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

Download NCLEX-RN V12 EXAM QUESTIONS &ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED 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 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 Explanatio 2 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 suggest alternatives, such as the hospital chapel. (B) Refusal to leave the room demonstrates a lack of understanding related to the family's need to grieve in their 5 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 6 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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. NO.8 A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these 7 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 10 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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: C Explanatio n: 11 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 (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 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 12 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 metastasis of 15 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 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. 16 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 is: A. Respiratory obstruction B. Hypercalcemia C. Fistula formation D. Myxedema 17 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 Answer: A Explanatio n: (A) Respiratory obstruction due to edema of the glottis, bilateral laryngeal nerve damage, or tracheal compression from hemorrhage is a major complication after a thyroidectomy. (B) Hypocalcemia accompanied by tetany from accidental removal of one or more parathyroid glands is a major complication, not hypercalcemia. (C) Fistula formation is not a major complication associated with a thyroidectomy. It is a major complication with a laryngectomy.(D) Myxedema is hypothyroidism that occurs in adults and is not a complication of a thyroidectomy. A thyroidectomy client tends to develop thyroid storm, which is excess production of thyroid hormone. NO.21 The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase? A. Mother is concerned about her recovery. B. Mother calls infant by name. C. Mother lightly touches infant. D. Mother is concerned about her weight gain. Answer: B Explanatio n: (A) This observation can be made during the taking-in phase when the mother's needs 20 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 21 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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. 22 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NO.27 A client states to his nurse that "I was told by the doctor not to take one of my drugs because it seems to have caused decreasing blood cells." Based on this information, which drug might the nurse expect to be discontinued? A. Prednisone B. Timolol maleate (Blocadren) C. Garamycin (Gentamicin) D. Phenytoin (Dilantin) Answer: D Explanation: (A) Prednisone is not linked with hematological side effects. (B) Timolol, a -adrenergic blocker is metabolized by the liver. It has not been linked to blood dyscrasia. (C) Gentamicin is ototoxic and nephrotoxic. (D) Phenytoin usage has been linked to blood dyscrasias such as aplastic anemia. The drug most commonly linked to aplastic anemia is chloramphenicol (Chlormycetin). NO.28 A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should: A. Notify the physician immediately B. Hold the morning lithium dose and continue to observe the client C. Administer the morning lithium dose as scheduled D. Obtain an order for benztropine (Cogentin) Answer: C Explanatio n: (A) There is no need to phone the physician because the lithium level is within 25 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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. In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises. 26 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 She will teach the client to: A. Inhale slowly and deeply through the nose until the lungs are fully expanded, hold the breath a couple of seconds, and then exhale slowly through the mouth. Repeat 2-3 more times to complete the series every 1-2 hours while awake B. Purse the lips and take quick, short breaths approximately 18-20 times/min C. Take a large gulp of air into the mouth, hold it for 10-15 seconds, and then expel it through the nose. Repeat 4-5 times to complete the series D. Inhale as deeply as possible and then immediately exhale as deeply as possible at a rate of approximately 20-24 times/min Answer: A Explanatio n: (A) This is the correct method of teaching diaphragmatic breathing, which allows full lung expansion to increase oxygenation, prevent atelectasis, and move secretions up and out of the lungs to decrease risk of pneumonia. (B) Quick, short breaths do not allow for full lung expansion and movement of secretions up and out of the lungs. Quick, short breaths may lead to O2 depletion, hyperventilation, and hypoxia. (C) Expelling breaths through the nose does not allow for full lung expansion and the use of diaphragmatic muscles to assist in moving secretions up and out of the lungs. (D) Inhaling and exhaling at a rate of 20-24 times/min does not allow time for full lung expansion to increase oxygenation. This would most likely lead to O2 depletion and hypoxia. NO.32 The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take? 27 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 A. Place a tongue blade in the child's mouth. B. Restrain the child so he will not injure himself. C. Go to the nurses station and call the physician. D. Move furniture out of the way and place a blanket under his head. Answer: D Explanatio n: (A) The nurse should not put anything in the child's mouth during a seizure; this action could obstruct the airway. (B) Restraining the child's movements could cause constrictive injury. (C) Staying with the child during a seizure provides protection and allows the nurse to observe the seizure activity. (D) The nurse should provide safety for the child by moving objects and protecting the head. NO.33 An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action? A. Apply ice packs to both legs. B. Begin debridement by removing all charred clothing from wound. C. Apply Silvadene cream (silver sulfadiazine). D. Immerse both legs in cool water. Answer: D Explanatio n: 30 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 health maintenance. (C) This statement reflects lack of insight into the importance of compliance. (D) This statement reflects no insight into his illness or his responsibility in health maintenance. NO.36 A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful? A. Examine the 4 year old first. B. Provide time for play and becoming acquainted. C. Have the mother leave the room with one child, and examine the other child privately. D. Examine painful areas first to get them "over with." Answer: B Explanatio n: (A) The 6 month old should be examined first. If several children will be examined, begin with the most cooperative and less anxious child to provide modeling. (B) Providing time for play and getting acquainted minimizes stress and anxiety associated with assessment of body parts. (C) Children generally cooperate best when their mother remains with them. (D) Painful areas are best examined last and will permit maximum accuracy of assessment. NO.37 Diagnostic assessment findings for an infant with possible coarctation of 31 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 the aorta would include: A. A third heart sound B. A diastolic murmur C. Pulse pressure difference between the upper extremities D. Diminished or absent femoral pulses Answer: D Explanatio n: (A) S1 and S2 in an infant with coarctation of the aorta are usually normal. S3 and S4 do not exist with this diagnosis. (B) Either no murmur will be heard or a systolic murmur from an associated cardiac defect will be heard along the left upper sternal border. A diastolic murmur is not associated with coarctation of the aorta. (C) Pulse pressure differences of>20 mm Hg exist between the upper extremities and the lower extremities. It is important to evaluate the upper and lower extremities with the appropriate- sized cuffs. (D) Femoral and pedal pulses will be diminished or absent in infants with coarctation of the aorta. NO.38 During a client's first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus. This may be due to: A. Endometritis B. Fibroid tumor on the uterus C. Displacement due to bowel distention D. Urine retention or a distended bladder Answer: D 32 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 incorrect. Persons at risk tend to lack communication skills and effective coping 35 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 B. There is no real psychological basis for his illness C. The disorder is a threat to his physical well-being D. He is unable to participate in planning his care Answer: C Explanatio n: (A) There may be a medical emergency that takes top priority; however, the basis of the problem is emotional. (B) The problem is a physical manifestation of an emotional conflict. (C) The bleeding ulcer can be life threatening. (D) For lifestyle change to occur, the client must participate in the planning of his care so that he is committed to changes that will have positive results. NO.42 A 55-year-old man has recently been diagnosed with hypertension. His physician orders a low- sodium diet for him. When he asks, "What does salt have to do with high blood pressure?'' the nurse's initial response would be: A. "The reason is not known why hypertension is associated with a high-salt diet." B. "Large amounts of salt in your diet can cause you to retain fluid, which increases your blood pressure." C. "Salt affects your blood vessels and causes your blood pressure to be high." D. "Salt is needed to maintain blood pressure, but too much causes hypertension." Answer: B Explanatio 36 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 offers false reassurance and dismisses the husband's underlying concerns about his 37 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 wife. 40 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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: A. Excoriation 41 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 n: (A) Bulging fontanelles are a symptom of increased intracranial pressure in infants. (B) 42 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 Seizure is a 45 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 organs and does not promote maximum 46 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 immediately. 47 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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: A. Should not be there on the second day B. Will stop when the Foley catheter is removed 50 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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. C. Only females are affected. 51 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 D. Two affected parents always have affected children. Answer: D Explanatio n: (A) The term heterozygote refers to an individual with one normal and one mutant allele at a given locus on a pair of homologous chromosomes. An individual who is heterozygous for the abnormal gene does not manifest obvious symptoms. (B) Disorders carried on either the X or Y sex chromosome are referred to as sex-linked recessive. (C) Either sex may be affected by autosomal recessive genetic disorders because the responsible allele can be on any one of the 46 chromosomes. (D) If both parents are affected by the disorder and are not just carriers, then all their children would manifest the same disorder. NO.60 The pediatric nurse charts that the parents of a 4-yearold child are very anxious. Which observation would indicate to the nurse unhealthy coping by these parents: A. Discussing their needs with the nursing staff B. Discussing their needs with other family members C. Seeking support from their minister D. Refusing to participate in the child's care Answer: D Explanatio n: 52 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 (A, B, C) These methods are healthy ways of dealing with anxiety. (D) Participation minimizes feelings of helplessness and powerlessness. It is important that parents have accurate information and that they seek support from sources available to them. NO.61 The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury. Normal fluid intake for a child of 2 years is: A. 900 mL/24 hr B. 1300 mL/24 hr C. 1600 mL/24 hr D. 2000 mL/24 hr Answer: C Explanation: (A, B, D) These values are incorrect. Normal intake for a child of 2 years is about 1600 mL in 24 hours. (C) This value is correct. Normal intake for a child of 2 years is about 1600 mL in 24 hours. NO.62 A couple is planning the conception of their first child. The wife, whose normal menstrual cycle is 34 days in length, correctly identifies the time that she is most likely to ovulate if she states that ovulation should occur on day: A. 14+2 days B. 20+2 days C. 16+2 days D. 22+2 days 55 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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? 56 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 A. Hearing test B. Gait C. Strabismus D. Papillede ma Answer: C Explanation: (A) Hearing should be assessed separately. (B) Gait should be assessed separately. Client usually remains in one place for vision screening. Gait is part of neurological assessment. (C) Strabismus is crossing of eyes or outward deviation, which may cause diplopia or ambylopia. It is easily assessed during vision screening. (D) Papilledema is assessed by an ophthalmoscopic examination, which follows vision screening. It is part of neurological assessment. NO.68 Which of the following ECG changes would be seen as a positive myocardial stress test response? A. Hyperacute T wave B. Prolongation of the PR interval C. ST-segment depression D. Pathological Q wave Answer: C Explanation: 57 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 (A) Hyperacute T waves occur with hyperkalemia. (B) Prolongation of the P R interval occurs with first-degree AV block. (C) Horizontal ST-segment depression of>1 mm during exercise isdefinitely a positive criterion on the exercise ECG test. (D) Patho-logical Q waves occur with MI. NO.69 A client with cystic fibrosis exhibits activity intolerance related to the pulmonary problems associated with his disease. However, he needs to be encouraged to participate in daily physical exercise. The ultimate aim of exercise is to: A. Create a sense of well-being and self-worth B. Help him overcome respiratory infections C. Establish an effective, habitual breathing pattern D. Promote normal growth and development Answer: C Explanatio n: (A) Regular exercise does promote a sense of well-being and selfworth, but this is not the ultimate goal of exercise for this client. (B) Regular chest physiotherapy, not exercise per se, helps to prevent respiratory infections. (C) Physical exercise is an important adjunct to chest physiotherapy. It stimulates mucus secretion, promotes a feeling of well-being, and helps to establish a habitual breathing pattern. (D) Along with adequate nutrition and minimization of pulmonary complications, exercise does help promote normal growth and development. However, exercise is promoted primarily to help establish a habitual breathing pattern. 60 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NO.73 The nurse is assessing breath sounds in a bronchovesicular client. She should expect that: A. Inspiration is longer than expiration B. Breath sounds are high pitched C. Breath sounds are slightly muffled D. Inspiration and expiration are equal Answer: D Explanatio n: (A) Inspiration is normally longer in vesicular areas. (B) Highpitched sounds are normal in bronchial area. (C) Muffled sounds are considered abnormal. (D) Inspiration and expiration are equal normally in this area, and sounds are medium pitched. NO.74 Parents should be taught not to prop the bottle when feeding their infants. In addition to the risk of choking, it puts the infant at risk for: A. Otitis media B. Asthma C. Conjunctivitis D. Tonsillit is Answer: A Explanatio n: (A) Because the eustachian tube is short and straight in the infant, formula that pools in 61 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 the back of the throat attacks bacteria which can enter the middle ear and cause an infection. (B) Asthma is not associated with propping the bottle. (C) Conjunctivitis is an eye infection and not associated with propping the bottle. (D) Tonsillitis is usually a result of pharyngitis and not propping the bottle. NO.75 A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent: A. Bladder spasms B. Clot formation C. Scrotal edema D. Prostatic infection Answer: B Explanation: (A) The purpose of bladder irrigation is not to prevent bladder spasms, but to drain the bladder and decrease clot formation and obstruction. (B) A three-way system of bladder irrigation will cleanse the bladder and prevent formation of blood clots. A catheter obstructed by clots or other debris will cause prostatic distention and hemorrhage. (C) Scrotal edema seldom occurs after TURP. Bladder irrigation will not prevent this complication. (D) Prostatic infection seldom occurs after TURP. Bladder irrigation will not prevent this complication. 62 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 Explanatio 65 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 D. Continuous changes in respiratory rate and depth Answer: C Explanatio n: (A) Altered surfactant production is found in sudden infant death syndrome. (B) Paradoxical breathing occurs when a negative intrathoracic pressure is transmitted to the abdomen by a weakened, poorly functioning diaphragm. (C) Asthma is characterized by spasm and constriction of the airways resulting in increased resistance to airflow. (D) If the pulmonary tree is obstructed for any reason, inspired air has difficulty overcoming the resistance and getting out. The rate of respiration increases in order to compensate, thus increasing air exchange. NO.81 The FHR pattern in a laboring client begins to show early decelerations. The nurse would best respond by: A. Notifying the physician B. Changing the client to the left lateral position C. Continuing to monitor the FHR closely D. Administering O2 at 8 L/min via face mask Answer: C Explanatio n: (A) Early decelerations are reassuring and do not warrant notification of the physician. (B) Because early decelerations is a reassuring pattern, it would not be necessary to change the client's position. 66 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 B. Prevent fluid from entering the pleural space C. Provide a means to measure chest drainage 67 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 70 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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: A. Is given to prevent rejection and makes him less susceptible to infection 71 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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. 72 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 Answer: C 75 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 D. Afterload reduction therapy 76 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 77 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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. (D) Haloperidol is a high-potency neuroleptic and first-line choice for rapid 80 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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." Which nursing response to him would be most effective? 81 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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? 82 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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 Answer: C 85 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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. Antiemet ic Answer: B Explanatio 86 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 n: 87 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 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: A. Immediate treatment of mild PIH includes the administration of a variety of 90 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 A. Coating the inflamed areas with zinc oxide B. Using talcum powder on the inflamed areas to promote drying C. Removing the diaper entirely for extended periods of time D. Cleaning the inflamed area thoroughly with disposable wet "wipes" at each diaper change Answer: C Explanatio n: (A) Zinc oxide is not usually applied to inflamed areas because it contributes to sweat retention. (B) Talcum powder is of questionable benefit and poses a hazard of accidental inhalation. (C) Removing the diaper and exposing the area to air and light facilitate drying and healing. (D) Infants may be sensitive to one or more agents in the wet "wipes." It is better to simply clean with a wet cloth. NO.111 The nurse is admitting a client with folic acid deficiency anemia. Which of the following questions is most important for the nurse to ask the client? A. "Do you take aspirin on a regular basis?" B. "Do you drink alcohol on a regular basis?" C. "Do you eat red meat?" D. "Have your stools been normal?" Answer: B 91 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 Explanation: (A) Aspirin does not affect folic acid absorption. (B) Folic acid deficiency is strongly associated with alcohol abuse. (C) Because folic acid is a coenzyme for single carbon transfer purines, calves liver or other purines are the meat sources. (D) Folic acid does not affect stool character. NO.112 A client is receiving IV morphine 2 days after colorectal surgery. Which of the following observations indicate that he may be becoming drug dependent? A. The client requests pain medicine every 4 hours. B. He is asleep 30 minutes after receiving the IV morphine. C. He asks for pain medication although his blood pressure and pulse rate are normal. D. He is euphoric for about an hour after each injection. Answer: D Explanatio n: (A) Frequent requests for pain medication do not necessarily indicate drug dependence after complex surgeries such as colorectal surgery. (B) Sleeping after receiving IV morphine is not an unexpected effect because the pain is relieved. (C) A person may be in pain even with normal vital signs. (D) A subtle sign of drug dependency is the tendency for the person to appear more euphoric than relieved of pain. NO.113 When preparing insulin for IV administration, the nurse identifies which kind of insulin to use? A. NPH B. Human or pork C. Regular 92 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 D. Long acting Answer: C Explanation : (A, B, D) Intermediate-acting and long-acting preparations contain materials that increase length of absorption time from the subcutaneous tissues but cause the preparation to be cloudy and unsuitable for IV use. Human insulin must be given SC. (C) Only regular insulin can be given IV. NO.114 A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, "Oh dear, I feel like I have to urinate again!" Which of the following is the most appropriate initial nursing response? A. Assure her that this is most likely the result of bladder spasms. B. Check the collection bag and tubing to verify that the catheter is draining properly. C. Instruct her to do Kegel exercises to diminish the urge to void. D. Ask her if she has felt this way before. Answer: B Explanatio n: (A) Although this may be an appropriate response, the initial response would be to assure the patency of the catheter. (B) The most frequent reason for an urge to void with an indwelling catheter is blocked tubing. This response would be the best initial response. (C) Kegel exercises while a 95 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 Explanation: (A) It is within the nurse's realm of practice to grant visiting privileges according to hospital policy. ECT treatments do not make clients sick. (B) Visitors are allowed and encouraged, particularly family members. (C) Clients are usually awake within 1 hour posttreatment. Drowsiness wanes as the anesthetic wears off. (D) A family member is encouraged to stay with the client after return to the unit. The nurse has used an opportunity to do family teaching and allay fears by explaining temporary side effects of the treatment. NO.118 A client at 6 months' gestation complains of tiredness and dizziness. Her hemoglobin level is 10 g/dL, and her hematocrit value is 32%. Her nutritional intake is assessed as sufficient. The most likely diagnosis is: A. Iron-deficiency anemia B. Physiological anemia C. Fatigue due to stress D. No problem indicated Answer: A Explanatio n: (A) This clinical situation is indicative of iron-deficiency anemia because the client has inadequate nutritional intake. Her blood volume is increasing faster than her red blood cell volume. Anemia is present in the second trimester when the hemoglobin level is <10.5 and the hematocrit value falls below 35%. She needs increased iron supplements with follow-up. (B) The client's values are below levels for physiological anemia. (C) The client is fatigued because of a low hemoglobin level. (D) Her hemoglobin level is low and 96 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 will probably decrease even more when the blood volume peaks at 28 weeks. NO.119 At 32 weeks' gestation, a client is scheduled for a fetal activity test (nonstress test). She calls the clinic and asks the RN, "How do I prepare for the test I am scheduled for?" The RN will most likely inform her of the following instructions to help prepare her for the test: A. "You need to know that an IV is always started before the test." B. "You will need to drink 6 to 8 glasses of water to fill your bladder." C. "Do not eat any food or drink any liquids before the test is started." D. "You will have to remain as still as you possibly can." Answer: D Explanatio n: (A) An IV line is not started in a nonstress test, because this test is used as an indicator of fetal well- being. This test measures fetal activity and heart rate acceleration. (B) The bladder does not have to be full prior to this test. It is not a sonogram test where a full bladder enables other structures to be scanned. (C) It has been proved that eating or drinking liquids prior to the test can assist in increasing fetal activity. (D) Any maternal activity will interfere with the results of the test. NO.120 An infant with a congenital heart defect is being discharged with an order for the administration of digoxin elixir every 12 hours. The parents need to be taught when administering digoxin to the infant that: 97 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 NCLEX-RN V12 EXAM QUESTIONS AND ANSWERS EXPLAINED BEST SOLVED SOLUTIONS RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022 A. If the infant vomits within 30 minutes of the digoxin administration, repeat the dose B. They need to mix it with formula so the infant swallows it easily C. If the infant vomits two or more consecutive doses or becomes listless or anorexic, notify the physician D. If a dose of digoxin is skipped for more than 6 hours, a new timetable for administration must be developed Answer: C Explanatio n: (A) Occasionally the child may vomit. They should not repeat the dose because the amount of digoxin that was absorbed is un-known, and serum levels of digoxin that are too high are more dangerous than those that are temporarily too low. (B) To ensure that the entire dose of digoxin is received, never mix it with food or formula. (C) Vomiting, anorexia, and listlessness are all signs of digoxin toxicity and should be reported to the physician immediately. (D) If a dose is forgotten for more than 6 hours, the nurse should advise the parents to skip that dose and to continue the next dose as scheduled. NO.121 A 26-year-old client has no children. She has had an abdominal hysterectomy. In the first 24 hours postoperatively, the nurse would be concerned if the client: A. Cries easily and says she is having abdominal pain B. Develops a temperature of 102_F C. Has no bowel sounds D. Has a urine output of 200 mL for 4 hours