Pass Your NCLEX Exam with NCLEX-RN Exam Dumps (Updated 865 Questions)
NCLEX-RN Exam Dumps - NCLEX Practice Test Questions
NEW QUESTION 32
The nurse instructs a client on the difference between true labor and false labor. The nurse explains, "In true labor:
- A. Uterine contractions will weaken with walking."
- B. Uterine contractions will strengthen with walking."
- C. The cervix does not dilate."
- D. The fetus does not descend."
Answer: B
Explanation:
Section: Questions Set C
Explanation:
(A) Uterine contractions increase with activity. (B) Walking will increase the strength and regularity of uterine contractions in true labor. (C) Uterine contractions that are strong and regular facilitate cervical dilation. (D) Regular, strong uterine contractions, as in true labor, result in fetal descent.
NEW QUESTION 33
The following medications were noted on review of the client's home medication profile. Which of the medications would most likely potentiate or elevate serum digoxin levels?
- A. Quinidine
- B. Theophylline
- C. KCl
- D. Thyroid agents
Answer: A
Explanation:
Section: Questions Set A
Explanation:
(A) Hypokalemia can cause digoxin toxicity. Administration of KCl would prevent this. (B) Thyroid agents decrease digoxin levels. (C) Quinidine increases digoxin levels dramatically. (D) Theophylline is not noted to have an effect on digoxin levels.
NEW QUESTION 34
A schizophrenic client has made sexual overtures toward her physician on numerous occasions. During lunch, the client tells the nurse, "My doctor is in love with me and wants to marry me." This client is using which of the following defense mechanisms?
- A. Displacement
- B. Suppression
- C. Projection
- D. Reaction formation
Answer: C
Explanation:
Explanation
(A) Displacement involves transferring feelings to a more acceptable object. (B) Projection involves attributing one's thoughts or feelings to another person. (C) Reaction formation involves transforming an unacceptable impulse into the opposite behavior. (D) Suppression involves the intentional exclusion of unpleasant thoughts or experiences.
NEW QUESTION 35
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. Melena
- B. A bowel movement every 3-5 days
- C. Episodes of nausea and vomiting
- D. Pain in the middle of the night
Answer: A
Explanation:
(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.
NEW QUESTION 36
The nurse assesses a client's monitor strip and finds the following: uterine contractions every 3-4 minutes, lasting 60-70 seconds; FHR baseline 134-146 bpm, with accelerations to 158 bpm with fetal movement.
Which nursing intervention is appropriate?
- A. Start IV for fetal distress and administer O2 at 6-8 liters by mask.
- B. Notify physician of nonreassuring FHR pattern.
- C. Turn the client to her left side.
- D. Evaluate to see if the monitor strip is reassuring.
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) These indices are within normal parameters; therefore, the nurse does not need to contact the physician. (B) The purpose of turning a client to her left side is to maximize uteroplacental blood flow.
Based on the above assessment, there is no indication that blood flow is compromised. (C) These interventions are appropriate nursing interventions for late and prolonged decelerations. Following these interventions, the nurse should notify the physician. These indices are within normal parameters; therefore, the nurse does not need to start an IV and administer O2. (D) Variations of 20 bpm above or below the baseline FHR is considered normal. Normal FHRs range from 120-160 bpm. As the fetus moves, the FHR increases, and accelerations often occur in concert with contractions. During the active phase of labor, the frequency of uterine contractions is every 2-4 minutes, with an appropriate duration of 60 sec.
NEW QUESTION 37
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. Nicotine withdrawal
- C. A birth defect
- D. Anemia
Answer: A
Explanation:
Explanation/Reference:
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.
NEW QUESTION 38
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. Early symptoms of Parkinson's disease
- C. Tardive dyskinesia, which may be a side effect of antipsychotic medication
- D. The need to change her medication from haloperidol to another antipsychotic drug to lessen symptoms
Answer: C
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 39
The nurse has been caring for a 16-year-old female who recently experienced date rape. After having had crisis intervention and been hospitalized for 2 weeks, the nurse knows that the client is effectively coping with the rape when she tells the nurse:
- A. "I know now that it was not my fault, but I want to continue counseling after my discharge."
- B. "I know it was my fault that it happened, because I shouldn't have been out so late."
- C. "If I had not worn that sexy dress that night, he wouldn't have raped me."
- D. "I know my date just had so much passion he couldn't handle me saying 'no.' "
Answer: A
Explanation:
(A) This response does not show any insight; the client falsely assumes that she is responsible for the rape. (B) The client continues to falsely assume responsibility for the rapist's behavior. (C) The client believes falsely that rape is an act of passion, rather than one of violence, control, and domination. (D) The client has insight into the rape; she does not believe it was her fault and shows good judgment in deciding to continue with counseling after discharge.
NEW QUESTION 40
A chronic alcoholic client's condition deteriorates, and he begins to exhibit signs of hepatic coma. Which of the following is an early sign of impending hepatic coma?
- A. Fetor hepaticus
- B. Anorexia
- C. Hiccups
- D. Mental confusion
Answer: D
Explanation:
Explanation
(A) Hiccups are not a sign of impending hepatic coma. (B) Anorexia is not a sign of impending hepatic coma.
(C) One of the earliest symptoms of hepatic coma is mental confusion. Asterixis, a flapping tremor of the hand, may also be seen. (D) This sign is associated with the later stages of hepatic coma. Fetor hepaticus, a characteristic odor on the breath that smells like acetone, may sometimes be noted when the liver fails.
NEW QUESTION 41
Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. The physician is immediately notified and orders 50 mL of dextrose and 10 U of regular insulin IV push. The nurse administering these drugs knows the Rationale for this therapy is to:
- A. Remove the potassium from the body by renin exchange
- B. Protect the myocardium from the effects of hypokalemia
- C. Promote rapid protein catabolism
- D. Drive potassium from the serum back into the cells
Answer: D
Explanation:
(A) Sodium polystyrene sulfonate (Kayexalate), a cation exchange resin, exchanges sodium ions for potassium ions in the large intestine reducing the serum potassium. (B) Calcium is administered to 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.
NEW QUESTION 42
A newborn infant is exhibiting signs of respiratory distress. Which of the following would the nurse recognize as the earliest clinical sign of respiratory distress?
- A. Decreased respirations
- B. Increased respirations
- C. Cyanosis
- D. Sternal and subcostal retractions
Answer: D
Explanation:
(A) Cyanosis is a late clinical sign of respiratory distress. (B) Rapid respirations are normal in a newborn. (C) The newborn has to exert an extra effort for ventilation, which is accomplished by using the accessory muscles of ventilation. The diaphragm and abdominal muscles are immature and weak in the newborn. (D) Decreased respirations are a late clinical sign. In the newborn, decreased respirations precede respiratory failure.
NEW QUESTION 43
On assessment, the nurse learns that a chronic paranoid schizophrenic has been taking "the blue pill" (haloperidol) in the morning and evening, and "the white pill" (benztropine) right before bedtime. The nurse might suggest to the client that she try:
- A. Taking her medication with food or milk
- B. Decreasing the haloperidol dosage for a few days
- C. Doubling the daily dose of benztropine
- D. Taking the benztropine in the morning
Answer: D
Explanation:
(A) Suggesting that a client increase a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order. (B) To suggest that a client decrease a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order. (C) This response is an appropriate independent nursing action. Because motorrestlessness can also be a side effect of cogentin, the nurse may suggest that the client try taking the drug early in the day rather than at bedtime. (D) Certain medications can cause gastric irritation and may be taken with food or milk to prevent this side effect.
NEW QUESTION 44
The initial treatment for a client with a liquid chemical burn injury is to:
- A. Inject calcium chloride into the burned area
- B. Apply lanolin ointment to the area
- C. Irrigate the area with neutralizing solutions
- D. Flush the exposed area with large amounts of water
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) In the past, neutralizing solutions were recommended, but presently there is concern that these solutions extend the depth of burn area. (B) The use of large amounts of water to flush the area is recommended for chemical burns. (C) Calcium chloride is not recommended therapy and would likely worsen the problem. (D) Lanolin is of no benefit in the initial treatment of a chemical injury and may actually extend a thermal injury.
NEW QUESTION 45
The nurse notes scattered crackles in both lungs and 1+ pitting edema when assessing a cardiac client. The physician is notified and orders furosemide (Lasix) 80 mg IV push stat. Which of the following diagnostic studies is monitored to assess for a major complication of this therapy?
- A. 12-Lead ECG
- B. Serum electrolytes
- C. Arterial blood gases
- D. Complete blood count
Answer: B
Explanation:
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.
NEW QUESTION 46
A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty-eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications?
- A. Decreased cardiac output
- B. Severe hypotension
- C. Fluid volume excess
- D. Fluid volume deficit
Answer: C
Explanation:
Section: Questions Set B
Explanation:
(A) Fluid volume deficit resulting from fluid shifts to the interstitial spaces occurs in the first 48 hours. (B) Forty- eight hours to 72 hours after the burn injury and fluid resuscitation, capillary permeability is restored and fluid requirements decrease. Interstitial fluid returns rapidly to the vascular compartment, and the nurse must monitor the child for signs and symptoms of hypervolemia. (C) Increased cardiac output results as fluids shift back to the vascular compartment. (D) Hypertension is the result of hypervolemia.
NEW QUESTION 47
A school-age child with asthma is ready for discharge from the hospital. His physician has written an order to continue the theophylline given in the hospital as an oral home medication. Immediately prior to discharge, he complains of nausea and becomes irritable. His vital signs were normal except for tachycardia. What first nursing actions would be essential in this situation?
- A. Hold the child's discharge for 1 hour.
- B. Discharge the child as the physician ordered.
- C. Administer an antiemetic as necessary.
- D. Notify the physician immediately.
Answer: D
Explanation:
Section: Questions Set D
Explanation:
(A) Holding the child's discharge alone does not address the client's problem. (B) Nausea, tachycardia, and irritability are all symptoms of theophylline toxicity. The physician should benotified immediately so that a serum theophylline level can be ordered. Theophylline dose should be withheld until the physician is notified. (C) The child must be evaluated for theophylline toxicity before any discharge. (D) Cause of the nausea should be investigated before the administration of an antiemetic.
NEW QUESTION 48
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. Early symptoms of Parkinson's disease
- C. Tardive dyskinesia, which may be a side effect of antipsychotic medication
- D. The need to change her medication from haloperidol to another antipsychotic drug to lessen symptoms
Answer: C
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 49
A 30-year-old client in the third trimester of her pregnancy asks the nurse for advice about upper respiratory discomforts. She complains of nasal stuffiness and epistaxis, most noticeable on the left side. Which reply by the nurse is correct?
- A. "It sounds as though you are coming down with a bad cold. I'll ask the doctor to prescribe a decongestant for relief of symptoms."
- B. "These discomforts are all a result of increased blood supply; one of the pregnancy hormones, estrogen, causes them."
- C. "This is most unusual. I'm sure your obstetrician will want you to see an ENT (ear, nose, throat) specialist."
- D. "A good vaporizer will help; avoid the cool air kind. Also, try saline nose drops, and spend less time on your left side."
Answer: B
Explanation:
Explanation
(A) Decongestants may exaggerate the nasal stuffiness associated with pregnancy. Judicious use of decongestants and nasal sprays is advocated during pregnancy. (B) Cool air vaporizers and saline drops may help to relieve the nasal stuffiness. Positioning on either lateral side does not decrease nasal stuffiness or prevent epistaxis. (C) Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness.
Estrogen also promotes vasodilation, which contributes to epistaxis. The nurse may recommend cool air vaporizers and saline drops to help with the nasal stuffiness. (D) Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation discomforts associated with pregnancy.
NEW QUESTION 50
A client who has been diagnosed with anorexia nervosa refuses to eat lunch. The most therapeutic response by the nurse to her refusal is:
- A. "It's not appropriate for you to try to manipulate the staff into granting your wishes."
- B. "Okay, missing one meal won't hurt."
- C. "You'll have to eat lunch, or we'll force-feed you."
- D. "We will not allow you to starve yourself. You may choose to eat voluntarily or be fed."
Answer: D
Explanation:
Explanation
(A) This response reinforces the client's maladaptive behavior, thereby contributing to the client's risk. (B) Ultimatums are not therapeutic. (C) This comment invites an argument because it puts the client on the defensive and stabs at her self-esteem, which is already compromised. (D) Setting limits assures the client that staff has genuine concern for her safety and well-being. Giving her an actual choice will give the client an increased sense of control over her life and avoid an argument or power struggle.
NEW QUESTION 51
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. Evisceration
- C. Dehiscence
- D. Decortication
Answer: B
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 in thoracic surgery. (D) Evisceration occurs when the incision separates and the contents of the cavity spill out.
NEW QUESTION 52
The nurse would teach a male client ways to minimize the risk of infection after eye surgery. Which of the following indicates the client needs further teaching?
- A. "I will wear sunglasses when going outside."
- B. "I will wash my hands before instilling eye medications."
- C. "I will maintain the sterility of the eye medications."
- D. "I will wear an eye patch for the first 3 postoperative days."
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Hand washing would be an important action designed to prevent transmission of pathogens from the hands to the eye. (B) Wearing sunglasses when going outside will prevent airborne pathogens from entering the eye. (C) Eye patches are most frequently ordered to be worn while the client sleeps or naps, not constantly for this length of time. (D) Eye medications are sterile; clients need to be taught how to maintain this sterility.
NEW QUESTION 53
A client has returned to the unit from the recovery room after having a thyroidectomy. The nurse knows that a major complication after a thyroidectomy is:
- A. Respiratory obstruction
- B. Myxedema
- C. Fistula formation
- D. Hypercalcemia
Answer: A
Explanation:
(A)
Respiratory obstruction due to edema of the glottis, bilateral laryngeal nerve damage, or tracheal compression from hemorrhage is a major complication after a thyroidectomy.
(B)
Hypocalcemia accompanied by tetany from accidental removal of one or more parathyroid glands is a major complication, not hypercalcemia. (C) Fistula formation is not a major complication associated with a thyroidectomy. It is a major complication with a laryngectomy.(D) Myxedema is hypothyroidism that occurs in adults and is not a complication of a thyroidectomy. A thyroidectomy client tends to develop thyroid storm, which is excess production of thyroid hormone.
NEW QUESTION 54
Nursing care for the parents of a child with a congenital heart defect would include:
- A. Encouraging the parents not to tell the child about the seriousness of the congenital heart defect, so the child will function as normally as possible
- B. Identifying anger and resentment as destructive emotions that serve no purpose
- C. Expressing to the parents after the corrective surgery has been completed successfully that all their grief feelings will resolve
- D. Acknowledging the fear and concern surrounding their child's health and assisting the parents through the grieving process as they mourn the loss of their fantasized healthy child
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) It is important to discuss with parents the need to treat the child as they would any other children, but they must be truthful and honest with the child about the heart defect. As the child grows older, explanations can go into greater depth. (B) Parents of children with congenital heart defects go through a grieving process over the loss of their "healthy" child. The nurse needs to recognize these feelings and give the parents a role in the child's care when they are ready. (C) Anger and resentment are normal feelings that must be dealt with appropriately. (D) Parents may go through a second grieving process after the repair of the cardiac defect. During this grieving period, they mourn the loss of the "defective" child who now may be essentially "normal."
NEW QUESTION 55
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