Sep 19, 2021 Step by Step Guide to Prepare for NCLEX-RN Exam BrainDumps
NCLEX Certification NCLEX-RN Real Exam Questions and Answers FREE Updated on 2021
NEW QUESTION 300
Priapism may be a sign of:
- A. Reproductive dysfunction
- B. Urinary incontinence
- C. Imminent death
- D. Altered neurological function
Answer: D
Explanation:
Explanation
(A) Priapism in the trauma client is due to the neurological dysfunction seen in spinal cord injury. Priapism is an abnormal erection of the penis; it may be accompanied by pain and tenderness. This may disappear as spinal cord edema is relieved. (B) Priapism is not associated with death. (C) Urinary retention, rather than incontinence, may occur. (D) Reproductive dysfunction may be a secondary problem.
NEW QUESTION 301
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 urine output is equal to his total fluid intake.
- B. His blood pressure is 94/62.
- C. His weight increases from 165 to 175 lb.
- D. His urine output has been>35 mL/hr for the past 12 hours.
Answer: D
Explanation:
Explanation
(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.
NEW QUESTION 302
A 45-year-old client diagnosed with major depression is scheduled for electroconvulsive therapy (ECT) in the morning. Which of the following medications are routinely administered either before or during ECT?
- A. Sodium, potassium, and magnesium
- B. Atropine, sodium brevitol, and succinylcholine chloride (Anectine)
- C. Carbamazepine (Tegretol), haloperidol, and trihexyphenidyl (Artane)
- D. Thioridazine (Mellaril), lithium, and benztropine
Answer: B
Explanation:
(A) Thioridazine (an antipsychotic drug), lithium (an antimanic drug), and benztropine (an antiparkinsonism agent) are generally administered to treat schizophrenic and bipolar disorders. (B) Atropine (a cholinergic blocker), sodium brevitol (a shortacting anesthetic), and succinylcholine (a neuromuscular blocker) are administered either before or during ECT to coun teract bradycardia and to provide anesthesia and total muscle relaxation. (C) These are electrolyte substances administered to correct fluid and electrolyte imbalances in the body. (D) Carbamazepine (an anticonvulsant), haldoperidol (an antipsychotic), and trihexyphenydyl (an antiparkinsonism agent) are usually administered in psychiatric settings to control problems associated with psychotic behavior.
NEW QUESTION 303
The nurse is aware that nutrition is an important aspect of care for a client with hepatitis. Which of the following diets would be most therapeutic?
- A. High protein and low carbohydrate
- B. High carbohydrate and high calorie
- C. Low carbohydrate and high calorie
- D. Low calorie and low protein
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Protein increases the workload of the liver. Increased carbohydrates provide needed calories and promote palatability. (B) Dietary intake should be adequate to ensure wound healing. (C) Increased carbohydrates provide needed calories. (D) A highcalorie diet is best obtained from carbohydrates because of their palatability. Fats increase the workload of the liver.
NEW QUESTION 304
A couple is experiencing difficulties conceiving a baby. The nurse explains basal body temperature (BBT) by instructing the female client to take her temperature:
- A. Only one time during the day as long as it is always at the same time of day
- B. Orally in the morning and at bedtime
- C. As soon as she awakens, prior to any activity
- D. Rectally at bedtime
Answer: C
Explanation:
Section: Questions Set G
Explanation:
(A) Monitoring temperature twice a day predicts the biphasic pattern of ovulation. (B) Prediction of ovulation relies on consistency in taking temperature. (C) Nightly rectal temperatures are more accurate in predicting ovulation. (D) Activity changes the accuracy of basal body temperature and ability to detect the luteinizing hormone surge.
NEW QUESTION 305
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:
Section: Questions Set D
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 306
Which of the following risk factors associated with breast cancer would a nurse consider most significant in a client's history?
- A. Early menopause
- B. Nulliparity
- C. Maternal family history of breast cancer
- D. Menarche after age 13
Answer: C
Explanation:
Explanation
(A) Women who begin menarche late (after 13 years old) have a lower risk of developing breast cancer than women who have begun earlier. Average age for menarche is 12.5 years. (B) Women who have never been pregnant have an increased risk for breast cancer, but a positive family history poses an even greater risk. (C) A positive family history puts a woman at an increased risk of developing breast cancer. It is recommended that mammography screening begin 5 years before the age at which an immediate female relative was diagnosed with breast cancer. (D) Early menopause decreases the risk of developing breast cancer.
NEW QUESTION 307
A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse anticipates the physician ordering:
- A. Oxytocin
- B. Ampicillin
- C. Tetracycline
- D. Magnesium sulfate (MgSO4)
Answer: B
Explanation:
(A) Oxytocin is prescribed to stimulate uterine contractions. (B) MgSO4is a central nervous system depressant prescribed to prevent and control convulsions related to preeclampsia. (C) Ampicillin is a penicillin derivative with no known teratogenic effects. This is the safest antibiotic during pregnancy. (D) Tetracycline stains teeth yellow and is not as safe as ampicillin during pregnancy.
NEW QUESTION 308
A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:
- A. Avoiding manipulation of the tracheostomy including cuff deflation
- B. Changing tracheostomy dressing only as necessary using one-half strength hydrogen peroxide to cleanse the site
- C. Deflating the cuff for 10 minutes every other hour instead of 5 minutes every hour
- D. Reporting any signs of crepitus immediately to the physician
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) The tracheal cuff should not be deflated within the first 24 hours following surgery. (B) To minimize bleeding, any manipulation, including cuff deflation, should be avoided. (C) Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician. (D) The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.
NEW QUESTION 309
While the nurse is taking a male client's blood pressure, he makes flirtatious remarks to her. The nurse will handle this effectively if she:
- A. Ignores the remarks and hopes he will not try it again
- B. Confronts the remarks but attempts not to reject the client
- C. Politely tells the client, "Keep your hands off "
- D. Leaves the room in order to compose herself
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) This response does not recognize normal feelings of attraction and rejects the client. (B) By ignoring the situation, the nurse has not set limits to discourage other remarks or perhaps more sexually aggressive behavior. (C) By confronting the remarks, she can recognize that his feelings of attraction may be normal but are not appropriate within the context of their nurse-client relationship. (D) Leaving the room does not deal with setting limits for future interactions.
NEW QUESTION 310
The nurse has been assigned a client who delivered a 6- lb, 12-oz baby boy vaginally 40 minutes ago. The initial assessment of greatest importance for this client would be:
- A. Amount of IV fluid to be infused
- B. Type of episiotomy
- C. Length of her labor
- D. Character of the fundus
Answer: D
Explanation:
Explanation
The length of labor has little bearing on the fourth stage of labor. The type of labor and delivery is significant.
(B) The type of episiotomy will affect the client's comfort level. However, the nurse's assessment and implementations center on prevention of hemorrhage during the fourthstage of labor. The amount of bleeding from the episiotomy or hematoma formation is of higher priority than the type of episiotomy. (C) The amount of IV fluid to be infused is a nursing function to be attended to; however, it is lower in priority than determining if hemorrhaging is occurring. (D) Character of the fundus would be the priority nursing assessment because changes in uterine tone may identify possible postpartum hemorrhage.
NEW QUESTION 311
A 3-year-old child was hospitalized for acute laryngotracheobronchitis. During her hospitalization, the child was placed under an oxygen mist tent. The nurse's frequent monitoring of the child's temperature frightened her parents. Which response by the nurse would be most appropriate?
- A. Checking the temperature will prevent febrile seizures.
- B. Monitoring the temperature prevents undue chilling.
- C. Rapid temperature elevations can occur in children.
- D. Taking the child's temperature can prevent airway obstruction.
Answer: B
Explanation:
(A)
The refrigerated cool mist tent creates a cool, moist environment. The child as well as bedding and clothing may become dampened. Monitoring the temperature of the child will ensure warmth and prevent chilling. (B) Only a low-grade fever is expected in laryngotracheobronchitis. (C) Febrile seizures are not expected with the low-grade fever.
(D)
Inflammation of the mucosal lining in the respiratory tract can cause airway obstruction. However, monitoring the child's temperature would not prevent airway obstruction.
NEW QUESTION 312
Morphine sulfate 4 mg IV push q2h prn for chest pain was ordered for a client in the emergency room with severe chest pain. The nurse administering the morphine sulfate knows which of the following therapeutic actions is related to the morphine sulfate?
- A. Increased level of consciousness
- B. Increased rate and depth of respirations
- C. Increased peripheral vasodilation
- D. Increased perception of pain
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Morphine sulfate, a narcotic analgesic, causes sedation and a decrease in level of consciousness. (B) The side effects of morphine sulfate include respiratory depression. (C) Morphine sulfate causes peripheral vasodilation, which decreases afterload, producing a decrease in the myocardial workload. (D) Morphine sulfate alters the perception of pain through an unclear mechanism. This alteration promotes pain relief.
NEW QUESTION 313
The nurse is admitting a client with folic acid deficiency anemia. Which of the following questions is most important for the nurse to ask the client?
- A. "Do you drink alcohol on a regular basis?"
- B. "Do you eat red meat?"
- C. "Do you take aspirin on a regular basis?"
- D. "Have your stools been normal?"
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Aspirin does not affect folic acid absorption. (B) Folic acid deficiency is strongly associated with alcohol abuse. (C) Because folic acid is a coenzyme for single carbon transfer purines, calves liver or other purines are the meat sources. (D) Folic acid does not affect stool character.
NEW QUESTION 314
A client is diagnosed with diabetic ketoacidosis. The nurse should be prepared to administer which of the following IV solutions?
- A. D5in normal saline
- B. D5W
- C. D5in lactated Ringer's
- D. 0.9 normal saline
Answer: D
Explanation:
(A) D5in normal saline would increase serum glucose. (B) D5W would increase serum glucose. (C) A concentration of 0.9 NS is used to correct extracellular fluid depletion. (D) D5in Ringer's lactate would increase serum glucose.
NEW QUESTION 315
A 52-year-old client's abdominal aortic aneurysm ruptured. She received rapid massive blood transfusions for bleeding. One potential complication of blood administration for which she is especially at risk is:
- A. Hypocalcemia
- B. Air embolus
- C. Circulatory overload
- D. Hypokalemia
Answer: A
Explanation:
Explanation
(A) Air embolism is a potential complication of blood administration, but it is fairly rare and can be prevented by using good IV technique. (B) Circulatory overload is a potential complication of blood administration, but because this client is actively bleeding, she is not at high risk for overload. (C) Hypocalcemia is a potential complication of blood administration that occurs in situations where massive transfusion has occurred over a short period of time. It occurs because the citrate in stored blood binds with the client's calcium. Another potential complication for which this client is especially at risk is hypothermia, which can be prevented by using a blood warmer to administer the blood. (D) Hypokalemia is not a complication of blood administration.
NEW QUESTION 316
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. Phone a rape counselor to begin working with the victim as soon as she enters the hospital.
- B. Inform the victim to bring insurance information with her to the hospital so she can be properly cared for.
- C. Inform the victim not to wash, change clothes, douche, brush teeth, or eat or drink anything.
- D. Do not leave the victim alone to collect her thoughts.
Answer: C
Explanation:
(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.
NEW QUESTION 317
A male client receives 10 U of regular human insulin SC at 9:00 AM. The nurse would expect peak action from this injection to occur at:
- A. 9:30 AM
- B. 12 noon
- C. 10:30 AM
- D. 4:00 PM
Answer: B
Explanation:
Explanation
(A) This is too early for peak action to occur. (B) This is too early for peak action to occur. (C) Regular insulin peak action occurs 2-4 hours after administration. (D) This is too late for peak action to occur.
NEW QUESTION 318
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