NCLEX National Council Licensure Examination Study Guide, Exams of Nursing

Download NCLEX National Council Licensure Examination Study Guide and more Exams Nursing in PDF only on Docsity! 1 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score NO.2 Cystic fibrosis is transmitted as an autosomal recessive trait. This means that: A. Mothers carry the gene and pass it to their sons B. Fathers carry the gene and pass it to their daughters C. Both parents must have the disease for a child to have the disease D. Both parents must be carriers for a child to have the disease Answer: D Explanation: (A) Cystic fibrosis is not an X-linked or sex-linked disease. (B) The only characteristic on the Y chromosome is the trait for hairy ears. (C) Both parents do not need to have the disease but must be carriers. (D) If a trait is recessive, two genes (one from each parent) are necessary to produce an affected child. NO.3 A 24-year-old client presents to the emergency department protesting "I am God." The nurse identifies this as a: A. Delusion B. Illusion C. Hallucination D. Conversion Answer: A Explanation: (A) Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion is the expression of intrapsychic conflict through sensory or motor manifestations. NO.4 In acute episodes of mania, lithium is effective in 1-2 weeks, but it may take up to 4 weeks, or 2 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms. In addition to the lithium, which one of the following medications might the physician prescribe? A. Diazepam (Valium) B. Haloperidol (Haldol) C. Sertraline (Zoloft) D. Alprazolam (Xanax) Answer: B Explanation: (A) Diazepam is an antianxiety medication and is not designed to reduce psychotic symptoms. (B) Haloperidol is an antipsychotic medication and may be used until the lithium takes effect. (C) Sertraline is an antidepressant and is used primarily to reduce symptoms of depression. (D) Alprazolam is an antianxiety medication and is not designed to reduce psychotic symptoms. NO.5 A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints? A. Give fluids if the client requests them. B. Assess skin integrity and circulation of extremities before applying restraints and as they are removed. C. Measure vital signs at least every 4 hours. D. Release restraints every 2 hours for client to exercise. Answer: D Explanation: (A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly while the client is restrained, not only before restraints are applied and after they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains agitated in restraints, vital signs should be monitored even more closely, perhaps every 1-2 hours. (D) Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation. NO.6 The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on oral griseofulvin. The nurse should emphasize which of these instructions to the mother and/or child? A. Administer oral griseofulvin on an empty stomach for best results. B. Discontinue drug therapy if food tastes funny. C. May discontinue medication when the child experiences symptomatic relief. D. Observe for headaches, dizziness, and anorexia. Answer: D Explanation: 5 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score B. Both lower extremities cyanotic when placed in a dependent position 6 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score C. Decreased or absent pedal pulse in the left leg D. The left leg warmer to touch than the right leg Answer: C Explanation: (A) This statement describes a normal assessment finding of the lower extremities. (B) This assessment finding reflects problems caused by venous insufficiency. (C) Decreased or absentpedal pulses reflect a problem caused by arterial insufficiency. (D) The leg that is experiencing arterial insufficiency would be cool to touch due to the decreased circulation. NO.10 A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician? A. pH 7.39 B. White blood cell (WBC) count 10,000 WBCs/mm3 C. Hematocrit 60% D. Bleeding time of 4 minutes Answer: C Explanation: (A) Normal pH of arterial blood gases for an infant is 7.35-7.45. (B) Normal white blood cell count in an infant is 6,000-17,500 WBCs/mm3. (C) Normal hematocrit in infant is 28%-42%. A 60% hematocrit may indicate polycythemia, a common complication of cyanotic heart disease. (D) Normal bleeding time is 2-7 minutes. NO.11 A male client is experiencing extreme distress. He begins to pace up and down the corridor. What nursing intervention is appropriate when communicating with the pacing client? A. Ask him to sit down. Speak slowly and use short, simple sentences. B. Help him to recognize his anxiety. C. Walk with him as he paces. D. Increase the level of his supervision. Answer: C Explanation: (A) The nurse should not ask him to sit down. Pacing is the activity he has chosen to deal with his anxiety. The nurse dealing with this client should speak slowly and with short, simplesentences. (B) The client may already recognize the anxiety and is attempting to deal with it. (C) Walk with the client as he paces. This gives support while he uses anxiety-generated energy. (D) Increasing the level of supervision may be appropriate after he stops pacing. It would minimize self-injury and/or loss of control. NO.12 Prior to an amniocentesis, a fetal ultrasound is done in order to: A. Evaluate fetal lung maturity B. Evaluate the amount of amniotic fluid 7 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score C. Locate the position of the placenta and fetus D. Ensure that the fetus is mature enough to perform the amniocentesis Answer: C 10 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score breast cancer. Teaching related to skin care for the client would include which of the following? A. Teach her to completely clean the skin to remove all ointments and markings after each treatment . B. Teach her to cover broken skin in the treated area with a medicated ointment. C. Encourage her to wear a tight-fitting vest to support her scapula. D. Encourage her to avoid direct sunlight on the area being treated. Answer: D 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. NO.16 The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue healing? A. Vitamin C B. Vitamin B1 C. Vitamin D D. Vitamin A Answer: A Explanation : (A) Vitamin C (ascorbic acid) is essential in promoting wound healing and collagen formation. (B) Vitamin B1 (thiamine) maintains normal gastrointestinal (GI) functioning, oxidizes carbohydrates, and is essential for normal functioning of nervous tissue. (C) Vitamin D regulates absorption of calcium and phosphorus from the GI tract and helps prevent rickets. (D) Vitamin A is necessary for the formation and maintenance of skin and mucous membranes. It is also essential for normal growth and development of bones and teeth. NO.17 A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony. Which of the following nursing implementations would be most effective in helping him cope with immobility? A. Providing him with books, challenging puzzles, and games as diversionary activities B. Allowing him to do as much for himself as he is able, including learning to do pin-site care under supervision 11 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score C. Having a volunteer come in to sit with the client and to read him stories D. Stimulating rest and relaxation by gentle rubbing with lotion and changing the client's position frequently Answer: B 12 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score Explanation: (A) These activities could be frustrating for the client if he is having difficulty with problem solving and concentration. (B) Selfcare is usually well received by the child, and it is one of the most useful interventions to help the child cope with immobility. (C) This may be helpful to the client if he has no visitors, but it does little to help him develop coping skills. (D) This will helpto prevent skin irritation or breakdown related to immobility but will not help to prevent behavioral changes related to immobility. NO.18 In client teaching, the nurse should emphasize that fetal damage occurs more frequently with ingestion of drugs during: A. First trimester B. Second trimester C. Third trimester D. Every trimester Answer: A Explanation: (A) Organogenesis occurs in the first trimester. Fetus is most susceptible to malformation during this period. (B) Organogenesis has occurred by the second trimester. (C) Fetal development is complete by this time. (D) The dangerous period for fetal damage is the first trimester, not the entire pregnancy. NO.19 On admission, the client has signs and symptoms of pulmonary edema. The nurse places the client in the most appropriate position for a client in pulmonary edema, which is: A. High Fowler B. Lying on the left side C. Sitting in a chair D. Supine with feet elevated Answer: A Explanation: (A) High Fowler position decreases venous return to the heart and permits greater lung expansion so that oxygenation is maximized. (B) Lying on the left side may improve perfusion to the left lung but does not promote lung expansion. (C) Sitting in a chair will decrease venous return and promote maximal lung expansion. However, clients with pulmonary edema can deteriorate quickly and require intubation and mechanical ventilation. If a client is sitting in achair when this deterioration happens, it will be difficult to intervene quickly. (D) The supine with feet elevated position increases venous return and will worsen pulmonary edema. NO.20 A client has returned to the unit from the recovery room after having a thyroidectomy. The nurse knows that a major complication after a thyroidectomy is: A. Respiratory obstruction B. Hypercalcemia 15 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score 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. NO.23 A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will teach her to: A. Limit activities which require focusing (close vision) B. Take more frequent naps C. Use artificial tears D. Wear a patch over one eye Answer: D Explanation: (A) Limiting activities requiring close vision will not alleviate the discomfort of double vision. (B) Frequent naps may be comforting, but they will not prevent double vision. (C) Artificial tears are necessary in the absence of a corneal reflex, but they have no effect on diplopia. (D) An eye patch over either eye will eliminate the effects of double vision during the time the eye patch is worn. An eye patch is safe for a person with an intact corneal reflex. NO.24 One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is: A. Blood pressure B. Level of consciousness C. Skin turgor D. Fluid intake Answer: B Explanation: (A) Blood pressure can remain normotensive in a state of hypovolemia. (B) Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. (C) Skin turgor is not a reliable indicator for assessing hydration in a burn client. (D) Fluid intake does not indicate adequacy of fluid resuscitation in a burn client. NO.25 Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who suffered partial- and fullthickness burns to 25% of her body? 16 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score A. Urine output B. Edema C. Hypertension D. Bulging fontanelle 17 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score Answer: A Explanation: (A) Urinary output is a reliable indicator of renal perfusion, which in turn indicates that fluid resuscitation is adequate. IV fluids are adjusted based on the urinary output of the child during fluid resuscitation. (B) Edema is an indication of increased capillary permeability following a burn injury. (C) Hypertension is an indicator of fluid volume excess. (D) Fontanelles close by 18 months of age. NO.26 A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report: A. Dizziness and tachypnea B. Circumoral pallor and lightheadedness C. Headache and facial flushing D. Pallor and itching of the face and neck Answer: C Explanation: (A) Tachypnea is not a symptom. (B) Circumoral pallor is not a symptom. (C) Autonomic dysreflexia is an uninhibited and exaggerated reflex of the autonomic nervous system to stimulation, which results in vasoconstriction and elevated blood pressure. (D) Pallor and itching are not symptoms. NO.27 A client states to his nurse that "I was told by the doctor not to take one of my drugs because it seems to have caused decreasing blood cells." Based on this information, which drug might the nurse expect to be discontinued? A. Prednisone B. Timolol maleate (Blocadren) C. Garamycin (Gentamicin) D. Phenytoin (Dilantin) Answer: D Explanation: (A) Prednisone is not linked with hematological side effects. (B) Timolol, a -adrenergic blocker is metabolized by the liver. It has not been linked to blood dyscrasia. (C) Gentamicin is ototoxic and nephrotoxic. (D) Phenytoin usage has been linked to blood dyscrasias such as aplastic anemia. The drug most commonly linked to aplastic anemia is chloramphenicol (Chlormycetin). NO.28 A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should: A. Notify the physician immediately B. Hold the morning lithium dose and continue to observe the client C. Administer the morning lithium dose as scheduled D. Obtain an order for benztropine (Cogentin) 20 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score NO.31 A 52-year-old client is scheduled for a small-bowel resection in the morning. In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises. 21 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score She will teach the client to: A. Inhale slowly and deeply through the nose until the lungs are fully expanded, hold the breath a couple of seconds, and then exhale slowly through the mouth. Repeat 2-3 more times to complete the series every 1-2 hours while awake B. Purse the lips and take quick, short breaths approximately 18-20 times/min C. Take a large gulp of air into the mouth, hold it for 10-15 seconds, and then expel it through the nose. Repeat 4-5 times to complete the series D. Inhale as deeply as possible and then immediately exhale as deeply as possible at a rate of approximately 20-24 times/min Answer: A Explanation: (A) This is the correct method of teaching diaphragmatic breathing, which allows full lung expansion to increase oxygenation, prevent atelectasis, and move secretions up and out of the lungs to decrease risk of pneumonia. (B) Quick, short breaths do not allow for full lung expansion and movement of secretions up and out of the lungs. Quick, short breaths may lead to O2 depletion, hyperventilation, and hypoxia. (C) Expelling breaths through the nose does not allow for full lung expansion and the use of diaphragmatic muscles to assist in moving secretions up and out of the lungs. (D) Inhaling and exhaling at a rate of 20-24 times/min does not allow time for full lung expansion to increase oxygenation. This would most likely lead to O2 depletion and hypoxia. NO.32 The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take? A. Place a tongue blade in the child's mouth. B. Restrain the child so he will not injure himself. C. Go to the nurses station and call the physician. D. Move furniture out of the way and place a blanket under his head. Answer: D Explanation: (A) The nurse should not put anything in the child's mouth during a seizure; this action could obstruct the airway. (B) Restraining the child's movements could cause constrictive injury. (C) Staying with the child during a seizure provides protection and allows the nurse to observe the seizure activity. (D) The nurse should provide safety for the child by moving objects and protecting the head. NO.33 An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action? A. Apply ice packs to both legs. B. Begin debridement by removing all charred clothing from wound. C. Apply Silvadene cream (silver sulfadiazine). D. Immerse both legs in cool water. 22 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score Answer: D Explanation: 25 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score 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. NO.36 A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful? A. Examine the 4 year old first. B. Provide time for play and becoming acquainted. C. Have the mother leave the room with one child, and examine the other child privately. D. Examine painful areas first to get them "over with." Answer: B Explanation: (A) The 6 month old should be examined first. If several children will be examined, begin with the most cooperative and less anxious child to provide modeling. (B) Providing time for play and getting acquainted minimizes stress and anxiety associated with assessment of body parts. (C) Children generally cooperate best when their mother remains with them. (D) Painful areas are best examined last and will permit maximum accuracy of assessment. NO.37 Diagnostic assessment findings for an infant with possible coarctation of the aorta would include: A. A third heart sound B. A diastolic murmur C. Pulse pressure difference between the upper extremities D. Diminished or absent femoral pulses Answer: D 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. NO.38 During a client's first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus. This may be due to: A. Endometritis B. Fibroid tumor on the uterus 26 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score C. Displacement due to bowel distention D. Urine retention or a distended bladder Answer: D 27 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score Explanation: (A, B) Endometritis, urine retention, or bladder distention provide good distractors because they may delay involution but do not usually cause the uterus to be lateral. (C) Bowel distention and constipation are common in the postpartum period but do not displace the uterus laterally. (D) Urine retention or bladder distention commonly displaces the uterus to the right and may delay involution. NO.39 An 80-year-old widow is living with her son and daughter- in-law. The home health nurse has been making weekly visits to draw blood for a prothrombin time test. The client is taking 5 mg of coumadin per day. She appears more debilitated, and bruises are noted on her face. Elder abuse is suspected. Which of the following are signs of persons who are at risk for abusing an elderly person? A. A family member who is having marital problems and is regularly abusing alcohol B. A person with adequate communication and coping skills who is employed by the family C. A friend of the family who wants to help but is minimally competent D. A lifelong friend of the client who is often confused Answer: A Explanation: (A) This answer is correct. Two risk factors are identified in this answer. (B) This answer is incorrect. Persons at risk tend to lack communication skills and effective coping patterns. (C) This answer is incorrect. Persons at risk are usually family members or those reluctant to provide care. (D) This answer is incorrect. This individual has a vested interest in providing care. NO.40 A 32-year-old female client is being treated for Guillain- Barre syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation? A. Complaints of a headache B. Loss of superficial and deep tendon reflexes C. Complaints of shortness of breath D. Facial paralysis Answer: C Explanation: (A) Headaches are not associated with Guillain-Barre syndrome. (B) Loss of superficial and deep tendon reflexes is expected with this diagnosis. (C) Complaints of shortness of breath must be further evaluated. Forty percent of all clients have some detectable respiratory weakness and should be prepared for a possible tracheostomy. Pneumonia is also a common complication of this syndrome. (D) Facial paralysis is expected and is not considered abnormal. 30 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score the husband to identify underlying fears and knowledge deficits. (D) This response offers false reassurance and dismisses the husband's underlying concerns about his wife. 31 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score NO.44 A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening complications may occur initially, so the nurse will monitor him closely for serum: A. Chloride level of 99 mEq/L B. Sodium level of 136 mEq/L C. Potassium level of 3.1 mEq/L D. Potassium level of 6.3 mEq/L Answer: D Explanation: (A) The chloride level is within acceptable limits. (B) The sodium level is within acceptable limits. (C) This value indicates hypokalemia, rather than the hyperkalemia that occurs during diabetic ketoacidosis. (D) When diabetic ketoacidosis exists, intracellular dehydration occurs and potassium leaves the cells and enters the vascular system, thus increasing the serum level beyond an acceptable range. When insulin and fluids are administered, cell walls are repaired and potassium is transported back into the cells. Normal serum potassium levels range from 3.5-5.0 mEq/L. NO.45 A 27-year-old primigravida at 32 weeks' gestation has been diagnosed with complete placenta previa. Conservative management including bed rest is the proper medical management. The goal for fetal survival is based on fetal lung maturity. The test used to determine fetal lung maturity is: A. Dinitrophenylhydrazine B. Metachromatic stain C. Blood serum phenylalanine test D. Lecithin-sphingomyelin ratio Answer: D Explanation: (A) Dinitrophenylhydrazine is a laboratory test used to detect phenylketonuria, maple syrup urine disease, and Lowe's syndrome. (B) Metachromatic stain is a laboratory test that may be used to diagnose Tay-Sachs and other lipid diseases of the central nervous system. (C) The blood serum phenylalanine test is diagnostic of phenylketonuria and can be used for wide-scale screening. (D) A lecithin-sphingomyelin ratio of at least 2:1 is indicative of fetal lung maturity, and survival of the fetus is likely. NO.46 One week ago, a 21-year-old client with a diagnosis of bipolar disorder was started on lithium 300 mg po qid. A lithium level is ordered. The client's level is 1.3 mEq/L. The nurse recognizes that this level is considered to be: A. Within therapeutic range B. Below therapeutic range C. Above therapeutic range D. At a level of toxic poisoning Answer: A Explanation: 32 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score (A) This answer is correct. The therapeutic range is 1.0-1.5 mEq/L in the acute phase. Maintenance control levels are 0.6-1.2 mEq/L. (B, C) This answer is incorrect. A level of 35 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score late sign of increased intracranial pressure. (C) Headache is a very early symptom of increased intracranial pressure in the child. (D) Ataxia is a late sign of increased intracranial pressure. NO.50 Which nursing implication is appropriate for a client undergoing a paracentesis? A. Have the client void before the procedure. B. Keep the client NPO. C. Observe the client for hypertension following the procedure. D. Place the client on the right side following the procedure. Answer: A Explanation: (A) A full bladder would impede withdrawal of ascitic fluid. (B) Keeping the client NPO is not necessary. (C) The client may exhibit signs and symptoms of shock and hypertension. (D) No position change is needed after the procedure. NO.51 A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, "The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart." The nurse's best response is: A. "I know you're feeling frightened right now, but I want you to know that I don't see anyone in the corner." B. "You'll probably see strange things for a while until the PCP wears off." C. "Try to sleep. When you wake up, the devil will be gone." D. "You're probably feeling guilty because you used illegal drugs tonight." Answer: A Explanation: (A) The nurse is the client's link to reality. This response validates the authenticity of the client's experience by casting doubt on his belief and reinforcing reality. (B) Although this statement may be literally correct, it is nontherapeutic because it lacks validation. (C) This response encourages the client to attempt to do something that may be impossible at this time, offers false reassurance, and reinforces delusional content. (D) The nurse is making an incorrect assumption about the client's feelings by offering a nontherapeutic interpretation of the motivation for the client's actions. NO.52 To facilitate maximum air exchange, the nurse should position the client in: A. High Fowler B. Orthopneic C. Prone D. Flat-supine Answer: B Explanation: (A) The high Fowler position does increase air exchange, but not to the extent of orthopneic position. 36 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score (B) The orthopneic position is a sitting position that allows maximum lung expansion. (C) The prone position places pressure on diaphragm and does not promote maximum air exchange. (D) The flat- supine position places pressure on diaphragm by abdominal organs and does not promote maximum 37 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score air exchange. NO.53 A 48-year-old client is in the surgical intensive care unit after having had three-vessel coronary artery bypass surgery yesterday. She is extubated, awake, alert and talking. She is receiving digitalis for atrial arrhythmias. This morning serum electrolytes were drawn. Which abnormality would require immediate intervention by the nurse after contacting the physician? A. Serum osmolality is elevated indicating hemoconcentration. The nurse should increase IV fluid rate. B. Serum sodium is low. The nurse should change IV fluids to normal saline. C. Blood urea nitrogen is subnormal. The nurse should increase the protein in the client's diet as soon as possible. D. Serum potassium is low. The nurse should administer KCl as ordered. Answer: D Explanation: (A) An elevated serum osmolality poses no immediate danger and is not corrected rapidly. (B) A low serum sodium alone does not warrant changing IV fluids to normal saline. Other assessment parameters, such as hydration status, must be considered. (C) A low serum blood urea nitrogen is not necessarily indicative of protein deprivation. It may also be the result of overhydration. (D)A low serum potassium potentiates the effects of digitalis, predisposing the client to dangerous arrhythmias. It must be corrected immediately. NO.54 A male client is scheduled to have angiography of his left leg. The nurse needs to include which of the following when preparing the client for this procedure? A. Validate that he is not allergic to iodine or shellfish. B. Instruct him to start active range of motion of his left leg immediately following the procedure. C. Inform him that he will not be able to eat or drink anything for 4 hours after the procedure. D. Inform him that vital signs will be taken every hour for 4 hours after the procedure. Answer: A Explanation: (A) Angiography, an invasive radiographic examination, involves the injection of a contrast solution (iodine) through a catheter that has been inserted into an artery. (B) The client is kept on complete bed rest for 6-12 hours after the procedure. The extremity in which the catheter was inserted must be immobilized and kept straight during this time. (C) The contrast dye, iodine, is nephrotoxic. The client must be instructed to drink a large quantity of fluids to assist the kidneys in excreting this contrast media. (D) The major complication of this procedure is hemorrhage. Vital signs are assessed every 15 minutes initially for signs of bleeding. NO.55 A client had a transurethral resection of the prostate yesterday. He is concerned about the small amount of blood that is still in his urine. The nurse explains that the blood in his urine: 40 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score (A) Aspirin should never be given to children with influenza because of the possibility of causing Reye's syndrome. Pepto- Bismol is also classified as a salicylate and should be avoided. (B) Depending 41 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score on the severity of symptoms, the child may be receiving IV therapy or clear liquids. (C) The disease has a 1-3 day incubation period and affected children are most infectious 24 hours before and after the onset of symptoms. (D) Although viral pneumonia can be a complication of influenza, this would not be an initial priority. NO.58 A male client is considering having laser abdominal surgery and asks the nurse if there is any advantage in having this type of surgery? The nurse will respond based on the knowledge that laser surgery: A. Has a smaller postoperative infection rate than routine surgery B. Will eliminate the need for preoperative sedation C. Will result in less operating time D. Generally eliminates problems with complications Answer: A Explanation: (A) A lower postoperative infection has been documented as a result of laser therapy versus routine surgery. (B) Clients will still need preoperative sedation to facilitate anxiety reduction. (C) Operating time may actually increase in some laser surgeries. (D) The client must still be observed for postoperative complications. NO.59 Based on your knowledge of genetic inheritance, which of these statements is true for autosomal recessive genetic disorders? A. Heterozygotes are affected. B. The disorder is always carried on the X chromosome. C. Only females are affected. D. Two affected parents always have affected children. Answer: D Explanation: (A) The term heterozygote refers to an individual with one normal and one mutant allele at a given locus on a pair of homologous chromosomes. An individual who is heterozygous for the abnormal gene does not manifest obvious symptoms. (B) Disorders carried on either the X or Y sex chromosome are referred to as sex-linked recessive. (C) Either sex may be affected by autosomal recessive genetic disorders because the responsible allele can be on any one of the 46 chromosomes. (D) If both parents are affected by the disorder and are not just carriers, then all their children would manifest the same disorder. NO.60 The pediatric nurse charts that the parents of a 4-yearold child are very anxious. Which observation would indicate to the nurse unhealthy coping by these parents: A. Discussing their needs with the nursing staff B. Discussing their needs with other family members C. Seeking support from their minister 42 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score D. Refusing to participate in the child's care Answer: D Explanation: 45 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score NO.64 A child becomes neutropenic and is placed on protective isolation. The purpose of protective isolation is to: A. Protect the child from infection B. Provide the child with privacy C. Protect the family from curious visitors D. Isolate the child from other clients and the nursing staff Answer: A Explanation: (A) The child no longer has normal white blood cells and is extremely susceptible to infection. (B) There are more appropriate ways to provide privacy, and there is no need to protect the child from healthy visitors. (C) Visitors and visiting hours may be at the client's and/or family's request without regard to the isolation precaution. (D) The child may have strong positive relationships with other clients or staff. As long as proper precautions are observed, there is no reason to isolate her from them. NO.65 A schizophrenic client who is experiencing thoughts of having special powers states that "I am a messenger from another planet and can rule the earth." The nurse assesses this behavior as: A. Ideas of reference B. Delusions of persecution C. Thought broadcasting D. Delusions of grandeur Answer: D Explanation: (A) Clients experiencing ideas of reference believe that information from the environment (e.g., the television) is referring to them. (B) Clients experiencing delusions of persecution believe that others in the environment are plotting against them. (C) Clients experiencing thought broadcasting perceive that others can hear their thoughts. (D) Clients experiencing delusions of grandeur think that they are omnipotent and have superhuman powers. NO.66 Following a gastric resection, which of the following actions would the nurse reinforce with the client in order to alleviate the distress from dumping syndrome? A. Eating three large meals a day B. Drinking small amounts of liquids with meals C. Taking a long walk after meals D. Eating a low-carbohydrate diet Answer: D Explanation: (A) Six small meals are recommended. (B) Liquids after meals increase the time food empties from the stomach. (C) Lying down after meals is recommended to prevent gravity from producing dumping. (D) A low-carbohydrate diet will prevent a hypertonic bolus, which causes dumping. 46 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score NO.67 A 6-year-old child is attending a pediatric clinic for a routine examination. What should the nurse assess for while conducting a vision screening? 47 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score A. Hearing test B. Gait C. Strabismus D. Papilledema Answer: C Explanation: (A) Hearing should be assessed separately. (B) Gait should be assessed separately. Client usually remains in one place for vision screening. Gait is part of neurological assessment. (C) Strabismus is crossing of eyes or outward deviation, which may cause diplopia or ambylopia. It is easily assessed during vision screening. (D) Papilledema is assessed by an ophthalmoscopic examination, which follows vision screening. It is part of neurological assessment. NO.68 Which of the following ECG changes would be seen as a positive myocardial stress test response? A. Hyperacute T wave B. Prolongation of the PR interval C. ST-segment depression D. Pathological Q wave Answer: C Explanation: (A) Hyperacute T waves occur with hyperkalemia. (B) Prolongation of the P R interval occurs with first-degree AV block. (C) Horizontal ST-segment depression of>1 mm during exercise isdefinitely a positive criterion on the exercise ECG test. (D) Patho-logical Q waves occur with MI. NO.69 A client with cystic fibrosis exhibits activity intolerance related to the pulmonary problems associated with his disease. However, he needs to be encouraged to participate in daily physical exercise. The ultimate aim of exercise is to: A. Create a sense of well-being and self-worth B. Help him overcome respiratory infections C. Establish an effective, habitual breathing pattern D. Promote normal growth and development Answer: C Explanation: (A) Regular exercise does promote a sense of well-being and selfworth, but this is not the ultimate goal of exercise for this client. (B) Regular chest physiotherapy, not exercise per se, helps to prevent respiratory infections. (C) Physical exercise is an important adjunct to chest physiotherapy. It stimulates mucus secretion, promotes a feeling of well-being, and helps to establish a habitual breathing pattern. (D) Along with adequate nutrition and minimization of pulmonary complications, 50 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score medications areused for sedation during the procedure. (C) Oozing at the arterial puncture site is not normal and should be closely evaluated. (D) The leg where the arterial puncture occurred must be kept straight for 8-12 hours to minimize the risk of bleeding. 51 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score NO.73 The nurse is assessing breath sounds in a bronchovesicular client. She should expect that: A. Inspiration is longer than expiration B. Breath sounds are high pitched C. Breath sounds are slightly muffled D. Inspiration and expiration are equal Answer: D Explanation: (A) Inspiration is normally longer in vesicular areas. (B) Highpitched sounds are normal in bronchial area. (C) Muffled sounds are considered abnormal. (D) Inspiration and expiration are equal normally in this area, and sounds are medium pitched. NO.74 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. Tonsilliti s Answer: A 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. NO.75 A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent: A. Bladder spasms B. Clot formation C. Scrotal edema D. Prostatic infection Answer: B Explanation: (A) The purpose of bladder irrigation is not to prevent bladder spasms, but to drain the bladder and decrease clot formation and obstruction. (B) A three-way system of bladder irrigation will cleanse the bladder and prevent formation of blood clots. A catheter obstructed by clots or other debris will cause 52 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score prostatic distention and hemorrhage. (C) Scrotal edema seldom occurs after TURP. Bladder irrigation will not prevent this complication. (D) Prostatic infection seldom occurs after TURP. Bladder irrigation will not prevent this complication. 55 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score site; this would be extremely painful to the infant. (D) Special care and observance should continue until the site is completely covered with clean, pink granulation tissue, which could take 7-10 days. NO.79 The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have: A. A low birth weight B. A birth defect C. Anemia D. Nicotine withdrawal Answer: A Explanation: (A) Women who smoke during pregnancy are at increased risk for miscarriage, preterm labor, and IUGR in the fetus. (B) Although smoking produces harmful effects on the maternal vascular system and the developing fetus, it has not been directly linked to fetal anomalies. (C) Smoking during pregnancy has not been directly linked to anemia in the fetus. (D) Smoking during pregnancy has not been linked to nicotine withdrawal symptoms in the newborn. NO.80 Respiratory function is altered in a 16-year-old asthmatic. Which of the following is the cause of this alteration? A. Altered surfactant production B. Paradoxical movements of the chest wall C. Increased airway resistance D. Continuous changes in respiratory rate and depth Answer: C Explanation: (A) Altered surfactant production is found in sudden infant death syndrome. (B) Paradoxical breathing occurs when a negative intrathoracic pressure is transmitted to the abdomen by a weakened, poorly functioning diaphragm. (C) Asthma is characterized by spasm and constriction of the airways resulting in increased resistance to airflow. (D) If the pulmonary tree is obstructed for any reason, inspired air has difficulty overcoming the resistance and getting out. The rate of respiration increases in order to compensate, thus increasing air exchange. NO.81 The FHR pattern in a laboring client begins to show early decelerations. The nurse would best respond by: A. Notifying the physician B. Changing the client to the left lateral position C. Continuing to monitor the FHR closely D. Administering O2 at 8 L/min via face mask Answer: C 56 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score Explanation: (A) Early decelerations are reassuring and do not warrant notification of the physician. (B) Because early decelerations is a reassuring pattern, it would not be necessary to change the client's position. 57 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score (C) Early decelerations warrant the continuation of close FHR monitoring to distinguish them from more ominous signs. (D) O2 is not warranted in this situation, but it is warranted in situations involving variable and/or late decelerations. NO.82 A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must: A. Assess the site for leakage of blood or fluids B. Auscultate the site for a bruit C. Assess the site for bruising or hematoma D. Inspect the site for color, warmth, and sensation Answer: B Explanation: (A) This is an internal device. Assessment of the site should include assessing for swelling, pain, warmth, and discoloration. This measure does not assess patency. (B) The presence of a bruit indicates good blood flow through the device. (C) The nurse should inspect the site for bruising or hematoma; however, this measure does not assure patency of the device. (D) The nurse should inspect the vascular access site frequently for signs of infection. However, this does not assure patency. NO.83 A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to: A. Prevent air from entering the pleural space B. Prevent fluid from entering the pleural space C. Provide a means to measure chest drainage D. Provide an indicator of respiratory effort Answer: A Explanation: (A) A chest tube extends from the pleural space to a collection device. The tube is placed below the surface of the saline so that air cannot enter the pleural space. (B) Fluid may enter the pleural space as a result of injury or disease. A chest tube may drain fluid from the pleural space, but the water seal is not involved in this. (C) Chest drainage should be measured, but the water seal is not involved in this. (D) Fluctuations in the tube in the water-sealed bottle will give an indication of respiratory effort, but that is not the purpose of the water seal. NO.84 A 42-year-old male client has been treated at an alcoholic rehabilitation center for physiological alcohol dependence. The nurse will be able to determine that he is preparing for discharge and is effectively coping with his problem when he shares with her the following information: A. "I know that I will not ever be able to socially drink alcohol again and will need the support of the AA group." B. "I know that I can only drink one or two drinks at social gatherings in the future, but at least I don't have to continue AA." 60 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score D. Ingestion of antacids Answer: A Explanation: 61 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score (A) Lifting heavy objects will increase intrathoracic pressure, thus placing the client at risk for rupturing esophageal varices. (B, C, D) This activity will not cause an increase in intrathoracic pressure. NO.88 The nurse is admitting an infant with bacterial meningitis and is prepared to manage the following possible effects of meningitis: A. Constipation B. Hypothermia C. Seizure D. Sunken fontanelles Answer: C Explanation: (A) Constipation may occur if the child is dehydrated, but it is not directly associated with meningitis. (B) It is more likely the child will have fever. (C) Seizure is often the initial sign of meningitis in children and could become frequent. (D) It is more likely the child will have bulging fontanelles. NO.89 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. Is given to prevent rejection and makes him less susceptible to infection than other oral corticosteroids B. Is available at discount pharmacies for a reduced price C. Is usually not necessary after the first year following transplantation D. May initially cause weakness, dizziness, and fatigue, but these side effects will gradually resolve themselves Answer: A 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. NO.90 After the RN is finished the initial assessment of a newborn baby and after the initial bonding between the newborn and the mother has taken place in the delivery room, the RN will bring the newborn to the well-baby nursery. Before the newborn is taken from the delivery room and brought to 62 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score the well-baby nursery, the RN makes sure that which of the following interventions was completed? A. The physician verifies the exact time of birth. 65 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score her postoperative care, the nurse is aware that a priority nursing diagnosis for her will be high risk for: A. Knowledge deficit B. Urinary retention C. Impaired physical mobility D. Ineffective breathing pattern Answer: D Explanation: (A) The client may have a knowledge deficit, but reducing the risk for knowledge deficit is not a priority nursing diagnosis postoperatively. (B) The client will have a Foley catheter for a day or two after surgery. Urinary retention is usually not a problem once the Foley catheter is removed. (C) A client having a cholecystectomy should not be physically impaired. In fact, the client is encouraged to begin ambulating soon after surgery. (D) Because of the location of the incision, the client having a cholecystectomy is reluctant to breathe deeply and is at risk for developing pneumonia. These clients have to be reminded and encouraged to take deep breaths. NO.94 To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and O2 demand will occur with which of the following? A. Positive inotropic therapy B. Negative chronotropic therapy C. Increase in balance of myocardial O2 supply and demand D. Afterload reduction therapy Answer: A Explanation: (A) Inotropic therapy will increase contractility, which will increase myocardial O2 demand. (B) Decreased heart rate to the point of bradycardia will increase coronary artery filling time. This should be used cautiously because tachycardia may be a compensatory mechanism to increase cardiac output. (C) The goal in the care of the MI client with angina is to maintain a balance between myocardial O2 supply and demand. (D) Decrease in systemic vascular resistance by drug therapy, such as IV nitroglycerin or nitroprusside, or intra-aortic balloon pump therapy, would decrease myocardial work and O2 demand. NO.95 A gravida 2 para 1 client is hospitalized with severe preeclampsia. While she receives magnesium sulfate (MgSO4) therapy, the nurse knows it is safe to repeat the dosage if: A. Deep tendon reflexes are absent B. Urine output is 20 mL/hr C. MgSO4serum levels are>15 mg/dL 66 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score D. Respirations are>16 breaths/min Answer: D 67 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score Explanation: (A) MgSO4is a central nervous system depressant. Loss of reflexes is often the first sign of developing toxicity. (B) Urinary output at <25 mL/hr or 100 mL in 4 hours may result in the accumulation of toxic levels of magnesium. (C) The therapeutic serum range for MgSO4is 6-8 mg/dL. Higher levels indicate toxicity. (D) Respirations of>16 breaths/min indicate that toxic levels of magnesium have not been reached. Medication administration would be safe. NO.96 The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 1-2 hours if needed. The most likely rationale for this order is: A. The client will settle down more quickly if he thinks the staff is medicating him B. The medication will sedate the client until the physician arrives C. Haloperidol is a minor tranquilizer and will not oversedate the client D. Rapid neuroleptization is the most effective approach to care for the violent or potentially violent client Answer: D Explanation: (A) If the client could think logically, he would not be paranoid. In fact, he is probably suspicious of the staff, too. Newly admitted clients frequently experience high levels of anxiety, which can contribute to delusions. (B) The goal of pharmacological intervention is to calm the client and assist with reality-based thinking, not to sedate him. (C) Haloperidol is a neuroleptic and antipsychotic drug, not a minor tranquilizer. (D) Haloperidol is a high-potency neuroleptic and first-line choice for rapid neuroleptization, with low potential for sedation. NO.97 A 27-year-old primigravida stated that she got up from the chair to fix dinner and bright red blood was running down her legs. She denies any pain previously or currently. The client is very concerned about whether her baby will be all right. Her vital signs include P 120 bpm, respirations 26 breaths/min, BP 104/58 mm Hg, temperature 98.2_F, and fetal heart rate 146 bpm. Laboratory findings revealed hemoglobin 9.0 g/dL, hematocrit 26%, and coagulation studies within normal range. On admission, the peripad she wore was noted to be half saturated with bright red blood. A medical diagnosis of placenta previa is made. The priority nursing diagnosis for this client would be: A. Decreased cardiac output related to excessive bleeding B. Potential for fluid volume excess related to fluid resuscitation C. Anxiety related to threat to self D. Alteration in parenting related to potential fetal injury Answer: A Explanation: (A) Based on the client's history, presence of bright red vaginal bleeding, and hemoglobin value on admission, the priority nursing diagnosis would be decreased cardiac output related to excessive bleeding. (B) This nursing diagnosis is a potential problem that does not exist at the present time, and therefore is not the priority problem. (C) The client's expressed anxiety is for her child. The fetus will remain physiologically safe if the decreased cardiac output is resolved. (D) Initial spontaneous 70 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score 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? 71 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score A. Dissociation B. Intellectualization C. Rationalization D. Displacement Answer: B 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. NO.101 A 27-year-old healthy primigravida is brought to the labor and birthing room by her husband at 32 weeks' gestation. She experienced a sudden onset of painless vaginal bleeding. Following an ultrasound examination, the diagnosis of bleeding secondary to complete placenta previa is made. Expected assessment findings concerning the abdomen would include: A. A rigid, boardlike abdomen B. Uterine atony C. A soft relaxed abdomen D. Hypertonicity of the uterus Answer: C Explanation: (A) A rigid, boardlike abdomen is an assessment finding indicative of placenta abruptio. (B) A cause of postbirth hemorrhage is uterine atony. With placenta previa, uterine tone is within normal range. (C) The placenta is located directly over the cervical os in complete previa. Blood will escape through the os, resulting in the uterus and abdomen remaining soft and relaxed. (D) In placenta abruptio, hypertonicity of the uterus is caused by the entrapment of blood between the placenta and uterine wall, a retroplacental bleed. This does not exist in placenta previa. NO.102 The nurse assesses a client on the second postpartum day and finds a dark red discharge on the peripad. The stain appears to be about 5 inches long. Which of the following correctly describes the character and amount of lochia? A. Lochia alba, light B. Lochia serosa, heavy C. Lochia granulosa, heavy D. Lochia rubra, moderate Answer: D Explanation: 72 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score (A) Lochia alba occurs approximately 10 days after birth and is yellow to white. A discharge is classified as light when less than a 4-inch stain exists. (B) Lochia serosa is pink to brown and occurs 3- 75 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score (A) An anticonvulsant effect is the goal of drug therapy for PIH. However, we would not want to increase the vasoconstriction that is already present. This would make the symptoms more severe. (B) An anticon-vulsant effect and vasodilation are the desired outcomes when administering this drug. (C) An anticonvulsant effect is the goal of drug therapy for PIH; however, hypertensive drugs would increase the blood pressure even more. (D) An anticonvulsant effect is the goal of drug therapy for PIH. MgSO4is not classified as an antiemetic. Antiemetics are not indicated for PIH treatment. NO.106 The nurse is caring for a 6-week-old girl with meningitis. To help her develop a sense of trust, the nurse should: A. Give her a small soft blanket to hold B. Give her good perineal care after each diaper change C. Leave the door open to her room D. Pick her up when she cries Answer: D Explanation: (A) A soft blanket may be comforting, but it is not directed toward developing a sense of trust. (B) Good perineal care is important, but it is not directed toward developing a sense of trust. (C) An infant with meningitis needs frequent attention, but leaving the door open does not foster trust. (D) Consistently picking her up when she cries will help the child feel trust in her caregivers. NO.107 The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because: A. Immediate treatment of mild PIH includes the administration of a variety of medications B. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation 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: (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. NO.108 A client at 9 weeks' gestation comes for an initial prenatal visit. On assessment, the nurse discovers this is her second pregnancy. Her first pregnancy resulted in a spontaneous abortion. She is 28 years old, in good health, and works full-time as an elementary school teacher. This information alerts the nurse to which of the following: A. An increased risk in maternal adaptation to pregnancy B. The need for anticipatory guidance regarding the pregnancy 76 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score C. The need for teaching regarding family planning D. An increased risk for subsequent abortions Answer: B 77 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score Explanation: (A, D) There are no data to support this. (B) Anticipatory guidance and health maintenance is a first- line defense in the promotion of healthy mothers and healthy babies. (C) There are no data to support this at this time. This will be a concern later. NO.109 A mother is unsure about the type of toys for her 17-month-old child. Based on knowledge of growth and development, what toy would the nurse suggest? A. A pull toy to encourage locomotion B. A mobile to improve hand-eye coordination C. A large toy with movable parts to improve pincer grasp D. Various large colored blocks to teach visual discrimination Answer: A Explanation: (A) Increased locomotive skills make push-pull toys appropriate for the energetic toddler. (B) Infants progress from reflex activity through simple repetitive behaviors to imitative behavior. Hand- eye coordination forms the foundation of other movements. (C) At age 8 months, infants begin to have pincer grasp. Toys that help infants develop the pincer grasp are recommended for this age group. (D) Various large colored blocks are suggested toys for infants 6-12 months of age to help visual stimulation. NO.110 During an examination, the nurse notes that an infant has diaper rash on the convex surfaces of his buttocks, inner thighs, and scrotum. Which of the following nursing interventions will be most effective in resolving the condition? A. Coating the inflamed areas with zinc oxide B. Using talcum powder on the inflamed areas to promote drying C. Removing the diaper entirely for extended periods of time D. Cleaning the inflamed area thoroughly with disposable wet "wipes" at each diaper change Answer: C Explanation: (A) Zinc oxide is not usually applied to inflamed areas because it contributes to sweat retention. (B) Talcum powder is of questionable benefit and poses a hazard of accidental inhalation. (C) Removing the diaper and exposing the area to air and light facilitate drying and healing. (D) Infants may be sensitive to one or more agents in the wet "wipes." It is better to simply clean with a wet cloth. NO.111 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. "Do you take aspirin on a regular basis?" B. "Do you drink alcohol on a regular basis?" 80 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score Explanation: (A) Although this may be an appropriate response, the initial response would be to assure the patency of the catheter. (B) The most frequent reason for an urge to void with an indwelling catheter is blocked tubing. This response would be the best initial response. (C) Kegel exercises while a 81 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score retention catheter is in place would not help to prevent a voiding urge and could irritate the urethral sphincter. (D) Though the nurse would want to ascertain whether the client has felt the same urge to void before, the initial response should be to assure the patency of the catheter. NO.115 Following TURP, which of the following instructions would be appropriate to prevent or alleviate anxiety concerning the client's sexual functioning? A. "You may resume sexual intercourse in 2 weeks." B. "Many men experience impotence following TURP." C. "A transurethral resection does not usually cause impotence." D. "Check with your doctor about resuming sexual activity." Answer: C Explanation: (A) Sexual activity should be delayed until cleared by the client's physician. (B) Although many men experience retrograde ejaculation following prostate surgery, potency is seldom affected. (C) Although the client may experience retrograde ejaculation, it will not limit his ability to engage in sexual intercourse. (D) Although the client should obtain clearance from his physician before resuming sexual activity, this statement does not give the client any information or reassurance about future sexual activity or potency that could decrease his anxiety. NO.116 The most frequent cause of early postpartum hemorrhage is: A. Hematoma B. Coagulation disorders C. Uterine atony D. Retained placental fragments Answer: C Explanation: (A) Hematomas, which are the result of damage to a vessel wall without laceration of the tissue, are a cause, though not the most frequent cause. (B) Coagulation disorders are among the causes of postpartal hemorrhage, but they are less common. (C) The most frequent causes of hemorrhage in the postpartal period are related to an interference with involution of the uterus. Uterine atony is the most frequent cause, occurring in the first 24 hours after delivery. (D) Retained placental fragments are also a cause, although these bleeds usually occur 7-14 days after delivery. NO.117 A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse's best response is: A. "You'll have to get permission from the physician to visit. Clients are pretty sick after the first treatment." B. "Visitors are not allowed. We will telephone you to inform you of her progress." C. "There's really no need to stay with her. She's going to sleep for several hours after the treatment." 82 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score D. "Yes, you may visit. She may experience temporary drowsiness, confusion, or memory loss after each treatment." Answer: D 85 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score A. If the infant vomits within 30 minutes of the digoxin administration, repeat the dose B. They need to mix it with formula so the infant swallows it easily C. If the infant vomits two or more consecutive doses or becomes listless or anorexic, notify the physician D. If a dose of digoxin is skipped for more than 6 hours, a new timetable for administration must be developed Answer: C Explanation: (A) Occasionally the child may vomit. They should not repeat the dose because the amount of digoxin that was absorbed is un-known, and serum levels of digoxin that are too high are more dangerous than those that are temporarily too low. (B) To ensure that the entire dose of digoxin is received, never mix it with food or formula. (C) Vomiting, anorexia, and listlessness are all signs of digoxin toxicity and should be reported to the physician immediately. (D) If a dose is forgotten for more than 6 hours, the nurse should advise the parents to skip that dose and to continue the next dose as scheduled. NO.121 A 26-year-old client has no children. She has had an abdominal hysterectomy. In the first 24 hours postoperatively, the nurse would be concerned if the client: A. Cries easily and says she is having abdominal pain B. Develops a temperature of 102_F C. Has no bowel sounds D. Has a urine output of 200 mL for 4 hours Answer: B Explanation: (A) The client may be more tearful than normal due to the stress of the surgery and its implications for her future life. She would be expected to have pain following surgery. (B) A temperature of 102_F indicates an infectious process. This is not a normal sequence to surgery and indicates a need for further assessment. (C) The client is expected to have no bowel soundsfor 24-48 hours after surgery because of the trauma to the bowel. (D) Normal urine output is 30 mL/hr. This represents an output of 50 mL/hr, which is greater than normal. NO.122 A 9-year-old child was in the garage with his father, who was repairing a lawnmower. Some gasoline ignited and caused an explosion. His father was killed, and the child has split- thickness and full-thickness burns over 40% of his upper body, face, neck, and arms. All of the following nursing diagnoses are included on his care plan. Which of these nursing diagnoses should have top priority during the first 24-48 hours postburn? A. Pain related to tissue damage from burns B. Potential for infection related to contamination of wounds C. Fluid volume deficit related to increased capillary permeability D. Potential for impaired gas exchange related to edema of respiratory tract Answer: D 86 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score Explanation: 87 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score (A, B, C) These answers are all correct; however, maintenance of airway is the top priority. (D) Persons burned about the face and neck during an explosion are also likely to suffer burns of the respiratory tract, which can lead to edema and respiratory arrest. NO.123 A 35-year-old client is admitted to the hospital with diabetic ketoacidosis. Results of arterial blood gases are pH 7.2, PaO2 90, PaCO2 45, and HCO3 16. The nursing assessment of arterial blood gases indicate the presence of: A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis Answer: D Explanation: (A) Respiratory alkalosis is determined by elevated pH and low PaCO2. (B) Respiratory acidosis is determined by low pH and elevated PaCO2. (C) Metabolic alkalosis is determined by elevated pH and HCO3.(D) Metabolic acidosis is determined by low pH and HCO3. NO.124 A client is dilated 8 cm and entering the transition phase of labor. Common behaviors of the laboring woman during transition are: A. Frustration, vague in communication B. Seriousness, some difficulty following directions C. Calmness, follows directions easily D. Excitement, openness to instructions Answer: A Explanation: (A) During the transition phase, the mother may become frustrated and unclear in her communication owing to severe pain and fear of loss of control. (B) These behaviors are common in the active phase of labor. (C) These behavioral clues are seen in the latent phase of labor. (D) These characteristics are observed in the latent phase of labor. NO.125 A 30-year-old client has a history of several recent traumatic experiences. She presents at the physician's office with a complaint of blindness. Physical exam and diagnostic testing reveal no organic cause. The nurse recognizes this as: A. Delusion B. Illusion C. Hallucination D. Conversion Answer: D Explanation: (A) The client's blindness is real. Delusion is a false belief. (B) Illusion is the misrepresentation of a 90 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score Answer: D Explanation: (A) Chronic alcoholism can lead to deficiencies of B complex vitamins including thiamine and 91 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score pyroxidine. (B) Chronic alcoholism can lead to deficiencies of vitamins A, D, K, and B complex. (C) Chronic alcoholism can lead to deficiencies of vitamins A, D, K, and B complex. (D) Vitamins A, D, K, and B require bile salts to be absorbed from the gastrointestinal tract. A damaged liver does not form bile salts. NO.129 A complication for which the nurse should be alert following a liver biopsy is: A. Hepatic coma B. Jaundice C. Ascites D. Shock Answer: D Explanation : (A) Hepatic coma may occur in liver disease due to the increased NH3levels, not due to liver biopsy. (B) Jaundice may occur due to increased bilirubin levels, not due to liver biopsy. (C) Ascites would occur due to portal hypertension, not due to liver biopsy. (D) Hemorrhage and shock are the most likely complications after liver biopsy because of already existing bleeding tendencies in the vascular makeup of the liver. NO.130 Proper positioning for the child who is in Bryant's traction is: A. Both hips flexed at a 90-degree angle with the knees extended and the buttocks elevated off the bed B. Both legs extended, and the hips are not flexed C. The affected leg extended with slight hip flexion D. Both hips and knees maintained at a 90-degree flexion angle, and the back flat on the bed Answer: A Explanation: (A) The child's weight supplies the countertraction for Bryant's traction; the buttocks are slightly elevated off the bed, and the hips are flexed at a 90-degree angle. Both legs are suspended by skin traction. (B) The child in Buck's extension traction maintains the legs extended and parallel to the bed. (C) The child in Russell traction maintains hip flexion of the affected leg at the prescribed angle with the leg extended. (D) The child in "90-90" traction maintains both hips and knees at a 90-degree flexion angle and the back is flat on the bed. NO.131 A female baby was born with talipes equinovarus. Her mother has requested that the nurse assigned to the baby come to her room to discuss the baby's condition. The nurse knows that the pediatrician has discussed the baby's condition with her mother and that an orthopedist has been consulted but has not yet seen the baby. What should the nurse do first? A. Call the orthopedist and request that he come to see the baby now. B. Question the mother and find out what the pediatrician has told her about the baby's condition. 92 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score C. Tell the mother that this is not a serious condition. D. Tell the mother that this condition has been successfully treated with exercises, casts, and/or braces. Answer: B 95 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score D. Meperidine (Demerol) Answer: D Explanation: (A) Morphine sulfate is contraindicated in clients with pancreatitis because it may cause spasms of the sphincter of Oddi and increase pancreatic pain. (B) Ketorolac tromethamine is currently not approved by the Food and Drug Administration for IV use. (C) Promethazine is a medication that has no analgesic properties. (D) Meperidine is the drug of choice for clients with pancreatitis. It will not cause spasms at the sphincter of Oddi, which can lead to increased pancreatic pain. NO.135 The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this finding? A. Palpate these pulses again in 15 minutes. B. Use a Doppler to determine presence and strength of these pulses. C. Document the finding that the pulses are not palpable. D. Call the physician and notify the physician of this finding. Answer: B Explanation: (A) Palpating these pulses again in 15 minutes may only result in the same findings. (B) Any time during an assessment that the nurse is unable to palpate pulses, the nurse should then obtain a Doppler and assess for presence or absence of the pulse and pulse strength, if a pulse is present. (C) Pulses may be present and assessed through use of a Doppler. Absence of palpable pulses does not indicate absence of blood flow unless pulses cannot be located with a Doppler. (D) The nurse would only call the physician after determining that the pulses are absent by both palpation and Doppler. NO.136 A 33-year-old client is diagnosed with bipolar disorder, acute phase. This is her first psychiatric hospitalization, and she is being evaluated for treatment with lithium. Which of the following diagnostic tests are essential prior to the initiation of lithium therapy with this client? A. Hematocrit, hemoglobin, and white blood cell (WBC) count B. Blood urea nitrogen, electrolytes, and creatinine C. Glucose, glucose tolerance test, and random blood sugar D. X-rays, electroencephalogram, and electrocardiogram (ECG) Answer: B Explanation: (A) These are general diagnostic blood studies (usually done on admission), but they are not reliable indicators of lithium therapy clearance. (B) These are the primary diagnostic tests to determine kidney functioning. Because lithium is excreted through the kidneys and because it can be very toxic, adequate renal function must be ascertained before therapy begins. (C) These are diagnostic blood tests used to determine the presence of endocrine (not renal) dysfunction. (D) These are other types of diagnostic procedures used to determine musculoskeletal, neural, and cardiac (rather than renal) functioning. 96 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score NO.137 A 60-year-old woman exhibits forgetfulness, emotional lability, confusion, and decreased 97 NCLEX NATINONAL COUNCIL LICENSURE EXAMINATION NEW DOC . Download to score 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. Confronting confabulations C. Reality testing D. Providing a highly stimulating environment Answer: A 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. NO.138 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. Allow the infant to breast-feed at the next feeding time to empty the breasts C. Apply ice packs to the breasts and wear a supportive, well-fitting bra D. Take a warm shower and express milk from both breasts until empty Answer: C Explanation: (A) Judicious use of analgesics is appropriate with breast engorgement; however, mechanical suppression would be the initial recommendation. (B) Breast-feeding every 112-3 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. NO.139 While changing the dressing on a client's central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be appropriate to implement based on this finding? A. Discontinue the central line. B. Begin a peripheral IV. C. Document in the nurse's notes and notify the physician after redressing the site. D. Clean the site well and redress.