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Passing the NCLEX-RN exam is a crucial step in obtaining licensure as a registered nurse in the United States. It is important to note that the exam is not designed to test a candidate's memorization skills but rather their ability to apply their knowledge and critical thinking skills to real-world nursing scenarios. As such, candidates must not only be well-versed in the material but must also be able to think critically and make sound decisions under pressure.
NCLEX-RN exam is a critical step in the process of becoming a licensed RN in the United States. NCLEX-RN exam is designed to ensure that all RNs possess the knowledge and skills necessary to provide safe and effective care to patients. Students should take advantage of nursing program resources and test preparation materials to ensure that they are fully prepared to pass the exam and begin their careers as RNs.
NEW QUESTION # 312
A 5-year-old child was recently diagnosed as having acute lymphoid leukemia. She is hospitalized for additional tests and to begin a course of chemotherapy designed to induce a remission. She is scheduled to have a bone marrow aspiration tomorrow. She has had a bone marrow test previously and is apprehensive about having another. Which of the following interventions will be most effective in relieving her anxiety?
- A. Explain what will take place and what she will see, feel, and hear.
- B. Remind her that she has had this procedure before and that it is nothing to be afraid of.
- C. Tell her not to worry about it, that it will be over soon and she can join her friends in the playroom.
- D. Give her a big hug and tell her that she is a big girl now and that she will do just fine.
Answer: A
Explanation:
Explanation
(A) Even though the child has had the procedure before, she will probably need additional explanations and emotional support. (B) The fact that the child has had the procedure before and possibly found it painful or uncomfortable may increase, not relieve, her stress. (C) This intervention does nothing to reassure the child and may well prevent her from expressing her feelings. (D) This does not prepare the child for the test and burdens her with the expectation that she act bigger and braver than she is.
NEW QUESTION # 313
A 6-year-old child returned to the surgical floor 20 hours ago after an appendectomy for a gangrenous appendix. His mother tells the nurse that he is becoming more restless and is anxious. Assessment findings indicate that the child has atelectasis. Appropriate nursing actions would include:
- A. Having the child turn, cough, and deep breathe every 1-2 hours
- B. Remaining with the child and keeping as calm and quiet as possible
- C. Administering analgesics as ordered
- D. Allowing the child to remain in the position of comfort, preferably semi-or high-Fowler position
Answer: A
Explanation:
Section: Questions Set G
Explanation:
(A) Allowing the client to remain in the position of comfort will not resolve the atelectasis. This position, if left unchanged, over time may actually increase the atelectasis. (B) Analgesics will not resolve the atelectasis and may contribute to it if proper nursing actions are not taken to help resolve the atelectasis. (C) Having the client turn, cough, and deep breathe every 1-2 hours will aid in resolving the atelectasis. Surgery clients are at risk for postoperative respiratory complications because pulmonary function is reduced as a result of anesthesia and surgery. (D) Remaining with the client and keeping him calm and quiet will not affect the client's anxiety, restlessness, or help to resolve the atelectasis. The cause (atelectasis) needs to be treated, not the symptoms (anxiety and restlessness).
NEW QUESTION # 314
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. Assess the FHR.
- B. Note the color and amount of fluid on her clothes.
- C. Place the nitrazine test paper at the cervical os and note the color change.
- D. Notify the physician.
Answer: A
Explanation:
Section: Questions Set F
Explanation:
(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.
NEW QUESTION # 315
A client is being treated for congestive heart failure. His medical regimen consists of digoxin (Lanoxin) 0.25 mg po daily and furosemide 20 mg po bid. Which laboratory test should the nurse monitor?
- A. Potassium
- B. Intake and output
- C. Magnesium
- D. Calcium
Answer: A
Explanation:
(A) Intake and output are not laboratory tests. (B) Serum calcium levels are not affected by digoxin or furosemide. (C) Furosemide is a non-potassium-sparing loop diuretic. Hypokalemia is a common side effect of furosemide and may enhance digoxin toxicity. (D) Serum magnesium levels are not affected by digoxin or furosemide.
NEW QUESTION # 316
A client is in active labor and has been admitted to the labor and delivery unit. The RN has just done a sterile vaginal exam and determines that the client is dilated 5 cm, effaced 85%, and the fetus's head is at 0 station. She asks if she could have a lumbar epidural now. The epidural is started, and the anesthetic agent used is bupivacaine (Marcaine). After the client has received her lumbar epidural, it is important for the RN to monitor her for which of the following side effects:
- A. Hyperglycemia
- B. Hypertension
- C. Hypoglycemia
- D. Hypotension
Answer: D
Explanation:
(A) The medication bupivacaine will cause vasodilation in the vascular system, and this does not result in elevation of the ma-ternal blood pressure. (B) The medication bupivacaine will cause vasodilation in the vascular system, and this will result in lowering the maternal blood pressure. (C) Bupivacaine does not interfere with the functioning of the endocrine system. (D) Bupivacaine does not interfere with the functioning of the endocrine system.
NEW QUESTION # 317
A 4-year-old child with a history of sickle cell anemia is admitted to the nursing unit with dizziness, shortness of breath, and pallor. Nursing assessment findings reveal tenderness in the abdomen. The child is most likely experiencing a/an:
- A. Sequestration crisis
- B. Vaso-occlusive crisis
- C. Dactylitis crisis
- D. Aplastic crisis
Answer: A
Explanation:
(A) Aplastic anemia is characterized by a lack of reticulocytes in the blood. Platelet and white blood cell counts are usually not depressed. It is usually self-limiting, lasting 5-10 days. (B) Vaso-occlusive crisis is the most common type of crisis in sickle cell anemia. Sickled cells become clogged, leading to distal tissue hypoxia and infarction. Joints and extremities are the most commonly affected areas. (C) Dactylitis crisis, or "hand-foot syndrome," causes symmetrical infarction of the bones in the hands and feet, resulting in painful swelling in the soft tissues of the hands and feet. (D) Sequestration crisis occurs as enormous volumes of blood pool within the spleen. The spleen enlarges, causing tenderness. Signs of shock including pallor, tachypnea, and faintness result, related to the deficient intravascular volume. This type of crisis is potentially fatal.
NEW QUESTION # 318
A husband and wife and their two children, age 9 and age 5, are requesting family therapy.
Which of the following strategies is most therapeutic for the nurse to use during the initial interaction with a family?
- A. Allow family members to assume the seats as they choose.
- B. Encourage the mother to speak for the children.
- C. Interpret immediately what seems to be going on within the family.
- D. Always allow the most vocal person to state the problem first.
Answer: A
Explanation:
(A) One will always hear what the most vocal person has to say. It is best to start with the quietest family member to encourage that person to express emotions. (B) All family members are encouraged to speak for themselves. (C) In the initial family assessment, only data collection occurs; interpretations are made later. (D) Allowing family members to choose their own seats will assist the nurse in assessing the family system and in determining who feels closer to whom.
NEW QUESTION # 319
A 9-month-old infant visits her pediatrician for a routine visit. A developmental assessment was initiated by the nurse. Which skill would cause the nurse to be concerned about the infant's developmental progression?
- A. She pulls herself to her feet with help.
- B. She stands while holding onto furniture.
- C. She sits briefly alone with assistance.
- D. She creeps and crawls.
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) The 9-month-old infant can sit alone for long periods. By the age of 6 months, many infants can pull themselves to a sitting position. (B, C, D) This skill represents normal development.
NEW QUESTION # 320
A mother came to the pediatric clinic with her 17- month-old child. The mother would like to begin toilet training. What should the nurse teach her about implementing toilet training?
- A. Show disapproval if she does not void or defecate.
- B. Explain to the child she is going to "void" and "defecate."
- C. Have a child-sized toilet seat or training potty on hand.
- D. Take two or three favorite toys with the child.
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Giving her toys will distract her and interfere with toilet training because of inappropriate reinforcement.
(B) A child-sized toilet seat or training potty gives a child a feeling of security. (C) She should use words that are age appropriate for the child. (D) Children should be praised for cooperative behavior and/or successful evacuation.
NEW QUESTION # 321
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 not be concerned about having to fly on a commuter airplane on a weekly basis.
- B. He should monitor his sputum, stools, and urine for signs of bleeding.
- C. His daily diet should include a large amount of fluid.
- D. He should not worry about having children because this disease is passed on only by female carriers.
Answer: C
Explanation:
(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.
NEW QUESTION # 322
A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following nutritional interventions would be most therapeutic for him at this time?
- A. Small, frequent feedings of foods that can be carried
- B. Tube feedings with nutritional supplements
- C. Giving him a quiet place where he can sit down to eat meals
- D. Allowing him to eat when and what he wants
Answer: A
Explanation:
(A) The manic client is unable to sit still long enough to eat an adequate meal. Small,
frequent feedings with finger foods allow him to eat during periods of activity. (B) This type of therapy should be implemented when other methods have been exhausted. (C) The manic client should not be in control of his treatment plan. This type of client may forget to eat. (D) The manic client is unable to sit down to eat full meals.
NEW QUESTION # 323
A client has ascites, which is caused by:
- A. Electrolyte imbalance
- B. Decreased plasma proteins
- C. Portal hypertension
- D. Decreased renal function
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) A decrease in plasma proteins causes a decrease in intravascular osmotic pressure resulting in leakage of fluid into peritoneal cavity. (B) Fluid and electrolyte imbalance may occur as a result of the ascites. (C) Ascites is a result of hepatic malfunction, not renal malfunction. (D) Portal hypertension causes esophageal varices, not ascites.
NEW QUESTION # 324
A 2-month-old infant is receiving IV fluids with a volume control set. The nurse uses this type of tubing because it:
- A. Prevents entry of air into tubing
- B. Prevents phlebitis
- C. Prevents inadvertent administration of a large amount of fluids
- D. Prevents administration of other drugs
Answer: C
Explanation:
(A) A volume control set has a chamber that permits the administration of compatible drugs. (B) Air may enter a volume control set when tubing is not adequately purged. (C) A volume control set allows the nurse to control the amount of fluid administered over a set period. (D) Contamination of volume control set may cause phlebitis.
NEW QUESTION # 325
A 29-year-old client is admitted for a hysterectomy. She has repeatedly told the nurses that she is worried about having this surgery, has not slept well lately, and is afraid that her husband will not find her desirable after the surgery. Shortly into the preoperative teaching, she complains of a tightness in her chest, a feeling of suffocation, lightheadedness, and tingling in her hands. Her respirations are rapid and deep.
Assessment reveals that the client is:
- A. Wanting attention from the nurses
- B. Having a heart attack
- C. Suffering from complete upper airway obstruction
- D. Hyperventilating
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Classic symptoms of a heart attack include heaviness or squeezing pain in the chest, pain spreading to the jaw, neck, and arm. Nausea and vomiting, sweating, and shortness of breath may be present. The client does not exhibit these symptoms. (B) Clients suffering from anxiety or fear prior to surgical procedures may develop hyperventilation. This client is not seeking attention. (C) Symptoms of complete airway obstruction include not being able to speak, and no airflow between the nose and mouth. Breath sounds are absent. (D) Tightness in the chest; a feeling of suffocation; lightheadedness; tingling in the hands; and rapid, deep respirations are signs and symptoms of hyperventilation. This is almost always a manifestation of anxiety.
NEW QUESTION # 326
A 65-year-old client who has a new colostomy is preparing for discharge from the hospital. As part of the instructions on colostomy care, the nurse explains to the client that to regulate the bowel, colostomy irrigation should be performed at the same time each day. The best time is:
- A. Before meals
- B. Every 2 hours
- C. After meals
- D. At bedtime
Answer: C
Explanation:
(A) Bowel movements should be regulated at a specific time each day to prevent "accidents." Irrigating after meals takes advantage of the gastrocolic reflex and time of increased peristalsis, so better results may be produced. After meals is the normal time that peristalsis begins in most persons and evacuation of feces occurs. (B) Irrigating before meals may cause poor results because of decreased gastrocolic reflex and decreased peristalsis. (C) Irrigating a colostomy every 2 hours may produce hyperactivity of the bowel, leading to irritation and diarrhea. This would not aid in regulation of the bowel. (D) If irrigation of a colostomy were done at bedtime, there is greater chance of having an "accident" during sleep. This would not be an advantageous practice of bowel regulation.
NEW QUESTION # 327
When caring for a postoperative cholecystectomy client, the nurse assesses patency and documents drainage of the T-tube. The nurse recognizes that the expected amount of drainage during the first 24 hours postoperatively is:
- A. 200-300 mL
- B. 50-100 mL
- C. 1000-1200 mL
- D. 300-500 mL
Answer: D
Explanation:
Explanation
(A) During the first 24 hours after surgery, the drainage is normally 300-500 mL and then decreases to about
200 mL in 24 hours during the next 3-4 days. (B) This range is the amount of drainage after the first 24 hours postoperatively. During the first 24 hours, it is 300-500 mL. (C) During the first 24 hours after surgery, this range is the expected amount of drainage. (D) The expected amount of drainage during the first 24 hours is
300-500 mL. An output of >500 mLshould be reported to the physician, because an occlusion of some type, caused by a retained gallstone or an inflammatory process within the biliary drainage system, is evident.
NEW QUESTION # 328
On the third postpartum day, the nurse would expect the lochia to be:
- A. Alba
- B. Serosa
- C. Rubra
- D. Scant
Answer: C
Explanation:
(A) This discharge occurs from delivery through the 3rd day. There is dark red blood, placental debris, and clots. (B) This discharge occurs from days 4-10. The lochia is brownish, serous, and thin. (C) This discharge occurs from day 10 through the 6thweek. The lochia is yellowish white. (D) This is not a classification of lochia but relates to the amount of discharge.
NEW QUESTION # 329
The nurse writes the following nursing diagnosis for a client in acute renal failure-Impaired gas exchange related to:
- A. Increased levels of vitamin D
- B. Decreased red blood cell production
- C. Decreased production of renin
- D. Increased red blood cell production
Answer: B
Explanation:
Explanation
(A) Red blood cell production is impaired in renal failure owing to impaired erythropoietin production. This causes a decrease in the delivery of oxygen to the tissue and impairs gas exchange. (B) The conversion of vitamin D to its physiologically active form is impaired in renal failure. (C) In renal failure, a decrease in red blood cell production occurs owing to an impaired production of erythropoietin, leading to impaired gas exchange at the cellular level. (D) The decreased production of renin in renal failure causes an increased production of aldosterone causing sodium and water retention.
NEW QUESTION # 330
Which of the following nursing actions is essential to prevent drug-resistant tuberculosis?
- A. Monitor renal function.
- B. Monitor compliance with drug therapy.
- C. Monitor liver function.
- D. Assess knowledge of respiratory isolation.
Answer: B
Explanation:
Section: Questions Set D
Explanation:
(A) Monitoring liver function will not prevent the development of drug-resistant organisms. (B) Monitoring renal function will not prevent the development of drug-resistant organisms. (C) Knowledge of respiratory isolation will reduce transmission of tuberculosis but will not prevent development of drug-resistant organisms. (D) Noncompliance with prescribed antituberculosis drug regimen is the primary cause of drug-resistant organisms. Noncompliance permits the mutation of organisms.
NEW QUESTION # 331
A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements?
- A. "As soon as I leave here, I'm throwing away my medicines. I never thought I needed them anyway."
- B. "When I get home, I should be able to taper myself off the Haldol because the voices are gone now."
- C. "If I have any side effects from my medicines, I will take an extra dose of Cogentin."
- D. "When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices."
Answer: D
Explanation:
Explanation
(A) The client verbalizes that he is responsible for compliance and keeping the treatment team member informed of progress. This behavior puts him at the lowest risk for relapse. (B) Noncompliance is a major cause of relapse. This statement reflects lack of responsibility for his own health maintenance. (C) This statement reflects lack of insight into the importance of compliance. (D) This statement reflects no insight into his illness or his responsibility in health maintenance.
NEW QUESTION # 332
The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which of the following indicates that he understands this teaching?
- A. "I'll be sure to walk at least 2-3 blocks every day."
- B. "I'll be sure to restrict my fluid intake to four or five glasses a day."
- C. "I'll be sure not to take any more aspirin while I amon this drug."
- D. "I'll be sure to rise slowly and sit for a few minutes after lying down."
Answer: D
Explanation:
Explanation
(A) This response will help to prevent the occurrence of postural hypotension, a common side effect of this drug and a common reason for falls. (B) Although walking is an excellent exercise, it is not specific to the reduction of risks associated with diuretic therapy. (C) Clients on diuretic therapy are generally taught to ensure that their fluid intake is at least 2000-3000 mL daily, unless contraindicated. (D) Aspirin is a safe drug to take along with furosemide.
NEW QUESTION # 333
A 19-year-old client has sustained a C-7 fracture, which resulted in his spinal cord being partially transected.
By 2 weeks' postinjury, his neck has been surgically stabilized, and he has been transferred from the intensive care unit. A potential life-threatening complication the nurse monitors the client for is:
- A. Central cord syndrome
- B. Spinal shock
- C. Bradycardia
- D. Autonomic dysreflexia
Answer: D
Explanation:
Explanation
(A) Autonomic dysreflexia is the exaggerated sympathetic nervous system response to various stimuli in the anesthetized area. Sympathetic stimulation results in severe, uncontrolled hypertension, which may result in myocardial infarction or cerebral hemorrhage. (B) Bradycardia occurs as a result of sympathetic blockade in the immediate postinjury period. After spinal shock recedes, cardiovascular stability returns, but the client will be bradycardiac for life. (C) Central cord syndrome is a specific type of spinal cord injury that occurs as a result of either hyperextension injuries or disrupted blood flow to the spinal cord. (D) Spinal shock occurs in the immediate postinjury phase and usually resolves in approximately 72 hours.
NEW QUESTION # 334
A 7-year-old child is brought to the ER at midnight by his mother after symptoms appeared abruptly. The nurse's initial assessment reveals a temperature of 104.5F (40.3C), difficulty swallowing, drooling, absence of a spontaneous cough, and agitation. These symptoms are indicative of which one of the following?
- A. Acute tracheitis
- B. Acute epiglottis
- C. Acute laryngotracheobronchitis
- D. Acute spasmodic croup
Answer: B
Explanation:
Explanation
(A) Clinical manifestations of acute tracheitis include a 2-3 day history of URI, croupy cough, stridor, purulent secretions, high fever. (B) Clinical manifestations of spasmodic croup include a history of URI, croupy cough, stridor, dyspnea, low-grade fever, and a slow progression. The age group most affected is 3 months to 3 years. (C) Three clinical observations have been found to be predictive of epiglottitis: the presence of drooling, absence of spontaneous cough, and agitation.Epiglottitis has a rapid onset that is accompanied by high fever and dysphagia. (D) Clinical manifestations of acute laryngotracheobronchitis (LTB) include slow onset with a history of URI, low-grade fever, stridor, brassy cough, and irritability.
NEW QUESTION # 335
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