NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEE, Exams of Nursing

Download NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEE and more Exams Nursing in PDF only on Docsity! 1 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NO.1 Prior to an amniocentesis, a fetal ultrasound is done in order to: A. Evaluate fetal lung maturity B. Evaluate the amount of amniotic fluid C. Locate the position of the placenta and fetus D. Ensure that the fetus is mature enough to perform the amniocentesis Answer: C Explanation: (A) Amniocentesis can be performed to assess for lung maturity. Fetal ultrasound can be used for gestational dating, although it does not separately determine lung maturity. (B) Ultrasound can evaluate amniotic fluid volume, which may be used to determine congenital anomalies. (C) Amniocentesis involves removal of amniotic fluid for evaluation. The needle, inserted through the abdomen, is guided by ultrasound to avoid needle injuries, and the test evaluates the position of the placenta and the fetus. (D) Amniocentesis can be performed as early as the 15th-17th week of pregnancy. 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 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 2 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 Explanatio n: (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 female client has just died. Her family is requesting that all nursing staff leave the room. The family's religious leader has arrived and is ready to conduct a ceremony for the deceased in the room, requesting that only family members be present. The nurse assigned to the client should perform the appropriate nursing action, which might include: A. Inform the family that it is the hospital's policy not to conduct religious ceremonies in client rooms . B. Refuse to leave the room because the client's body is entrusted in the nurse's care until it can be brought to the morgue. C. Tell the family that they may conduct their ceremony in the client's room; however, the nurse must attend. D. Respect the client's family's wishes. Answer: D Explanatio n: (A) It is rare that a hospital has a specific policy addressing this particular issue. If the statement is true, the nurse should show evidence of the policy to the family and NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 5 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 Explanatio n: (A) Giving the drug with or after meals may allay gastrointestinal discomfort. Giving the drug with a fatty meal (ice cream or milk) increases absorption rate. (B) Griseofulvin may alter taste sensations NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 6 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 and thereby decrease the appetite. Monitoring of food intake is important, and inadequate nutrient intake should be reported to the physician. (C) The child may experience symptomatic relief after 48- 96 hours of therapy. It is important to stress continuing the drug therapy to prevent relapse (usually about 6 weeks). (D) The incidence of side effects is low; however, headaches are common. Nausea, vomiting, diarrhea, and anorexia may occur. Dizziness, although uncommon, should be reported to the physician. NO.7 A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube. The rationale for this therapy is to: A. Prevent systemic infection B. Promote diuresis C. Decrease ammonia formation D. Acidify the small bowel Answer: C Explanatio n: (A) Neomycin is an antibiotic, but this is not the Rationale for administering it to a client in hepatic coma. (B) Diuretics and salt-free albumin are used to promote diuresis in clients with cirrhosis of the liver. (C) Neomycin destroys the bacteria in the intestines. It is the bacteria in the bowel that break down protein into ammonia. (D) Lactulose is administered to create an acid environment in the bowel. Ammonia leaves the blood and migrates to this acidic environment where it is trapped and excreted. NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 7 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NO.8 A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures should be included in the postoperative care? A. Encourage the child to cough up blood if present. B. Give warm clear liquids when fully alert. C. Have child gargle and do toothbrushing to remove old blood. D. Observe for evidence of bleeding. Answer: D Explanatio n: (A) The nurse should discourage the child from coughing, clearing the throat, or putting objects in his mouth. These may induce bleeding. (B) Cool, clear liquids may be given when child is fully alert. Warm liquids may dislodge a blood clot. The nurse should avoid red- or brown-colored liquids to distinguish fresh or old blood from ingested liquid should the child vomit. (C) Gargles and vigorous toothbrushing could initiate bleeding. (D) Postoperative hemorrhage, though unusual, may occur. The nurse should observe for bleeding by looking directly into the throat and for vomiting of bright red blood, continuous swallowing, and changes in vital signs. NO.9 An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his left leg that started approximately 20 minutes ago. When performing the admission assessment, the nurse would expect to observe which of the following: A. Both lower extremities warm to touch with 2_pedal pulses B. Both lower extremities cyanotic when placed in a dependent position NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 10 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 D. Vitamin A Answer: A Explanatio n: (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.13 A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Nagele's rule is: A. March 27 B. February 1 C. February 27 D. January 3 Answer: NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 11 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 C Explanatio n: (A)March 27 is a miscalculation. (B) February 1 is a miscalculation. (C) February 27 is the correct answer. To calculate the estimated date of confinement using Nagele's rule, subtract 3 months from the date that the last menstrual cycle began and then add 7 days to the result. (D) January 3 is a miscalculation. NO.14 A client is now pregnant for the second time. Her first child weighed 4536 g at delivery. The client's glucose tolerance test shows elevated blood sugar levels. Because she only shows signs of diabetes when she is pregnant, she is classified as having: A. Insulin-dependent diabetes B. Type II diabetes mellitus C. Type I diabetes mellitus D. Gestational diabetes mellitus Answer: D Explanatio n: (A) Insulin-dependent diabetes mellitus, also known as type I diabetes, usually appears before the age of 30 years with an abrupt onset of symptoms requiring insulin for management. It is not related to onset during pregnancy. (B) Non-insulin-dependent diabetes (type II diabetes) usually appears in older adults. It has a slow onset and progression of symptoms. (C) This type of diabetes is the same as insulin-dependent diabetes. (D) Gestational diabetes mellitus has its onset of symptoms during pregnancy NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 12 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 and usually disappears after delivery. These symptoms are usually mild and not life threatening, although they are associated with increased fetal morbidity and other fetal complications. NO.15 A 44-year-old female client is receiving external radiation to her scapula for metastasis of NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 15 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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.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 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 16 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 Explanatio n: (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 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 17 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 is: A. Respiratory obstruction B. Hypercalcemia C. Fistula formation D. Myxedema NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 20 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 D. Wear a patch over one eye Answer: D Explanatio n: (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 : NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 21 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 (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? A. Urine output B. Edema C. Hypertension D. Bulging fontanelle NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 22 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 Answer: A Explanatio n: (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 Explanatio n: (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. NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 25 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 because there are no indications of toxicity present. (B) There is no reason to withhold the lithium because the blood level is within therapeutic range. Also, it is necessary to give the medication as scheduled to maintain adequate blood levels. (C) The lab results indicate that the client's lithium level is within therapeutic range (0.2-1.4 mEq/L), so the medication should be given as ordered. (D) Benztropine is an antiparkinsonism drug frequently given to counteractextrapyramidal symptoms associated with the administration of antipsychotic drugs (not lithium). NO.29 The primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed toward: A. Maintaining an adequate level of hydration B. Providing pain relief C. Preventing infection D. O2 therapy Answer: A Explanation : (A) Maintaining the hydration level is the focus for nursing intervention because dehydration enhances the sickling process. Both oral and parenteral fluids are used. (B) The pain is a result of the sickling process. Analgesics or narcotics will be used for symptom relief, but the underlying cause of the pain will be resolved with hydration. (C) Serious bacterial infections may result owing to splenic dysfunction. This is true at all times, not just during the acute period of a crisis. (D) O2 therapy is used for NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 26 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 symptomatic relief of the hypoxia resulting from the sickling process. Hydration is the primary intervention to alleviate the dehydration that enhances the sickling process. NO.30 Three weeks following discharge, a male client is readmitted to the psychiatric unit for depression. His wife stated that he had threatened to kill himself with a handgun. As the nurse admits him to the unit, he says, "I wish I were dead because I am worthless to everyone; I guess I am just no good." Which response by the nurse is most appropriate at this time? A. "I don't think you are worthless. I'm glad to see you, and we will help you." B. "Don't you think this is a sign of your illness?" C. "I know with your wife and new baby that you do have a lot to live for." D. "You've been feeling sad and alone for some time now?" Answer: D Explanatio n: (A) This response does not acknowledge the client's feelings. (B) This is a closed question and does not encourage communication. (C) This response negates the client's feelings and does not require a response from the client. (D) This acknowledges the client's implied thoughts and feelings and encourages a response. NO.31 A 52-year-old client is scheduled for a small-bowel resection in the morning. NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 27 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises. NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 30 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 (A) Ice creates a dramatic temperature change in the tissue, which can cause further thermal injury. (B) Charred clothing should not be removed from wound first. This creates further tissue damage. Debridement is not the first nursing action. (C) Applying silver sulfadiazine cream first insulates heat in injured tissue and increases potential for infection. (D) Emergency care of a thermal burn is immersing both legs in cool water. Cool water permits gradual temperature change and prevents further thermal damage. NO.34 The nurse notes scattered crackles in both lungs and 1+ pitting edema when assessing a cardiac client. The physician is notified and orders furosemide (Lasix) 80 mg IV push stat. Which of the following diagnostic studies is monitored to assess for a major complication of this therapy? A. Serum electrolytes B. Arterial blood gases C. Complete blood count D. 12-Lead ECG Answer: A Explanation: (A) Furosemide, a potassium-depleting diuretic, inhibits the reabsorption of sodium and chloride from the loop of Henle and the distal renal tubules. Serum electrolytes are monitored for hypokalemia. (B) Severe acid-base imbalances influence the NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 31 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 movement of potassium into and out of the cells, but arterial blood gases to not measure the serum potassium level. (C) Furosemide is a potassium-depleting diuretic. A complete blood count does not reflect potassium levels. (D) Abnormalities in potassium (both hyperkalemia and hypokalemia) are reflected in ECG changes, but these changes do not occur until the abnormality is severe. NO.35 A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements? A. "When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices." B. "If I have any side effects from my medicines, I will take an extra dose of Cogentin." C. "When I get home, I should be able to taper myself off the Haldol because the voices are gone now." D. "As soon as I leave here, I'm throwing away my medicines. I never thought I needed them anyway." Answer: A Explanatio n: (A) The client verbalizes that he is responsible for compliance and keeping the treatment team member informed of progress. This behavior puts him at the lowest risk for relapse. (B) Noncompliance is a major cause of relapse. This statement reflects lack of responsibility NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 32 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 for his own NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 35 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 D. Urine retention or a distended bladder Answer: D NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 36 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 Explanatio n: (A) This answer is correct. Two risk factors are identified in this answer. (B) This answer is NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 37 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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. NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 40 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 Explanatio n: (A) This response is untrue. (B) Decreasing salt intake reduces fluid retention and decreases blood pressure. (C) Salt does not have an effect on the blood vessels themselves, but on fluid retention, which accompanies salt intake. (D) This response is untrue. NO.43 A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2- week period. Her husband asks, "Isn't that a lot?" The nurse's best response is: A. "Yes, that does seem like a lot." B. "You'll have to talk to the doctor about that. The physician knows what's best for the client." C. "Six to 10 treatments are common. Are you concerned about permanent effects?" D. "Don't worry. Some clients have lots more than that." Answer: C Explanatio n: (A) This response indicates that the nurse is unsure of herself and not knowledgeable about ECT. It also reinforces the husband's fears. (B) This response is "passing the buck" unnecessarily. The information needed to appropriately answer the husband's question is well within the nurse's knowledge base. (C) The most common range for affective disorders is 6-10 treatments. This response confirms and reinforces the physician's plan for treatment. It also opens communicationwith the husband to identify underlying fears and knowledge deficits. (D) This response NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 41 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 offers false reassurance and dismisses the husband's underlying concerns about his wife. NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 42 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 Explanatio n: (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 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 45 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 1.3 mEq/L is within therapeutic range. (D) This answer is incorrect. Toxic poisoning is usually at the 2.0 level or higher. NO.47 When discussing the relationship between exercise and insulin requirements, a 26-year-old client with IDDM should be instructed that: A. When exercise is increased, insulin needs are increased B. When exercise is increased, insulin needs are decreased C. When exercise is increased, there is no change in insulin needs D. When exercise is decreased, insulin needs are decreased Answer: B Explanatio n: (A) If the client's insulin is increased when activity level is increased, hypoglycemia may result. (B) Exercise decreased the blood sugar by promoting uptake of glucose by the muscles. Consequently, less insulin is needed to metabolize ingested carbohydrates. Extra food may be required for extra activity. (C) This statement directly contradicts the correct answer and is inaccurate. (D) When exercise is decreased, the client's insulin dose does not need to be altered unless the blood sugar becomes unstable. NO.48 A client had a hemicolectomy performed 2 days ago. Today, when the nurse assesses the incision, a small part of the abdominal viscera is seen protruding through the incision. This complication of wound healing is known as: NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 46 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 A. Excoriation B. Dehiscence C. Decortication D. Eviscerati on Answer: D Explanation: (A) Excoriation is abrasion of the epidermis or of the coating of any organ of the body by trauma, chemicals, burns, or other causes. (B) Dehiscence is a partial or complete separation of the wound edges with no protrusion of abdominal tissue. (C) Decortication is removal of the surface layer of an organ or structure. It is a type of surgery, such as removing the fibrinous peel from the visceral pleura in thoracic surgery. (D) Evisceration occurs when the incision separates and the contents of the cavity spill out. NO.49 A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure? A. Bulging fontanelles B. Seizure C. Headache D. Ataxia Answer: C Explanatio NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 47 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 n: (A) Bulging fontanelles are a symptom of increased intracranial pressure in infants. (B) Seizure is a NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 50 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 (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 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 51 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 Explanatio n: (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 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 52 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 Explanatio n: (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: NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 55 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 Once the feeding tube placement is confirmed in the stomach, aspiration can occur if the client's stomach becomes too full. When suctioning the trachea, if secretions resemble tube feeding, the client has aspirated the feeding. (B) Because the trachea provides direct access to a client's airway, it would not be possible to place the catheter in the esophagus. (C) Blue-colored sputum is never considered a normal finding and should be reported and documented. (D) The nurse confirmed placement of the feeding tube in the stomach prior to initiating the tube feeding; therefore, it is highly unlikely that the feeding tube would be located in the trachea. NO.57 A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea, vomiting, and sore throat for the past several days. In caring for a young child with symptoms of influenza, the mother must be cautioned about: A. Giving aspirin and bismuth subsalicylate (Pepto-Bismol) to treat the symptoms B. Giving clear liquids too soon C. Allowing the child to come in contact with other children for 3 days D. The possibility of pneumonia as a complication Answer: A Explanatio n: (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 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 56 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 be avoided. (B) Depending NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 57 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 Explanatio n: (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. NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 60 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 days Answer: B Explanatio n: (A) Ovulation is dependent on average length of menstrual cycle, not standard 14 days. (B) Ovulation occurs 14+2 days before next menses (34 minus 14 does not equal 16). (C) Ovulation occurs 14+2 days before next menses (34 minus 14 equals 20). (D) Ovulation occurs 14+2 days before next menses (34 minus 14 does not equal 22). NO.63 The nurse is collecting a nutritional history on a 28- year-old female client with iron-deficiency anemia and learns that the client likes to eat white chalk. When implementing a teaching plan, the nurse should explain that this practice: A. Will bind calcium and therefore interfere with its metabolism B. Will cause more premenstrual cramping C. Interferes with iron absorption because the iron precipitates as an insoluble substance D. Causes competition at iron-receptor sites between iron and vitamin B1 Answer: C Explanatio n: (A) Eating chalk is not related to calcium and its absorption. (B) Poor nutritional habits may result in increased discomfort during premenstrual days, but this is not a primary reason for the client to stop eating chalk. Premenstrual discomfort has not been mentioned. (C) Iron is rendered insoluble and is excreted through the gastrointestinal tract. (D) There is no competition between the two nutrients. NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 61 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 Explanatio n: (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 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 62 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 Explanatio n: (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 Explanatio n: (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. 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? NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 65 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NO.70 A common complication of cirrhosis of the liver is prolonged bleeding. The nurse should be prepared to administer? A. Vitamin C B. Vitamin K C. Vitamin E D. Vitamin A Answer: B Explanatio n: (A) Vitamin C does not directly affect clotting. (B) Vitamin K is a fat-soluble vitamin that depends on liver function for absorption. Vitamin K is essential for clotting. (C) Vitamin E does not directly affect clotting. (D) Vitamin A does not directly affect clotting. NO.71 The nurse in the mental health center is instructing a depressed client about the dietary restrictions necessary in taking her medication, which is a monoamine oxidase (MAO) inhibitor. Which of the following is she restricting from the client's diet? A. Cream cheese B. Fresh fruits C. Aged cheese D. Yeast bread NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 66 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 Answer: C Explanation: (A) Cream cheese does not contain tyramine, which might cause a hypertensive crisis. (B) Fresh fruits do not contain tyramine, which might cause a hypertensive crisis. (C) Aged or matured cheese combined with a monoamine oxidase predisposes the client to a hypertensive crisis. (D) Bread products raised with yeast do not contain tyramine. NO.72 A 67-year-old client will be undergoing a coronary arteriography in the morning. Client teaching about postprocedure nursing care should include that: A. Bed rest with bathroom privileges will be ordered B. He will be kept NPO for 8-12 hours C. Some oozing of blood at the arterial puncture site is normal D. The leg used for arterial puncture should be kept straight for 8-12 hours Answer: D Explanatio n: (A) Bed rest will be ordered for 8-12 hours postprocedure. Flexing of the leg at the arterial puncture site will occur if the client gets out of bed, and this is contraindicated after arteriography. (B) The client will be able to eat as soon as he is alert enough to swallow safely and that will depend on what medications areused for sedation during the procedure. (C) Oozing at the arterial puncture site is not normal and should be closely evaluated. (D) NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 67 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 The leg where the arterial puncture occurred must be kept straight for 8-12 hours to minimize the risk of bleeding. NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 70 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NO.76 Priapism may be a sign of: A. Altered neurological function B. Imminent death C. Urinary incontinence D. Reproductive dysfunction Answer: A Explanatio n: (A) Priapism in the trauma client is due to the neurological dysfunction seen in spinal cord injury. Priapism is an abnormal erection of the penis; it may be accompanied by pain and tenderness. This may disappear as spinal cord edema is relieved. (B) Priapism is not associated with death. (C) Urinary retention, rather than incontinence, may occur. (D) Reproductive dysfunction may be a secondary problem. NO.77 The healthcare team determines that an elderly client has had progressive changes in memory over the last 2 years that have interfered with her personal, social, or occupational functioning. Her memory, learning, attention, and judgment have all been affected in some way. These symptoms describe which of the following conditions? A. Dementia B. Parkinsonism C. Delirium D. Mania Answer: A NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 71 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 Explanatio n: (A) These changes are common characteristics of dementia. (B) Parkinson's disease affects the muscular system. Progressive memory changes are not presenting symptoms. (C) Delirium includes an altered level of consciousness, which is not found in dementia. (D) Mania includes symptoms of hyperactivity, flight of ideas, and delusions of grandeur. NO.78 After instructing a female client on circumcision care, the nursery nurse asks her to restate some of the key points covered. Which statement shows that the client will properly care for her son's circumcision? A. "I'll make sure I soak the gauze with warm water first, before I take it off each time." B. "I'll make sure that I report any drainage around where they operated." C. "I'll apply alcohol to the area daily to clean it and prevent any infection." D. "I'll keep a close watch on it for a day or two." Answer: A Explanatio n: (A) Before petrolatum gauze is removed, it should be soaked with warm water to prevent trauma to adherent tissues. (B) A yellow exudate often forms normally over the surgical site. Only if it becomes foul-smelling and purulent would it need to be reported. (C) Alcohol should never be used on the NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 72 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 75 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 (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 Explanatio n: (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 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 76 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 Explanatio n: (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." C. "I really wasn't addicted to alcohol when I came here, I just needed some help dealing with my NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 77 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 divorce." D. "It really wasn't my fault that I had to come here. If my wife hadn't left, I wouldn't have needed those drinks." Answer: A Explanatio n: (A) The client has insight into the severity of his alcohol addiction and has chosen one of the most effective treatment strategies to support him-Alcoholics Anonymous. (B) The client is still using denial and is not dealing with his alcohol addiction. (C) The client is exhibiting denial about his alcohol addiction and projecting blame on his divorce. (D) The client is projecting blame onto his wife for being in the hospital while still denying his alcohol addiction. NO.85 Which of the following should be included in discharge teaching for a client with hepatitis C? A. He should take aspirin as needed for muscle and joint pain. B. He may become a blood donor when his liver enzymes return to normal. C. He should avoid alcoholic beverages during his recovery period. D. He should use disposable dishes for eating and drinking. Answer: C Explanatio n: (A) Aspirin is hepatotoxic, may increase bleeding, and should be avoided. (B) Blood should not be donated by a client who has had hepatitis C because of the possibility NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 80 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 (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: NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 81 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 Explanatio n: (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 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. NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 82 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 B. The nurse counts the instruments and sponges with the scrub nurse. C. The nurse instills prophylactic ointment in the conjunctival sacs of the newborn's eyes. D. The nurse makes sure the mother and her newborn have been tagged with identical bands. Answer: D Explanatio n: (A) The delivery room personnel are responsible for verifying time of birth. (B) The scrub and circulating nurses count sponges and instruments. (C) This intervention is done in the nursery. (D) Tagging the mother and infant with identical bands is of utmost importance. The mother wears one band, and the newborn wears two. Identical numbers on the three bands provide identification for the newborn and the birth mother. Every time the newborn is brought to the mother after delivery, those bands are checked to be sure that the numbers are identical. NO.91 A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction. One comfort measure the nurse can employ is to: A. Place her in knee-chest position during the contraction B. Use effleurage during the contraction C. Apply strong sacral pressure during the contraction D. Have her push with each contraction NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 85 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 Explanatio n: (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 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 86 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 D. Afterload reduction therapy Answer: A Explanatio n: (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 D. Respirations are>16 breaths/min Answer: D NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 87 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 Explanatio n: (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. NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 90 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 fetus will be postponed until fetal maturity is achieved and survival is likely. NO.98 A client has chronic obstructive pulmonary disease. She is slowly losing weight, and her daughter is very concerned about increasing her nutrition. The nurse helps the daughter devise a plan of care for her mother. The plan of care should include which of the following interventions to promote nutrition? A. Offer her oral hygiene before and after meals. B. Encourage her to consume milk products. C. Encourage her to engage in an activity before a meal to stimulate her appetite. D. Restrict her fluid intake to three glasses of water a day. Answer: A Explanatio n: (A) Clients with respiratory diseases are generally mouth breathers. Cleaning the oral cavity may improve the client's appetite, increase her feelings of well-being, and remove the taste and odor of sputum. (B) Milk causes thick sputum; therefore, milk products would not be beneficial for this client. (C) Exercise prior to a meal would require increased O2 consumption and most likely would decrease the client's ability to eat. (D) Clients with respiratory diseases need increased fluid to liquefy secretions. NO.99 In admitting a client to the psychiatric unit, the nurse must explain the rules and regulations of the unit. A client with antisocial personality disorder makes the following remark, "Forget all those rules. I always get along well with the nurses." NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 91 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 Which nursing response to him would be most effective? A. "OK, don't listen to the rules. See where you end up." B. "I'm pleased that you get along so well with the staff. You must still know and abide by the rules." C. "It is irrelevant whether you get along with the nurses." D. "I'm not the other nurses. You better read the rules yourself." Answer: B Explanatio n: (A) This answer is incorrect. A nurse should be an appropriate role model. Threats are not appropriate. No limit setting was stated. (B) This answer is correct. The nurse made a positive statement followed by a simple, clear, concise setting of limits. (C) This answer is incorrect. It appears to have a negative connotation. There was no limit setting. (D) This answer is incorrect. The nurse obviously responded in a negative manner. Learning takes place more readily when one is accepted, not rejected. No limits were set. NO.100 A 14-year-old teenager is demonstrating behavior indicative of an obsessive- compulsive disorder. She is obsessed with her appearance. She will not leave her room until her hair, clothes, and makeup are perfect. She always dresses immaculately. Recently, she expressed disgust over her appearance after she gained 5 lb. After observing a marked weight loss over a 2-week period, her mother suspects that she is experiencing bulimia. She eats everything on her plate, then runs to the bathroom. In interviewing the teenager, she discusses in great detail all of the events leading to her bulimia, but not her feelings. What defense mechanism is she using? NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 92 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 A. Dissociation B. Intellectualization C. Rationalization D. Displaceme nt 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 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 95 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 A. Crackles and paradoxical chest wall movement B. Decreased breath sounds on the left and chest pain with movement C. Rhonchi and frothy sputum D. Wheezing and dry cough Answer: B Explanatio n: (A) Crackles are caused by air moving through moisture in the small airways and occur with pulmonary edema. Paradoxical chest wall movement occurs with flail chest when a segment of the thorax moves outward on inspiration and inward on expiration. (B) Decreased breath sounds occur when a lung is collapsed or partially collapsed. Chest pain with movement occurs with rib fractures. (C) Rhonchi are caused by air moving through large fluid-filled airways. Frothy sputum may occur with pulmonary edema. (D) Wheezing is caused by fluid in large airways already narrowed by mucus or bronchospasm. Dry cough could indicate a cardiac problem. NO.105 MgSO4 is ordered IV following the established protocol for a client with severe PIH. The anticipated effects of this therapy are anticonvulsant and: A. Vasoconstrictive B. Vasodilative C. Hypertensive D. Antieme tic Answer: NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 96 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 B Explanation : NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 97 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 (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 Explanatio n: (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: NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022