NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS, Exams of Nursing

Download NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS and more Exams Nursing in PDF only on Docsity! Option C. Grunting occurs when an infant attempts to maintain an adequate functional residual capacity in the face of poorly compliant lungs by partial glottic closure. As the infant prolongs the expiratory phase against this partially closed glottis, there is a prolonged and increased residual volume that maintains the airway opening and also an audible expiratory sound. Option E: Nasal flaring occurs when the nostrils widen while breathing and is a sign of troubled breathing or respiratory distress. Correct Answers: C, E, F, & G NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS 1.1. Question While assessing a one-month-old infant, which of the findings warrants further investigation by the nurse? Select all that apply. o A. Abdominal respirations o B. Irregular breathing rate o C. Inspiratory grunt o D. Increased heart rate with crying o E. Nasal flaring o F. Cyanosis o G. Asymmetric chest movement NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS • 2. Question A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a preoperative client. List the order in which the nurse must carry out the following actions prior to the administration of preoperative medications. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o Option F: Cyanosis refers to the bluish discoloration of the skin and indicates a decrease in oxygen attached to the red blood cells in the bloodstream. o Option G: Asymmetric chest movement occurs when the abnormal side of the lungs expands less and lags behind the normal side. This indicates respiratory distress. o Option A: Abdominal respiration is normal among infants and young children. Since their intercostal muscles are not yet fully developed, they use their abdominal muscles much more to pull the diaphragm down for breathing. o Option B: Newborns can have irregular breathing patterns ranging from 30 to 60 breaths per minute with short periods of apnea (15 seconds). o Option D: An increase in heart rate is normal for an infant during activity (including crying). NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o 4. Question Which individual is at the greatest risk for developing hypertension? o A. 45-year-old African-American attorney NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Correct Answer: Gravida 3 para 1 Gravida is the number of confirmed pregnancies and each pregnancy is only counted one time, even if the pregnancy was a multiple gestation (i.e., twins, triplets). Para (parity) indicates the total number of pregnancies that have reached viability (20 weeks) regardless of whether the infants were born alive. Thus, for this woman, she is now pregnant, had 2 prior pregnancies, Option A: African-Americans develop high blood pressure at younger ages than other groups in the US. Researchers have uncovered that African-Americans respond differently to hypertensive drugs than other groups of people. They are also found out to be more sensitive to salt, which increases the risk of developing hypertension. Option B: The incidence of hypertension in Asian- Americans does not appear to be significantly higher than the general population, according to limited US data. Option C: The racial disparity in hypertension and hypertension-related outcomes has been recognized for decades with African-Americans with greater risks than Caucasians. Option D: Hypertension prevalence rates in Hispanics may vary by gender and country of origin. Hispanic Americans overall have relatively low levels of hypertension, despite elevated levels of diabetes and obesity. Correct Answer: A: 45-year-old African American attorney NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o B. 60-year-old Asian-American shop owner o C. 40-year-old Caucasian nurse o D. 55-year-old Hispanic teacher • 5. Question A 15-year-old female who ingested 15 tablets of maximum strength acetaminophen 45 minutes ago is rushed to the emergency department. Which of these orders should the nurse do first? o A. Gastric lavage o B. Administer acetylcysteine (Mucomyst) orally o C. Start an IV Dextrose 5% with 0.33% NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS normal saline to keep the vein open NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS can effectively adsorb it and neutralize the benefits. • 6. Question NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Option A: The reported incidence of myocardial infarction with angina at rest is less than 0.1%, and is mostly influenced by patient-related factors like the extent and severity of underlying cardiovascular- related diseases and technique-related factors. Options C & D: A falling BP and dizziness occur along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure. Correct Answer: B. Thrombus formation A thrombus formation may prevent blood from flowing normally through the circulatory system, which may become an embolism, and block the flow of blood towards major organs in the body. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? o A. Angina at rest o B. Thrombus formation o C. Dizziness o D. Falling blood pressure • 7. Question A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Correct Answer: C. Manage pain NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS The priority nursing goal for this client is: o A. Maintain fluid and electrolyte balance o B. Control nausea o C. Manage pain o D. Prevent urinary tract infection NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Correct Answer: A. Go get a blood pressure check within the next 15 minutes The blood pressure reading is moderately high with the need to have it rechecked after a few minutes to verify. The client states it is ‘usually much lower.’ Thus a concern exists for complications such as stroke. o Options B & D: Waiting 2 months or a week for follow-up is too long. o Option C: Immediate check by the provider of care is not warranted. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS • 9. Question At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states “My blood pressure is usually much lower.” The nurse should tell the client to: o A. Go get a blood pressure check within the next 15 minutes o B. Check blood pressure again in two (2) months o C. See the healthcare provider immediately o D. Visit the health care provider within one (1) week for a BP check NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o Option A: Decreasing amounts of body fat and muscle mass are common in toddlers. o Option B: A decrease in the change in body appearance occurs among young adults. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS • 10. Question The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission? NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Option B: The client with antibiotic-induced diarrhea still needs continuous strict monitoring as the blood sugar levels may become unstable and dehydration is still possible. Option C: Stevens-Johnson syndrome (SJS) is a rare, serious disorder of the skin and mucous membranes. It’s usually a reaction to medication that starts with flu-like symptoms, followed by a painful rash that spreads and blisters. Option D: Cellulitis is often an underestimated complication of HIV disease, but they are responsible for an appreciable morbidity. Correct Answer: A. A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago. The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o A. A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago. o B. A young adult with diabetes mellitus Type 2 for over ten (10) years and admitted with antibiotic-induced diarrhea 24 hours ago. o C. An elderly client with a history of hypertension, hypercholesterolemia, and lupus, and was admitted with Stevens-Johnson syndrome that morning. o D. An adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Correct Answer: D. Notify the healthcare provider of the child’s status NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o B. Examine the child’s throat o C. Collect a sputum specimen o D. Notify the healthcare provider of the child’s status NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Option A: If epiglottitis is seriously considered, no imaging studies are required. In less-clear cases, imaging studies are occasionally helpful in establishing the diagnosis or excluding epiglottitis. Option B: Examining the child’s throat should not be attempted because it may compromise respiratory effort. Option C: There are no indications for the collection of sputum specimens. These findings suggest a medical emergency and may be due to epiglottitis. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate care. Option A: Polyphagia or extreme hunger is one of the most common symptoms of diabetes both among adults and children. Option B: Dehydration is not a symptom of type 1 diabetes, but it can be one of the many complications. Option D: Unintentional weight loss would develop gradually in a child with type 1 diabetes. Correct Answer: C. Bedwetting One of the first symptoms of type 1 diabetes in children is bedwetting. Bedwetting in a school-age child is readily detected by the parents. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS • 13. Question In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school-age child for evaluation? o A. Polyphagia o B. Dehydration o C. Bedwetting o D. Weight loss NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS • 14. Question NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Option A: The client in option A might be experiencing an overdose. Option B: The client in option B is having withdrawal syndrome. Option D: The client in option D may experience a decrease in sensorium later on due to head trauma. Correct Answer: C. An adolescent who has been on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 10. Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. This client exhibits opioid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o D. An elderly client who reports having taken a “large crack hit” 10 minutes prior to walking into the emergency room. • 16. Question When teaching a client with coronary artery disease about nutrition, the nurse should emphasize: o A. Eating three (3) balanced meals a day o B. Adding complex carbohydrates o C. Avoiding very heavy meals NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Correct Answer: C. Avoiding very heavy meals Eating large, heavy meals can pull blood away from the heart for digestion and is dangerous for the client with coronary artery disease. Too much plaque may accumulate in the arteries and block the delivery of blood and oxygen in major organs of the body. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o D. Limiting sodium to 7 gms per day NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS • 17. Question Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain breakthrough for morphine drip is not working? o A. The client complains of discomfort at the IV insertion site o B. The client states “I just can’t get relief from my pain.” o C. The level of the drug is 100 ml at 8 AM and is 80 ml at noon NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o Option A: Eating a balanced diet should be a part of the management of a client with coronary artery disease. o Option B: Complex carbohydrates decrease inflammation and help decrease the risk of plaque build-up in the arteries. o Option C: People with cardiovascular diseases should have a limit of less than 1.5 Correct Answer: A. Decrease in the level of NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS The nurse is performing a neurological assessment on a client post right cerebrovascular accident. Which finding, if observed by the nurse, would warrant immediate attention? o A. Decrease in the level of consciousness o B. Loss of bladder control o C. Altered sensation to stimuli o D. Emotional lability NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Option B: The patient post-stroke may have transient urinary incontinence due to inability to communicate needs, or impaired motor and postural control. Control of the urinary sphincter may also be lost or diminished. Option C: Altered sensation to stimuli is expected for a patient post CVA. This may include sensory impairment to touch, loss of proprioception, difficulty interpreting visual, tactile, and auditory stimuli. Option D: Depression and anxiety are common responses by a patient after a catastrophic event such as in stroke. Emotional lability (or pseudobulbar affect), refers to the involuntary and uncontrollable bursts of emotion without an emotional trigger. A further decrease in the level of consciousness may indicate an increase in intracranial pressure leading to inadequate oxygenation of the brain. A decrease in LOC may also reveal the presence of a transient ischemic attack which may warn of impending thrombotic CVA. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS • 20. Question A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time? o A. Positive sweat test NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Correct Answer: C. Moist, productive cough Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva, and digestive juices. Normally, these NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o B. Bulky greasy stools o C. Moist, productive cough o D. Meconium ileus NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Option A: There is no need to keep the client on NPO before the procedure. Option B: Enemas are not recommended for any type of radiograph test. Option C: Furosemide (Lasix) is unnecessary for this examination. Correct Answer: D. No special orders are necessary for this examination There are no special orders for this procedure, however, the client must be instructed of the general rule during radiography tests: remove any clothing, jewelry, or objects that may interfere with the test. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS • 22. Question Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiography test? o A. Client must be NPO before the examination o B. Enema to be administered prior to the examination o C. Medicate client with furosemide 20 mg IV 30 minutes prior to the examination o D. No special orders are necessary for this examination NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o Option D: The symptoms are indicative of an emergency situation so the patient must be brought to the emergency department NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS • 23. Question The nurse is giving discharge teaching to a client seven (7) days post-myocardial infarction. He asks the nurse why he must wait six (6) weeks before having sexual intercourse. What is the best response by the nurse to this question? o A. “You need to regain your strength before attempting such exertion.” NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Option A: The instruction in option A is vague and does not specifically tell the patient how to determine if the activity is already appropriate for him. Option C: Having a glass of wine is not recommended for a client who just had a myocardial infarction. Option D: Having an active walking program does not guarantee that the client has regained strength for strenuous activity. Correct Answer: B. “When you can climb 2 flights of stairs without problems, it is generally safe.” There is a risk of cardiac rupture at the point of the myocardial infarction for about six (6) weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by healthcare providers. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o B. “When you can climb 2 flights of stairs without problems, it is generally safe.” o C. “Have a glass of wine to relax you, then you can try to have sex.” • 24. Question A triage nurse has these four (4) clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first? o A. A 2-month-old infant with a history of rolling off the bed and has bulging fontanelle NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Option A: The statement in Option A is correct but pertains to the risks associated with a toddler. Option B: Setting limits on a toddler may cause frustration instead of independence. Correct Answer: C. “I understand the need to use those new skills.” Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment and develop autonomy. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS those new skills.” o D. “I intend to keep control over our child.” NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Option B: It is also important to check that the feeding solution matches the dietary order to ensure that the client gets proper nutrition. Option C: Aspirating the gastric contents is one of the methods used to determine the last feeding amount in the stomach, but is not the most important action the nurse should do. Option D: Keep it at room temperature so it would not upset the stomach. Correct Answer: A. Verify correct placement of the tube Proper placement of the tube prevents aspiration and entrance of food content into the lungs. The definitive way to ascertain the position of the nasogastric tube is through visualization by an x- ray. Another method is to aspirate stomach contents and check its pH (usually pH 1 to 5). Aspirated stomach content can also be tested for bilirubin to confirm it is placed in the stomach. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS • 26. Question The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is: o A. Verify correct placement of the tube o B. Check that the feeding solution matches the dietary order o C. Aspirate abdominal contents to determine the amount of last feeding remaining in stomach o D. Ensure that feeding solution is at room NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o Option D: Controlling the child may be harmful to her development as toddlers should be developing their autonomy at this stage. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS temperature • 27. Question The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq potassium chloride in 1000 ml of 5% dextrose in water IV. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Option B: The cerebellum is not affected in rhabdomyosarcoma. Option C: The kidneys are not directly affected by the disease. Option D: Bones are not directly affected by the disease. Rhabdomyosarcoma is the most common children’s soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. Symptoms of rhabdomyosarcoma include if the cancer is in the head or neck area: sudden bulging or swelling of the eyes, conjunctival chemosis, and headache. It can also affect the urinary or reproductive system. Its common site of metastasis is the lung. Option A: Living in harmony with one’s natural environment with the aim of keeping all aspects of a person-mind, body, and spirit- in a state of harmony and balance so that disease never has a chance to develop. Option B: This balance and a healthy lifestyle are the focus of Chinese medicine which empowers the individual to participate in his own health. Correct Answer: D. Restore yin and yang For followers of Chinese medicine, health is maintained through the balance between the forces of yin and yang. Traditional Chinese medicine is a medical system that began being developed in China about 5000 years ago, which makes it the oldest continuous medical system on the planet. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS • 29. Question The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to: o A. Achieve harmony o B. Maintain a balance of energy o C. Respect life o D. Restore yin and yang NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Correct Answer: C. Force fluids and reassess blood pressure Orthostatic hypotension, a decrease in systolic blood pressure of more than 15 mmHg, and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicate volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency. o Option A: Fluids may not be necessarily protein-rich. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS • 30. Question During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to: o A. Increase fluids that are high in protein o B. Restrict fluids o C. Force fluids and reassess blood pressure o D. Limit fluids to non-caffeine beverages • 31. Question NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o Option C: In Chinese medicine, the body, and indeed a human being, is not seen as a machine, living in isolation from the world around it. Human beings are seen as part of the whole of things, which includes our Correct Answer: C. Force fluids and reassess blood pressure Orthostatic hypotension, a decrease in systolic blood pressure of more than 15 mmHg, and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicate volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency. o Option A: Fluids may not be necessarily protein-rich. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS The nurse prepares the client for the insertion of a pulmonary artery catheter (Swan-Ganz catheter). The nurse teaches the client that the catheter will be inserted to provide information about: NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Option A: Starting a peripheral IV can come after the C-A-B sequence. Option C: Establishing an airway comes after compressions. Option D: After performing the guidelines by the AHA, the crash cart can be obtained by another nurse responding to the scene. As per new guidelines, the American Heart Association recommends beginning CPR with chest compression (rather than checking for the airway first). Start CPR with 30 chest compressions before checking the airway and giving rescue breaths. Starting with chest compressions first applies to adults, children, and infants needing CPR, but not newborns. CPR can keep oxygenated blood flowing to the brain and other vital organs until more definitive medical treatment can restore a normal heart rhythm. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS • 33. Question A client is receiving digoxin (Lanoxin) 0.25 mg daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider? o A. Blood pressure 94/60 mm Hg NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Correct Answer: A. Blood pressure 94/60 mm Hg Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within the normal range (HR 60-100; systolic BP over 100) in order to safely administer both medications. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o B. Heart rate 76 bpm o C. Urine output 50 ml/hour o D. Respiratory rate 16 bpm NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Correct Answer: D. Progressive placental insufficiency Postmature or post-term pregnancy is a prolonged pregnancy that exceeds the limits of 38 to 42 weeks (normal term pregnancy). Infants of such pregnancy are considered postmature or dysmature if there is evidence that placental insufficiency has occurred and interfered with fetal growth. It occurs in 12% of all pregnancies. The placenta loses its adequacy to function after 42 weeks, after which it acquires calcium deposits which decrease the blood perfusion, supply of oxygen and nutrients to the fetus. o Options A, B, & C: Excessive fetal weight, NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS • 34. Question The nurse practicing in a maternity setting recognizes that the postmature fetus is at risk due to: o A. Excessive fetal weight o B. Low blood sugar levels o C. Depletion of subcutaneous fat o D. Progressive placental insufficiency • 35. Question The nurse is caring for a client who had a total hip replacement seven (7) days ago. Which statement by the cli t requires the n rse’s immediat attention? NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o Option C: Increase in urine output is the desired effect of diuretics, which is given with digoxin. o Option D: A respiratory rate of 16 is within the NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS 7 to 14 days following the surgery and can lead to pulmonary embolism. The nurse should be aware of the other signs of DVT which include: pain and tenderness at or below the area of the clot, skin discoloration, swelling, or tightness of the affected leg. Signs of pulmonary embolism include acute onset of dyspnea, tachycardia, confusion, and pleuritic chest pain. o Option A: Muscle spasms occur after total hip replacements and acute pain is expected after a surgical procedure. o Option C: May indicate urinary infection and needs further assessment by the nurse. o Option D: May require a reevaluation of pain and interventions to manage pain though does not need immediate action. • 36. Question A 33-year-old male client with heart failure has been taking furosemide for the past week. Which of the following assessment cues below may indicate the NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS client is experiencing a negative side effect from the medication? o A. Weight gain of 5 pounds NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Correct Answer: D. Decreased appetite Furosemide is a loop diuretic that is used for pulmonary edema, edema in heart failure, nephrotic syndrome, and hypertension. Furosemide causes a loss of potassium unless a supplement or a potassium-rich diet is taken. A decrease in appetite is caused by hypokalemia. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias, reduced urine osmolality, altered level of consciousness. o Option A: Weight gain is not a negative side effect of furosemide. o Option B: Edema of the ankles are indications for the administration of furosemide. o Option C: Gastric irritability is not a side Correct Answer: B. Improve the client’s nutrition status Venous stasis occurs when venous blood collects and stagnates in the lower leg due to incompetent venous valves. Eventually, little oxygen and nutrients are supplied NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o B. Edema of the ankles o C. Gastric irritability o D. Decreased appetite • 37. Question The nurse is caring for a 27-year-old female client with venous stasis ulcer. Which nursing intervention would be most effective in promoting healing? o A. Apply dressing using sterile technique o B. Improve the client’s nutrition status o C. Initiate limb compression therapy o D. Begin proteolytic debridement NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS to the event as possible o B. Staff is given feedback in equal amounts over time o C. Positive statements are to precede a negative statement NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Option B: Positive feedback is most useful when given immediately. Option C: Negative statements are never helpful in any given situation. Option D: Every goal should always be attainable. Correct Answer: A. Specific feedback is given as close to the event as possible Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if the standards are clearly understood. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o D. Performance goals should be higher than what is attainable • 39. Question The nurse is providing information to a client with multiple sclerosis on performing exercises and physical activities. The nurse determines the client needs additional teaching if the client makes which statements? Select all that apply. o A. “I can lift weights and do resistance training.” o B. “I should exercise to the point of exhaustion.” NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Option B: Patients with multiple sclerosis should not exercise to the point of fatigue as strenuous physical exercise raises body temperature and may aggravate symptoms. Option E: Continuous exercise with no rest periods is contraindicated for patients with multiple sclerosis Correct answers: B & E. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o C. “I can include aerobic exercises in my routine.” o D. “Proper stretching should be done before starting my routine.” o E. “I should exercise continuously without rest.” NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS • 41. Question A nurse is reviewing a patient’s medication during shift change. Which of the following medications would be contraindicated if the patient were pregnant? Select all that apply. o A. Warfarin (Coumadin) o B. Finasteride (Propecia, Proscar) NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS be removed in order to prevent falls and other injuries. A hazard-free home environment allows the patient maximum independence and a sense of autonomy. o Option A: In addition to proper nutrition, mealtimes should be kept pleasant, simple, calm, and without confrontations. Patients with AD prefer foods that are familiar, appetizing, and tastes good. Food should be cut into smaller pieces when possible to prevent choking. Hot food and beverages should be served warm or have their temperature checked to prevent burns. o Option B: Socialization is encouraged for patients with dementia. Participation in simple activities, visits from friends, doing hobbies, or caring for pets helps improve the quality of life. o Option A: Warfarin (Coumadin). Has a pregnancy category X and associated with central nervous system defects, spontaneous abortion, stillbirth, Correct Answer: A. Warfarin (Coumadin); B. Finasteride (Propecia, Proscar) NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o C. Celecoxib (Celebrex) o D. Clonidine (Catapres) o E. Transdermal nicotine (Habitrol) o F. Clofazimine(Lamprene) NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS • 42. Question A nurse is reviewing a patient’s past medical history (PMH). The history indicates the patient has photosensitive reactions to medications. Which of the following drugs is associated with photosensitive reactions? Select all that apply. o A. Ciprofloxacin (Cipro) o B. Sulfonamide NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS prematurity, hemorrhage, and ocular defects when given anytime during pregnancy and fetal warfarin syndrome when given during the first trimester. o Option B: Finasteride (Propecia, Proscar). Also has a pregnancy category X which has a high risk of causing permanent damage to the fetus. o Option C: Celecoxib (Celebrex). Large doses cause birth defects in rabbits; Pregnancy category C. o Option D: Clonidine (Catapres). Crosses the placenta but no adverse fetal effects have been observed. o Option E: Transdermal nicotine (Habitrol). Nicotine replacement products have been assigned to pregnancy category C (nicotine NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Norfloxacin fights bacteria in the body. Norfloxacin is used to treat different bacterial infections of the prostate or urinary tract (bladder and kidneys). Norfloxacin is also used to treat gonorrhea. o Option D: Sulfamethoxazole and trimethoprim combination is used to treat infections such as urinary tract infections, middle ear infections (otitis media), bronchitis, traveler’s diarrhea, and shigellosis (bacillary dysentery). This medicine is also used to prevent or treat Pneumocystis jiroveci pneumonia or Pneumocystis carinii pneumonia (PCP), a very serious kind of pneumonia. Sulfamethoxazole and trimethoprim combination is an antibiotic. It works by eliminating the bacteria that cause many kinds of infections. o Option E: Isotretinoin is a drug used to treat severe acne that hasn’t responded to other treatments. It may be prescribed for other uses, including other skin problems NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS and certain kinds of cancer. This drug is a vitamin A derivative (retinoid), so your body reacts to it in a similar way that it does to vitamin A. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Option A: Sulfasalazine may discolor the urine or skin to orange-yellow color. Sulfasalazine is used to treat ulcerative colitis (UC), and to decrease the frequency of UC attacks. Sulfasalazine will not cure ulcerative colitis, but it can reduce the number of attacks you have. Option B: Levodopa may discolor the urine, saliva, or sweat to a dark brown color. Levodopa is in a class of medications called central nervous system agents. It works by being converted to dopamine in the brain. Carbidopa is in a class of medications called decarboxylase inhibitors. It works by preventing levodopa from being broken down before it reaches the brain. Correct Answer: D. Aspirin Aspirin is not known to cause discoloration of the urine. Side effects and complications of taking aspirin include stroke caused by a burst blood vessel. The Food and Drug Administration doesn’t recommend aspirin therapy for the prevention of heart attacks in people who haven’t already had a heart attack, stroke or another cardiovascular condition. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS • 43. Question A patient tells you that her urine is starting to look discolored. If you believe this change is due to medication, which of the following of the patient’s medication does not cause urine discoloration? o A. Sulfasalazine o B. Levodopa o C. Phenolphthalein o D. Aspirin NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o Option F: Nitro-Dur patch is used to prevent chest pain or angina. Its side effects are headache, lightheadedness, nausea, and NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS • 45. Question A 34-year-old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb? o A. IgA o B. IgD o C. IgE o D. IgG Correct Answer: D. IgG IgG is the only immunoglobulin that can cross the placental barrier. About 70-80% of the NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o Option D: Epoetin alfa IV (Epogen) vials should be stored at 2°C to 8°C (36°F to 46°F); Do not freeze. Do not shake. Protect from NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS immunoglobulins in the blood are IgG. Specific IgG antibodies are produced during an initial infection or other antigen exposure, rising a few weeks after it begins, then decreasing and stabilizing. The body retains a catalog of IgG antibodies that can be rapidly reproduced whenever exposed to the same antigen. IgG antibodies form the basis of long-term protection against microorganisms. o Option A: IgA antibodies protect body surfaces that are exposed to outside foreign substances. Immunoglobulin A (IgA) is the first line of defence in the resistance against infection, via inhibiting bacterial and viral adhesion to epithelial cells and by neutralisation of bacterial toxins and virus, both extra- and intracellularly. IgA also eliminates pathogens or antigens via an IgA- mediated excretory pathway where binding to IgA is followed by poly immunoglobulin receptor-mediated transport of immune complexes. o Option B: IgD antibodies are found in NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS small amounts in the tissues that line the belly or chest. Secreted IgD appears to enhance mucosal homeostasis and NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS nerves, which control the bladder, intestinal tract, and genitals, among other organs. Paralysis of the bladder is a common symptom of this type of neuropathy, as manifested by bladder urgency and inability to start urination. o Option A: Atherosclerosis, or hardening of the arteries, is a condition in which plaque builds up inside the arteries. Plaque is made of cholesterol, fatty substances, cellular waste products, calcium, and fibrin (a clotting material in the blood). o Option B: Diabetic nephropathy (DN) is typically defined by macro albuminuria— that is, a urinary albumin excretion of more than 300 mg in a 24-hour collection—or macroalbuminuria and abnormal renal function as represented by an abnormality in serum creatinine, calculated creatinine clearance, or glomerular filtration rate (GFR). Clinically, diabetic nephropathy is characterized by a progressive increase in proteinuria and an increased need to NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS urinate. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Option A: Multiple sclerosis (MS) is a demyelinating disease in which the insulating covers of the nerve cells in the brain and spinal cord are damaged. Option C: On the other hand, bulimia nervosa features binge eating followed by a feeling of guilt, humiliation, and self-deprecation. These feelings cause the patient to engage in self-induced vomiting, use of laxatives, or diuretics. Option D: Systemic sclerosis or systemic scleroderma is an autoimmune disease of the connective tissue. Correct Answer: B. Anorexia nervosa All of the clinical signs and symptoms point to a condition of anorexia nervosa. The key feature of anorexia nervosa is self- imposed starvation, resulting from a distorted body image and an intense, irrational fear of gaining weight, even when the patient is emaciated. Anorexia nervosa may include refusal to eat accompanied by compulsive exercising, self-induced vomiting, or laxative or diuretic abuse. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS • 48. Question You are taking the history of a 14-year-old girl who has a (BMI) of 18. The girl reports inability to eat, induced vomiting and severe constipation. Which of the following would you most likely suspect? o A. Multiple sclerosis o B. Anorexia nervosa o C. Bulimia nervosa o D. Systemic sclerosis NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o Option D: Somatic neuropathy affects the whole body and presents with diverse clinical pictures, most common is the development of diabetic foot followed by diabetic ulceration and NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS mothers that have a infant. o A. RH positive, RH positive o B. RH positive, RH negative o C. RH negative, RH positive NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o D. RH negative, RH negative Correct Answer: C. RH negative, RH positive Rhogam prevents the production of anti-RH antibodies in the mother that has an Rh-positive fetus. o Option A: RhoGAM is a prescription medicine that is used to prevent Rh immunization, a condition in which an individual with Rh-negative blood develops antibodies after exposure to Rh-positive blood. o Option B: If the father or baby is not conclusively shown to be Rh-negative, RhoGAM should be given to an Rh-negative mother in the following clinical situations to prevent Rh immunization: after delivery of an Rh-positive baby; routine prevention of Rh immunization at 26 to 28 weeks of pregnancy; maternal or fetal bleeding during pregnancy from certain conditions; or an actual or threatened pregnancy loss at any NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS stage. o Option D: It isn’t until second and subsequent pregnancies when antibodies are already built up, that Rh incompatibility can cause problems. Indeed, these antibodies can cross the placenta and attack the baby’s red blood cells. This can cause the baby to develop anemia, and in severe cases, result in miscarriage. • 51. Question A new mother has some questions about phenylketonuria (PKU). Which of the following statements made by a nurse is not correct regarding PKU? o A. A Guthrie test can check the necessary lab values o B. The urine has a high concentration of phenyl pyruvic acid NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o Option A: The Guthrie test as a bacterial inhibition assay was formerly used, but now being replaced by tandem mass spectrometry. The Guthrie test, also called the PKU test, is a diagnostic tool to test infants for phenylketonuria a few days after birth. To administer the Guthrie test, doctors use Guthrie cards to collect capillary blood from an infant’s heel, and the cards are saved for later testing. o Option B: Phenylalanine is present in high concentrations in the urine because of its increased build up in the body. In addition to its role in protein production, phenylalanine is used to make other important molecules in the body, several of which send signals between different parts of the body. Phenylalanine has been studied as a treatment for several medical conditions, including skin disorders, depression, and pain o Option C: Without treatment, children NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS affected with PKU develop a permanent intellectual disability. Seizures, delayed development, behavioral problems, and psychiatric disorders are also common. Untreated individuals may have a musty or mouse-like odor as a side effect of excess phenylalanine in the body. Children with classic PKU tend to have lighter skin and NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS • 52. Question A patient has taken an overdose of aspirin. Which of the following should a nurse must closely monitor for during acute management of this patient? o A. Onset of pulmonary edema o B. Metabolic alkalosis o C. Respiratory alkalosis o D. Parkinson’s disease type symptoms Correct Answer: A. Onset of pulmonary edema Aspirin overdose can lead to metabolic acidosis and cause pulmonary edema development. Early symptoms of aspirin poisoning also include tinnitus, hyperventilation, vomiting, NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS hair than unaffected family members and are also likely to have skin disorders such as Option A: Letting others know is correct, so that the other staff may become aware of the patient’s condition. However, this is not a priority. Option B: Before communication with the supervisor, the charge nurse must secure the environmental safety of the client first. Option C: Continuously updating the patient on the social environment is also correct, but this can come after securing the client’s safety. Correct Answer: D. Provide a secure environment for the patient. This patient’s safety is your primary concern. Patient safety protocols can help reduce medical mistakes and prevent adverse patient outcomes. When the goal is to help people, it seems obvious that it’s important to work to protect them from unintended or unexpected harm. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS A 50-year-old blind and deaf patient has been admitted to your floor. As the charge nurse, your primary responsibility for this patient is? o A. Let others know about the patient’s deficits. o B. Communicate with your supervisor your patient safety concerns. o C. Continuously update the patient on the social environment. o D. Provide a secure environment for the patient. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS • 54. Question A patient is getting discharged from a skilled nursing facility (SNF). The patient has a history of severe COPD and PVD. The patient is primarily concerned about his ability to breathe easily. Which of the following would be the best instruction for this patient? o A. Deep breathing techniques to increase oxygen levels. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS Option A: Deep breathing exercises can help the client’s lungs from becoming more damaged. When one has healthy lungs, breathing is natural and easy. You breathe in and out with the diaphragm doing about 80 percent of the work to fill the lungs with a mixture of oxygen and other gases, and then send the waste gas out. Option B: Coughing may help clear the airway, however, it may not be as effective as taking bronchodilators. Coughing moves mucus out of the large airways. However, moving mucus out of the small airways requires airway clearance techniques (ACTs). This is why coughing should be done with other ACTs. Option D: Changing the level of oxygen at home without asking the healthcare provider is not recommended. Correct Answer: C. Cough following bronchodilator utilization The bronchodilator will allow a more productive cough. NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS o B. Cough regularly and deeply to clear airway passages. o C. Cough following bronchodilator utilization. o D. Decrease CO2 levels by increased oxygen take output during meals. • 55. Question A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present? o A. Slow pulse rate NCLEX-RN EXAM PACK SET 1 (75 QUESTIONS & ANSWERS UPDATED 2023) ASSURED SUCCESS