NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022, Exams of Nursing

Download NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 and more Exams Nursing in PDF only on Docsity! NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 1. The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching? A. “I will drink 500mL of fluid or less each day.” B. “I will wear support hose when I am up.” C. “I will use an electric razor for shaving.” D. “I will eat foods low in iron.” Rationale: The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day is important in preventing clot formation, so the statement to drink less than 500mL is incorrect. Options B, C, and D: Support hose promotes venous return, the electric razor prevents bleeding due to injury, and a diet low in iron is essential to preventing further red cell formation. 2. A 33-year-old male is being evaluated for possible acute leukemia. Which of the following would the nurse inquire about as a part of the assessment? A. The client collects stamps as a hobby. B. The client recently lost his job as a postal worker. NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 C. The client had radiation for treatment of Hodgkin’s disease as a teenager. D. The client’s brother had leukemia as a child. Rationale: Radiation treatment for other types of cancer can result in leukemia. Some hobbies and occupations involving chemicals are linked to leukemia. Option D: The incidence of leukemia is higher in twins than in siblings. 3. An African American client is admitted with acute leukemia. The nurse is assessing for signs and symptoms of bleeding. Where is the best site for examining for the presence of petechiae? A. The abdomen B. The thorax C. The earlobes D. The soles of the feet Rationale: Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the hand provide a lighter surface for assessing the client for petechiae. NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 A. Platelet count B. White blood cell count C. Potassium levels D. Partial prothrombin time (PTT) Rationale: Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making answer A the correct answer. Options B, C, and D: White cell counts, potassium levels, and PTT are not affected in ATP. 8. The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client’s platelet count currently is 80, It will be most important to teach the client and family about: A. Bleeding precautions B. Prevention of falls C. Oxygen therapy D. Conservation of energy Rationale: The normal platelet count is 120,000–400,000 Bleeding occurs in clients with low platelets. The priority is to prevent and minimize bleeding. Options B and D are of lesser priority and are incorrect in this instance. Option C is important, but platelets do not carry oxygen. NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 9. A client with a pituitary tumor has had a transsphenoidal hypophysectomy. Which of the following interventions would be appropriate for this client? A. Place the client in Trendelenburg position for postural drainage B. Encourage coughing and deep breathing every 2 hours C. Elevate the head of the bed 30° D. Encourage the Valsalva maneuver for bowel movements Rationale: Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates headaches. A, B, and D are incorrect Options A, B, and D: Trendelenburg, Valsalva maneuver, and coughing all increase the intracranial pressure. 10. The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is: A. Measure the urinary output B. Check the vital signs C. Encourage increased fluid intake D. Weigh the client NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 Rationale: A large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of electrolytes would be reflected in the vital signs. Option A: Measuring the urinary output is important, but the stem already says that the client has polyuria. Option C: Encouraging fluid intake will not correct the problem. Option D: Weighing the client is not necessary at this time. 11. A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding? A. Place the client in a sitting position with the head hyperextended B. Pack the nares tightly with gauze to apply pressure to the source of bleeding C. Pinch the soft lower part of the nose for a minimum of 5 minutes D. Apply ice packs to the forehead and back of the neck Rationale: The client should be positioned upright and leaning forward, to prevent aspiration of blood. Options A, B, and D: Direct pressure to the nose stops the bleeding, and ice packs should be applied directly to the nose as well. If a pack is necessary, the nares are loosely packed. 12. A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate postoperative period for NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 15. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority? A. Impaired physical mobility related to decreased endurance B. Hypothermia r/t decreased metabolic rate C. Disturbed thought processes r/t interstitial edema D. Decreased cardiac output r/t bradycardia Rationale: The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices. 16. The client is having an arteriogram. During the procedure, the client tells the nurse, “I’m feeling really hot.” Which response would be best? A. “You are having an allergic reaction. I will get an order for Benadryl.” B. “That feeling of warmth is normal when the dye is injected.” C. “That feeling of warmth indicates that the clots in the coronary vessels are dissolving.” D. “I will tell your doctor and let him explain to you the reason for the hot feeling that you are experiencing.” NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 Rationale: It is normal for the client to have a warm sensation when dye is injected. Options A, C, and D indicate that the nurse believes that the hot feeling is abnormal, so they are incorrect. 17. The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching? A. The nursing assistant wears gloves while giving the client a bath. B. The nurse wears goggles while drawing blood from the client. C. The doctor washes his hands before examining the client. D. The nurse wears gloves to take the client’s vital signs. Rationale: It is not necessary to wear gloves to take the vital signs of the client. If the client has active infection with methicillin-resistant Staphylococcus aureus, gloves should be worn. Options A, B, and C: The health care workers indicate knowledge of infection control by their actions. 18. The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective? A. The client loses consciousness. NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 B. The client vomits. C. The client’s ECG indicates tachycardia. D. The client has a grand mal seizure. Rationale: During ECT, the client will have a grand mal seizure. This indicates completion of the electroconvulsive therapy. Options A, B, and C do not indicate that the ECT has been effective. 19. The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to: A. Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep B. Scrape the skin with a piece of cardboard and bring it to the clinic C. Obtain a stool specimen in the afternoon D. Bring a hair sample to the clinic for evaluation Rationale: Infection with pinworms begins when the eggs are ingested or inhaled. The eggs hatch in the upper intestine and mature in 2–8 weeks. The females then mate and migrate out the anus, where they lay up to 17,000 eggs. This causes intense itching. The mother should be told to use a flashlight to examine the rectal area about 2–3 hours after the child is asleep. Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen should then be brought in to be evaluated. NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 Option C: The client has an increase in growth hormone and poses no risk to himself or others. Option D: The client has hypothyroidism or myxedema and poses no risk to others or himself. 23. The nurse caring for a client in the neonatal intensive care unit administers adult- strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with: A. Negligence B. Tort C. Assault D. Malpractice Rationale: The nurse could be charged with malpractice, which is failing to perform, or performing an act that causes harm to the client. Giving the infant an overdose falls into this category. Option A: Negligence is failing to perform care for the client. a tort is a wrongful act committed Option B: A tort is a wrongful act committed on the client or their belongings Option C: Assault is a violent physical or verbal attack. 24. Which assignment should not be performed by the licensed practical nurse? A. Inserting a Foley catheter B. Discontinuing a nasogastric tube NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 C. Obtaining a sputum specimen D. Starting a blood transfusion Rationale: The licensed practical nurse should not be assigned to begin a blood transfusion. Options A, B, and C: The licensed practical nurse can insert a Foley catheter, discontinue a nasogastric tube, and collect sputum specimen. 25. The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. Which action by the nurse should receive priority? A. Continuing to monitor the vital signs B. Contacting the physician C. Asking the client how he feels D. Asking the LPN to continue the post-op care Rationale: The vital signs are abnormal and should be reported immediately. Option A: Continuing to monitor the vital signs can result in deterioration of the client’s condition. Option C: Asking the client how he feels will only provide subjective data. Option D: Assigning an unstable client to an LPN is inappropriate. 26. Which nurse should be assigned to care for the postpartum client with preeclampsia? NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 A. The RN with 2 weeks of experience in postpartum B. The RN with 3 years of experience in labor and delivery C. The RN with 10 years of experience in surgery D. The RN with 1 year of experience in the neonatal intensive care unit Rationale: The nurse with 3 years of experience in labor and delivery knows the most about possible complications involving preeclampsia. Option A: The nurse is a new staff to the unit hence lacking the experience needed. Options C and D: These nurses lack sufficient experience with a postpartum client. 27. Which information should be reported to the state Board of Nursing? A. The facility fails to provide literature in both Spanish and English. B. The narcotic count has been incorrect on the unit for the past 3 days. C. The client fails to receive an itemized account of his bills and services received during his hospital stay. D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath. Rationale: The Joint Commission on Accreditation of Hospitals will probably be interested in the problems in answers A and C. The failure of the nursing assistant to care for the client with NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 chest pain Rationale: The pregnant client and the client with a broken arm and facial lacerations are the best choices for placing in the same room. Options A, C, and D: The following group of clients needs to be placed in separate rooms due to the serious nature of their injuries. 31. The nurse is caring for a 6-year-old client admitted with a diagnosis of conjunctivitis. Before administering eye drops, the nurse should recognize that it is essential to consider which of the following? A. The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops. B. The child should be allowed to instill his own eye drops. C. The mother should be allowed to instill the eyedrops. D. If the eye is clear from any redness or edema, the eyedrops should be held. Rationale: Before instilling eye drops, the nurse should cleanse the area with water. Option B: A 6-year-old child is not developmentally ready to instill his own eyedrops. Option C: Although the mother of the child can instill the eye drops, the area must be cleansed before administration. Option D: Although the eye might appear to be clear, the nurse should instill the eyedrops, as NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 ordered, so answer D is incorrect. 32. The nurse is discussing meal planning with the mother of a 2-year-old toddler. Which of the following statements, if made by the mother, would require a need for further instruction? A. “It is okay to give my child white grape juice for breakfast.” B. “My child can have a grilled cheese sandwich for lunch.” C. “We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch.” D. “For a snack, my child can have ice cream.” Rationale: Remember the ABCs (airway, breathing, circulation) when answering this question. Answer C because a hotdog is the size and shape of the child’s trachea and poses a risk of aspiration. Options A, B, and D: A white grape juice, grilled cheese sandwich, and ice cream do not pose a risk of aspiration for a child. 33. A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect? A. Ask the parent/guardian to leave the room when assessments are being performed. B. Ask the parent/guardian to take the child’s favorite blanket home because anything from NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 the outside should not be brought into the hospital. C. Ask the parent/guardian to room-in with the child. D. If the child is screaming, tell him this is inappropriate behavior. Rationale: The nurse should encourage rooming-in to promote parent-child attachment. It is okay for the parents to be in the room for assessment of the child. Options A and B: Allowing the child to have items that are familiar to him is allowed and encouraged. Option D: Telling the child that screaming is inappropriate behavior is not part of the nurse’s responsibilities. 34. Which instruction should be given to the client who is fitted for a behind-the- ear hearing aid? A. Remove the mold and clean every week. B. Store the hearing aid in a warm place. C. Clean the lint from the hearing aid with a toothpick. D. Change the batteries weekly. Rationale: The hearing aid should be stored in a warm, dry place. Option A: It should be cleaned daily but should not be moldy. Option C: A toothpick is inappropriate to use to clean the aid; the toothpick might break off in NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 expect the admitting assessment to reveal? A. Bradycardia B. Decreased appetite C. Exophthalmos D. Weight gain Rationale: Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. Options A, B, and D: The client with hyperthyroidism will often exhibit tachycardia, increased appetite, and weight loss. 39. The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions? A. Ham sandwich on whole-wheat toast B. Spaghetti and meatballs C. Hamburger with ketchup D. Cheese omelet Rationale: The child with celiac disease should be on a gluten-free diet. Options A, B, and C: These food items all contain gluten. NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 40. The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning rounds, the nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first? A. Notify the physician B. Recheck the O2 saturation level in 15 minutes C. Apply oxygen by mask D. Assess the pulse Rationale: Remember the ABCs (airway, breathing, circulation) when answering this question. Before notifying the physician or assessing the pulse, oxygen should be applied to increase the oxygen saturation, so answers A and D are incorrect. The normal oxygen saturation for a child is 92%–100%, making answer B incorrect. 41. A gravida 3 para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse be expected to make after the amniotomy? A. Fetal heart tones 160bpm B. A moderate amount of straw-colored fluid NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 C. A small amount of greenish fluid D. A small segment of the umbilical cord Rationale: An amniotomy is an artificial rupture of membranes and normal amniotic fluid is straw-colored and odorless. Options A and C: Fetal heart tones of 160 indicate tachycardia, and greenish fluid is indicative of meconium. Option D: If the nurse notes the umbilical cord, the client is experiencing a prolapsed cord and would need to be reported immediately. 42. The client is admitted to the unit. A vaginal exam reveals that she is 2cm dilated. Which of the following statements would the nurse expect her to make? A. “We have a name picked out for the baby.” B. “I need to push when I have a contraction.” C. “I can’t concentrate if anyone is touching me.” D. “When can I get my epidural?” Rationale: Dilation of 2 cm marks the end of the latent phase of labor. Option A is a vague answer. Option B indicates the end of the first stage of labor. Option C indicates the transition phase. NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 heart tone rate of 160–170 bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is: A. The cervix is closed. B. The membranes are still intact. C. The fetal heart tones are within normal limits. D. The contractions are intense enough for insertion of an internal monitor. Rationale: The nurse decides to apply an external monitor because the membranes are intact. Options A, C, and D: The cervix is dilated enough to use an internal monitor, if necessary. An internal monitor can be applied if the client is at 0-station. Contraction intensity has no bearing on the application of the fetal monitor. 47. The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primigravida as she completes the early phase of labor? A. Impaired gas exchange related to hyperventilation B. Alteration in placental perfusion related to maternal position C. Impaired physical mobility related to fetal-monitoring equipment D. Potential fluid volume deficit related to decreased fluid intake NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 Rationale: Clients admitted in labor are told not to eat during labor, to avoid nausea and vomiting. Ice chips may be allowed, but this amount of fluid might not be sufficient to prevent fluid volume deficit. Option A: Impaired gas exchange related to hyperventilation would be indicated during the transition phase. Options B and C: Impaired physical mobility and fluid volume deficit are not correct in relation to the stem. 48. As the client reaches 8 cm dilation, the nurse notes late decelerations on the fetal monitor. The FHR baseline is 165–175 bpm with variability of 0–2bpm. What is the most likely explanation of this pattern? A. The baby is asleep. B. The umbilical cord is compressed. C. There is a vagal response. D. There is uteroplacental insufficiency. Rationale: This information indicates a late deceleration. This type of deceleration is caused by uteroplacental lack of oxygen. Option A: Has no relation to the readings. Option B: Compressed umbilical cord results in a variable deceleration. Option C: A vagal response is indicative of an early deceleration. NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 49. The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to: A. Notify her doctor B. Start an IV C. Reposition the client D. Readjust the monitor Rationale: The initial action by the nurse observing a late deceleration should turn the client to the side—preferably, the left side. Administering oxygen is also indicated. Option A: Notifying the physician might be necessary but not before turning the client to her side. Option B: Starting an IV is not necessary at this time. Option D: Readjusting the fetal monitor is inappropriate since there is no data to indicate that the monitor has been applied incorrectly. 50. Which of the following is a characteristic of a reassuring fetal heart rate pattern? A. A fetal heart rate of 170–180 bpm B. A baseline variability of 25–35 bpm C. Ominous periodic changes D. Acceleration of FHR with fetal movements NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 A. Intrauterine device B. Oral contraceptives C. Diaphragm D. Contraceptive sponge Rationale: The best method of birth control for the client with diabetes is the diaphragm. Options A, B, and D: Permanent intrauterine device can cause a continuing inflammatory response in diabetics that should be avoided, oral contraceptives tend to elevate blood glucose levels, and contraceptive sponges are not good at preventing pregnancy. 55. The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of ectopic pregnancy? A. Painless vaginal bleeding B. Abdominal cramping C. Throbbing pain in the upper quadrant D. Sudden, stabbing pain in the lower quadrant Rationale: The signs of an ectopic pregnancy are vague until the fallopian tube ruptures. The client will complain of sudden, stabbing pain in the lower quadrant that radiates down the leg or up into the chest. NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 Options A, B, and C: Painless vaginal bleeding is a sign of placenta previa, abdominal cramping is a sign of labor, and throbbing pain in the upper quadrant is not a sign of an ectopic pregnancy. 56. The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client? A. Hamburger patty, green beans, French fries, and iced tea B. Roast beef sandwich, potato chips, baked beans, and cola C. Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea D. Fish sandwich, gelatin with fruit, and coffee Rationale: All of the choices are tasty, but the pregnant client needs a diet that is balanced and has increased amounts of calcium. This food item contains meat, fruit, potato salad, and yogurt, which has about 360 mg of calcium. Option A: These food items are lacking in fruits and milk. Option B: The potato chips, which contain a large amount of sodium. Option D: These food items are lacking vegetables and milk products. 57. The client with hyperemesis gravidarum is at risk for developing: A. Respiratory alkalosis without dehydration NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 B. Metabolic acidosis with dehydration C. Respiratory acidosis without dehydration D. Metabolic alkalosis with dehydration Rationale: The client with hyperemesis has persistent nausea and vomiting. With vomiting comes dehydration. When the client is dehydrated, she will have metabolic acidosis. Options A and C are incorrect because they are respiratory dehydration. Option D is incorrect because the client will not be in alkalosis with persistent vomiting. 58. A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is: A. Elevated human chorionic gonadotropin B. The presence of fetal heart tones C. Uterine enlargement D. Breast enlargement and tenderness Rationale: The most definitive diagnosis of pregnancy is the presence of fetal heart tones. The signs in answers A, C, and D are subjective and might be related to other medical conditions. Options A and C: Elevated human chorionic gonadotropin and uterine enlargement may be related to a hydatidiform mole. Option D: Breast enlargement and tenderness is often present before menses or with the use of oral contraceptives. NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 62. A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse’s first action should be to: A. Assess the fetal heart tones B. Check for cervical dilation C. Check for firmness of the uterus D. Obtain a detailed history Rationale: The symptoms of painless vaginal bleeding are consistent with placenta previa. Option B: Cervical check for dilation is contraindicated because this can increase the bleeding. Option C: Checking for firmness of the uterus can be done, but the first action should be to check the fetal heart tones. Option D: A detailed history can be done later. 63. A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when: A. Her contractions are 2 minutes apart. B. She has back pain and a bloody discharge. C. She experiences abdominal pain and frequent urination. D. Her contractions are 5 minutes apart. NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 Rationale: The client should be advised to come to the labor and delivery unit when the contractions are every 5 minutes and consistent. She should also be told to report to the hospital if she experiences rupture of membranes or extreme bleeding. Options A and B: She should not wait until the contractions are every 2 minutes or until she has a bloody discharge. Option C: Has a vague answer and can be related to a urinary tract infection. 64. The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy? A. Low birth weight B. Large for gestational age C. Preterm birth, but appropriate size for gestation D. Growth retardation in weight and length Rationale: Infants of mothers who smoke are often low in birth weight. Option B: Infants who are large for gestational age are associated with diabetic mothers. Option C: Preterm births are associated with smoking, but not with appropriate size for gestation. Option D: Growth retardation is associated with smoking, but this does not affect the infant length. NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 65. The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered: A. Within 72 hours of delivery B. Within 1 week of delivery C. Within 2 weeks of delivery D. Within 1 month of delivery Rationale: To provide protection against antibody production, RhoGam should be given within 72 hours. Options B, C, and D: These durations are too late to provide antibody protection. RhoGam can also be given during pregnancy. 66. After the physician performs an amniotomy, the nurse’s first action should be to assess the: A. Degree of cervical dilation B. Fetal heart tones C. Client’s vital signs D. Client’s level of discomfort Rationale: When the membranes rupture, there is often a transient drop in the fetal heart tones. NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 Option B: The client should not be positioned supine because the anesthesia can move above the respiratory center and the client can stop breathing. Option D: Fetal heart tones should be assessed after the blood pressure is checked. 70. The nurse is aware that the best way to prevent postoperative wound infection in the surgical client is to: A. Administer a prescribed antibiotic B. Wash her hands for 2 minutes before care C. Wear a mask when providing care D. Ask the client to cover her mouth when she coughs Rationale: The best way to prevent post-operative wound infection is hand washing. Option A: Use of prescribed antibiotics will treat infection, not prevent infections. Options C and D: Wearing a mask and asking the client to cover her mouth are good practices but will not prevent wound infections. NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022 NURS NCLEX EXAM TEST QUESTIONS WITH ANSWERS WITH RATIONALES 100% CORECT UPDATED 2022