Released NCLEX NCLEX-RN Updated Questions PDF
NCLEX-RN Dumps and Practice Test (865 Exam Questions)
NEW QUESTION # 103
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. Protect the myocardium from the effects of hypokalemia
- B. Promote rapid protein catabolism
- C. Drive potassium from the serum back into the cells
- D. Remove the potassium from the body by renin exchange
Answer: C
Explanation:
Section: Questions Set G
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 # 104
A 75-year-old client is hospitalized with pneumonia caused by gram-positive bacteria. Which one of the following best describes a gram-positive bacterial pneumonia?
- A. Escherichia colipneumonia
- B. Legionella pneumophilapneumonia
- C. Pneumococcal pneumonia
- D. Klebsiellapneumonia
Answer: C
Explanation:
(A)Klebsiellapneumonia is caused by gram-negative bacteria. (B) Pneumococcal pneumonia is caused by gram-positive bacteria. (C)Legionella pneumophilapneumonia is a nonbacterial pneumonia. (D)E. colipneumonia is caused by gram-negative bacteria.
NEW QUESTION # 105
Following a vaginal delivery, the postpartum nurse should observe for:
- A. Hemorrhage and infection
- B. Dystocia, kraurosis
- C. Chadwick's sign
- D. Fatigue, hemorrhoids
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Dystocia is difficult labor. The delivery has occurred. Kraurosis is atrophy and dryness of skin and any mucous membrane (vulva). (B) Chadwick's sign is a bluish color of vaginal mucosa suggestive of pregnancy. (C) Fatigue is a common symptom in the postpartal period. Hemorrhoids may occur with pregnancy. (D) Hemorrhage and infection are potential complications of vaginal delivery. Hemorrhage may result from retained placental fragments or soft uterus. Infection may occur from the introduction of organisms into the uterus during the delivery.
NEW QUESTION # 106
A client's record from the ED indicates that she overdosed on phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor. Which diet would be the most appropriate at this time?
- A. 1 g sodium
- B. High protein, high carbohydrate
- C. Tyramine-free
- D. High carbohydrate, low cholesterol
Answer: C
Explanation:
(A) There are no data to support the need for increased carbohydrates or decreased
cholesterol in the diet. (B) There is no data to support the need for increased protein or increased carbohydrates in the diet. (C) There is no assessment or laboratory data indicating that sodium should be restricted in the diet. (D) Tyramine is an amino acid activated by MAO in the liver and intestinal wall. It is released as proteins are hydrolyzed through aging, pickling, smoking, or spoilage of foods. When MAO is inhibited, tyramine levels rise, stimulating the adrenergic system to release large amounts of norepinephrine, which can produce a hypertensive crisis.
NEW QUESTION # 107
In a client with chest trauma, the nurse needs to evaluate mediastinal position. This can best be done by:
- A. Palpating for trachial deviation
- B. Auscultating heart sounds
- C. Auscultating bilateral breath sounds
- D. Palpating for presence of crepitus
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) No change in the breath sounds occurs as a direct result of the mediastinal shift. (B) Crepitus can occur owing to the primary disorder, not to the mediastinal shift. (C) Mediastinal shift occurs primarily with tension pneumothorax, but it can occur with very large hemothorax or pneumothorax. Mediastinal shift causes trachial deviation and deviation of the heart's point of maximum impulse. (D) No change in the heart sounds occurs as a result of the mediastinal shift.
NEW QUESTION # 108
A client is experiencing muscle weakness and lethargy. His serum K+is 3.2. What other symptoms might he exhibit?
- A. Tetany
- B. Numbness of extremities
- C. Dysrhythmias
- D. Headache
Answer: C
Explanation:
Explanation
(A) Tetany is seen with low calcium. (B) Low potassium causes dysrhythmias because potassium is responsible for cardiac muscle activity. (C) Numbness of extremities is seen with high potassium. (D) Headache is not associated with potassium excess or deficiency.
NEW QUESTION # 109
A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains of severe abdominal pain. Assessment reveals abdominal rigidity and distention, increased temperature, and tachycardia. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has developed:
- A. Gastritis
- B. Pulmonary embolism
- C. Evisceration
- D. Peritonitis
Answer: D
Explanation:
(A) Assessment findings for gastritis would reveal anorexia, nausea and vomiting, epigastric fullness and tenderness, and discomfort. (B) Evisceration is the extrusion of abdominal viscera as a result of trauma or sutures failing in a surgical incision. (C) Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and fluid into the abdominal cavity. This causes infection and irritation. (D) Assessment findings of pulmonary embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath, anxiety or panic, and wheezing and coughing often accompanied by blood-tinged sputum.
NEW QUESTION # 110
A client is being discharged from the hospital today. The discharge teaching for care of her colostomy included which of the following basic principles for protecting the skin around her stoma:
- A. Cutting the skin barrier 112 inches larger than the stoma
- B. Using a skin sealant under pouch adhesives
- C. Changing the pouch only when leakage occurs
- D. Taping a pouch that is leaking
Answer: B
Explanation:
(A) When a pouch seal leaks, the pouch should be immediately changed, not taped. Stool held against the skin can quickly result in severe irritation. (B) The skin barrier should be cut only slightly larger than the stoma (one-half inch). (C) The client should be taught to change pouches whenever possible before leakage occurs. (D) When skin sealant is used under the tape, the outermost layer of the epidermis remains intact. When no skin sealant
is used, this layer is removed when the tape is removed.
NEW QUESTION # 111
Following her surgery, a 5-year-old child will return to the pediatric unit with a long-arm cast. She experienced a supracondylar fracture of the humerus near the elbow. Which nursing action is most essential during the first
24 hours after surgery and cast application?
- A. Mobilization of the child
- B. Assessment of neurovascular status
- C. Discharge teaching
- D. Pain management
Answer: B
Explanation:
Section: Questions Set D
Explanation:
(A) Mobilization is important but not absolutely essential. (B) Discharge teaching should be initiated prior to surgery as well as during the postoperative period. (C) Assessment and management of pain are necessary and high in priority. (D) Neurovascular status of the extremity is of primary importance. The risk of circulatory impairment exists with any cast application. This type of fracture is common in children. A high incidence of neurovascular complications exists with fractures near the elbow.
NEW QUESTION # 112
Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients?
- A. Vitamin C and zinc
- B. Folic acid and niacin
- C. Vitamin A and biotin
- D. Thiamine and pyroxidine
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Chronic alcoholism can lead to deficiencies of B complex vitamins including thiamine and pyroxidine.
(B) Chronic alcoholism can lead to deficiencies of vitamins A, D, K, and B complex. (C) Chronic alcoholism can lead to deficiencies of vitamins A, D, K, and B complex. (D) Vitamins A, D, K, and B require bile salts to be absorbed from the gastrointestinal tract. A damaged liver does not form bile salts.
NEW QUESTION # 113
A primigravida is at term. The nurse can recognize the second stage of labor by the client's desire to:
- A. Push during contractions
- B. Walk between contractions
- C. Hyperventilate during contractions
- D. Relax during contractions
Answer: A
Explanation:
Section: Questions Set C
Explanation:
(A) The second stage of labor is characterized by uterine contractions, which cause the client to bear down. (B) Slow, deep, rhythmic breathing facilitates the laboring process. Hyperventilation is abnormal breathing resulting from loss of pain control. (C) The client should remain on bed rest during labor. (D) Contractions result in discomfort.
NEW QUESTION # 114
The initial focus when providing nursing care for a child with rheumatic fever during the acute phase of the illness should be to:
- A. Provide a nutritious diet
- B. Maintain her interest in school
- C. Maintain contact with her parents
- D. Provide for physical and psychological rest
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) This goal is helpful, but rest is essential during the acute phase. (B) Rest is essential for healing to occur and for pain to be relieved. (C) This goal is important, but rest is essential. (D) This goal should be part of the plan of care, but it is not the priority during the acute phase.
NEW QUESTION # 115
The mother of a client is apprehensive about taking home her 2 year old who was diagnosed with asthma after being admitted to the emergency room with difficulty breathing and cyanosis. She asks the nurse what symptoms she should look for so that this problem will not happen again. The nurse instructs her to watch for the following early symptoms:
- A. Fever, runny nose, and hyperactivity
- B. Changes in breathing pattern, moodiness, fatigue, and edema of eyes
- C. Fever, cough, paleness, and wheezing
- D. Fatigue, dark circles under the eyes, changes in breathing pattern, glassy eyes, and moodiness
Answer: D
Explanation:
Explanation
(A) The child with asthma may not have fever unless there is an underlying infection. (B) Edema of the eyes will not be present because the child with asthma is more likely to have dehydration related to excessive water loss during the work of breathing. (C) All of these symptoms indicate decreased oxygenation and are early symptoms of asthma. (D) Coughing and wheezing are not early signs of difficulty.
NEW QUESTION # 116
A 52-year-old client who underwent an exploratory laparotomy for a bowel obstruction begins to complain of hunger on the third postoperative day. His nasogastric (NG) tube was removed this morning, and he has an IV of D5W with 0.45% normal saline running at 125 mL/hr. He asks when he can get rid of his IV and start eating.
The nurse recognizes that he will be able to begin taking oral fluids and nourishment when:
- A. His blood pressure returns to its preoperative baseline level or greater
- B. It is determined that he has no signs of wound infection
- C. He is able to eat a full meal without evidence of nausea or vomiting
- D. The nurse can detect bowel sounds in all four quadrants
Answer: D
Explanation:
Section: Questions Set D
Explanation:
(A) The absence of wound infection is related to his surgical wound and not to postoperative GI functioning and return of peristalsis. (B) Routine postoperative protocol involves detection of bowel sounds and return of peristalsis before introduction of clear liquids, followed by progression of full liquids and a regular diet versus a full regular meal first. (C) Routine postoperative protocol for bowel obstruction is to assess for the return of bowel sounds within 72 hours after major surgery, because that is when bowel sounds normally return. If unable to detect bowel sounds, the surgeon should be notified immediately and have the client remain NPO.
(D) Routine postoperative protocol for bowel obstruction and other major surgeries involves frequent monitoring of vital signs in the immediate postoperative period (in recovery room) and then every 4 hours, or more frequently if the client is unstable, on the nursing unit. This includes assessing for signs of hypovolemic shock. Vital signs usually stabilize within the first 24 hours postoperatively.
NEW QUESTION # 117
The nurse in the mental health center is instructing a depressed client about the dietary restrictions necessary in taking her medication, which is a monoamine oxidase (MAO) inhibitor. Which of the following is she restricting from the client's diet?
- A. Cream cheese
- B. Yeast bread
- C. Fresh fruits
- D. Aged cheese
Answer: D
Explanation:
(A) Cream cheese does not contain tyramine, which might cause a hypertensive crisis. (B) Fresh fruits do not contain tyramine, which might cause a hypertensive crisis. (C) Aged or matured cheese combined with a monoamine oxidase predisposes the client to a hypertensive crisis. (D) Bread products raised with yeast do not contain tyramine.
NEW QUESTION # 118
A female client at 10 weeks' gestation complains to her physician of slight vaginal bleeding and mild cramps.
On examination, her physician determines that her cervix is closed. The client is exhibiting signs of:
- A. An incomplete abortion
- B. An inevitable abortion
- C. A threatened abortion
- D. A missed abortion
Answer: C
Explanation:
Explanation
(A) An inevitable abortion includes the signs of cervical dilation and effacement as well as pain and bleeding.
(B) A threatened abortion is a condition in which intrauterine bleeding occurs early in pregnancy, the cervix remains undilated, and the uterine contents are not necessarily expelled. (C) An incomplete abortion occurs when some portions of the products of conception are expelled from the uterus. (D) A missed abortion occurs when the embryo dies in utero and is retained in the uterus.
NEW QUESTION # 119
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. Peritoneal dialysis requires that a home health nurse prepare and administer the treatments.
- C. Peritoneal dialysis has almost no complications and is less time consuming than hemodialysis. Therefore it is preferred.
- D. Hemodialysis involves more time to filter the blood than does peritoneal dialysis.
Answer: A
Explanation:
(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.
NEW QUESTION # 120
An obstructing stone in the renal pelvis or upper ureter causes:
- A. Severe flank and abdominal pain with nausea, vomiting, diaphoresis, and pallor
- B. Radiating pain into the urethra with labia pain experienced in females or testicular pain in males
- C. Urinary frequency and dysuria
- D. Dull, aching, back pain
Answer: A
Explanation:
Explanation
(A) Radiating pain in the urethra in both sexes, extending into the labia in females and into the testicle or penis in the male, indicates a stone in the middle or lower segment of the ureter. (B) Urinary frequency and dysuria are caused by a stone in the terminal segment of the ureter withinthe bladder wall. (C) An obstructing stone in the renal pelvis or upper ureter causes severe flank and abdominal pain with nausea, vomiting, diaphoresis, and pallor. (D) Dull and aching pain may indicate early stages of hydronephrosis. Also, a stone in the renal pelvis or upper ureter causes severe flank and abdominal pain.
NEW QUESTION # 121
The physician of a client diagnosed with alcoholism orders neomycin 0.5 g q6h to prevent hepatic coma.
Neomycin decreases serum ammonia levels by:
- A. Decreasing the uptake of vitamin D, thereby drawing more water into the colon
- B. Decreasing nitrogen-forming bacteria in the intestines
- C. Irritating the bowel and promoting evacuation of stool
- D. Acidifying colon contents by causing ammonia retention in the colon
Answer: B
Explanation:
Explanation
(A) Neomycin interferes with protein synthesis in the bacterial cell, causing bacterial death. Neomycin reduces the growth of the ammonia-producing bacteria in the intestines and is used for the treatment of hepatic coma.
(B) This choice describes the action of lactulose, another drug commonly used to decrease systemic ammonia levels. (C) Neomycin's action doesnotdecrease uptake of vitamin D to reduce serum ammonia levels. (D) Bowel irritation with diarrhea is more likely to occur with administration of lactulose rather than of neomycin.
Besides, diarrhea is a side effect of a drug, not the action of the drug.
NEW QUESTION # 122
A female client comes for her second prenatal visit. The nurse-midwife tells her, "Your blood tests reveal that you do not show immunity to the German measles." Which notation will the nurse include in her plan of care for the client? "Will need . . .
- A. Rubella vaccine after delivery on the day of discharge"
- B. Rubella vaccine at the next visit"
- C. Rh-immune globulin within 3 days of delivery"
- D. Rh-immune globulin at the next visit"
Answer: A
Explanation:
(A) Rh immune globulin is given to Rh-negative mothers to prevent the maternal Rh immune response. (B) Rh immune globulin is given to Rh-negative mothers to prevent the maternal Rh immune response. (C) The rubella vaccine is not given during pregnancy because of its teratogenicity. (D) Nonimmune mothers are vaccinated early in the postpartum period to prevent future infection with the rubella virus.
NEW QUESTION # 123
A 2-day-old infant boy has been diagnosed with an atrial septal defect due to a persistent patent foramen ovale.
When explaining the diagnosis to the mother, the nurse includes in the discussion the function of the foramen ovale. In fetal circulation, the foramen ovale allows a portion of the blood to bypass the:
- A. Superior vena cava
- B. Liver
- C. Left ventricle
- D. Pulmonary system
Answer: D
Explanation:
(A)
The foramen ovale permits a percentage of the blood to shunt from the right atrium to the left atrium. The blood then goes to the left ventricle, permitting systemic fetal circulation with blood containing a higher O2 saturation. (B) As the blood shunts from the right atrium to the left atrium, the pulmonary system is bypassed. The fetus receives O2 from the maternal circulation, thereby permitting the partial bypass of the pulmonary system. (C) The foramen ovale is locatedin the atrial septum of the heart and does not affect the liver.
(D)
The superior vena cava returns blood to the heart, bringing blood to the location of the foramen ovale.
NEW QUESTION # 124
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. Walk with him as he paces.
- B. Increase the level of his supervision.
- C. Help him to recognize his anxiety.
- D. Ask him to sit down. Speak slowly and use short, simple sentences.
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(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.
NEW QUESTION # 125
A client had a transurethral resection of the prostate yesterday. He is concerned about the small amount of blood that is still in his urine. The nurse explains that the blood in his urine:
- A. Should not be there on the second day
- B. Will stop when the Foley catheter is removed
- C. Is normal and he need not be concerned about it
- D. Can be removed by irrigating the bladder
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Some hematuria is usual for several days after surgery. (B) The client will continue to have a small amount of hematuria even after the Foley catheter is removed. (C) Some hematuria is usual for several days after surgery. The client should not be concerned about it unless it increases. (D) Irrigating the bladder will not remove the hematuria. Irrigation is done to remove blood clots and facilitate urinary drainage.
NEW QUESTION # 126
A 4-year-old boy is brought to the emergency room with bruises on his head, face, arms, and legs. His mother states that he fell down some steps. The nurse suspects that he may have been physically abused. In accordance with the law, the nurse must:
- A. Confront the child's mother
- B. Report her suspicions to the authorities
- C. Talk to the child's father
- D. Tell the physician her concerns
Answer: B
Explanation:
Explanation
(A) Although the nurse probably would talk to the physician about these concerns, the nurse is not required by law to do so. (B) All healthcare workers are required by the Federal Child Abuse Prevention and Treatment Act of 1974 to report suspected and actual cases of child abuse and/or neglect. (C) Talking to the child's father may or may not help the child, and the nurse is not required by law to do so. (D) Confrontation may not be indicated; the nurse is not required by law to confront the child's mother with these suspicions.
NEW QUESTION # 127
A 2-year-old toddler is hospitalized with epiglottitis. In assessing the toddler, the nurse would expect to find:
- A. Crackles in the lower lobes
- B. Drooling
- C. Expiratory stridor
- D. A productive cough
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) A productive cough is not associated with epiglottitis. (B) Children with epiglottitis seldom have expiratory stridor. Inspiratory stridor is more common due to edema of the supraglottic tissues. (C) Because of difficulty with swallowing, drooling often accompanies epiglottitis. (D) Crackles are not heard in the lower lobes with epiglottitis because the infection is usually confined to the supraglottic structures.
NEW QUESTION # 128
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NCLEX-RN, or National Council Licensure Examination for Registered Nurses, is the standardized exam that nurses must pass in order to obtain their license to practice nursing in the United States. NCLEX-RN exam is administered by the National Council of State Boards of Nursing (NCSBN) and is designed to test the knowledge and skills of nurses at the entry level of practice. Passing the NCLEX-RN is a crucial step for nurses as it allows them to practice nursing legally and safely.
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