. Digoxin's toxic level is
>2.0 ng/mL.
NEW QUESTION # 139
When interviewing parents who are suspected of child abuse, the nurse would use which of the following interview techniques?
- A. After the interview, call child protective services.
- B. Ask the parents what they could have done differently to prevent this from happening to the child.
- C. Approach them in the emergency room as soon as you suspect abuse to "clear the air" right away.
- D. Be direct, honest, and attentive.
Answer: D
Explanation:
(A)
The nurse must be honest, direct, professional, and attentive in her interview to gain the parent's trust. (B) The nurse should approach the parents in private, away from the child.
(C)
Asking them to relive and evaluate the situation may be looked at as placing blame on the parents for the child's "accident." At this point, the parents may get defensive and stop communicating. (D) Although you may call child protective services, the nurse should inform the parents of their responsibility to do this and explain the process to them.
NEW QUESTION # 140
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. Pulmonary edema
- C. Pulmonary emboli
- D. Pneumonia
Answer: B
Explanation:
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, weakness, and crackles. However, the pulmonary hypertension that accompanies pulmonary emboli results in signs of increased systemic venous pressure as well.
NEW QUESTION # 141
A 45-year-old client has a permanent colostomy. Which of the following foods should he avoid?
- A. Tuna on whole-wheat bread and iced tea
- B. Oatmeal, whole-wheat toast, and milk
- C. Peanut butter and jelly sandwich and milk
- D. Corn beef and cabbage and boiled potatoes
Answer: D
Explanation:
(A, C, D) These foods are allowed with a colostomy. (B) Gasforming foods such as cabbage should be avoided.
NEW QUESTION # 142
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. Pulmonary edema
- C. Pulmonary emboli
- D. Pneumonia
Answer: B
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, weakness, and crackles. However, the pulmonary hypertension that accompanies pulmonary emboli results in signs of increased systemic venous pressure as well.
NEW QUESTION # 143
For the past several months, an elderly female client with Alzheimer's disease has experienced paranoia; hallucinations; and aggressive, disruptive behavior. The family is utilizing haloperidol as needed to control her behavior. On nursing assessment, you note that the client demonstrates involuntary movements of the tongue and fingers. This may most likely indicate:
- A. A more advanced stage of Alzheimer's disease than previously experienced by the client
- B. The need to change her medication from haloperidol to another antipsychotic drug to lessen symptoms
- C. Early symptoms of Parkinson's disease
- D. Tardive dyskinesia, which may be a side effect of antipsychotic medication
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Tardive dyskinesia is a common side effect of antipsychotic medications such as haloperidol.
Discontinuing the medication can alleviate symptoms. (B) Although mild tremors are an early sign of Parkinson's disease, haloperidol must be discontinued first and the client further evaluated. (C) These symptoms do not necessarily indicate a more advanced stage of Alzheimer's disease. (D) Most antipsychotic drugs are chemically similar and will produce the same side effects.
NEW QUESTION # 144
A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will:
- A. Maintain a fluid intake of at least 2000 mL daily
- B. Wash her hands before and after voiding
- C. Limit her fluid intake after 6 PM so that there is not a great deal of urine in her bladder while she sleeps
- D. Drink at least 8 oz of cranberry juice daily
Answer: C
Explanation:
Section: Questions Set B
Explanation:
(A) Cranberry juice helps to maintain urine acidity, thereby retarding bacterial growth. (B) A generous fluid intake will help to irrigate the bladder and to prevent bacterial growth within the bladder. (C) Hand washing is an effective means of preventing pathogen transmission. (D) Restricting fluid intake would contribute to urinary stasis, which in turn would contribute to bacterial growth.
NEW QUESTION # 145
In the coronary care unit, a client has developed multifocal premature ventricular contractions. The nurse should anticipate the administration of:
- A. Lidocaine
- B. Digoxin
- C. Furosemide
- D. Nitroglycerin
Answer: A
Explanation:
Explanation
(A) Furosemide is a loop diuretic. (B) Nitroglycerin is a vasodilator. (C) Lidocaine is the drug of choice to treat ectopic ventricular beats. (D) Digoxin slows down the electrical impulses and increases ventricular contractions, but it does not rapidly correct ventricular ectopy.
NEW QUESTION # 146
Diabetes mellitus is a disorder that affects 3.1 out of every 1000 children younger than 20 years old. It is characterized by an absence of, or marked decrease in, circulating insulin. When teaching a newly diagnosed diabetes client, the nurse includes information on the functions of insulin:
- A. Catabolism and hyperglycemia
- B. Transport of glucose into body cells and storage of glycogen in the liver
- C. Glycogenolysis and facilitation of glucose use for energy
- D. Glycogenolysis and catabolism
Answer: B
Explanation:
(A) Lack of insulin causes glycogenolysis, catabolism, and hyperglycemia. (B) Insulin promotes the conversion of glucose to glycogen for storage and regulates the rate at which carbohydrates are used by cells for energy. (C) Insulin is anabolic in nature. (D) Glucose stimulates protein synthesis within the tissue and inhibits the breakdown of protein into amino acids.
NEW QUESTION # 147
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