Verified NCLEX-RN Dumps Q&As - NCLEX-RN Test Engine with Correct Answers
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NEW QUESTION 203
The most important goal in the care plan for a child who was hospitalized with an accidental overdose would be to:
- A. Instruct parents in use of ipecac
- B. Reduce mother's sense of guilt
- C. Determine child's activity pattern
- D. Teach parents appropriate safety precautions
Answer: D
Explanation:
Section: Questions Set G
Explanation
Explanation:
(A) This goal is not the most important. (B) There is always some guilt when an accident occurs; however, the priority is to be sure future accidents are prevented. (C) Ipecac is not used for caustic alkali and acid ingestions. (D) Determining the parent's knowledge about safety hazards and teaching appropriate preventive measures are likely to prevent recurrence of accidents.
NEW QUESTION 204
A 10-month-old infant's mother says that he takes fresh whole milk eagerly, but that when she offered him baby foods at 6 months of age, he pushed them out of his mouth. Because he has gained weight appropriately, she has quit trying to get him to eat other foods. The nurse's response is based on the knowledge that:
- A. Milk intake should be limited to no more than four 8-oz bottles per day and should be followed by iron-enriched cereal or other solid foods or juices
- B. He should be started on iron-enriched cereal, meat, vegetables, fruits, and juices prior to bottle feeds.Milk intake should be limited to 1 qt/day
- C. Milk is an excellent food and will meet his nutritional needs adequately until he is ready to eat solid foods
- D. It is acceptable to continue to give him whole milk and to delay giving solid foods as long as he takes a vitamin supplement daily
Answer: B
Explanation:
Explanation
(A) If the infant is given the bottle first, he will be less likely to be hungry enough to eat the solid foods. (B) Milk is deficient in iron, vitamin C, zinc, and fluoride. It does not provide an adequate diet. (C) The vitamin supplement will help, but the infant needs an iron supplement. (D) Giving the solid food when the infant is hungriest will increase the likelihood that he will eat. The more solid food he takes, the less milk he will desire.
NEW QUESTION 205
Painless vaginal bleeding in the last trimester may be caused by:
- A. Placenta previa
- B. Menstruation
- C. Polyhydramnios
- D. Abruptio placentae
Answer: A
Explanation:
(A) Menstruation should not occur during pregnancy. (B) Abruptio placentae is marked by painful vaginal bleeding following a premature placental detachment after 20th week of gestation. (C) A low-lying placenta separates from the uterine wall as the uterus contracts and cervix dilates. This separation causes painless bleeding in the 7th-8th month. (D) Polyhydramnios is excessive amniotic fluid.
NEW QUESTION 206
In assessing cardiovascular clients with progression of aortic stenosis, the nurse should be aware that there is typically:
- A. Decreased pulmonary blood flow and cyanosis
- B. Increased pressure in the pulmonary veins and pulmonary edema
- C. Increased left ventricular systolic pressures and hypertrophy
- D. Systemic venous engorgement
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) These signs are seen in pulmonic stenosis or in response to pulmonary congestion and edema and mitral stenosis. (B) These signs are seen primarily in mitral stenosis or as a late sign in aortic stenosis after left ventricular failure. (C) These signs are seen primarily in right-sided heart valve dysfunction. (D) Left ventricular hypertrophy occurs to increase muscle mass and overcome the stenosis; left ventricular pressures increase as left ventricular volume increases owing to insufficient emptying.
NEW QUESTION 207
A male client seeks counseling after his wife of 19 years threatened to divorce him. For most of their marriage, he has physically and verbally abused her. When asked about his behavior in the process of the nursing assessment, the client states, "I was mean to my wife because she insists on cooking meals and wearing clothes that I do not like." This defense mechanism is an example of:
- A. Regression
- B. Rationalization
- C. Repression
- D. Reaction formation
Answer: B
Explanation:
(A) Repression is blocking a desire from conscious expression. The client is conscious of his desires. (B) Regression is returning to an earlier form of expression, which is not demonstrated here. (C) Reaction formation is acting out the opposite of true feelings. The client felt anger concerning his wife's cooking and acted out his feelings. (D) Rationalization is unconsciously falsifying an experience by giving a "rational" explanation. The client is attempting to justify his behavior by giving an explanation.
NEW QUESTION 208
When providing dietary teaching to an individual who has diabetes mellitus, type II, the nurse discusses the importance of consuming the recommended daily allowance of which of the following electrolytes?
- A. Sodium
- B. HCO3
- C. Magnesium
- D. Potassium
Answer: C
Explanation:
Explanation
(A) Potassium intake that meets the recommended daily allowance is important, especially in clients who have a history of cardiac disease. (B) Low levels of magnesium can cause an increase in resistance to insulin and can lead to carbohydrate intolerance. (C) Sodium is an important electrolyte for all clients but has no direct effect on diabetes mellitus. (D) Bicarbonate plays an important role in acid-base balance. It is equally necessary for maintenance of all body functions.
NEW QUESTION 209
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. Separate bathroom facilities if possible; if not, then cleansing daily of the facilities with a chloride solution
- B. Isolation of the client from the remainder of the family
- C. No necessary precautions because she is beyond the contagious phase
- D. Laundering clothes separately in cold water with a chloride solution
Answer: A
Explanation:
Explanation/Reference:
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.
NEW QUESTION 210
Succinylcholine chloride (Anectine) is ordered prior to electroconvulsive therapy treatment for depressed clients. The nurse explains that the purpose of the drug is to:
- A. Act as an anesthetic
- B. Relax muscles
- C. Relieve anxiety
- D. Reduce secretions
Answer: B
Explanation:
Section: Questions Set D
Explanation:
(A) Succinylcholine chloride relaxes muscles and decreases the intensity of the seizure. (B) Succinylcholine chloride does not relieve anxiety. (C) Atropine is given to reduce secretions. (D) Thiamylal sodium (Surital) or other phenobarbital preparations are used as brief anesthetics.
NEW QUESTION 211
A 30-year-old female client is receiving antineoplastic chemotherapy. Which of the following symptoms should especially concern the nurse when caring for her?
- A. Pulse rate of 80 bpm
- B. A sore throat
- C. Complaints of muscle aches
- D. Respiratory rate of 16 breaths/min
Answer: B
Explanation:
Explanation
(A) A respiratory rate of 16 breaths/min is normal and is not a cause for alarm. (B) A pulse rate of 80 bpm is normal and is not a cause for alarm. (C) Complaints of muscle aches are unrelated to her receiving chemotherapy. There may be other causes related to her hospital stay or the disease process. (D) A sore throat is an indication of a possible infection. A client receiving chemotherapy is at risk of neutropenia. An infection in the presence of neutropenia can result in a life-threatening situation.
NEW QUESTION 212
A young child has been placed in a spica cast. The chief concern of the nurse during the first few hours is:
- A. Using heated fans to dry the cast
- B. Prevention of loss of muscle tone
- C. Prevention of neurovascular complications
- D. Immobilization of the affected limb
Answer: C
Explanation:
Explanation
(A) Because the extremity may continue to swell and the cast could constrict circulation, the nurse should elevate the limb and observe for capillary refill, warmth, mobility of toes and circulation. (B) Although muscle tone may diminish over time in the affected limb, this is not the immediate concern. (C) The limb has been immobilized already by the cast, and therefore immobilization is not a concern. (D) Heated fans and dryers are discouraged because the outside cast will dry quickly, yet the area beneath the cast remains wet and could cause burns.
NEW QUESTION 213
A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening complications may occur initially, so the nurse will monitor him closely for serum:
- A. Potassium level of 3.1 mEq/L
- B. Sodium level of 136 mEq/L
- C. Chloride level of 99 mEq/L
- D. Potassium level of 6.3 mEq/L
Answer: D
Explanation:
Section: Questions Set F
Explanation:
(A) The chloride level is within acceptable limits. (B) The sodium level is within acceptable limits. (C) This value indicates hypokalemia, rather than the hyperkalemia that occurs during diabetic ketoacidosis. (D) When diabetic ketoacidosis exists, intracellular dehydration occurs and potassium leaves the cells and enters the vascular system, thus increasing the serum level beyond an acceptable range. When insulin and fluids are administered, cell walls are repaired and potassium is transported back into the cells. Normal serum potassium levels range from 3.5-5.0 mEq/L.
NEW QUESTION 214
Which of the following should the nurse anticipate receiving as an as-needed order for a postoperative carotid endarterectomy client?
- A. Furosemide 20 mg/PO for decreased urine output
- B. Magnesium salicylate to decrease inflammation
- C. Nitroglycerin gr 1/150 for chest pain
- D. Nifedipine 10 mg SL for B/P 140/90
Answer: D
Explanation:
Explanation
(A) It is important to maintain a normal to slightly lower pressure to prevent the graft from blowing and excessive pressure to surgical vascular areas. (B, C, D) None of these drugs is related to managing the problem at hand. Also, none of the problems for which these drugs would be indicated is expected with this type of surgery, except if there is a prior history.
NEW QUESTION 215
Which type of insulin can be administered by a continuous IV drip?
- A. NPH insulin
- B. Humulin N
- C. Lente insulin
- D. Regular insulin
Answer: D
Explanation:
Explanation
(A) Humulin N cannot be administered IV. (B) NPH insulin cannot be administered IV. (C) Regular insulin is the only insulin that can be administered IV. (D) Lente insulin cannot be administered IV.
NEW QUESTION 216
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. "Did you do something that could have made him so angry?"
- B. "I'll call the police and they will take care of him, and you can go home and get some rest."
- C. "Let's talk about people and resources available to you so that you don't have to go home."
- D. "I wouldn't want to go home either; call a friend who could help you."
Answer: C
Explanation:
Explanation/Reference:
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.
NEW QUESTION 217
A 40-year-old client is admitted to the coronary care unit with chest pain and shortness of breath. The physician diagnosed an anterior wall myocardial infarction.
What tests should the nurse anticipate?
- A. Lactic dehydrogenase, CPK
- B. Sedimentation rate, WBC count
- C. Reticulocyte count, creatinine phosphokinase (CPK)
- D. Aspartate transaminase, alanine transaminase
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Reticulocyte count measures the number of immature erythrocytes. CPK is an enzyme released from injured myocardial tissue. (B) Aspartate transaminase is an enzyme released from injured myocardial tissue. Alanine transaminase is an enzyme released for general tissue destruction, which is specific for liver injury. (C) Sedimentation rate is a nonspecific test for inflammation. (D) Lactic dehydrogenase and CPK are enzymes released from injured myocardial tissue.
NEW QUESTION 218
A 4-year-old child with a history of sickle cell anemia is admitted to the nursing unit with dizziness, shortness of breath, and pallor. Nursing assessment findings reveal tenderness in the abdomen. The child is most likely experiencing a/an:
- A. Sequestration crisis
- B. Dactylitis crisis
- C. Aplastic crisis
- D. Vaso-occlusive crisis
Answer: A
Explanation:
Explanation
(A) Aplastic anemia is characterized by a lack of reticulocytes in the blood. Platelet and white blood cell counts are usually not depressed. It is usually self-limiting, lasting 5-10 days. (B) Vaso-occlusive crisis is the most common type of crisis in sickle cell anemia. Sickled cells become clogged, leading to distal tissue hypoxia and infarction. Joints and extremities are the most commonly affected areas. (C) Dactylitis crisis, or
"hand-foot syndrome," causes symmetrical infarction of the bones in the hands and feet, resulting in painful swelling in the soft tissues of the hands and feet. (D) Sequestration crisis occurs as enormous volumes of blood pool within the spleen. The spleen enlarges, causing tenderness. Signs of shock including pallor, tachypnea, and faintness result, related to the deficient intravascular volume. This type of crisis is potentially fatal.
NEW QUESTION 219
An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction?
- A. Boardlike, rigid abdomen
- B. Loss of the urge to defecate
- C. Liquid stool
- D. Abdominal pain
Answer: C
Explanation:
(A) A boardlike, rigid abdomen would point to a perforated bowel, not a fecal impaction. (B) When a client is fecally impacted, a common symptom is the urge to defecate but the inability to do so. (C) When an impaction is present, only liquid stool will be able to pass around the impacted site. (D) Abdominal pain without distention is not a sign of a fecal impaction.
NEW QUESTION 220
Following a vaginal delivery, the postpartum nurse should observe for:
- A. Dystocia, kraurosis
- B. Chadwick's sign
- C. Hemorrhage and infection
- D. Fatigue, hemorrhoids
Answer: C
Explanation:
Section: Questions Set C
Explanation:
(A) Dystocia is difficult labor. The delivery has occurred. Kraurosis is atrophy and dryness of skin and any mucous membrane (vulva). (B) Chadwick's sign is a bluish color of vaginal mucosa suggestive of pregnancy.
(C) Fatigue is a common symptom in the postpartal period. Hemorrhoids may occur with pregnancy. (D) Hemorrhage and infection are potential complications of vaginal delivery. Hemorrhage may result from retained placental fragments or soft uterus. Infection may occur from the introduction of organisms into the uterus during the delivery.
NEW QUESTION 221
A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5'4" and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:
- A. Obtain an accurate weight
- B. Search the client's purse for pills
- C. Assign her to a room with someone her own age
- D. Assess vital signs
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) On admission, vital signs are the highest priority. Weight is not a vital sign. (B) Belongings are routinely searched on admission to a psychiatric unit, but this search is not a high priority. (C) Vital signs are a high priority when working with selfdestructive clients. (D) Room assignment is of low priority.
NEW QUESTION 222
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