Verified NCLEX-RN Dumps Q&As - NCLEX-RN Test Engine with Correct Answers
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NCLEX-RN exam is widely recognized as one of the most challenging licensure exams in the healthcare industry. Students must undergo extensive preparation and training to pass the exam, including studying nursing concepts and clinical practice, reviewing test-taking strategies, and practicing with sample questions and practice exams.
NEW QUESTION # 403
In addition to changing the mother's position to relieve cord pressure, the nurse may employ the following measure (s) in the event that she observes the cord out of the vagina:
- A. Keep the cord warm and moist by continuous applications of warm, sterile saline compresses.
- B. Apply a cord clamp to the exposed cord, and cover with a sterile towel.
- C. Cover the cord with a wet sponge.
- D. Immediately pour sterile saline on the cord, and repeat this every 15 minutes to prevent drying.
Answer: A
Explanation:
Explanation
(A) Saline should be warmed; waiting 15 minutes may not keep the cord moist. (B) This choice does not specify what the sponge was "wet" with. (C) This measure would stop circulation to the fetus. (D) The cord should be kept warm and moist to maintain fetal circulation. This measure is an accepted nursing action.
NEW QUESTION # 404
As the nurse assesses a male adolescent with chlamydia, the nurse determines that a sign of chlamydia is:
- A. Enlarged penis
- B. Epididymitis
- C. Secondary lymphadenitis
- D. Hepatomegaly
Answer: B
Explanation:
Section: Questions Set A
Explanation:
(A) An enlarged penis is not a sign of chlamydia. (B) Secondary lymphadenitis is a complication of lymphogranuloma venereum. (C) Untreated chlamydial infection can spread from the urethra, causing epididymitis, which presents as a tender, scrotal swelling. (D) Hepatomegaly is not a complication.
NEW QUESTION # 405
MgSO4 blood levels are monitored and the nurse would be prepared to administer the following antidote for MgSO4 side effects or toxicity:
- A. Naloxone (Narcan)
- B. Magnesium oxide
- C. Calcium hydroxide
- D. Calcium gluconate
Answer: D
Explanation:
(A, B) These drugs are not antidotes for MgSO4. (C) This drug is the standard antidote and should always be readily available when MgSO4is being administered. (D) This drug is an antidote for narcotics, not MgSO4.
NEW QUESTION # 406
A 33-year-old client was brought into the emergency room unconscious, and it is determined that surgery is needed. Informed consent must be obtained from his next of kin. The sequence in which the next of kin would be asked for the consent would be:
- A. Spouse, adult child, parent, sibling
- B. Parent, spouse, sibling, adult child
- C. Parent, spouse, adult child, sibling
- D. Spouse, parent, sibling, adult child
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Spouse and adult child would be asked before a parent. (B) The order of kin relationship for an adult, as determined from legal intestate succession, is usually spouse, adult child, parent, sibling. (C) Parent and sibling would be asked after adult child. (D) Spouse and adult child would be asked before parent.
Sibling would be asked last.
NEW QUESTION # 407
Following a fracture of the left femur, a client develops symptoms of osteomyelitis. During the acute phase of osteomyelitis, nursing care is directed toward:
- A. Providing the client with a high-protein, high-fiber diet to promote healing
- B. Moving or turning the client's left leg carefully to minimize pain and discomfort
- C. Allowing the client out of bed only in a wheelchair or gurney to minimize weight bearing on the left leg
- D. Instituting physical therapy to ensure restoration of optimal functioning of the leg
Answer: B
Explanation:
Section: Questions Set D
Explanation:
(A) Any movement of his affected limb will cause discomfort to the child. (B) No weight bearing will be allowed until healing is well underway to avoid pathological fractures. (C) The child will be anorexic and may experience vomiting. Diet should be simple and high caloric until appetite returns and symptoms subside. (D) Physical therapy is instituted only after infection subsides.
NEW QUESTION # 408
The nurse is admitting a client with folic acid deficiency anemia. Which of the following questions is most important for the nurse to ask the client?
- A. "Have your stools been normal?"
- B. "Do you eat red meat?"
- C. "Do you drink alcohol on a regular basis?"
- D. "Do you take aspirin on a regular basis?"
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Aspirin does not affect folic acid absorption. (B) Folic acid deficiency is strongly associated with alcohol abuse. (C) Because folic acid is a coenzyme for single carbon transfer purines, calves liver or other purines are the meat sources. (D) Folic acid does not affect stool character.
NEW QUESTION # 409
A client's congestive heart failure has been treated, and he will soon be discharged. Discharge teaching should include instruction to call the physician if he notices a 2-lb weight gain in a 24-hour period.
Increased weight gain may indicate:
- A. A diet too high in calories and saturated fat
- B. Decreasing renal function
- C. Decreasing cardiac output
- D. Development of diabetes insipidus
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Increased calories may result in weight gain, but there is no indication in this question that this man's diet has changed in a way that would result in increased calories. (B) Decreasing cardiac output stimulates the renin-angiotensin-aldosterone cycle and results in fluid retention, which is reflected by weight gain. (C) Decreasing renal function may result in fluid retention, but this question gives no indication that this man has any renal problems. (D) Profound diuresis occurs with diabetes insipidus, which results in weight loss.
NEW QUESTION # 410
A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular disorder. She arrives in her
room via stretcher and requires assistance to move to her bed. The nurse notes that her left leg is cold to touch. She complains of having recently experienced muscle spasms in that leg. To determine if these muscle spasms are indicative of intermittent claudication, the nurse would begin her assessment with the following question:
- A. "Do your muscle spasms occur following rest, walking, or exercising?"
- B. "Have you had any lesions of the affected leg that have been difficult to heal?"
- C. "Would you describe the intensity, duration, and symptoms associated with your pain?"
- D. "Do you experience swelling at the end of the day in the affected and unaffected leg?"
Answer: A
Explanation:
(A)
Describing pain is an important aspect of the assessment; however, assessing activity preceding muscle spasms is equally important. (B) Edema may occur with peripheral vascular disease, but it is not of particular importance in assessing intermittent claudication.
(C)
Lesions may be present with peripheral vascular disease, but they are not an indication of intermittent claudication. (D) With intermittent claudication, muscle spasms occur intermittently, mainly with walking and after exercising. Rest may relieve muscle spasms.
NEW QUESTION # 411
A 3-month-old infant has had a unilateral cleft lip repair. He has resumed feedings of oral formula. The nurse should feed the infant with:
- A. Gavage tube
- B. A straw and cup
- C. Syringe
- D. Nipple and bottle
Answer: C
Explanation:
Section: Questions Set C
Explanation:
(A) A gavage tube may damage suture line. It is the most invasive and should be the last measure. (B) A nipple and bottle require sucking, which may damage sutures. (C) A 3-month-old infant is not able to drink from a straw. (D) A syringe allows for the formula to be placed to the side and back of the mouth. This minimizes the amount of sucking needed.
NEW QUESTION # 412
A male client has been an insulin-dependent diabetic for approximately 30 years. He frequently indulges in highsugar foods and forgets to take his insulin. He has not experienced acute diabetic emergencies over the years but is now beginning to demonstrate symptoms of diabetic peripheral neuropathy. This distresses him because dancing is one of his favorite pastimes. He decides to question his wife's home health nurse about diabetic peripheral neuropathy. The nurse points out his noncompliance to his diabetic diet and insulin regimen. The client answers the nurse, "It has been my experience that the diabetic diet is very difficult to follow. As far as the insulin, isn't a fellow allowed to forget now and then?" The client's actions and response best demonstrate:
- A. Denial
- B. Depression
- C. Bargaining
- D. Anger
Answer: A
Explanation:
Explanation
(A) Depression may be an underlying feature, but it is not evident from limited data presented here. (B) Anger is not exhibited in his response. (C) Denial is evident in the client's actions; through the years, he has had a casual approach to his illness. He only becomes concerned when bodily changes affect his present lifestyle, when in fact he should have been concerned all along. His verbal response also reflects denial. (D) There is no evidence of bargaining in the client's actions or verbal response.
NEW QUESTION # 413
A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures should be included in the postoperative care?
- A. Have child gargle and do toothbrushing to remove old blood.
- B. Give warm clear liquids when fully alert.
- C. Encourage the child to cough up blood if present.
- D. Observe for evidence of bleeding.
Answer: D
Explanation:
Section: Questions Set E
Explanation:
(A) The nurse should discourage the child from coughing, clearing the throat, or putting objects in his mouth.
These may induce bleeding. (B) Cool, clear liquids may be given when child is fully alert. Warm liquids may dislodge a blood clot. The nurse should avoid red- or brown-colored liquids to distinguish fresh or old blood from ingested liquid should the child vomit. (C) Gargles and vigorous toothbrushing could initiate bleeding. (D) Postoperative hemorrhage, though unusual, may occur. The nurse should observe for bleeding by looking directly into the throat and for vomiting of bright red blood, continuous swallowing, and changes in vital signs.
NEW QUESTION # 414
An elective saline abortion has been performed on a 3- week primigravida. Following the procedure, the nurse should be alert for which early side effect?
- A. Edema
- B. Thirst
- C. Water satiety
- D. Diabetes insipidus
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) If the client is experiencing water satiety, there is no more desire for water. (B) Absorption of saline into circulation rather than into amniotic sac increases serum sodium and desire for water. (C) Edema can be a late side effect caused by water intoxication. (D) Diabetes insipidus occurs as a result of deficient antidiuretic hormone.
NEW QUESTION # 415
A female client has married recently. A month ago she visited her physician with complaints of burning on urination. She was given a prescription for trimethoprim- sulfamethoxazole (Bactrim) DS bid for 10 days. She was admitted through the emergency room on Saturday evening complaining of flank pain. Her temperature was 104_F. A preliminary urinalysis revealed 31 bacteria along with red and white blood cells in the urine. A preliminary diagnosis of pyelonephritis was made. During a nursing admission assessment, which statement by the client demonstrates a possible cause for pyelonephritis?
- A. "I took the Bactrim for 6 or 7 days. The burning stopped, so I saved the rest of the medication for the next time."
- B. "I have not been drinking six to eight glasses of water each day as the nurse had instructed."
- C. "I recently had the flu, which could be settling in my kidneys now."
- D. "I'm afraid I may have something wrong with my bladder because I have been getting bladder infections frequently since I've been married."
Answer: A
Explanation:
(A) Although it is important that the client drink adequate fluids while treating a bladder infection with trimethoprimsulfamethoxazole, the failure to do so will not cause pyelonephritis. (B) A stricture or abnormality may cause the progression of bladder infection to urinary tract infection, but this is rare. There is no indication in this situation that this has occurred. (C) The most common cause of pyelonephritis is improper treatment of bladder infections. The client typically feels better after several days, discontinues the medication, and saves the remainder forthe next occurrence of a bladder infection. For this reason, it is imperative to provide client education related to completion of the prescribed medication. (D) There is no evidence that infection in another body system could cause pyelonephritis.
NEW QUESTION # 416
A client diagnosed with severe anemia is to receive 2 U of packed red blood cells. Prior to starting the blood transfusion, the nurse must:
- A. Take a baseline set of vital signs
- B. Have the registered nurse in charge assume responsibility for verifying the client and blood product information
- C. Hang Ringer's lactate as the companion fluid
- D. Use microdrip tubing for the blood administration
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) A baseline set of vital signs is necessary to determine if any transfusion reactions occur as the blood product is being administered. (B) The only companion fluid to be used during a blood transfusion is normal saline. The calcium in Ringer's lactate can cause clotting. (C) Only a blood administration set should be used. A microdrip tube would cause lysis of the red blood cells. (D) Proper identification of the recipient and the blood product must be validated by at least two people.
NEW QUESTION # 417
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. "How long have you been in the hospital."
- C. "You shouldn't do things like that, just tell someone you feel bad."
- D. "Tell me more about what you couldn't take anymore."
Answer: D
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 # 418
A schizophrenic client has made sexual overtures toward her physician on numerous
occasions. During lunch, the client tells the nurse, "My doctor is in love with me and wants to marry me." This client is using which of the following defense mechanisms?
- A. Projection
- B. Reaction formation
- C. Displacement
- D. Suppression
Answer: A
Explanation:
(A) Displacement involves transferring feelings to a more acceptable object. (B) Projection involves attributing one's thoughts or feelings to another person. (C) Reaction formation involves transforming an unacceptable impulse into the opposite behavior. (D) Suppression involves the intentional exclusion of unpleasant thoughts or experiences.
NEW QUESTION # 419
A 44-year-old female client is receiving external radiation to her scapula for metastasis of breast cancer.
Teaching related to skin care for the client would include which of the following?
- A. Encourage her to avoid direct sunlight on the area being treated.
- B. Teach her to completely clean the skin to remove all ointments and markings after each treatment.
- C. Encourage her to wear a tight-fitting vest to support her scapula.
- D. Teach her to cover broken skin in the treated area with a medicated ointment.
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) The skin in a treatment area should be rinsed with water and patted dry. Markings should be left intact, and the skin should not be scrubbed. (B) Clients should avoid putting any creams or lotions on the treated area. This could interfere with treatment. (C) Radiation therapy clients should wear loose-fitting clothes and avoid tight, irritating fabrics. (D) The area of skin being treated is sensitive to sunlight, and the client should take care to prevent sun damage by avoiding direct sunlight and covering the area when she is in the sun.
NEW QUESTION # 420
The nurse will be alert to the most potentially lifethreatening side effect associated with the administration of monoamine oxidase (MAO) inhibitor. This is:
- A. Oculogyric crisis
- B. Orthostatic hypotension
- C. Hypertensive crisis
- D. Tardive dyskinesia
Answer: C
Explanation:
Section: Questions Set G
Explanation:
(A) Oculogyric crisis, involuntary upward deviation and fixation of the eyeballs, is usually associated with either postencephalitic parkinsonian or drug-induced extrapyramidal symptoms (EPS). (B) Hypertensive crisis is a potentially life-threatening side effect. This may occur if the client ingests foods, beverages, or medications containing tyramine. (C) Orthostatic hypotension, a drop-in blood pressure resulting from a rapid change of body position, can occur with the administration of antidepressants. (D) Tardive dyskinesia, characterized by slow, rhythmical, automatic or stereotyped muscular movements, usually is associated with the administration of certain antipsychotic medications.
NEW QUESTION # 421
On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle feeding. The nurse should initially recommend to her to:
- A. Take 2 ibuprofen (Motrin) tablets by mouth now because the baby will be returning for feeding in 20 minutes
- B. Apply ice packs to the breasts and wear a supportive, well-fitting bra
- C. Take a warm shower and express milk from both breasts until empty
- D. Allow the infant to breast-feed at the next feeding time to empty the breasts
Answer: B
Explanation:
Section: Questions Set F
Explanation
Explanation:
(A) Judicious use of analgesics is appropriate with breast engorgement; however, mechanical suppression would be the initial recommendation. (B) Breast-feeding every 1κΆ€2-3 hours will reduce and/or prevent breast engorgement. Breast-feeding will promote milk production, which will compound the distention and stasis of the venous circulation of engorgement in a bottlefeeding mother. (C) Ice packs reduce milk flow while the snug, supportive bra provides mechanical suppression and decreases pulling on Cooper's ligament. In addition, breast binders or ace bandages may be used for some women. (D) Warmth promotes milk production and may stimulate the let-down reflex. These measures would contribute to the venous congestion of engorgement.
NEW QUESTION # 422
A pregnant client is having a nonstress test (NST). It is noted that the fetal heart beat rises 20 bpm, lasting 20 seconds, every time the fetus moves. The nurse explains that:
- A. The test is normal and the fetus is reacting appropriately
- B. Further testing is needed
- C. The fetus is distressed
- D. The test is inconclusive and should be repeated
Answer: A
Explanation:
Explanation
(A) The test results were normal, so there would be no need to repeat to determine results. (B) There are no data to indicate further tests are needed, because the result of the NST was normal. (C) An NST is reported as reactive if there are two to three increases in the fetal heart rate of 15 bpm, lasting at least 15 seconds during a
15-minute period. (D) The NST results were normal, so there was no fetal distress.
NEW QUESTION # 423
Diagnostic assessment findings for an infant with possible coarctation of the aorta would include:
- A. Pulse pressure difference between the upper extremities
- B. A third heart sound
- C. Diminished or absent femoral pulses
- D. A diastolic murmur
Answer: C
Explanation:
(A) S1 and S2 in an infant with coarctation of the aorta are usually normal. S3 and S4 do not exist with this diagnosis. (B) Either no murmur will be heard or a systolic murmur from an associated cardiac defect will be heard along the left upper sternal border. A diastolic murmur is not associated with coarctation of the aorta. (C) Pulse pressure differences of>20 mm Hg exist between the upper extremities and the lower extremities. It is important to evaluate the upper and lower extremities with the appropriate- sized cuffs. (D) Femoral and pedal pulses will be diminished or absent in infants with coarctation of the aorta.
NEW QUESTION # 424
A client is diagnosed with organic brain disorder. The nursing care should include:
- A. Detailed explanations of procedures
- B. Challenging educational programs
- C. Organized, safe environment
- D. Long, extended family visits
Answer: C
Explanation:
Explanation
(A) A priority nursing goal is attending to the client's safety and well-being. Reorient frequently, remove dangerous objects, and maintain consistent environment. (B) Short, frequent visits are recommended to avoid overstimulation and fatigue. (C) Short, concise, simple explanations are easier to understand. (D) Mental capability and attention span deficits make learning difficult and frustrating.
NEW QUESTION # 425
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