RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE, Exams of Nursing

Download RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE and more Exams Nursing in PDF only on Docsity! RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE Sections 1. Questions Set A 2. Question Set B 3. Questions Set C 4. Questions Set D 5. Questions Set E 6. Questions Set F 7. Questions Set G Exam A QUESTION 1 To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardialwork 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 Correct Answer: A Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Inotropic therapy will increase contractility, which will increase myocardial O2 demand. (B) Decreased heart rate to the point of bradycardia will increase coronary artery filling time. This should be used cautiously because tachycardia may be a compensatory mechanism to increase cardiac output. (C) The goal in the care of the MI client with angina is to maintain a balance between myocardial O2 supply and demand. (D) Decrease in systemic vascular resistance by drug therapy, such RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE as IV nitroglycerin or nitroprusside, or intra-aortic balloon pump therapy, would decrease myocardial work and O2 demand. QUESTION 2 The nurse would need to monitor the serum glucose levels of a client RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE C Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Hypokalemia can cause digoxin toxicity. Administration of KCl would prevent this. (B) Thyroid agents decrease digoxin levels. (C) Quinidine increases digoxin levels dramatically. (D) Theophylline is not noted to have an effect on digoxin levels. QUESTION 5 In the client with a diagnosis of coronary artery disease, the nurse would anticipate the complication of bradycardia with occlusion of which coronary artery? A. Right coronary artery B. Left main coronary artery C. Circumflex coronary artery D. Left anterior descending coronary artery Correct Answer: A Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Sinus bradycardia and atrioventricular (AV) heart block are usually a result of right coronary artery occlusion. The right coronary artery perfuses the sinoatrial and AV nodes in RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE mostindividuals. (B) Occlusion of the left main coronary artery causes bundle branch blocks and premature ventricular contractions. (C) Occlusion of the circumflex artery does not cause bradycardia. (D) Sinus tachycardia occurs primarily with left anterior descending coronary artery occlusion because this form of occlusion impairs left ventricular function. QUESTION 6 When inspecting a cardiovascular client, the nurse notes that he needs to sit upright to breathe. This behavior is most indicative of: A. Pericarditis B. Anxiety C. Congestive heart failure D. Angina Correct Answer: C Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Pericarditis can cause dyspnea but primarily causes chest pain. (B) Anxiety can cause dyspnea resulting in SOB, yet it is not typically influenced by degree of head elevation. (C) The inability to oxygenate well without being upright is most indicative of congestive heart failure, due to alveolar drowning. (D) Angina causes primarily chest pain; any SOB associated with angina is not influenced by body position. RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE QUESTION 7 When a client questions the nurse as to the purpose of exercise electrocardiography (ECG) in thediagnosis of cardiovascular disorders, the nurse’s response should be based on the fact that: A. The test provides a baseline for further tests B. The procedure simulates usual daily activity and myocardial performance C. The client can be monitored while cardiac conditioning and heart toning are done D. Ischemia can be diagnosed because exercise increasesO2 consumption and demand Correct Answer: D Section: Questions Set A Explanation Explanation/Reference: Explanation: (A)The purpose of the study is not to provide a baseline for further tests. (B)The test causes an increase in O2 demand beyond that required to perform usual daily activities. (C) Monitoring does occur, but the test is not for the purpose of cardiac toning and conditioning. (D) Exercise ECG, or stress testing, is designed to elevate the peripheral and myocardial needs for O2 to evaluate the ability of the myocardium and coronary arteries to meet the additional demands. QUESTION 8 RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE (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. QUESTION 11 Assessment of the client with pericarditis may reveal which of the following? A. Ventricular gallop and substernal chest pain B. Narrowed pulse pressure and shortness of breath C. Pericardial friction rub and pain on deep inspiration D. Pericardial tamponade and widened pulse pressure Correct Answer: C Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) No S3 or S4 are noted with pericarditis. (B) No change in pulse pressure occurs. (C) The symptoms of pericarditis vary with the cause, but they usually include chest pain, dyspnea, tachycardia, rise in temperature, and friction rub caused by fibrin or other deposits. The pain seen with pericarditis typically worsens with deep inspiration. (D) Tamponade is not typically seen early on, and no change in pulse pressure occurs. QUESTION 12 Clinical manifestations seen in left-sided rather than in right- sided heart failure are: RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE A. Elevated central venous pressure and peripheral edema B. Dyspnea and jaundice C. Hypotension and hepatomegaly D. Decreased peripheral perfusion and rales Correct Answer: D Section: Questions Set A Explanation Explanation/Reference: Explanation: (A, B, C) Clinical manifestations of right-sided heart failure are weakness, peripheral edema, jugular venous distention, hepatomegaly, jaundice, and elevated central venous pressure. (D) Clinical manifestations of left-sided heart failure are left ventricular dysfunction, decreased cardiac output, hypotension, and the backward failure as a result of increased left atrium and pulmonary artery pressures, pulmonary edema, and rales. QUESTION 13 Which classification of drugs is contraindicated for the client with hypertrophic cardiomyopathy? A. Positive inotropes B. Vasodilators C. Diuretics D. Antidysrhythmics Correct Answer: A Section: RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE Questions Set A Explanation Explanation/Reference: Explanation: (A) Positive inotropic agents should not be administered owing to their action of increasing myocardial contractility. Increased ventricular contractility would increase outflow tract obstruction in the client with hypertrophic cardiomyopathy. (B) Vasodilators are not typically prescribed but are not contraindicated. (C) Diuretics are used with caution to avoid causing hypovolemia. (D) Antidysrhythmics are typically needed totreat both atrial and ventricular dysrhythmias. QUESTION 14 To ensure proper client education, the nurse should teach the client taking SL nitroglycerin to expect whichof the following responses with administration? A. Stinging, burning when placed under the tongue B. Temporary blurring of vision C. Generalized urticaria with prolonged use D. Urinary frequency Correct Answer: A Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Stinging or burning when nitroglycerin is placed under the RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE Questions Set A Explanation Explanation/Reference: Explanation: (A) Increased CO2 will occur in both acute and chronic respiratory acidosis. (B)Hypoxia does not determine acid-base status. (C) Elevation of HCO3 is a compensatory mechanism in acidosis that occurs almost immediately, but it takes hours to show any effect and days to reach maximum compensation. Renal disease and diuretic therapy may impair the ability of the kidneys to compensate. (D) Base excess is a nonrespiratory contributor to acid-base balance. It would increase to compensate for acidosis. QUESTION 17 Which of the following signs and symptoms indicates a tension pneumothorax as compared to an open pneumothorax? A. Ventilation-perfusion (V./Q.) mismatch B. Hypoxemia and respiratory acidosis C. Mediastinal tissue and organ shifting D. Decreased tidal volume and tachypnea Correct Answer: C Section: Questions Set A Explanation Explanation/Reference: Explanation: (A, B, D) These occur in both tension pneumothorax and open pneumothorax. (C) The tension pneumothorax acts like a one- RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE way valve so that the pneumothorax increases with each breath. Eventually, it occupies enough space to shift mediastinal tissue toward the unaffected side away from the midline. Tracheal deviation, movement of point of maximum impulse, and decreased cardiac output will occur. Theother three options will occur in both types of pneumothorax. QUESTION 18 Hematotympanum and otorrhea are associated with which of the following head injuries? A. Basilar skull fracture B. Subdural hematoma C. Epidural hematoma D. Frontal lobe fracture Correct Answer: A Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Basilar skull fractures are fractures of the base of the skull. Blood behind the eardrum or blood or cerebrospinal fluid (CSF) leaking from the ear are indicative of a dural laceration. Basilar skull fractures arethe only type with these symptoms. (B, C, D) These do not typically cause dural lacerations and CSF leakage. QUESTION 19 A client with a C-3–4 fracture has just arrived in the emergency room. The primary nursing intervention is: RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE A. Stabilization of the cervical spine B. Airway assessment and stabilization C. Confirmation of spinal cord injury D. Normalization of intravascular volume Correct Answer: B Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) If cervical spine injury is suspected, the airway should be maintained using the jaw thrust method that also protects the cervical spine. (B) Primary intervention is protection of the airway and adequate ventilation. (C, D) All other interventions are secondary to adequate ventilation. QUESTION 20 In a client with chest trauma, the nurse needs to evaluate mediastinal position. This can best be done by: A. Auscultating bilateral breath sounds B. Palpating for presence of crepitus C. Palpating for trachial deviation D. Auscultating heart sounds Correct Answer: C Section: Questions Set A RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE (A) Neurogenic shock is caused by injury to the cervical region, which leads to loss of sympathetic control. This loss leads to vasodilation of the vascular beds, bradycardia resulting from the lack of sympathetic balance to parasympathetic stimuli from the vagus nerve, and the loss of the ability to sweat below the level of injury. In neurogenic shock, the client is hypotensive but bradycardiac with warm, dry skin. (B) In hypovolemic shock, the client ishypotensive and tachycardiac with cool skin. (C) In hypovolemic shock, the capillary refill would be>5 seconds. (D) In neurogenic shock, there is no capillary delay, the vascular beds are dilated, and peripheral flow is good. QUESTION 23 Which of the following would have the physiological effect of decreasing intracranial pressure (ICP)? A. Increased core body temperature B. Decreased serum osmolality C. Administration of hypo-osmolar fluids D. Decreased PaCO2 Correct Answer: D Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) An increase in core body temperature increases metabolism and results in an increase in ICP. (B) Decreased serum osmolality indicates a fluid overload and may result in an increase in ICP. (C) Hypo- osmolar fluids are generally voided in the neurologically RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE compromised. Using IV fluids such as D5W results in the dextrose being metabolized, releasing free water that is absorbed by the brain cells, leading to cerebral edema. (D) Hypercapnia and hypoventilation, which cause retention of CO2 and lead to respiratory acidosis, both increase ICP. CO2 is the most potent vasodilator known. QUESTION 24 A client who has sustained a basilar skull fracture exhibits blood- tinged drainage from his nose. After establishing a clear airway, administering supplemental O2, and establishing IV access, the next nursing intervention would be to: A. Pass a nasogastric tube through the left nostril B. Place a 4 X 4 gauze in the nares to impede the flow C. Gently suction the nasal drainage to protect the airway D. Perform a halo test and glucose level on the drainage Correct Answer: D Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Basilar skull fracture may cause dural lacerations, which result in CSF leaking from the ears or nose. Insertion of a tube could lead to CSF going into the brain tissue or sinuses. (B) Tamponading flow could worsen the problem and increase ICP. (C) Suction could increase brain damage and dislocate tissue. (D) Testing the fluid from the nares would determine the presence of CSF. Elevation of the head, notification of the medical staff, and RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE prophylactic antibiotics are appropriate therapy. QUESTION 25 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 Correct Answer: C Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Tachypnea is not a symptom. (B) Circumoral pallor is not a symptom. (C) Autonomic dysreflexia is an uninhibited and exaggerated reflex of the autonomic nervous system to stimulation, which results in vasoconstriction and elevated blood pressure. (D) Pallor and itching are not symptoms. QUESTION 26 The initial treatment for a client with a liquid chemical burn injury is to: A. Irrigate the area with neutralizing solutions B. Flush the exposed area with large amounts of water RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE (A) Absorption would be increased, not decreased. (B) IM injections should not be used until the client ishemodynamically stable and has adequate tissue perfusion. Medications will remain in the subcutaneous tissue with the fluid that is present in the interstitial spaces in the acute phase of the thermal injury. The client will have a poor response to the medication administered, and a “dumping” of the medication can occur when the medication and fluid are shifted back into the intravascular spaces in the next phase of healing. (C) IV administration of the medication would hasten respiratory compromise, if present. (D) The desire to avoid causing the client additional pain is not a primary reason for this route of administration. QUESTION 29 The medication that best penetrates eschar is: A. Mafenide acetate (Sulfamylon) B. Silver sulfadiazine (Silvadene) C. Neomycin sulfate (Neosporin) D. Povidone-iodine (Betadine) Correct Answer: A Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Mafenide acetate is bacteriostatic against gram-positive and gram- negative organisms and is the agent that best penetrates eschar. (B) Silver sulfadiazine poorly penetrates eschar. (C) Neomycin sulfate does not penetrate eschar. (D) Povidoneiodine does not penetrate eschar. RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE QUESTION 30 When the nurse is evaluating lab data for a client 18–24 hours after a major thermal burn, the expected physiological changes would include which of the following? A. Elevated serum sodium B. Elevated serum calcium C. Elevated serum protein D. Elevated hematocrit Correct Answer: D Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Sodium enters the edema fluid in the burned area, lowering the sodium content of the vascular fluid. Hyponatremia may continue for days to several weeks because of sodium loss to edema, sodium shifting into the cells, and later, diuresis. (B) Hypocalcemia occurs because of calcium loss to edema fluid at the burned site (third space fluid). (C) Protein loss occurs at the burn site owing to increased capillary permeability. Serum protein levels remain low until healing occurs. (D) Hematocrit level is elevated owing tohemoconcentration from hypovolemia. Anemia is present in the postburn stage owing to blood loss and hemolysis, but it cannot be assessed until the client is adequately hydrated. QUESTION 31 RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be areaction to which of the following medications if applied in large amounts? A. Neosporin sulfate B. Mafenide acetate C. Silver sulfadiazine D. Povidone-iodine Correct Answer: B Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) The side effects of neomycin sulfate include rash, urticaria, nephrotoxicity, and ototoxicity. (B) The sideeffects of mafenide acetate include bone marrow suppression, hemolytic anemia, eosinophilia, and metabolic acidosis. The hyperventilation is a compensatory response to the metabolic acidosis. (C) The side effects of silver sulfadiazine include rash, itching, leukopenia, and decreased renal function. (D) The primary side effect of povidone- iodine is decreased renal function. QUESTION 32 The primary reason for sending a burn client home with a pressure garment, such as a Jobst garment, is that the garment: A. Decreases hypertrophic scar formation RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE B. Increased heart sounds C. Decreased anteroposterior chest diameter D. Collapsed neck veins Correct Answer: A Section: Questions Set A Explanation Explanation/Reference: Explanation: (A)Distant breath sounds are found in clients with emphysema owing to increased anteroposterior chest diameter, overdistention, and air trapping. (B)Deceased heart sounds arepresent because of the increased anteroposterior chest diameter. (C) A barrel- shaped chest is characteristic of emphysema. (D) Increased distention of neck veins is found owing to right-sided heart failure, which may be present in advanced emphysema. QUESTION 35 The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should: A. Increase his nasal O2 to 6 L/min B. Place him in a lateral Sims’ position C. Encourage pursed-lip breathing D. Have him breathe into a paper bag Correct Answer: RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE C Section: Questions Set A Explanation Explanation/Reference: Explanation: (A)Giving too high a concentration of O2 to a client with em- physema may remove his stimulus to breathe. (B)The client should sit forward with his hands on his knees or an overbed table and with shoulders elevated. (C) Pursed-lip breathing helps the client to blow off CO2 and to keep air passages open. (D) Covering the face of a client extremely short of breath may cause anxiety and further increase dyspnea. QUESTION 36 Signs and symptoms of an allergy attack include which of the following? A. Wheezing on inspiration B. Increased respiratory rate C. Circumoral cyanosis D. Prolonged expiration Correct Answer: D Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Wheezing occurs during expiration when air movement is RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE impaired because of constricted edematous bronchial lumina. (B) Respirations are difficult, but the rate is frequently normal. (C) The circumoral area is usually pale. Cyanosis is not an early sign of hypoxia. (D) Expiration is prolonged because the alveoli are greatly distended and air trapping occurs. QUESTION 37 A 55-year-old man is admitted to the hospital with complaints of fatigue, jaundice, anorexia, and clay- colored stools. His admitting diagnosis is “rule out hepatitis.” Laboratory studies reveal elevated liver enzymes and bilirubin. In obtaining his health history, the nurse should assess his potential for exposure tohepatitis. Which of the following represents a high-risk group for contracting this disease? A. Heterosexual males B. Oncology nurses C. American Indians D. Jehovah’s Witnesses Correct Answer: B Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Homosexual males, not heterosexual males, are at high risk for contracting hepatitis. (B) Oncology nurses are employed in high- risk areas and perform invasive procedures that expose them to potential sources of infection. (C) The literature does not support the idea that any ethnic groups are at higher risk. RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE A Section: Questions Set A Explanation Explanation/Reference: Explanation: (A)The source of infection with hepatitis C is contaminated blood products. (B)Modified bed rest should bemaintained while the client is symptomatic. Routine activities can be slowly resumed once the client is asymptomatic. (C) Nausea and vomiting occur frequently with hepatitis C. A high Fowler position may decrease the tendency to vomit. (D) The buildup of bilirubin in the client’s skin may cause pruritus. Alcohol is a drying agent. QUESTION 41 Which of the following should be included in discharge teaching for a client with hepatitis C? A. He should take aspirin as needed for muscle and joint pain. B. He may become a blood donor when his liver enzymes return to normal. C. He should avoid alcoholic beverages during his recovery period. D. He should use disposable dishes for eating and drinking. Correct Answer: C Section: Questions Set A Explanation Explanation/Reference: Explanation: RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE (A)Aspirin is hepatotoxic, may increase bleeding, and should be avoided. (B)Blood should not be donatedby a client who has had hepatitis C because of the possibility of transmission of disease. (C) Alcohol is detoxified in the liver. (D) Hepatitis C is not spread through the oral route. QUESTION 42 A 27-year-old man was diagnosed with type I diabetes 3 months ago. Two weeks ago he complained of pain, redness, and tenderness in his right lower leg. He is admitted to the hospital with a slight elevation of temperature and vague complaints of “not feeling well.” At 4:30 PM on the day of his admission, his blood glucose level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to: A. Give him 3 tbsp of sugar dissolved in 4 oz of grape juice to drink B. Ask him to dissolve three pieces of hard candy in his mouth C. Have him drink 4 oz of orange juice D. Monitor him closely until dinner arrives Correct Answer: C Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) The combination of sugar and juice will increase the blood sugar beyond the normal range. (B) Concentrated sweets are not absorbed as fast as juice; consequently, they elevate the blood RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE sugar beyondthe normal limit. (C) Four ounces of orange juice will act immediately to raise the blood sugar to a normal level and sustain it for 30 minutes until supper is served. (D) There is an increased potential for the client’s blood sugar to decrease even further, resulting in diabetic coma. QUESTION 43 A male client receives 10 U of regular human insulin SC at 9:00 AM. The nurse would expect peak actionfrom this injection to occur at: A. 9:30 AM B. 10:30 AM C. 12 noon D. 4:00 PM Correct Answer: C Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) This is too early for peak action to occur. (B) This is too early for peak action to occur. (C) Regularinsulin peak action occurs 2–4 hours after administration. (D) This is too late for peak action to occur. QUESTION 44 A type I diabetic client is diagnosed with cellulitis in his right lower extremity. The nurse would expect whichof the following to be present in relation to his blood sugar level? RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE Explanation/Reference: Explanation: (A) The percentage of carbohydrates is too low to maintain blood sugar levels. The percent range of protein is too high and may cause extra workload on the kidney as it is metabolized. (B) The percentage of carbohydrates is too low to maintain blood sugar levels. The percent range of protein is too high and may cause extra workload on the kidney. (C) The percentage of carbohydrates is too high; the percent range of protein is too high, and of fat, too low. (D) This combination provides enough carbohydrates to maintain blood glucose levels, enough protein to maintain body repair, and enough fat to ensure palatability. QUESTION 47 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. Correct Answer: B Section: Question Set B Explanation Explanation/Reference: Explanation: RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE (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 retention catheter is in place would not help to prevent a voiding urge and could irritate the urethral sphincter. (D) Though the nurse would want to ascertain whether the client has felt the same urge to void before, the initial response should be to assure the patency of the catheter. QUESTION 48 In cleansing the perineal area around the site of catheter insertion, the nurse would: A. Wipe the catheter toward the urinary meatus B. Wipe the catheter away from the urinary meatus C. Apply a small amount of talcum powder after drying the perineal area D. Gently insert the catheter another 1⁄2 inch after cleansing to prevent irritation from the balloon Correct Answer: B Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Wiping toward the urinary meatus would transport microorganisms from the external tubing to the urethra, thereby RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE increasing the risk of bladder infection. (B) Wiping away from the urinary meatus would remove microorganisms from the point of insertion of the catheter, thereby decreasing the risk of bladder infection. (C) Talcum powder should not be applied following catheter care, because powders contribute tomoisture retention and infection likelihood. (D) The catheter should never be inserted further into the urethra, because this would serve no useful purpose and would increase the risk of infection. QUESTION 49 Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheterinclude: A. Cleanse area around the meatus twice a day B. Empty the catheter drainage bag at least daily C. Change the catheter tubing and bag every 48 hours D. Maintain fluid intake of 1200–1500 mL every day Correct Answer: A Section: Question Set B Explanation Explanation/Reference: Explanation: RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE choices indicate that this teaching has been understood? A. Omelette and hash browns B. Pancakes and syrup C. Bagel with cream cheese D. Cooked oatmeal and grapefruit half Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Eggs and hash browns do not provide much fiber and bulk, so they do not effectively prevent constipation. (B) Pancakes and syrup also have little fiber and bulk, so they do not effectively prevent constipation. (C) Bagel and cream cheese do not provide intestinal bulk. (D) A combination of oatmeal and fresh fruit will provide fiber and intestinal bulk. QUESTION 53 One of the medications that is prescribed for a male client is furosemide (Lasix) 80 mg bid. To reduce his risk of falls, the nurse would teach him to take this medication: A. On arising and no later than 6 PM B. At evenly spaced intervals, such as 8 AM and 8 PM C. With at least one glass of water per pill D. With breakfast and at bedtime RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE Correct Answer: A Section: Question Set B Explanation Explanation/Reference: Explanation: (A) This option provides adequate spacing of the medication and will limit the client’s need to get up to go to the bathroom during the night hours, when he is especially at high risk for falls. (B) This option would result in the need to get up during the night to urinate and would thus increase the risk of falls. This option also does not take into consideration the client’s usual daily routine. (C) Taking this medication with at least one glass of water would not have an impact on the risk of falls. (D) This option would result in the need toget up during the night to urinate and would thus increase the risk of falls. QUESTION 54 The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which of thefollowing indicates that he understands this teaching? A. “I’ll be sure to rise slowly and sit for a few minutes after lying down.” B. “I’ll be sure to walk at least 2–3 blocks every day.” C. “I’ll be sure to restrict my fluid intake to four or five glasses a day.” D. “I’ll be sure not to take any more aspirin while I amon this drug.” Correct Answer: RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE A Section: Question Set B Explanation Explanation/Reference: Explanation: (A) This response will help to prevent the occurrence of postural hypotension, a common side effect of this drug and a common reason for falls. (B) Although walking is an excellent exercise, it is not specific to the reduction of risks associated with diuretic therapy. (C) Clients on diuretic therapy are generally taught to ensure that their fluid intake is at least 2000–3000 mL daily, unless contraindicated. (D) Aspirin is a safe drug to take along with furosemide. QUESTION 55 A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful? A. Pork chop, baked acorn squash, brussel sprouts B. Chicken breast, rice, and green beans C. Roast beef, baked potato, and diced carrots D. Tuna casserole, noodles, and spinach Correct Answer: A Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Both acorn squash and brussels sprouts are potassium-rich foods. RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE Correct Answer: C Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Although influenza is common, the elderly are more at risk because of decreased effectiveness of theirimmune system, not because the incidence is increasing. (B) Older clients have the same degree of illness when stricken as other populations. (C) As people age, their immune system becomes less effective, increasing their risk for influenza. (D) Older clients have no more exposure to the causative agents than do school-age children, for example. QUESTION 59 In evaluating the laboratory results of a client with severe pressure ulcers, the nurse finds that her albuminlevel is low. A decrease in serum albumin would contribute to the formation of pressure ulcers because: A. The proteins needed for tissue repair are diminished. B. The iron stores needed for tissue repair are inadequate. C. A decreased serum albumin level indicates kidney disease. D. A decreased serum albumin causes fluid movement into the blood vessels, causing dehydration. Correct Answer: A Section: RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE Question Set B Explanation Explanation/Reference: Explanation: (A) Serum albumin levels indicate the adequacy of protein stores available for tissue repair. (B) Serum albumin does not measure iron stores. (C) Serum albumin levels do not measure kidney function. (D) Adecreased serum albumin level would cause fluid movement out of blood vessels, not into them. QUESTION 60 Which of the following menu choices would indicate that a client with pressure ulcers understands the role diet plays in restoring her albumin levels? A. Broiled fish with rice B. Bran flakes with fresh peaches C. Lasagna with garlic bread D. Cauliflower and lettuce salad Correct Answer: A Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Broiled fish and rice are both excellent sources of protein. (B) Fresh fruits are not a good source of protein. (C) Foods in the bread group are not high in protein. (D) Most vegetables are not high in protein; peas and beans are the major vegetables higher RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE in protein. QUESTION 61 The nurse observes that a client has difficulty chewing and swallowing her food. A nursing response designed to reduce this problem would include: A. Ordering a full liquid diet for her B. Ordering five small meals for her C. Ordering a mechanical soft diet for her D. Ordering a puréed diet for her Correct Answer: C Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Full liquids would be difficult to swallow if the muscle control of the swallowing act is affected; this is a probable reason for her difficulties, given her medical diagnosis of multiple sclerosis. (B) Five small meals would do little if anything to decrease her swallowing difficulties, other than assure that she tires less easily. (C) A mechanical soft diet should be easier to chew and swallow, because foods would be more evenly consistent. (D) A pureed diet would cause her to regress more than might be needed; the mechanical softdiet should be tried first. QUESTION 62 When a client with pancreatitis is discharged, the nurse needs to RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE Section: Question Set B Explanation Explanation/Reference: Explanation: (A, B, D) Cigarettes, cigars, and chewing gum would stimulate gastric acid secretion. (C) Smoking on a fullstomach minimizes effect of nicotine on gastric acid. QUESTION 64 Iron dextran (Imferon) is a parenteral iron preparation. The nurse should know that it: A. Is also called intrinsic factor B. Must be given in the abdomen C. Requires use of the Z-track method D. Should be given SC Correct Answer: C Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Intrinsic factor is needed to absorb vitamin B12.(B) Iron dextran is given parenterally, but Z-track in a large muscle. (C) A Ztrack method of injection is required to prevent staining and irritation of RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE the tissue. (D)An SC injection is not deep enough and may cause subcutaneous fat abscess formation. QUESTION 65 A nasogastric (NG) tube inserted preoperatively is attached to low, intermittent suctions. A client with anNG tube exhibits these symptoms: He is restless; serum electrolytes are Na 138, K 4.0, blood pH 7.53. This client RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE is most likely experiencing: A. Hyperkalemia B. Hyponatremia C. Metabolic acidosis D. Metabolic alkalosis Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Sodium level is within normal limits. (B) Sodium level is within normal limits. (C) pH level is consistent with alkalosis. (D) With an NG tube attached to low, intermittent suction, acids are removed and a client willdevelop metabolic alkalosis. QUESTION 66 A client is experiencing muscle weakness and lethargy. His serum K+is 3.2. What other symptoms might he exhibit? A. Tetany B. Dysrhythmias C. Numbness of extremities D. Headache RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE colitis. Which of the following is anursing implication for this drug? A. Limit fluids to 500 mL/day. B. Administer 2 hours before meals. C. Observe for skin rash and diarrhea. D. Monitor blood pressure, pulse. Correct Answer: C Section: Question Set B Explanation Explanation/Reference: Explanation: (A)Fluids up to 2500–3000 mL/day are needed to prevent kidney stones. (B)The client should be instructed to take oral preparations with meals or snacks to lessen gastric irritation. (C) Sulfasalazinecauses skin rash and diarrhea. (D) Blood pressure and pulse are not altered by sulfasalazine. QUESTION 69 Other drugs may be ordered to manage a client’s ulcerative colitis. Which of the following medications, if ordered, would the nurse question? A. Methylprednisolone sodium succinate (Solu-Medrol) B. Loperamide (Imodium) C. Psyllium D. 6-Mercaptopurine RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE (A) Methylprednisolone sodium succinate is used for its anti- inflammatory effects. (B) Loperamide would be used to control diarrhea. (C) Psyllium may improve consistency of stools by providing bulk. (D) An immunosuppressant such as 6- mercaptopurine is used for chronic unrelenting Crohn’s disease. QUESTION 70 A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should: A. Explain that he will be kept NPO for 24 hours before the exam B. Practice with him so he will be able to hold his breath for 1 minute C. Explain that he will be receiving a laxative to prevent a distended bowel from applying pressure on theliver D. Explain that his vital signs will be checked frequently after the test Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) There is no NPO restriction prior to a liver biopsy. (B) The client would need to hold his breath for 5–10seconds. (C) There is no pretest laxative given. (D) Following the test, the client is watched for hemorrhageand shock. QUESTION 71 After a liver biopsy, the best position for the client is: A. High Fowler RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE Hemorrhage and shock are the most likely complications after liver biopsy because of already existing bleeding tendencies in the vascular makeup of the liver. QUESTION 73 Which nursing implication is appropriate for a client undergoing a paracentesis? A. Have the client void before the procedure. RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE B. Keep the client NPO. C. Observe the client for hypertension following the procedure. D. Place the client on the right side following the procedure. Correct Answer: A Section: Question Set B Explanation Explanation/Reference: Explanation: (A) A full bladder would impede withdrawal of ascitic fluid. (B) Keeping the client NPO is not necessary. (C) The client may exhibit signs and symptoms of shock and hypertension. (D) No position change is needed after the procedure. QUESTION 74 The nurse would assess the client’s correct understanding of the fertility awareness methods that enhanceconception, if the client stated that: A. “My sexual partner and I should have intercourse when my cervical mucosa is thick and cloudy.” B. “At ovulation, my basal body temperature should rise about 0.5F.” C. “I should douche immediately after intercourse.” D. “My sexual partner and I should have sexual intercourse on day 14 of my cycle regardless of the length of the cycle.” Correct Answer: B Section: Question Set B RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE Explanation Explanation/Reference: Explanation: (A) At ovulation, the cervical mucus is increased, stretchable, and watery RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE C. October 22 D. October 29 Correct Answer: C Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Incorrect application of Nägele’s rule: correctly subtracted 3 months but subtracted 7 days rather than added. (B) Incorrect application of Nägele’s rule: correctly subtracted 3 months but did not add 7 days. (C) Correct application of Nägele’s rule: correctly subtracted 3 months and added 7 days. (D) Incorrect application of Nägele’s rule: correctly subtracted 3 months but added 14 days instead of 7 days. QUESTION 77 The nurse instructs a pregnant client (G2P1) to rest in a side-lying position and avoid lying flat on her back. The nurse explains that this is to avoid “vena caval syndrome,” a condition which: A. Occurs when blood pressure increases sharply with changes in position B. Results when blood flow from the extremities is blocked or slowed C. Is seen mainly in first pregnancies D. May require medication if positioning does not help Correct Answer: B Section: RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE Question Set B Explanation Explanation/Reference: Explanation: (A) Blood pressure changes are predominantly due to pressure of the gravid uterus. (B) Pressure of thegravid uterus on the inferior vena cava decreases blood return from lower extremities. (C) Inferior vena cava RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE syndrome is experienced in the latter months of pregnancy regardless of parity. (D) There are no medications useful in the treatment of interior vena cava syndrome; alleviating pressure by position changes is effective. QUESTION 78 A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnanttwice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL system to record her obstetrical history, the nurse should record: A. 3-2-0-0-2 B. 2-2-0-2-2 C. 3-1-1-0-2 D. 2-1-1-0-2 Correct Answer: C Section: Question Set B Explanation Explanation/Reference: Explanation: (A) This answer is an incorrect application of the GTPAL method. One prior pregnancy was a preterm birth at 36 weeks (T =1, P= 1; not T = 2). (B) This answer is an incorrect application of the GTPAL method. The client is currently pregnant for the third time (G = 3, not 2), one prior pregnancy was preterm (T= 1, P= 1; not T= 2), and she has had no prior abortions (A =0). (C) This answer is the correct application of GTPAL method. The client is currently RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE currently pregnant for third time (G = 3, not 2). QUESTION 80 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 RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE C. MgSO4serum levels are>15 mg/dL D. Respirations are>16 breaths/min Correct Answer: D Section: Question Set B Explanation Explanation/Reference: 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. QUESTION 81 Prenatal clients are routinely monitored for early signs of pregnancy- induced hypertension (PIH). For the prenatal client, which of the following blood pressure changes from baseline would be most significant forthe nurse to report as indicative of PIH? A. 136/88 to 144/93 B. 132/78 to 124/76 C. 114/70 to 140/88 RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE D. 140/90 to 148/98 Correct Answer: C Section: Question Set B Explanation Explanation/Reference: Explanation: RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE Question Set B Explanation Explanation/Reference: Explanation: RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE (A) In pulling the infant away from the breast without breaking suction, nipple trauma is likely to occur. (B)In pulling the breast away from the infant without breaking suction, nipple trauma is likely to occur. (C) Compressing the maternal tissue does not break the suction of the infant on the breast and can cause nipple trauma. (D) By inserting a finger into the infant’s mouth beside the nipple, the lactating mother can break the suction and the nipple can be removed without trauma. QUESTION 84 A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to be boggy, high, and deviated to the right. The most appropriate nursing action is to: A. Notify the physician B. Place the client on a pad count C. Massage the uterus and re-evaluate in 30 minutes D. Have the client void and then re-evaluate the fundus Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) The nurse should initiate actions to remove the most frequent cause of uterine displacement, which involves emptying the bladder. Notifying the physician is an inappropriate nursing action. (B) The pad count gives an estimate of blood loss, which is likely to increase with a boggy uterus; but this action does not RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE remove the most frequent cause of uterine displacement, which is a full bladder. (C) Massage may firm theuterus temporarily, but if a full bladder is not emptied, the uterus will remain displaced and is likely to relax again. (D) The most common cause of uterine displacement is a full bladder. QUESTION 85 A client delivered her first-born son 4 hours ago. She asks the nurse what the white cheeselike substanceis under the baby’s arms. The nurse should RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE Question Set B Explanation Explanation/Reference: Explanation: (A) LOA identifies a fetus whose back is on its mother’s left side, whose head is the presenting part, andwhose back is toward its mother’s anterior. It is easiest to auscultate fetal heart tones (FHTs) through thefetus’s back. (B)The identified fetus’s back is on its mother’s left side, not right side. It is easiest to auscultate FHTs through the fetus’s back. (C) In an LOA position, the fetus’s head is presenting with the back to the left anterior side of the mother. The umbilicus is too high of a landmark for auscultating the fetus’s heart rate through its back. (D) This is the correct auscultation point for a fetus in the left sacroanterior position, where the sacrum is presenting, not LOA. QUESTION 87 In performing the initial nursing assessment on a client at the prenatal clinic, the nurse will know that whichof the following alterations is abnormal during pregnancy? A. Striae gravidarum B. Chloasma C. Dysuria D. Colostrum Correct Answer: C Section: Question Set B Explanation RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE Explanation/Reference: Explanation: (A) Striae gravidarum are the normal stretch marks that frequently occur on the breasts, abdomen, and thighs as pregnancy progresses. (B) Chloasma is the “mask of pregnancy” that normally occurs in many RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE pregnant women. (C) Dysuria is an abnormal danger sign during pregnancy and may indicate a urinary tract infection. (D) Colostrum is a yellow breast secretion that is normally present during the last trimester of pregnancy. QUESTION 88 A 35-weeks-pregnant client is undergoing a nonstress test (NST). During the 20-minute examination, thenurse notes three fetal movements accompanied by accelerations of the fetal heart rate, each 15 bpm, lasting 15 seconds. The nurse interprets this test to be: A. Nonreactive B. Reactive C. Positive D. Negative Correct Answer: B Section: Question Set B Explanation Explanation/Reference: Explanation: (A) In a nonreactive NST, the criteria for reactivity are not met. (B) A reactive NST shows at least two accelerations of FHR with fetal movements, each 15 bpm, lasting 15 seconds or more, over 20 minutes. (C, D) This term is used to interpret a contraction stress test (CST), or oxytocin challenge test, not an NST. QUESTION 89 RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE Correct Answer: C Section: Question Set B Explanation Explanation/Reference: Explanation: RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE (A) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is above the ischial spines, the station is negative. (B) When the biparietal diameter is at the level of the ischial spines, the presenting part is generally at a +4 or +5 station. (C) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is below the ischial spines, the station is positive. Thus, 2 cm below the ischial spines is the station +2. (D) When the biparietal diameter is above the ischial spines by 5 cm, the presenting part is usually engaged or at station 0. QUESTION 91 A pregnant client is at the clinic for a third trimester prenatal visit. During this examination, it has been determined that her fetus is in a vertex presentation with the occiput located in her right anterior quadrant. On her chart this would be noted as: A. Right occipitoposterior B. Right occipitoanterior C. Right sacroanterior D. LOA Correct Answer: B Section: Question Set B Explanation Explanation/Reference: Explanation: RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE (A) The fetus in the right occipitoposterior position would be presenting with the occiput in the maternal right posterior quadrant. (B) Fetal position is defined by the location of the fetal presenting part in the four quadrants of the maternal pelvis. The right occipitoanterior is a fetus presenting with the occiput in mother’s right anterior quadrant. (C) The fetus in right sacroanterior position would be presenting a sacrum, not an occiput. (D) RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE B. “Make sure you take a deep cleansing breath as the contractions start, focus on an object, and breatheabout 16–20 times a minute with shallow chest breaths.” C. “Find a comfortable position before you start a contraction. Once the contraction has started, take slow breaths using your abdominal muscles.” D. “If a woman in labor listens to her body and takes rapid, deep breaths, she will be able to deal with hercontractions quite well.” Correct Answer: B Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Lamaze childbirth preparation teaches the use of chest, not abdominal, breathing. (B) In Lamaze preparation, every patterned breath is preceded by a cleansing breath; as labor progresses, shallow, paced breathing is found to be effective. (C) It is important to assume a comfortable position in labor, but the Lamazeprepared laboring woman is taught to breathe with her chest, not abdominal, muscles. (D) When deep chest breathing patterns are used in Lamaze preparation, they are slowly paced at a rate of 6–9 breaths/min. QUESTION 94 A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching? RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE A. “If he develops diarrhea lasting for more than 2–3 days, I will contact the doctor or nurse.” B. “I should anticipate that he will gain about 1 lb/day now that he is on continuous feedings.” C. “It is important to keep the head of his bed elevated or sit him in the chair during feedings.” D. “I should use prepared or open formula within 24 hours and store unused portions in the refrigerator.” RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE Correct Answer: B Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Diarrhea is a complication of tube feedings that can lead to dehydration. Diarrhea may be the result of hypertonic formulas that can draw fluid into the bowel. Other causes of diarrhea may be bacterial contamination, fecal impaction, medications, and low albumin. (B) A consistent weight gain of more than 0.22 kg/day (1⁄2 lb/day) over several days should be reported promptly. The client should be evaluated for fluid volume excess. (C) Elevating the client’s head prevents reflux and thus formula from entering the airway. (D) Bacteria proliferate rapidly in enteral formulas and can cause gastroenteritis and even sepsis. QUESTION 95 A 74-year-old obese man who has undergone open reduction and internal fixation of the right hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to right lower leg pain, described as “a cramp in my leg.” An appropriate nursing action is to: A. Assess for pain with plantiflexion B. Assess for edema and heat of the right leg C. Instruct him to rub the cramp out of his leg D. Elevate right lower extremity with pillows propped under the knee RN515 NCLEX-NURSING REVIEW QUESTIONS WITH ANSWERS 100 CORRECTLY verrified 2022/2023 UPDATE