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Latest NCLEX NCLEX-RN Practice Test Questions, National Council Licensure Examination(NCLEX-RN) Exam Dumps
NEW QUESTION 257
The parents of a 2-year-old child are ready to begin toilet training activities with him. His parents feel he is ready to train because he is now 2 years old. What would the nurse identify as readiness in this child?
- A. The child awakening wet from his naps
- B. Communicating the urge to defecate or urinate
- C. Patience by the child when wearing soiled diapers
- D. The age at which the child's siblings were trained
Answer: B
Explanation:
(A) Children experience impatience with soiled diapers when readiness for training is apparent. They often desire to be changed immediately. (B) A child must be able to use verbal or nonverbal skills to communicate needs. (C) A readiness indicator would be awaking dry from naps. (D) The age at which a sibling was toilet trained has no implications for training this child.
NEW QUESTION 258
The nurse notes scattered crackles in both lungs and 1+ pitting edema when assessing a cardiac client.
The physician is notified and orders furosemide (Lasix) 80 mg IV push stat. Which of the following diagnostic studies is monitored to assess for a major complication of this therapy?
- A. Complete blood count
- B. Serum electrolytes
- C. Arterial blood gases
- D. 12-Lead ECG
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Furosemide, a potassium-depleting diuretic, inhibits the reabsorption of sodium and chloride from the loop of Henle and the distal renal tubules. Serum electrolytes are monitored for hypokalemia. (B) Severe acid-base imbalances influence the movement of potassium into and out of the cells, but arterial blood gases to not measure the serum potassium level. (C) Furosemide is a potassium-depleting diuretic. A complete blood count does not reflect potassium levels. (D) Abnormalities in potassium (both hyperkalemia and hypokalemia) are reflected in ECG changes, but these changes do not occur until the abnormality is severe.
NEW QUESTION 259
Which classification of drugs is contraindicated for the client with hypertrophic cardiomyopathy?
- A. Diuretics
- B. Vasodilators
- C. Antidysrhythmics
- D. Positive inotropes
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Positive inotropic agents should not be administered owing to their action of increasing myocardial contractility. Increased ventricular contractility would increase outflow tract obstruction in the client with hypertrophic cardiomyopathy. (B) Vasodilators are not typically prescribed but are not contraindicated. (C) Diuretics are used with caution to avoid causing hypovolemia. (D) Antidysrhythmics are typically needed to treat both atrial and ventricular dysrhythmias.
NEW QUESTION 260
The postpartum nurse should include which of the following instructions to breast-feeding mothers?
- A. Daily caloric intake should be increased by 500 cal.
- B. Limit feeding times for several days to avoid nipple soreness.
- C. Wash the nipples with soap and water before and after each feeding.
- D. Breast milk is totally digestible by the baby because it contains lactose.
Answer: A
Explanation:
(A) Limiting initial feeding times will only delay nipple soreness as well as the establishment of the letdown reflex, thus encouraging engorgement from clogged ducts and ductules. (B) Soap should be avoided because it may be excessively drying, predisposing nipples to cracking. (C) For optimal milk production, an additional 500 kcal over maintenance levels are needed daily. (D) Lipase, not lactose, emulsifies the fat in breast milk, making it almost totally digestible by infants.
NEW QUESTION 261
When planning care for the passive-aggressive client, the nurse includes the following goal:
- A. Allow the client to have time away from therapeutic responsibilities.
- B. Allow the client to give excuses if he forgets to give staff information.
- C. Allow the client to use humor, because this may be the only way this client can express self.
- D. Allow the client to express anger by using "I" messages, such as "I was angry when . . .," etc.
Answer: D
Explanation:
Explanation
(A) Ceasing to use humor and sarcasm is a more appropriate goal, because this client uses these behaviors covertly to express aggression instead of being open with anger. (B) Use of "I" messages demonstrates proper use of assertive behavior to express anger instead of passive-aggressive behavior. (C) Client is expected to complete share of work in therapeutic community because he has often obstructed other's efforts by failing to do his share. (D) Client has used conveniently forgetting or withholding information as a passive-aggressive behavior, which is not acceptable.
NEW QUESTION 262
A male client was involved in a motor vehicle accident earlier in the day. The nurse caring for him on evenings notices that on admission to the hospital, he lost a lot of blood and required multiple blood transfusions. The nurse would anticipate which blood product would be ordered when a large blood loss has occurred?
- A. Fresh frozen plasma
- B. Platelets
- C. Packed red blood cells
- D. Whole blood
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Whole blood is the transfusion component of choice when large volumes of blood need to be replaced.
Whole blood contains all blood components that are lost during active bleeding. (B) Platelet therapy is indicated for thrombocytopenia if the client's platelet count is below 15,000/mm3. (C) Infusion of fresh frozen plasma is required when the prothrombin time and partial thromboplastic time are prolonged. (D) Packed red blood cells are transfused in instances of anemia with decreases in hematocrit and hemoglobin.
NEW QUESTION 263
When assessing residual volume in tube feeding, the feeding should be delayed if the amount of gastric contents (residual) exceeds:
- A. 25 mL
- B. 20 mL
- C. 30 mL
- D. 50 mL
Answer: D
Explanation:
Section: Questions Set D
Explanation:
(A) A residual volume of 20 mL is not excessive. (B) A residual volume of 25 mL is not excessive. (C) A residual volume of 30 mL is not excessive. (D) Tube feedings should be withheld and physician notified for residual volumes of 50-100 mL.
NEW QUESTION 264
A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, "Why did this happen to my baby?" is:
- A. "I can see you're upset. Would you like to see and hold your baby?"
- B. "You're young. You can have other children later."
- C. "It's God's will. It was probably for the best. There was something probably wrong with your baby."
- D. "I know your other children will be a great comfort to you."
Answer: A
Explanation:
Explanation
(A) The mother and the father require support; the nurse should not minimize their grief in this situation. (B) Attachment to this infant occurs during the pregnancy for both the mother and father. Another child cannot replace this child. (C) Attachment to this infant occurs during the pregnancy for both the mother and father.
Siblings will not replace their feelings or minimize their loss of this infant. (D) Holding and viewing the infant decreases denial and may facilitate the grief process. The nurse should prepare family members for how the infant appears ("she is bruised") and provide support.
NEW QUESTION 265
The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?
- A. Diuresis by her second or third postpartum day
- B. Diaphoresis by her third postpartum day
- C. Vaginal discharge or rubra, serosa, then rubra
- D. Pulse rate of 50-70 bpm by her third postpartum day
Answer: C
Explanation:
Explanation
(A) Bradycardia is an expected assessment during the postpartum period. (B) Diuresis can occur during labor and the postpartum period and is an expected physiological adaptation. (C) A return of rubra after the serosa period may indicate a postpartal complication. (D) Diaphoresis, especially at night, is an expected physiological change and does not indicate an infectious process. Bradycardia, diuresis, and diaphoresis are normal postpartum physiological responses to adjust the cardiac output and blood volume to the nonpregnant state.
NEW QUESTION 266
An 8-year-old child is admitted to the hospital for surgery. She has had no previous hospitalizations, and both she and her family appear anxious and fearful. It will be most helpful for the nurse to:
- A. Explain that as soon as the child goes to the operating room she will have time to answer any questions the family has
- B. Take the child to her room and calmly and matter-offactly begin to get her ready to go to the operating room
- C. Take time to orient the child and her family to the hospital and the forthcoming events
- D. Tell the child and her family that there is nothing to worry about, that the operation will not take long, and she will soon be as "good as new"
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) This action does nothing to prepare the child and her family for what will happen or to relieve their anxiety and fear. (B) This action provides security by preparing the child and the family for what will happen and will help to relieve fear and anxiety. (C) This action does nothing to help prepare the child for what will happen and does not give the parents permission to ask questions until later. (D) This action provides possibly false reassurance and may prevent the child and/or the family from asking pressing questions.
NEW QUESTION 267
A 35-year-old primigravida comes to the clinic for her first prenatal visit. The midwife, on examining the client, suspects that she is approximately 11 weeks pregnant. The pregnancy is positively confirmed by finding:
- A. Chadwick's sign
- B. Breast tenderness and enlargement
- C. FHR by ultrasound
- D. Enlargement of the uterus
Answer: C
Explanation:
Section: Questions Set F
Explanation:
(A) Chadwick's sign is a presumptive sign of pregnancy. The coloration may not subside from past pregnancy or could be caused by other situations that create vasocongestion. (B) FHR (movement) observed on ultrasound is a positive diagnosis of pregnancy. (C) Enlargement of the uterus may be due to fibroids or infection. It is considered a probable sign. (D) Breast tenderness and enlargement is a presumptive sign because it may be due to other conditions, such as premenstrual changes.
NEW QUESTION 268
Degenerative disorders are attributed to many factors. As a nurse assigned to a convalescent home, one must often educate families about how such conditions occur. Which of the following statements might the nurse need to explore when a daughter tries to explain to her mother what caused her degenerative disorder?
- A. "Some folks believe that aging causes this, Mother."
- B. "It can be caused by lots of things, toxic agents and even alcohol, Mother."
- C. "I know some people who are having this problem and they were exposed to chemicals at work, Mother."
- D. "Perhaps, it's the way your parents used those double- bind messages, Mother."
Answer: D
Explanation:
Explanation
(A) Aging is a factor in the cause of degenerative disorders. (B) Double-bind messages may be found in the histories of families of individuals who develop schizophrenia, but they are not related to degenerative disorders. (C) Chemicals (toxic agents) in work environments are predisposing factors to degenerative disorders. (D) Alcohol causes some degenerative disorders, such as Wernicke's syndrome.
NEW QUESTION 269
A male infant is to be discharged home this morning. Which instruction related to his cord care should be included in his mother's discharge teaching plan?
- A. Clean the umbilical cord daily with soap and water during the bath.
- B. Clean the umbilical cord with alcohol at each diaper change.
- C. Keep the umbilical area moist with Vaseline until the stump falls off.
- D. Keep the umbilical area covered at all times with the diaper.
Answer: B
Explanation:
Explanation
(A) The umbilical area should be kept dry for healing to occur. Moisture is conducive to bacterial growth and therefore could lead to infection at the site. (B) The diaper should be folded below the cord to allow the cord stump to be exposed to the air for healing. (C) The umbilical cord should be swabbed with alcohol at each diaper change to remove urine and stool and to facilitate the desiccation process through drying. (D) Soap and water should not be used to clean the umbilical area because the area could retain moisture, thus making it susceptible to bacterial growth and infection.
NEW QUESTION 270
A 16-year-old student has a long history of bronchial asthma and has experienced several severe asthmatic attacks during the school year. The school nurse is required to administer 0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How does the school nurse evaluate the effectiveness of this intervention?
- A. Increased pulse rate
- B. Decreased inspiratory difficulty
- C. Increased expectorate of secretions
- D. Increased respiratory rate
Answer: B
Explanation:
Explanation
(A) A side effect of epinephrine is fatal ventricular fibrillation owing to its effects on cardiac stimulation. (B) Medications used to treat asthma are designed to decrease bronchospasm, not to increase expectorate of secretions. (C) Epinephrine decreased inspiratory difficulty by stimulating -, 1, and 2-receptors causing sympathomimetic stimulation (e.g., bronchodilation). (D) The person with asthma fights to inspire sufficient air thus increasing respiratory rate.
NEW QUESTION 271
A common complication of cirrhosis of the liver is prolonged bleeding. The nurse should be prepared to administer?
- A. Vitamin A
- B. Vitamin C
- C. Vitamin K
- D. Vitamin E
Answer: C
Explanation:
(A) Vitamin C does not directly affect clotting. (B) Vitamin K is a fat-soluble vitamin that depends on liver function for absorption. Vitamin K is essential for clotting. (C) Vitamin E does not directly affect clotting. (D) Vitamin A does not directly affect clotting.
NEW QUESTION 272
A client was admitted to the hospital after falling in her home. At the time of admission, her blood alcohol level was 0.27 mg%. Her family indicates that she has been drinking a fifth of vodka a day for the past 9 months.
She had her last drink 30 minutes prior to admission. Alcohol withdrawal symptoms would most likely be exhibited by her:
- A. Immediately on admission
- B. Twenty-four hours after the last drink
- C. Two to 4 hours after the last drink
- D. Six to 8 hours after the last drink
Answer: D
Explanation:
Section: Questions Set D
Explanation:
(A) This answer is incorrect. Alcohol withdrawal usually begins approximately 6-8 hours after the last drink. (B) This answer is correct. It takes approximately 6-8 hours for metabolism of alcohol. (C) This answer is incorrect.
The alcohol is still in the system, as indicated by the high blood alcohol level. (D) This answer is incorrect.
Symptoms of alcohol withdrawal usually begin within 6-8 hours of the last drink.
NEW QUESTION 273
Degenerative disorders are attributed to many factors. As a nurse assigned to a convalescent home, one must often educate families about how such conditions occur. Which of the following statements might the nurse need to explore when a daughter tries to explain to her mother what caused her degenerative disorder?
- A. "Some folks believe that aging causes this, Mother."
- B. "It can be caused by lots of things, toxic agents and even alcohol, Mother."
- C. "I know some people who are having this problem and they were exposed to chemicals at work, Mother."
- D. "Perhaps, it's the way your parents used those double- bind messages, Mother."
Answer: D
Explanation:
(A) Aging is a factor in the cause of degenerative disorders. (B) Double-bind messages may be found in the histories of families of individuals who develop schizophrenia, but they are not related to degenerative disorders. (C) Chemicals (toxic agents) in work environments are predisposing factors to degenerative disorders. (D) Alcohol causes some degenerative disorders, such as Wernicke's syndrome.
NEW QUESTION 274
A client is having an amniocentesis. Prior to the procedure, an ultrasound is performed. In preparing the client, the nurse explains the reason for a sonogram in this situation to be:
- A. Determination of gross anomalies
- B. Determination of placental location
- C. Determination of multiple gestations
- D. Determination of fetal age
Answer: B
Explanation:
Section: Questions Set F
Explanation:
(A) Sonography can be used to determine the presence of multiple gestation. In this question, the sonogram is used as a preparatory step for a specific invasive procedure. (B) Sonography can be used to determine the presence of gross anomalies. In this question, the sonogram is used as a preparatory step for a specific invasive procedure. (C) Prior to amniocentesis, the abdomen is scanned by ultrasound to locate the placenta, thus reducing the possibility of penetrating it with the spinal needle used to obtain amniotic fluid. (D) Sonography can be used to determine fetal age. In this question, the sonogram is used as a preparatory step for a specific invasive procedure.
NEW QUESTION 275
A 14-year-old teenager is demonstrating behavior indicative of an obsessive-compulsive disorder. She is obsessed with her appearance. She will not leave her room until her hair, clothes, and makeup are perfect. She always dresses immaculately. Recently, she expressed disgust over her appearance after she gained 5 lb. After observing a marked weight loss over a 2-week period, her mother suspects that she is experiencing bulimia. She eats everything on her plate, then runs to the bathroom. In interviewing the teenager, she discusses in great detail all of the events leading to her bulimia, but not her feelings. What defense mechanism is she using?
- A. Intellectualization
- B. Rationalization
- C. Displacement
- D. Dissociation
Answer: A
Explanation:
(A) Dissociation is separating a group of mental processes from consciousness or identity, such as multiple personalities. That is not evident in this situation. (B) Intellectualization is excessive use of reasoning, logic, or words usually without experiencing associated feelings. This is the defense mechanism that this client is using. (C) Rationalization is giving a socially acceptable reason for behavior rather than the actual reason. She is discussing events, not reasons. (D) Displacement is a shift of emotion associated with an anxiety-producing person, object, or situation to a less threatening object.
NEW QUESTION 276
A 14-year-old teenager is hospitalized for anorexia nervosa. She is admitted to the adolescent mental health unit and placed on a behavior modification program. Nursing interventions for the teenager will most likely include:
- A. Administering medications such as lithium
- B. Requiring the client to eat more during meals
- C. Checking the client's room frequently
- D. Establishing routine tasks and activities around mealtimes
Answer: D
Explanation:
(A) Providing a more structured, supportive environment addresses safety and comfort needs, thereby helping the anorexic client develop more internal control. (B) Medications (commonly antidepressants) are frequently ordered for the anorexic client. However, lithium (used primarily with bipolar disorder) is not commonly used to treat the anorexic client. (C) Requiring and/or demanding that the anorexic client "eat more" at mealtimes increases the client's feelings of powerlessness. (D) Like the previous strategy, checking the client's room frequently contributes to the client's feelings of powerlessness.
NEW QUESTION 277
A male client is undergoing cardiac tests. He has been instructed to wear a Holter monitor. The nurse knows she has included the appropriate information in her teaching when the client tells her:
- A. "He is to refrain from activities that cause chest pain."
- B. "He is to keep a record of everything he does during the day."
- C. "Damage to his heart muscle will be recorded by the monitor."
- D. "He should remove the electrodes for bathing."
Answer: B
Explanation:
(A) The client should leave the electrodes in place during the entire time the test is ordered. He should not even remove the electrodes for bathing. (B) The Holter monitor will record cardiac electrical activity but will not record damage to his myocardium. (C) The client should keep a record of all of his activities so the physician can correlate the ECG findings with his activities. (D) The client should continue doing his regular activities. The purpose of the Holter monitor is to record heart activity during routine activities.
NEW QUESTION 278
When assessing a female child for Turner's syndrome, the nurse observes for which of the following symptoms?
- A. Gynecomastia
- B. Tall stature
- C. Amenorrhea
- D. Secondary sex characteristics
Answer: C
Explanation:
Section: Questions Set G
Explanation:
(A) This syndrome is caused by absence of one of the X chromosomes. These children are short in stature. (B) Amenorrhea is a symptom of Turner's syndrome, which appears at puberty. (C) Sexual infantilism is characteristic of this syndrome. (D) Gynecomastia is a symptom in Klinefelter's syndrome.
NEW QUESTION 279
When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the nurse take?
- A. Turn client on right side.
- B. Continue monitoring because this is a normal occurrence.
- C. Decrease IV fluids.
- D. Report to physician or midwife.
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) This is not a normal occurrence. Late decelerations need prompt intervention for immediate infant recovery. (B) To increase O2 perfusion to the unborn infant, the mother should be placed on her left side.
(C) IV fluids should be increased, not decreased. (D) Immediate action is warranted, such as reporting findings, turning mother on left side, administering O2, discontinuing oxytocin (Pitocin), assessing maternal blood pressure and the labor process, preparing for immediate cesarean delivery, and explaining plan of action to client.
NEW QUESTION 280
The nurse should know that according to current thinking, the most important prognostic factor for a client with breast cancer is:
- A. Client's previous history of disease
- B. Client's level of estrogen-progesterone receptor assays
- C. Axillary node status
- D. Tumor size
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Although tumor size is a factor in classification of cancer growth, it is not an indicator of lymph node spread. (B) Axillary node status is the most important indicator for predicting how far the cancer has spread. If the lymph nodes are positive for cancer cells, the prognosis is poorer. (C) The client's previous history of cancer puts her at an increased risk for breast cancer recurrence, especially if the cancer occurred in the other breast. It does not predict prognosis, however. (D) The estrogen-progesterone assay test is used to identify present tumors being fedfrom an estrogen site within the body. Some breast cancers grow rapidly as long as there is an estrogen supply such as from the ovaries. The estrogen-progesterone assay test does not indicate the prognosis.
NEW QUESTION 281
Children often experience visual impairments. Refractive errors affect the child's visual activity. The main refractive error seen in children is myopia. The nurse explains to the child's parents that myopia may also be described as:
- A. Cataracts
- B. Farsightedness
- C. Lazy eye
- D. Nearsightedness
Answer: D
Explanation:
(A) Cataracts are not considered refractive errors. Cataracts canbe described as opacity of the lens. (B)Hyperopiais the term forfarsightedness. One can see objects at a distance more clearlythan close objects. (C)Myopiais the term for nearsightedness.Objects that are close in distance are more clearly seen. (D) Lazyeye refers to strabismus or misalignment of the eyes.
NEW QUESTION 282
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