[Nov 22, 2021] NCLEX-RN Dumps PDF and Test Engine Exam Questions - TestBraindump
Verified NCLEX-RN exam dumps Q&As with Correct 865 Questions and Answers
NEW QUESTION 109
A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will:
- A. Wash her hands before and after voiding
- B. Drink at least 8 oz of cranberry juice daily
- C. Maintain a fluid intake of at least 2000 mL daily
- D. Limit her fluid intake after 6 PM so that there is not a great deal of urine in her bladder while she sleeps
Answer: D
Explanation:
(A)
Cranberry juice helps to maintain urine acidity, thereby retarding bacterial growth. (B) A generous fluid intake will help to irrigate the bladder and to prevent bacterial growth within the bladder. (C) Hand washing is an effective means of preventing pathogen transmission.
(D)
Restricting fluid intake would contribute to urinary stasis, which in turn would contribute to bacterial growth.
NEW QUESTION 110
Which of the following nursing care goals has the highest priority for a child with epiglottitis?
- A. Be afebrile throughout her hospital stay.
- B. Participate in play activities 4 hr/day.
- C. Sleep or lie quietly 10 hr/day.
- D. Consume foods from all four food groups.
Answer: C
Explanation:
Explanation
(A) Of these four goals, maintenance of a calm, quiet atmosphere to reduce anxiety and to allow for rest is the most important. (B) Although nutrition is important, the child needs fluids to maintain fluid and electrolyte balance more than solid foods. In addition, the child may not be able to swallow solid foods owing to epiglottic swelling. (C) This goal is unrealistic because fever is a common symptom of the infection associated with epiglottitis. (D) If overexerted, the child will need more O2 and energy than available, and these requirements may exacerbate the condition.
NEW QUESTION 111
A 60-year-old woman exhibits forgetfulness, emotional lability, confusion, and decreased concentration.
She has been unable to perform activities of daily living without assistance. After a thorough medical evaluation, a diagnosis of Alzheimer's disease was made. An appropriate nursing intervention to decrease the anxiety of this client would include:
- A. Allowing the client to perform activities of daily living as much as possible unassisted
- B. Providing a highly stimulating environment
- C. Reality testing
- D. Confronting confabulations
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) This answer is correct. The more the client is able to control her daily routine, the less anxiety she will experience. (B) This answer is incorrect. Confrontation tends to increase anxiety. (C) This answer is incorrect. Reality testing is an assessment tool. It does not decrease anxiety. (D) This answer is incorrect.
A highly stimulating environment increases distractibility and anxiety.
NEW QUESTION 112
A registered nurse is trying to determine the appropriate care that she should provide for her obstetrical clients. Which of the following documents is considered the legal standard of practice?
- A. State nursing practice act
- B. American Nurses' Association Standards of Maternal- Child Health Nursing
- C. International Council of Nurses' Code
- D. AWHONN Standards for the Nursing Care of Women and Newborns
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) The state nursing practice act determines the standard of care for the professional nurse. (B) AWHONN Standards are published as recommendations and guidelines for maternal-newborn nursing. (C) American Nurses' Association Standards are published as recommendations and guidelines for maternalchild health nursing. (D) The International Council of Nurses' Code emphasizes the nurse's obligations to the client rather than to the physician. It is published as recommendations and guidelines by the international organization for professional nursing.
NEW QUESTION 113
A client has consented to have a central venous catheter placed. The best position in which to place the client is the Trendelenburg position. The reason is that the Trendelenburg position:
- A. Allows the physician to visualize the subclavian vein
- B. Reduces the possibility of air embolism
- C. Reduces the possibility of hematoma formation
- D. Makes the procedure more comfortable for the client
Answer: B
Explanation:
Section: Questions Set C
Explanation:
(A) The subclavian vein is not visible during central line insertion regardless of the client's position. (B) The Trendelenburg position reduces the possibility of air embolism because it places slight positive pressure on the central veins. It also distends the veins, and distention facilitates insertion. (C) This response is untrue; it has no effect on hematoma formation. (D) This position is not necessarily more comfortable for the client, and many clients, especially those who may be short of breath, may find the position uncomfortable and difficult to maintain.
NEW QUESTION 114
A murmur has been discovered during the routine physical examination of a 1-year-old child. The parent is extremely concerned about this diagnosis. Which of the following explanations by the nurse indicates understanding of this dysfunction?
- A. Surgical closure by suture or patch is recommended before school age.
- B. Most atrial septal defects close spontaneously.
- C. The blood shifts from the right to the left atrium.
- D. The child can be treated medically with antibiotics to prevent bacterial endocarditis.
Answer: A
Explanation:
Explanation
(A) Because the left atrial pressure is greater than right atrial pressure, oxygenated blood flows from the left to the right atria. (B) Because of the risk of pulmonary obstructive diseases and congestive heart failure later in life, surgery is usually performed between age 4 and 6 years, with essentially no operative mortality or postoperative complications. (C) Many ventricular septal defects close spontaneously (20-60%) as a result of growth and proliferation of the muscular septum or formation of a membrane across the opening. (D) This management is usually recommended with children with mild pulmonary stenosis.
NEW QUESTION 115
A client is being admitted to the labor and delivery unit. She has had previous admissions for "false labor." Which clinical manifestation would be most indicative of true labor?
- A. Uterine contractions
- B. Increased bloody show
- C. Decreased discomfort with ambulation
- D. Progressive dilatation and effacement of the cervix
Answer: D
Explanation:
Explanation
(A) Bloody show is considered a sign of imminent labor, which usually begins in 24-48 hours. An increase in bloody show is an indication that the cervix is changing. (B) Contractions of true labor produce progressive cervical effacement and dilatation. (C) Contractions of false labor may mimic those of true labor. However, the contractions of false labor do not produce progressive effacement and dilatation of the cervix. (D) In true labor, the discomfort is not relieved by ambulation; walking may intensify the discomfort.
NEW QUESTION 116
A male client received a heart-lung transplant 1 month ago at a local transplant center. While visiting the nursing center to have his blood pressure taken, he complains of recent weakness and fatigue. He also tells the nurse that he is considering stopping his cyclosporine because it is expensive and is causing his face to become round. He fears he will catch viruses and be more susceptible to infections. The nurse responds to this last statement by explaining that cyclosporine:
- A. May initially cause weakness, dizziness, and fatigue, but these side effects will gradually resolve themselves
- B. Is given to prevent rejection and makes him less susceptible to infection than other oral corticosteroids
- C. Is usually not necessary after the first year following transplantation
- D. Is available at discount pharmacies for a reduced price
Answer: B
Explanation:
(A) Cyclosporine is the immunosuppressive drug of choice. It provides immunosuppression but does not lower the white blood cell count; therefore, the client is less susceptible to infection. (B) Cyclosporine is available at discount pharmacies. The cost may be absorbed by health insurance, or Medicare, if the client is eligible. However, this statement does not address the entire problem verbalized by the client. (C) Immunosuppressive agents will be taken for the client's entire life because rejection can occur at any time. (D) These side effects do not necessarily resolve in time; however, the client may adapt.
NEW QUESTION 117
A 5-year-old child is hospitalized for an acute illness. The nurse encourages the family to bring her favorite objects from home. What is the nurse's rationale?
- A. To prevent or minimize separation anxiety
- B. To keep the child calm
- C. To establish a trusting relationship
- D. To reduce fear of the unknown
Answer: A
Explanation:
Explanation
(A) Objects from home do not reduce fear of the unknown. Children need explanations, reassurance, and preparation for the unknown. Also, parental presence can promote comfort and feelings of security. (B) A calm, relaxed, and reassuring manner will assist in calming the child. The child's objects from home will not assist in calming the child. (C) A trusting relationship is based on the quality of the nurse-client relationship.
Objects from home have no impact. (D) Favorite objects from home assist in creating a familiar setting. Also, these objects may prevent or minimize separation from the child's usual routine and family support.
NEW QUESTION 118
On an assessment of a client's mouth, the nurse notices white patches on the buccal mucosa. The nurse tries to obtain a sample for a culture, but the lesion cannot be rubbed off. The nurse would suspect that this lesion is:
- A. Xerosteromia
- B. Leukoplakia
- C. Stomatitis
- D. Candidiasis
Answer: B
Explanation:
Explanation
(A) Xerostomia is dry mouth. (B) Candidiasis can be rubbed off, but it will bleed. (C) Leukoplakia cannot be rubbed off. (D) Stomatitis is caused by candidiasis and gram-negative bacteria.
NEW QUESTION 119
Which of the following physician's orders would the nurse question on a client with chronic arterial insufficiency?
- A. Arteriogram in the morning
- B. Neurovascular checks every 2 hours
- C. Elevate legs on pillows
- D. No smoking
Answer: C
Explanation:
(A) Neurovascular checks are a routine part of assessment with clients having this diagnosis. (B) Elevation of the legs is contraindicated because it reduces blood flow to areas already compromised. (C) Arteriogram is a routine diagnostic order. (D) Smoking is highly correlated with this disorder.
NEW QUESTION 120
A male client has asthma and his physician has prescribed beclomethasone (Vanceril) 3 puffs tid in addition to his other medications. After taking his beclomethasone, the client should be instructed to:
- A. Use his bronchodilator inhaler
- B. Drink a glass of water
- C. Clean his inhaler with warm water and soak it in a 10% bleach solution
- D. Sit and rest
Answer: B
Explanation:
Section: Questions Set C
Explanation:
(A) Inhalers should be cleaned once a day. They should be taken apart, washed in warm water, and dried according to manufacturer's instructions. Soaking in bleach is inappropriate. (B) A common side effect of inhaled steroid preparations is oral candidal infection. This can be prevented by drinking a glass of water or gargling after using a steroid inhaler. (C) There is nothing wrong with sitting and resting after using a steroid inhaler, but it is not necessary. (D) If a person is using a steroid inhaler as well as a bronchodilator inhaler, the bronchodilator should always be used first. The reason for this is that the bronchodilator opens up the person's airways so that when the steroid inhaler is used next, there will be better distribution of medication.
NEW QUESTION 121
A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse anticipates the physician ordering:
- A. Tetracycline
- B. Oxytocin
- C. Magnesium sulfate (MgSO4)
- D. Ampicillin
Answer: D
Explanation:
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 122
The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:
- A. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation
- B. Immediate treatment of mild PIH includes the administration of a variety of medications
- C. Self-discipline is required to control caloric intake throughout the pregnancy
- D. The client may not recognize the early symptoms of PIH
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Mild PIH is not treated with medications. (B) Emotional stress is not the cause of blood pressure elevation in PIH. (C) Excessive caloric intake is not the cause of weight gain in PIH. (D) The client most frequently is not aware of the signs and symptoms in mild PIH.
NEW QUESTION 123
A male client is started on IV anticoagulant therapy with heparin. Which of the following laboratory studies will be ordered to monitor the therapeutic effects of heparin?
- A. Red blood cell (RBC) count
- B. Partial thromboplastin time
- C. Hemoglobin
- D. Prothrombin time
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Partial thromboplastin time is used to monitor the effects of heparin, and dosage is adjusted depending on test results. It is a screening test used to detect deficiencies in all plasma clotting factors except factors VII and XIII and platelets. (B) Hemoglobin is the main component of RBCs. Its main function is to carry O2from the lungs to the body tissues and to transport CO2back to the lungs. (C) RBC count is the determination of the number of RBCs found in each cubic millimeter of whole blood. (D) PT is used to monitor the effects of oral anticoagulants, e.g., coumarintype anticoagulants.
NEW QUESTION 124
A child with celiac disease is being discharged from the hospital. The mother demonstrates knowledge of nutritional needs of her child when she is able to state the foods which are included in a:
- A. Gluten-restricted diet
- B. Lactose-restricted diet
- C. Phenylalanine-restricted diet
- D. Fat-restricted diet
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) A lactose-restricted diet is prescribed for children with lactose intolerance or diarrhea. (B) A gluten- restricted diet is the diet for children with celiac disease. (C) A phenylalaninerestricted diet is prescribed for children with phenylketonuria. (D) A fat-restricted diet is prescribed for children with disorders of the liver, gallbladder, or pancreas.
NEW QUESTION 125
A measurable outcome criterion in the nursing care of an adolescent with anorexia nervosa would be:
- A. Exhibiting increased self-esteem
- B. Having an improved perception of her body image
- C. Verbalizing realistic feelings about her body
- D. Accepting her present body image
Answer: C
Explanation:
(A) This outcome criterion is inadequate because the term "accepts" is not directly measurable. (B) This outcome criterion is directly measurable because specific goal-related verbalizations can be heard and verified by the nurse. (C) "Improved perception of body image" is not directly measurable and is therefore open to many interpretations. (D) Although long-term goals for the anorexic client should focus on increased self-esteem, this outcome criterion (as stated) does not include specific indicators or behaviors for which to observe.
NEW QUESTION 126
The therapeutic blood-level range for lithium is:
- A. 0.25-1.0 mEq/L
- B. 1.0-2.0 mEq/L
- C. 2.0-2.5 mEq/L
- D. 0.5-1.5 mEq/L
Answer: D
Explanation:
(A) This range is too low to be therapeutic. (B) This is the therapeutic range for lithium. (C) This range is above the therapeutic level. (D) This range is toxic and may cause severe side effects.
NEW QUESTION 127
A male client is admitted to the psychiatric unit after experiencing severe depression. He states that he intends to kill himself, but he asks the nurse not to repeat his intentions to
other staff members. Which response demonstrates understanding and appropriate action on the part of the nurse?
- A. "This is very serious. I do not want any harm to come to you. I will have to report this to the rest of the staff."
- B. "We need to discuss this further, but right now let's complete these forms."
- C. "I understand you're depressed, but killing yourself is not a reasonable option."
- D. "Don't do that, you have so much to live for. You have a wonderful wife and children. The client in the next room has no one."
Answer: A
Explanation:
(A) To the client, suicide may be a reasonable action and the only one he can cope with at this time. (B) This response indicates to the client that his intention to commit suicide is not important to the nurse at this time. (C) The client is so depressed that he is not able to see the positive aspects of his life. At no time should the nurse discuss another client's problems in conversation. (D) This statement tells the client that the nurse recognizes his problem is of a serious nature and will take all steps necessary to help him.
NEW QUESTION 128
A 26-year-old female client presents at 10 weeks' gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her grandmother also has insulin-dependent diabetes. The client's previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches tall and her current weight is
130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following factors places her at risk for gestational diabetes?
- A. Maternal weight
- B. Family history of heart disease
- C. Age >25 years
- D. Previous birth of an infant weighing>9 lb
Answer: D
Explanation:
Section: Questions Set F
Explanation:
(A) Maternal age older than 30 years is an identified risk factor for diabetes. Age younger than 30 years is insignificant for diabetes unless there is a familial history of diabetes. (B) The client's weight is appropriate for her height. Obesity or pregnancy weight >20% of the ideal weight is a contributing factor to the development of gestational diabetes. (C) The birth of an infant weighing >9 lb (4000 g) is an identified risk factor for gestational diabetes. (D) A familial history of heart disease is insignificant in the development of diabetes. However, a familial history of type II diabetes mellitus is identified as a risk factor in the development of diabetes during pregnancy.
NEW QUESTION 129
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