Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 113
Questions 1. During the admitting mental health assessment, a client demonstrates involuntary muscular activity. He has a marked facial tic around the mouth that is distracting to the nurse during the interview. The nurse recognizes the behavior and documents it as:A) DyskinesiaB) AkathisiaC) EchopraxiaD) Echolalia2. A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?A) 'I did not get the raise because my boss does not like me.'B) 'I felt a lump in my breast 2 weeks ago. I put off getting it checked until after my sister - s wedding.'C) 'My son died 3 years ago. I still cannot bring myself to clean out his room.'D) 'My husband told me this morning that he wants a divorce. I am upset, but I cannot discuss the matter with him until after my company - s board meeting today.'3. When interviewing parents who are suspected of child abuse, the nurse would use which of the following interview techniques?A) Be direct, honest, and attentive.B) Approach them in the emergency room as soon as you suspect abuse to 'clear the air' right away.C) Ask the parents what they could have done differently to prevent this from happening to the child.D) After the interview, call child protective services.4. In an interview for suspected child abuse, the childs mother openly discusses her feelings. She feels her husband is too aggressive in disciplining their child. The child - s father states, 'Being a school custodian, I see kids every day that are bad because they did not get enough discipline at home. That will not happen to our child.' Based on this remark, the nurse would make the following nursing diagnosis:A) Fear related to retaliation by the fatherB) Actual injury related to poor impulse control by the fatherC) Ineffective copingD) Altered family process related to physical abuse5. As a nurse in the emergency room, you receive an outside call from an elderly woman who states she has just been raped. She states, 'I know I must come to the hospital, but what do I do next?' You advise her to call the police, then come to the hospital emergency room. What action by the nurse would indicate an understanding of the examination process once the victim enters the emergency room?A) Inform the victim not to wash, change clothes, douche, brush teeth, or eat or drink anything.B) Inform the victim to bring insurance information with her to the hospital so she can be properly cared for.C) Phone a rape counselor to begin working with the victim as soon as she enters the hospital.D) Do not leave the victim alone to collect her thoughts. Right Answer and Explanation: 1. Right Answer: AExplanation: (A) The client is demonstrating dyskinesia, which is involuntary muscular activity, such as tic, spasm, or myoclonus. (B) Akathisia is regular rhythmic movements usually of the lower limbs, such as constant motor restlessness. (C) Echopraxia is mimicking the movements of another person. (D) Echolalia is mimicking the speech of another person.2. Right Answer: DExplanation: (A) This statement is an example of adaptive rationalization. She is coping with her disappointment by rationalizing. This is adaptive because no harm is done to self or others. It is used to protect her ego. (B) This is an example of maladaptive suppression. She is suppressing the seriousness of the lump. It is maladaptive because delaying treatment will cause harm to her. (C) The clients actions are an example of maladaptive denial. She is denying her sons death by not facing his possessions. Until she faces his death, she cannot face reality. (D) This is an example of adaptive suppression. She realizes the impact of her husbands statement but delays discussion until she can devote her full attention to the matter.3. Right Answer: AExplanation: (A) The nurse must be honest, direct, professional, and attentive in her interview to gain the parents 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.4. Right Answer: DExplanation: (A) There is no evidence of fear as the child is unable to communicate. (B) There is actual injury, but the parents have not yet admitted causing the childs injuries.(C) This diagnosis is incomplete. There is no specific ineffective coping behavior identified in this nursing diagnosis. (D) Altered family process best describes the family dynamics in this situation. The parents have admitted severe disciplinary action.5. Right Answer: AExplanation: (A) Providing the victim with these instructions will aid in the determination of physical evidence of rape. Victims frequently feel 'dirty' after rape, and their first instinct is to take care of personal hygiene before facing anyone. (B) This action is of lesser importance at this time. (C) Although this is a nursing measure appropriate in this situation, contacting a counselor can be done once the victim enters the hospital. Frequently victims call but do not follow up with the visit. (D)Once the victim enters the emergency room, it is important not to leave her alone. .col-md-12 { -webkit-user-select: none; -ms-user-select: none; user-select: none; } .flash-sale-container{background:#134981;text-align:center;padding:2%;} p.flash-sale-text{ font-size:24px;font-family:"Poppins";letter-spacing:2px;line-height:1.4em; } span.flash-break{ display:block; } .flash-sale-text { -webkit-animation-name:flash; animation: blink 1.5s infinite; } @keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } @-webkit-keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } 80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
More detailsPublished - Thu, 23 Feb 2023
Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 114
Questions 1. 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) DissociationB) IntellectualizationC) RationalizationD) Displacement2. 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.3. 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.4. A female client has been recently diagnosed as bipolar. She has taken lithium for the past several weeks to control mania. What must be included in client education regarding lithium toxicity?A) Maintain a normal diet; however, limit salt intake to no more than 3 g/day.B) Take lithium between meals to increase absorption.C) Withhold lithium if experiencing diarrhea, vomiting, or diaphoresis.D) For pain or fever, avoid aspirin or acetaminophen (Tylenol). Nonsteroidal anti-inflammatory drugs are preferred.5. For the past several months, an elderly female client with Alzheimers 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) Tardive dyskinesia, which may be a side effect of antipsychotic medicationB) Early symptoms of Parkinson - s diseaseC) A more advanced stage of Alzheimer - s disease than previously experienced by the clientD) The need to change her medication from haloperidol to another antipsychotic drug to lessen symptoms Right Answer and Explanation: 1. Right Answer: BExplanation: (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.2. Right Answer: CExplanation: (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.3. Right Answer: AExplanation: (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.4. Right Answer: CExplanation: (A) The client should maintain a normal diet including normal salt intake. A low-sodium diet can cause lithium retention, leading to toxicity. (B) Lithium must be taken with meals because it is irritating to the gastric mucosa. (C) Diarrhea, vomiting, or diaphoresis can cause dehydration, which will increase lithium blood levels. If these symptoms occur, the nurse should instruct the client to withhold lithium. (D) Lithium is not to be taken with over-the-counter drugs without specific instruction. Some drugs raise lithium levels, whereas others lower lithium levels.5. Right Answer: AExplanation: (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 Parkinsons disease, haloperidol must be discontinued first and the client further evaluated. (C) These symptoms do not necessarily indicate a more advanced stage of Alzheimers disease. (D) Most antipsychotic drugs are chemically similar and will produce the same side effects. .col-md-12 { -webkit-user-select: none; -ms-user-select: none; user-select: none; } .flash-sale-container{background:#134981;text-align:center;padding:2%;} p.flash-sale-text{ font-size:24px;font-family:"Poppins";letter-spacing:2px;line-height:1.4em; } span.flash-break{ display:block; } .flash-sale-text { -webkit-animation-name:flash; animation: blink 1.5s infinite; } @keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } @-webkit-keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } 80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
More detailsPublished - Thu, 23 Feb 2023
Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 115
Questions 1. A 32-year-old male client is a marketing representative. His job requires him to have a tremendous amount of energy during the day. He frequently uses cocaine to sustain his energy level. Lately he has increased his use of cocaine and even experimented with crack cocaine. Realizing he can no longer continue this destructive behavior, he is seeking treatment for cocaine addiction. In planning nursing care for the clients inpatient stay, which expected outcome is most appropriate?A) He will attend four consecutive group educational sessions on substance abuse.B) He will name activities that he would most likely be involved in posttreatment.C) He will meet with his family in counseling sessions and discuss his feelings.D) He will be able to deal with his feelings through participation in group therapy sessions.2. A client has been instructed in how to take her nitroglycerin tablets. The nurse giving her instructions knows the client understands the information when she tells her:A) 'I should contact my physician if I have headaches after I take this medicine.'B) 'I should keep the tablets in the refrigerator.'C) 'I should call the doctor if three doses of the medicine do not relieve my pain.'D) 'I should take these with water but not with milk.'3. A client has renal failure. Today - s lab values indicate he has an elevated serum potassium. What additional priority information does the nurse need to obtain?A) Evaluation of his level of consciousnessB) Evaluation of an electrocardiogramC) Measurement of his urine output for the past 8 hoursD) Serum potassium lab values for the last several days4. A clients wife is concerned over his behavior in recent months. He has been diagnosed with Parkinsons disease, and she is telling his nurse that he has been doing 'strange things.' The nurse reassures the wife that the following behavior is normal with Parkinson - s disease:A) 'Your husband will experience some periods of muscle flaccidity. Be sure to make him sit down during these periods.'B) 'Your husband may move his hands in motions that look like he is rolling a pill between his fingers.'C) 'Twitching of the muscles is to be expected and can occur at any time during the day.'D) 'Parkinson - s disease causes severe pain in the joints. You should give your husband Tylenol at those times.'5. A male client tells his nurse that he has had an ulcer in the past and is afraid it is 'flaring up again.' The nurse begins to ask him specific questions about his symptoms. The nurse knows that a symptom that might indicate a serious complication of an ulcer is:A) Pain in the middle of the nightB) A bowel movement every 3 - 5 daysC) MelenaD) Episodes of nausea and vomiting Right Answer and Explanation: 1. Right Answer: DExplanation: (A) This expected outcome is specific as related to attendance, but not specific as related to outcome criteria. (B) Stating activities does not guarantee involvement. (C) This goal may help the recovery process, but postcounseling behavior is not addressed. (D) This statement best describes the expected outcome. The client will be attending group therapy sessions and through them he will deal with his feelings.2. Right Answer: CExplanation: (A) Headaches may occur after taking nitroglycerin because of vasodilation. (B) The tablets do not need to be refrigerated. The client should carry them with her.(C) The client should contact the physician if repeated doses of nitroglycerin do not relieve the discomfort. (D) Nitroglycerin tablets should be dissolved under the tongue, not swallowed.3. Right Answer: BExplanation: (A) The level of consciousness is not affected by elevated potassium levels. (B) An electrocardiogram (EKG) can tell the nurse whether this client is experiencing any cardiac dysfunction or arrhythmias related to the elevated potassium level. (C) Measurement of the urine output is not a priority nursing action at this time. (D)The clients serum potassium values for the past several days may provide information about his renal function, but they are not a priority at this time.4. Right Answer: BExplanation: (A) Clients with Parkinsons disease generally experience stiffness and rigid movement. (B) Pill-rolling movements are a symptom experienced by the Parkinson client. (C) Twitching of the muscles is not an expected symptom of Parkinsons disease. (D) Parkinsons disease does not cause joint pain. Mild muscular pain may be present.5. Right Answer: CExplanation: (A) Clients with ulcers generally experience abdominal pain. It is common to have pain in the early morning hours with an ulcer. (B) Constipation is not a symptom associated with ulcers and would indicate a need to look at other factors. (C) Melena is blood in the stools. This could indicate a slow bleeding ulcer, which could result in significant amounts of blood loss over time.(D) Nausea and vomiting may be present as a result of the ulcer, especially if it is a gastric ulcer. This does not indicate an immediate life-threatening complication. .col-md-12 { -webkit-user-select: none; -ms-user-select: none; user-select: none; } .flash-sale-container{background:#134981;text-align:center;padding:2%;} p.flash-sale-text{ font-size:24px;font-family:"Poppins";letter-spacing:2px;line-height:1.4em; } span.flash-break{ display:block; } .flash-sale-text { -webkit-animation-name:flash; animation: blink 1.5s infinite; } @keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } @-webkit-keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } 80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
More detailsPublished - Thu, 23 Feb 2023
Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 116
Questions 1. 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.2. 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.'3. A 50-year-old male client is to receive chemotherapy. The physicians orders include antiemetics. When planning his care, the nurse should take into consideration that antiemetics are best administered in the following way:A) Give antiemetics when nausea is experienced and continue on a regular schedule for 12 - 24 hours.B) Give antiemetics prior to the client receiving chemotherapy and continue on a regular basis for at least24 - 48 hours after chemotherapy.C) Give antiemetics one at a time because combinations of antiemetics cause overwhelming side effects.D) Give antiemetics intermittently during the entire course of chemotherapy.4. 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) Respiratory rate of 16 breaths/minB) Pulse rate of 80 bpmC) Complaints of muscle achesD) A sore throat5. Seven days ago, a 45-year-old female client had an ileostomy. She is self-sufficient and well otherwise. Which of the following long-term objectives would be unrealistic?A) She should be able to control evacuation of her bowels.B) She should be able to return to a regular diet.C) She should be able to resume sexual activity.D) She should be able to manage her own care. Right Answer and Explanation: 1. Right Answer: AExplanation: (A) Clients with respiratory diseases are generally mouth breathers. Cleaning the oral cavity may improve the clients 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 clients ability to eat. (D) Clients with respiratory diseases need increased fluid to liquefy secretions.2. Right Answer: CExplanation: (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.3. Right Answer: BExplanation: (A) Nausea is more difficult to control if antiemetics are withheld until nausea is experienced. (B) Antiemetics should be given prophylactically at the beginning of chemotherapy and continued on an around-the-clock basis to prevent nausea. (C) Combinations of antiemetics give the best control for nausea by blocking various causes of nausea induced by chemotherapy. (D) Antiemetics should be given around the clock during the course of chemotherapy. This prevents nausea from developing and prevents anticipatory nausea during subsequent chemotherapy administrations.4. Right Answer: DExplanation: (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.5. Right Answer: AExplanation: (A) Because of the location of an ileostomy, the client will not be able to control the evacuation of her bowels. The ileostomy will drain liquid stool continuously. (B)The client should be able to return to a normal, well-balanced diet. She should avoid foods that cause diarrhea or excessive gas production, and she should eat small meals. (C) The client should be able to resume sexual activity. She will be able to wear a pouch. (D) The client has no other health or mental problems and should be able to manage her own ileostomy. .col-md-12 { -webkit-user-select: none; -ms-user-select: none; user-select: none; } .flash-sale-container{background:#134981;text-align:center;padding:2%;} p.flash-sale-text{ font-size:24px;font-family:"Poppins";letter-spacing:2px;line-height:1.4em; } span.flash-break{ display:block; } .flash-sale-text { -webkit-animation-name:flash; animation: blink 1.5s infinite; } @keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } @-webkit-keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } 80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
More detailsPublished - Thu, 23 Feb 2023
Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 117
Questions 1. A 26-year-old client has no children. She has had an abdominal hysterectomy. In the first 24 hours postoperatively, the nurse would be concerned if the client:A) Cries easily and says she is having abdominal painB) Develops a temperature of 102_FC) Has no bowel soundsD) Has a urine output of 200 mL for 4 hours2. 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.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.3. A male client is being treated in the burn unit for thirddegree burns on his head, neck, and upper chest received in the last 24 hours. The nurse is evaluating the effectiveness of fluid resuscitation. Which of the following indicates effective fluid balance?A) His weight increases from 165 to 175 lb.B) His urine output is equal to his total fluid intake.C) His urine output has been>35 mL/hr for the past 12 hours.D) His blood pressure is 94/62.4. A 24-year-old male client is admitted with a diagnosis of sickle cell anemia. The nurse discusses his disease with him and emphasizes the following information:A) He should monitor his sputum, stools, and urine for signs of bleeding.B) His daily diet should include a large amount of fluid.C) He should not be concerned about having to fly on a commuter airplane on a weekly basis.D) He should not worry about having children because this disease is passed on only by female carriers.5. A female client has been diagnosed with chronic renal failure. She is a candidate for either peritoneal dialysis or hemodialysis and must make a choice between the two. Which information should the nurse give her to help her decide?A) Hemodialysis involves less time to filter the blood; but the client must consider travel time, distance, and inconvenience.B) Hemodialysis involves more time to filter the blood than does peritoneal dialysis.C) Peritoneal dialysis has almost no complications and is less time consuming than hemodialysis. Therefore it is preferred.D) Peritoneal dialysis requires that a home health nurse prepare and administer the treatments. Right Answer and Explanation: 1. Right Answer: BExplanation: (A) The client may be more tearful than normal due to the stress of the surgery and its implications for her future life. She would be expected to have pain following surgery. (B) A temperature of 102_F indicates an infectious process. This is not a normal sequence to surgery and indicates a need for further assessment. (C)The client is expected to have no bowel soundsfor 2448 hours after surgery because of the trauma to the bowel. (D) Normal urine output is 30 mL/hr. This represents an output of 50 mL/hr, which is greater than normal.2. Right Answer: DExplanation: (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 loose-fitting 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.3. Right Answer: CExplanation: (A) A weight gain of 10 lb represents a state of overhydration. (B) He is losing fluids through insensible losses; a urine output equal to his intake indicates that he is receiving too little fluids. (C) A urine output greater than his intake indicates that he is receiving adequate fluid resuscitation to account for urinary and insensible losses. (D) A blood pressure of 94/62 indicates a state of underhydration and inadequate circulatory volume.4. Right Answer: BExplanation: (A) Bleeding is not a symptom of sickle cell anemia or sickle cell crisis. (B) Decreased blood viscosity leads to sickling of red blood cells. Increased fluid intake maintains adequate circulating blood volume and decreases the chance of sickling. (C) Hypoxia leads to sickling of cells. Flying in nonpressurized planes places the client in a situation of low O2 tension, which can lead to sickling. (D) Male and female clients with sickle cell disease can pass the trait on to their offspring.Therefore, this client should receive genetic counseling prior to having children.5. Right Answer: AExplanation: (A) Hemodialysis is faster in clearing the blood of toxins than peritoneal dialysis. However, clients must consider the time that they spend traveling to the dialysis center and the disruption in their daily lives. (B) Peritoneal dialysis requires several exchanges with dwelling time for the dialysate and therefore takes longer than hemodialysis. (C) Several serious complications of peritoneal dialysis include peritonitis, catheter displacement and/or plugging, or pain during dialysis. (D) A client can be taught to self-administer peritoneal dialysis without the aid of a professional. .col-md-12 { -webkit-user-select: none; -ms-user-select: none; user-select: none; } .flash-sale-container{background:#134981;text-align:center;padding:2%;} p.flash-sale-text{ font-size:24px;font-family:"Poppins";letter-spacing:2px;line-height:1.4em; } span.flash-break{ display:block; } .flash-sale-text { -webkit-animation-name:flash; animation: blink 1.5s infinite; } @keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } @-webkit-keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } 80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
More detailsPublished - Thu, 23 Feb 2023
Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 118
Questions 1. A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must:A) Assess the site for leakage of blood or fluidsB) Auscultate the site for a bruitC) Assess the site for bruising or hematomaD) Inspect the site for color, warmth, and sensation2. A client is receiving peritoneal dialysis. He has been taught to warm the dialyzing fluid prior to instilling it because:A) Warmed solution helps keep the body temperature maintained within a normal range during instillationB) Warmed solution helps dilate the peritoneal blood vesselsC) Warmed solution decreases the risk of peritoneal infectionD) Warmed solution promotes a relaxed abdominal muscle3. A female client is exhibiting signs of respiratory distress. Which of the following signs indicate a possible pneumothorax?A) Crackles or rales on the affected sideB) Bradypnea and bradycardiaC) Shortness of breath and sharp pain on the affected sideD) Increased breath sounds on the affected side4. A female client has a chest tube placed. It is accidentally pulled out of the intrapleural space when she is ambulating. The first action the nurse should take is to:A) Instruct the client to cough deeply to re-expand her lungB) Put on sterile gloves and replace the tubeC) Apply a petrolatum dressing over the siteD) Auscultate the lung to determine if she needs the tube replaced5. A male client has heart failure. He has been instructed to gradually increase his activities. Which signs and symptoms of worsening heart failure should the nurse tell him to watch for that would indicate a need for him to lower his activity level?A) Pain in his legs when he walksB) Thirst, weight loss, and polyuriaC) Drowsiness and lethargy after his activitiesD) Weight gain, edema in his lower extremities, and shortness of breath Right Answer and Explanation: 1. Right Answer: BExplanation: (A) This is an internal device. Assessment of the site should include assessing for swelling, pain, warmth, and discoloration. This measure does not assess patency. (B) The presence of a bruit indicates good blood flow through the device. (C) The nurse should inspect the site for bruising or hematoma; however, this measure does not assure patency of the device. (D) The nurse should inspect the vascular access site frequently for signs of infection. However, this does not assure patency.2. Right Answer: BExplanation: (A) Instilling a cool solution does not significantly lower the body temperature during peritoneal dialysis. (B) Warmed solution does help dilate the peritoneal blood vessels, facilitating the exchange of fluids. (C) Warming the dialysate does not decrease the risk of peritoneal infection. Sterile technique decreases this risk. (D)Relaxing the abdominal muscles does not facilitate peritoneal dialysis.3. Right Answer: CExplanation: (A) With a pneumothorax, air occupies the pleural space. Crackles or rales are heard with increased fluid or secretions and would not be present with air in the space. (B) With a pneumothorax, the client would experience tachypnea and tachycardia to compensate for the decrease in oxygenation. (C) Symptoms of pneumothorax include shortness of breath, sharp pain on the affected side with movement or coughing, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. (D) With a pneumothorax, breath sounds would be decreased on the affected side (indicates air in the pleural space).4. Right Answer: CExplanation: (A) This action is inappropriate. Coughing will not re-expand the lung and could result in further harm. (B) This action is a medical procedure, not a nursing procedure. (C) An occlusive dressing will prevent further air leak until the physician institutes further treatment. (D) The decision to reinsert the tube is a medical decision, not a nursing one.5. Right Answer: DExplanation: (A) Pain in the legs could be indicative of doing too much too quickly, but not of worsening heart failure. The client should be cautioned to increase his activities slowly. (B) Thirst, weight loss, and frequent urination are not indicative of heart failure. The client should report these symptoms to his physician. (C) Drowsiness and lethargy are not indicative of worsening heart failure. The client should report these symptoms to his physician. (D) All of these symptoms indicate a worsening cardiac condition possibly associated with too much activity. The clients activity level should be evaluated. .col-md-12 { -webkit-user-select: none; -ms-user-select: none; user-select: none; } .flash-sale-container{background:#134981;text-align:center;padding:2%;} p.flash-sale-text{ font-size:24px;font-family:"Poppins";letter-spacing:2px;line-height:1.4em; } span.flash-break{ display:block; } .flash-sale-text { -webkit-animation-name:flash; animation: blink 1.5s infinite; } @keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } @-webkit-keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } 80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
More detailsPublished - Thu, 23 Feb 2023
Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 119
Questions 1. A male client is undergoing cardiac tests. He has been instructed to wear a Holter monitor. The nurse knows she has included the appropriate information in her teaching when the client tells her:A) 'He should remove the electrodes for bathing.'B) 'Damage to his heart muscle will be recorded by the monitor.'C) 'He is to keep a record of everything he does during the day.'D) 'He is to refrain from activities that cause chest pain.'2. To prevent thrombophlebitis in a client on complete bed rest, the nursing care plan should include:A) Dangle the client - s legs over the edge of the bed every shift.B) Massage the client - s calves briskly every shift.C) Keep the client - s legs extended and discourage any movement.D) Have the client tighten and relax leg muscles several times daily.3. A 78-year-old female client has a total hip arthroplasty. Her nurse should know that which of the following is contraindicated?A) Encourage exercises in the unaffected extremities.B) Encourage her to cross and uncross her legs.C) Check neurological and circulatory status of the affected leg hourly.D) Place a trochanter roll along the upper thigh of the affected leg.4. A male client has a history of diverticulosis. He has questions about the foods that he should eat. His nurse gives him the following information:A) He should be on a high-fiber diet.B) He should eat a low-residue diet.C) He should drink minimal amounts of fluids.D) He does not need to make any modifications.5. A term neonate has experienced no distress at birth and has an Apgar score of 9. Her mother has asked to breastfeed her following delivery. Immediately after birth, the neonate was most susceptible to heat loss. The most appropriate intervention to conserve heat loss and promote bonding is to:A) Place her under the radiant warmerB) Dry her with blanketsC) Place her to her mother - s breastD) Place her on a heated pad Right Answer and Explanation: 1. Right Answer: CExplanation: (A) The client should leave the electrodes in place during the entire time the test is ordered. He should not even remove the electrodes for bathing. (B) The Holter monitor will record cardiac electrical activity but will not record damage to his myocardium. (C) The client should keep a record of all of his activities so the physician can correlate the ECG findings with his activities. (D) The client should continue doing his regular activities. The purpose of the Holter monitor is to record heart activity during routine activities.2. Right Answer: DExplanation: (A) Dangling the clients legs over the edge of the bed will contribute to stasis and pooling of blood and increases the risk of thrombus formation. (B) Massaging the clients calves could result in dislodging an embolus. (C) Decreased movement will contribute to pooling of blood and increased risk of venous thrombosis. (D)Tightening and relaxing leg muscles increases circulation and decreases the risk of venous thrombosis.3. Right Answer: BExplanation: (A) Exercising the unaffected extremities will prevent contractures and emboli. (B) Crossing and uncrossing the affected leg after surgery can dislocate the joint.(C) Neurological and circulatory status of the affected leg has been compromised by surgery. Hourly checks are needed to monitor the status of the leg. (D) A trochanter roll will prevent the upper thigh from rolling outward, increasing the chances of dislocation.4. Right Answer: AExplanation: (A) Clients with diverticulosis should maintain a high-fiber diet and prevent constipation with bran or bulk laxatives. (B) Lowresidue diets lead to constipation and are contraindicated in clients with diverticulosis. (C) Clients with diverticulosis should drink at least eight glasses of water each day to prevent constipation. (D)Clients with diverticulosis should modify their diet to include high-fiber foods and bulk laxatives.5. Right Answer: CExplanation: (A) A radiant warmer maintains an optimal thermal environment by use of a thermal skin sensor taped to the infant. The warmer limits parental attachment, so, although appropriate, it is not an intervention that promotes infant attachment. (B) Warmed blankets prevent heat loss in the neonate by conduction. In addition, tactile stimuli promote crying and lung expansion. This intervention does not promote attachment, however. (C) Skin-to-skin contact is an effective way to conserve heat after delivery and promotes parental attachment following birth in the healthy term infant. The first period of reactivity lasts approximately 30 minutes following birth. A strong sucking reflex and an active, awake newborn characterize this period. (D) Surfaces of objects warmer than the infant promote overheating by conduction, and neonatal hyperthermia may result. .col-md-12 { -webkit-user-select: none; -ms-user-select: none; user-select: none; } .flash-sale-container{background:#134981;text-align:center;padding:2%;} p.flash-sale-text{ font-size:24px;font-family:"Poppins";letter-spacing:2px;line-height:1.4em; } span.flash-break{ display:block; } .flash-sale-text { -webkit-animation-name:flash; animation: blink 1.5s infinite; } @keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } @-webkit-keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } 80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
More detailsPublished - Thu, 23 Feb 2023
Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 120
Questions 1. A client who is gravida 1 para 1 vaginally delivered a 7- lb girl. She received a midline episiotomy at delivery. When assessing the level of her uterus immediately following delivery, the nurse would expect the fundus to be located:A) At the umbilicusB) At the symphysis pubisC) Midway between the umbilicus and the xiphoid processD) Midway between the umbilicus and the symphysis pubis2. 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 clients 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 phaseB) Stage 1, active phaseC) Stage 3, transition phaseD) Stage 1, latent phase3. A client is pregnant for the fourth time and has had three normal vaginal deliveries. She is in active labor and fully dilated. Suddenly she calls, 'Nurse, the baby is coming.' As the nurse responds to her call, which one of the following observations should the nurse make first?A) Inspect the perineum.B) Time the contractions.C) Prepare a sterile area for delivery.D) Auscultate for fetal heart rate (FHR).4. A client has just received an epidural block. She is laboring on her right side. The nurse notes that her blood pressure has dropped from 132/68 to 78/42 mm Hg.The nurses first action would be to:A) Call the physician immediately and give dopamine IMB) Turn her on her left side and recheck her blood pressure in 5 minutesC) Administer oxytocin (Pitocin) immediately and increase the rate of IV fluidsD) Increase the rate of IV fluids and start O2 by mask5. A 28-year-old client comes to the clinic for her first prenatal examination. In relating her obstetrical history, she tells the nurse that she has been pregnant twice before. She had a 'miscarriage' with the first pregnancy after 6 weeks. With the second pregnancy, she delivered twin girls at 31 weeks - gestation. One of the twins was stillborn and the other twin died at 4 days of age. Using a five-digit system, the nurse records her as being:A) 2-0-2-1-0B) 2-2-2-1-2C) 3-0-1-1-0D) 2-1-1-0-0 Right Answer and Explanation: 1. Right Answer: DExplanation: (A) Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. (B) The uterus descends into the pelvic cavity at approximately 1012 postpartal days and can no longer be palpated abdominally. (C) Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. An enlarged uterus may indicate subinvolution or postpartal hemorrhage. (D) Immediately following delivery, the uterus lies midline, about midway between the umbilicus and the symphysis pubis.2. Right Answer: DExplanation: (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 (03 cm), the active phase (47 cm), and the transitional phase (710 cm). The client is
More detailsPublished - Thu, 23 Feb 2023
Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 121
Questions 1. 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 wasFebruary 16, with 3 days of spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to be:A) November 23rdB) December 26thC) September 14thD) December 9th2. 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 minutesB) Allow the infant to breast-feed at the next feeding time to empty the breastsC) Apply ice packs to the breasts and wear a supportive, well-fitting braD) Take a warm shower and express milk from both breasts until empty3. A registered nurse is trying to determine the appropriate care that she should provide for her obstetrical clients. Which of the following documents is considered the legal standard of practice?A) State nursing practice actB) AWHONN Standards for the Nursing Care of Women and NewbornsC) American Nurses - Association Standards of Maternal- Child Health NursingD) International Council of Nurses - Code4. A female client admitted to the labor and delivery unit thinks her bag of water 'broke' approximately 2 hours ago. She is having mild contractions 5 minutes apart.The most immediate nursing intervention would be to:A) Note the color and amount of fluid on her clothes.B) Assess the FHR.C) Notify the physician.D) Place the nitrazine test paper at the cervical os and note the color change.5. A new mother experiences strong uterine contractions while breast-feeding her baby. She excitedly rings for the nurse. When the nurse arrives the mother tells her, 'Something is wrong. This is like my labor.' Which reply by the nurse identifies the physiological response of the client?A) 'Your breasts are secreting a hormone that enters your bloodstream and causes your abdominal muscles to contract.'B) 'Prolactin increases the blood supply to your uterus, and you are feeling the effects of this blood vessel engorgement.'C) 'The same hormone that is released in response to the baby - s sucking, causing milk to flow, also causes the uterus to contract.'D) 'There is probably a small blood clot or placental fragment in your uterus, and your uterus is contracting to expel it.' Right Answer and Explanation: 1. Right Answer: AExplanation: (A) Naeles rule is as follows: add 7 days to the 1st day of the last menstrual period, subtract 3 months, and then add 1 year. (B) Naeles rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naeles rule. (C) Naeles rule presumes that the woman has a 28-day menstrual cycle, with conception occurringon the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naeles rule. (D) Naeles rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14thday of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naeles rule.2. Right Answer: CExplanation: (A) Judicious use of analgesics is appropriate with breast engorgement; however, mechanical suppression would be the initial recommendation. (B) Breast- feeding every 1123 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 Coopers ligament. In addition, breast binders or ace bandages may be used for some women. (D) Warmth promotes milk production and may stimulate the let-down reflex. These measures would contribute to the venous congestion of engorgement.3. Right Answer: AExplanation: (A) The state nursing practice act determines the standard of care for the professional nurse. (B) AWHONN Standards are published as recommendations and guidelines for maternal-newborn nursing. (C) American Nurses Association Standards are published as recommendations and guidelines for maternalchild health nursing. (D) The International Council of Nurses Code emphasizes the nurses obligations to the client rather than to the physician. It is published as recommendations and guidelines by the international organization for professional nursing.4. Right Answer: BExplanation: (A) Amniotic fluid is generally pale and straw colored. Meconium- stained amniotic fluid would indicate a previous hypoxic episode. This intervention, though appropriate, is not the immediate priority. (B) With rupture of the membranes, the umbilical cord may prolapse if the presenting part does not fill the pelvis.Assessing FHR ascertains fetal well-being. (C) More information regarding fetal status and assessing for membrane rupture is needed prior to contacting the physician. (D) Nitrazine test paper differentiates amniotic fluid from urine. Amniotic fluid is normally alkaline in contrast to urine, which is acidic. This intervention, though appropriate, is not the immediate priority.5. Right Answer: CExplanation: (A) Mammary growth as well as milk production and maintenance in the breast occur in response to hormones produced primarily by the hypothalamus and the pituitary gland. (B) Prolactin stimulates the alveolar cells of the breast to produce milk. It is important in the initiation of breast-feeding. (C) Oxytocin, which is released by the posterior pituitary, stimulates the let-down reflex by contraction of the myoepithelial cells surrounding the alveoli. In addition, it causes contractions of the uterus and uterine involution. (D) Afterpains may occur with retained placental fragments. A boggy uterus and continued bleeding are other symptoms that occur in response to retained placental fragments. .col-md-12 { -webkit-user-select: none; -ms-user-select: none; user-select: none; } .flash-sale-container{background:#134981;text-align:center;padding:2%;} p.flash-sale-text{ font-size:24px;font-family:"Poppins";letter-spacing:2px;line-height:1.4em; } span.flash-break{ display:block; } .flash-sale-text { -webkit-animation-name:flash; animation: blink 1.5s infinite; } @keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } @-webkit-keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } 80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
More detailsPublished - Thu, 23 Feb 2023
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