Sep 26, 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 67
A family by court order undergoes treatment by a family therapist for child abuse. The nurse, who is the child's case manager knows that treatment has been effective when:
- A. The child is removed from the home and placed in foster care
- B. The child's father is arrested for child abuse
- C. The child's parents can identify appropriate behaviors for children in his age group
- D. The child's parents identify the ways in which he is different from the rest of the family
Answer: C
Explanation:
(A) Removing an abused child from the home and placement in a foster home are not the desired outcome of treatment. (B) Children who are perceived as "different" from the rest of the family are more likely to be abused. (C) Although legal action may be taken against abusive parents, it is not an indicator of an effective treatment program. (D) Identification of age-appropriate behaviors is essential to the role of parents, because misunderstanding children's normal developmental needs often contributes to abuse or neglect.
NEW QUESTION 68
The nurse is caring for a 3-month-old girl with meningitis. She has a positive Kernig's sign. The nurse expects her to react to discomfort if she:
- A. Flexes her spine
- B. Plantiflexes her wrist
- C. Dorsiflexes her ankle
- D. Turns her head to the side
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Discomfort with ankle dorsiflexion is not expected with meningitis. (B) Spinal flexion, flexing the neck or the hips with legs extended, causes discomfort if the meninges are irritated. (C) Discomfort with wrist flexion is not expected with meningitis. (D) Rotating the cervical spine may cause discomfort with meningitis, but pain with flexion is more indicative of meningeal irritation.
NEW QUESTION 69
A client's transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing, anxious, and very restless. The nurse knows these assessment findings are congruent with:
- A. Febrile transfusion reaction
- B. Hemolytic transfusion reaction
- C. Circulatory overload
- D. Allergic transfusion reaction
Answer: D
Explanation:
(A) A hemolytic transfusion reaction would be characterized by fever, chills, chest pain, hypotension, and tachypnea. (B) Fever, chills, and headaches are indicative of a febrile transfusion reaction. (C) Circulatory overload is manifest by dyspnea, cough, and pulmonary crackles. (D) Urticaria, pruritus, wheezing, and anxiety are indicative of an allergic transfusion reaction.
NEW QUESTION 70
The child with iron poisoning is given IV deforoxamine mesylate (Desferal). Following administration, the child suffers hypotension, facial flushing, and urticaria. The initial nursing intervention would be to:
- A. Take all vital signs, and report to the physician
- B. Stop the medication, and begin a normal saline infusion
- C. Assess urinary output, and if it is 30 mL an hour, maintain current treatment
- D. Discontinue the IV
Answer: B
Explanation:
(A)
The IV line should not be discontinued because other IV medications will be needed.
(B)
Stop the medication and begin a normal saline infusion. The child is exhibiting signs of an allergic reaction and could go into shock if the medication is not stopped. The line should be kept opened for other medication. (C) Taking vital signs and reporting to the physician is not an adequate intervention because the IV medication continues to flow. (D) Assessing urinary output and, if it is 30 mL an hour, maintaining current treatment is an inappropriate intervention owing to the child's obvious allergic reaction.
NEW QUESTION 71
A psychiatric nurse is providing an orientation to a new staff nurse. She reminds the nurse that psychiatrists often use categories of medications and that it is important that she recall that some categories of medications have synonyms. Another name used to describe minor tranquilizers is which of the following?
- A. Antidepressant medications
- B. Antimania medication
- C. Antipsychotic medications
- D. Antianxiety medications
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Antipsychotic medications are also known as major tranquilizers. (B) Antidepressants fall into different categories, such as the tricyclics or the MAO inhibitors. (C) Antianxiety medications are also known as minor tranquilizers. (D) Antimania medications are those such as lithium and lithium carbonate (Lithobid).
NEW QUESTION 72
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. Early symptoms of Parkinson's disease
- B. The need to change her medication from haloperidol to another antipsychotic drug to lessen symptoms
- C. A more advanced stage of Alzheimer's disease than previously experienced by the client
- D. Tardive dyskinesia, which may be a side effect of antipsychotic medication
Answer: D
Explanation:
Section: Questions Set E
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 73
The nurse is teaching a child's parents how to protect the child from lead poisoning. The nurse knows that a common source of lead poisoning in children is:
- A. Pencils
- B. Stuffing from toy animals
- C. Old paint
- D. Dandelion leaves
Answer: C
Explanation:
(A) Dandelion leaves are not a source of lead. (B) Pencils are not a source of lead poisoning. (C) Chewing on objects painted before 1960 is a common source of lead poisoning in children. Gasoline is another source. (D) Stuffed animals are not a source of lead.
NEW QUESTION 74
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. Yeast bread
- B. Fresh fruits
- C. Aged cheese
- D. Cream cheese
Answer: C
Explanation:
Section: Questions Set F
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 75
The physician is preparing to induce labor on a 40-week multigravida. The nurse should anticipate the administration of:
- A. Progesterone
- B. Vasopressin (Pitressin)
- C. Ergonovine maleate
- D. Oxytocin (Pitocin)
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Oxytocin is a hormone secreted by the neurohypophysis during suckling and parturition that produces strong uterine contractions. (B) Progesterone has a quiescence effect on the uterus. (C) Vasopressin is an antidiuretic hormone that promotes water reabsorption by the renal tubules. (D) Ergonovine produces dystocia as a result of sustained uterine contractions.
NEW QUESTION 76
The nurse caring for a client who has pneumonia, which is caused by a gram-positive bacteria, inspects her sputum. Because the client's pneumonia is caused by a gram-positive bacteria, the nurse experts to find the sputum to be:
- A. Rust colored
- B. Green colored
- C. Bright red with streaks
- D. Pink-tinged and frothy
Answer: A
Explanation:
Section: Questions Set D
Explanation:
(A) Bright red sputum with streaks is associated with pneumonia caused by gram-negative bacteria, such as Klebsiellapneumonia. (B) Pneumococcal pneumonia, caused by gram-positive bacteria, has a characteristic productive cough with green or rust-colored sputum. (C) Green-colored sputum is more characteristic of Pseudomonasthan of gram-positive bacterial pneumonia. (D) Pink-tinged and frothy sputum is more characteristic of pulmonary edema than of gram-positive bacterial pneumonia.
NEW QUESTION 77
A 42-year-old client on an inpatient psychiatric unit comments that he was brought to the hospital by his wife because he had taken too many pills and states, "I just couldn't take it anymore." The nurse's best response to this disclosure would be:
- A. "I'm sure you probably didn't mean to kill yourself."
- B. "Tell me more about what you couldn't take anymore."
- C. "How long have you been in the hospital."
- D. "You shouldn't do things like that, just tell someone you feel bad."
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Disapproving gives the impression that the nurse has a right to pass judgment on the client's thoughts, actions, or ideas. (B) Giving a broad opening gives the client encouragement to continue with verbalization.
(C) Failing to acknowledge the client's feelings conveys a lack of understanding and empathy. (D) Changing the subject takes the conversation away from the client and is indicative of the nurse's anxiety or insensitivity.
NEW QUESTION 78
The nurse documents a client's surgical incision as having red granulated tissue. This indicates that the wound is:
- A. Healing
- B. Necrotic
- C. Infected
- D. Not healing
Answer: A
Explanation:
(A)
The wound is not infected. An infected wound would contain pus, debris, and exudate.
(B)
The wound is healing properly. (C) A necrotic wound would appear black or brown. (D) The wound is healing properly and is filled with red granulated tissue and fragile capillaries.
NEW QUESTION 79
A 25-year-old outpatient presents with a diagnosis of compulsive personality disorder. His coworkers become annoyed with his rigid, perfectionistic manner and preoccupation with trivial details and schedules.
A nursing intervention appropriate for this client would include:
- A. Encouraging him to engage in recreational activities
- B. Avoiding discussion of his annoying behavior
- C. Contracting with him for the amount of time he will spend on the compulsive behaviors
- D. Encouraging the client to set a time schedule and deadlines for himself
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) This answer is incorrect. The client will work hard at the activity instead of enjoying it. (B) This answer is incorrect. The nurse should allow the client to discuss these thoughts, within limits, not to avoid discussing them. (C) This answer is incorrect. The compulsive client tends to control time to excess. It should not be encouraged. (D) This answer is correct. A contract with the client regarding the amount of time that will be spent discussing the compulsive activities is appropriate. Time allotted should be gradually decreased.
NEW QUESTION 80
A female client has just died. Her family is requesting that all nursing staff leave the room. The family's religious leader has arrived and is ready to conduct a ceremony for the deceased in the room, requesting that only family members be present. The nurse assigned to the client should perform the appropriate nursing action, which might include:
- A. Tell the family that they may conduct their ceremony in the client's room; however, the nurse must attend.
- B. Refuse to leave the room because the client's body is entrusted in the nurse's care until it can be brought to the morgue.
- C. Inform the family that it is the hospital's policy not to conduct religious ceremonies in client rooms.
- D. Respect the client's family's wishes.
Answer: D
Explanation:
Explanation
(A) It is rare that a hospital has a specific policy addressing this particular issue. If the statement is true, the nurse should show evidence of the policy to the family and suggest alternatives, such as the hospital chapel.
(B) Refusal to leave the room demonstrates a lack of understanding related to the family's need to grieve in their own manner. (C) The nurse should leave the room and allow the family privacy in their grief. (D) The family's wish to conduct a religious ceremony in the client's room is part of the grief process. The request is based on specific cultural and religious differences dictating social customs.
NEW QUESTION 81
Parents should be taught not to prop the bottle when feeding their infants. In addition to the risk of choking, it puts the infant at risk for:
- A. Otitis media
- B. Asthma
- C. Conjunctivitis
- D. Tonsillitis
Answer: A
Explanation:
Explanation
(A) Because the eustachian tube is short and straight in the infant, formula that pools in the back of the throat attacks bacteria which can enter the middle ear and cause an infection. (B) Asthma is not associated with propping the bottle. (C) Conjunctivitis is an eye infection and not associated with propping the bottle. (D) Tonsillitis is usually a result of pharyngitis and not propping the bottle.
NEW QUESTION 82
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. Drive potassium from the serum back into the cells
- B. Protect the myocardium from the effects of hypokalemia
- C. Remove the potassium from the body by renin exchange
- D. Promote rapid protein catabolism
Answer: A
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 83
A 38-year-old female client with a history of chronic schizophrenia, paranoid type, is currently an outpatient at the local mental health and mental retardation clinic. The client comes in once a week for medication evaluation and/or refills. She self-administers haloperidol 5 mg twice a day and benztropine 1 mg once a day. During a recent clinic visit, she says to the nurse, "I can't stay still at night. I toss and turn and can't fall asleep." The nurse suspects that she may be experiencing:
- A. Dystonia
- B. Opisthotonos
- C. Akinesia
- D. Akathisia
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Akathisia, or motor restlessness, is a reversible EPS frequently associated with the administration of antipsychotic drugs such as haloperidol. (B) Akinesia, or muscular or motor retardation, is an example of reversible EPS frequently associated with the administration of major tranquilizers such as haloperidol. (C) Acute dystonic reactions, bizarre and severe muscle contractions usually of the tongue, face, neck or extraocular muscles, are examples of EPS. (D) Opisthotonos, a severe type of whole-body dystonic reaction in which the head and heels are bent backward while the body is bowed forward, is an example of EPS.
NEW QUESTION 84
Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following statements by the client would validate an understanding of his medication?
- A. "I should always take this medication with an antacid."
- B. "I should only take the medication if my heart rate is greater than 100 bpm."
- C. "I would notify my physician immediately if I experience nausea, vomiting, and double vision."
- D. "I could stop taking this medication when I begin to feel better."
Answer: C
Explanation:
Explanation
(A) The first signs of digoxin toxicity include abdominal pain, anorexia, nausea, vomiting, and visual disturbances. The physician should be notified if any of these symptoms are experienced. (B) The positive inotropic effects of digoxin increase cardiac output and result in an enhanced activity tolerance. "Feeling better" indicates the drug is working and medication therapy must be continued. (C) Clients should be taught to take their pulse prior to taking the digoxin. If their pulse rate becomes irregular, slows significantly, or is
>100 bpm the physician should be notified. (D) Antacids decrease the effectiveness of digoxin.
NEW QUESTION 85
The nurse who is caring for a client with pneumonia assesses that the client has become increasingly irritable and restless. The nurse realizes that this is a result of:
- A. Prolonged bed rest
- B. The client's maintaining a semi-Fowler position
- C. IV fluids of 2.5-3 liters in 24 hours
- D. Cerebral hypoxia
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Maintaining bed rest helps to decrease the O2 needs of the tissues, which decreases dyspnea and workload on the respiratory system. (B) The semi-Fowler or high-Fowler position is necessary to aid in lessening pressure on the diaphragm from the abdominal organs, which facilitates comfort and easier breathing patterns. (C) Cerebral hypoxia causes the client with pneumonia to be increasingly irritable and restless and results from the client not obtaining enough O2 to meet metabolic needs. (D) Proper hydration facilitates liquefaction of mucus trapped in the bronchioles and alveoli and enhances expectoration. Unless contraindicated, a reasonable amount of IV fluids to be administered is at least 2.5-3 liters in a 24-hour period.
NEW QUESTION 86
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