Ultimate Guide to Prepare NCLEX-RN Certification Exam for NCLEX Certification in 2023
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NEW QUESTION # 266
The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on oral griseofulvin. The nurse should emphasize which of these instructions to the mother and/or child?
- A. Discontinue drug therapy if food tastes funny.
- B. Administer oral griseofulvin on an empty stomach for best results.
- C. Observe for headaches, dizziness, and anorexia.
- D. May discontinue medication when the child experiences symptomatic relief.
Answer: C
Explanation:
(A) Giving the drug with or after meals may allay gastrointestinal discomfort. Giving the drug with a fatty meal (ice cream or milk) increases absorption rate. (B) Griseofulvin may alter taste sensations and thereby decrease the appetite. Monitoring of food intake is important, and inadequate nutrient intake should be reported to the physician. (C) The child may experience symptomatic relief after 48-96 hours of therapy. It is important to stress continuing the drug therapy to prevent relapse (usually about 6 weeks). (D) The incidence of side effects is low; however, headaches are common. Nausea, vomiting, diarrhea, and anorexia may occur. Dizziness, although uncommon, should be reported to the physician.
NEW QUESTION # 267
A client has been diagnosed as being preeclamptic. The physician orders magnesium sulfate. Magnesium sulfate (MgSO4) is used in the management of preeclampsia for:
- A. Sedation
- B. Prevention of seizures
- C. Fetal lung protection
- D. Prevention of uterine contractions
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) MgSO4 is classified as an anticonvulsant drug. In preeclampsia management, MgSO4 is used for prevention of seizures. (B) MgSO4 has been used to inhibit hyperactive labor, but results are questionable.
(C) Negative side effects such as respiratory depression should not be confused with generalized sedation. (D) MgSO4 does not affect lung maturity. The infant should be assessed for neuromuscular and respiratory depression.
NEW QUESTION # 268
A client has consented to have a central venous catheter placed. The best position in which to place the client is the Trendelenburg position. The reason is that the Trendelenburg position:
- A. Makes the procedure more comfortable for the client
- B. Allows the physician to visualize the subclavian vein
- C. Reduces the possibility of air embolism
- D. Reduces the possibility of hematoma formation
Answer: C
Explanation:
Explanation
(A) The subclavian vein is not visible during central line insertion regardless of the client's position. (B) The Trendelenburg position reduces the possibility of air embolism because it places slight positive pressure on the central veins. It also distends the veins, and distention facilitates insertion. (C) This response is untrue; it has no effect on hematoma formation. (D) This position is not necessarily more comfortable for the client, and many clients, especially those who may be short of breath, may find the position uncomfortable and difficult to maintain.
NEW QUESTION # 269
The nurse is developing a plan of care for a client with an electrolyte imbalance and identifies a nursing diagnosis of decreased physical mobility. Which alteration is most likely the etiology?
- A. Hypokalemia
- B. Hypomagnesemia
- C. Hypocalcemia
- D. Hypernatremia
Answer: A
Explanation:
Explanation
(A) A deficit in sodium concentration results in muscular weakness and lethargy. (B) Muscle fatigue and hypotonia are caused by hypercalcemia. (C) Muscle weakness and fatigue are classic signs of hypokalemia.
(D) Hypermagnesemia can cause muscle weakness, paralysis, and coma.
NEW QUESTION # 270
A client is dilated 8 cm and entering the transition phase of labor. Common behaviors of the laboring woman during transition are:
- A. Frustration, vague in communication
- B. Excitement, openness to instructions
- C. Calmness, follows directions easily
- D. Seriousness, some difficulty following directions
Answer: A
Explanation:
Explanation
(A) During the transition phase, the mother may become frustrated and unclear in her communication owing to severe pain and fear of loss of control. (B) These behaviors are common in the active phase of labor. (C) These behavioral clues are seen in the latent phase of labor. (D) These characteristics are observed in the latent phase of labor.
NEW QUESTION # 271
In discussing the plan of care for a child with chronic nephrosis with the mother, the nurse identifies that the purpose of weighing the child is to:
- A. Impress the child with the importance of eating well
- B. Determine changes in the amount of edema
- C. Check the accuracy of the fluid intake record
- D. Measure adequacy of nutritional management
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Weighing a child with nephrosis is to assess for edema, not nutrition. (B, C) This is not the purpose for weighing the child. (D) Weight and measurement are the primary ways of evaluating edema and fluid shifts.
NEW QUESTION # 272
A 52-year-old client is scheduled for a small-bowel resection in the morning. In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises. She will teach the client to:
- A. Inhale as deeply as possible and then immediately exhale as deeply as possible at a rate of approximately 20-24 times/min
- B. Take a large gulp of air into the mouth, hold it for 10-15 seconds, and then expel it through the nose. Repeat 4-5 times to complete the series
- C. Purse the lips and take quick, short breaths approximately 18-20 times/min
- D. Inhale slowly and deeply through the nose until the lungs are fully expanded, hold the breath a couple of seconds, and then exhale slowly through the mouth. Repeat 2-3 more times to complete the series every 1-2 hours while awake
Answer: D
Explanation:
(A) This is the correct method of teaching diaphragmatic breathing, which allows full lung expansion to increase oxygenation, prevent atelectasis, and move secretions up and out of the lungs to decrease risk of pneumonia. (B) Quick, short breaths do not allow for full lung expansion and movement of secretions up and out of the lungs. Quick, short breaths may lead to O2 depletion, hyperventilation, and hypoxia. (C) Expelling breaths through the nose does not allow for full lung expansion and the use of diaphragmatic muscles to assist in moving secretions up and out of the lungs. (D) Inhaling and exhaling at a rate of 20-24 times/min does not allow time for full lung expansion to increase oxygenation. This would most likely lead to O2 depletion and hypoxia.
NEW QUESTION # 273
A complication for which the nurse should be alert following a liver biopsy is:
- A. Shock
- B. Jaundice
- C. Ascites
- D. Hepatic coma
Answer: A
Explanation:
Explanation
(A) Hepatic coma may occur in liver disease due to the increased NH3levels, not due to liver biopsy. (B) Jaundice may occur due to increased bilirubin levels, not due to liver biopsy. (C) Ascites would occur due to portal hypertension, not due to liver biopsy. (D) Hemorrhage and shock are the most likely complications after liver biopsy because of already existing bleeding tendencies in the vascular makeup of the liver.
NEW QUESTION # 274
At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her contractions are every 5 minutes and last 60 seconds, her cervix is closed, and the suture placed around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is still intact. She is very concerned about delivering prematurely. She asks the RN, "What is the greatest risk to my baby if it is born prematurely?" The RN's answer should be:
- A. Lack of development of the lungs
- B. Hypoglycemia
- C. Hyperglycemia
- D. Lack of development of the intestines
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Any infant would be at risk for hyperglycemia because the infant's liver is missing the islets of Langerhans, which secrete insulin to break down glucose for cellular use. Prematurity is not an added risk for hyperglycemia. (B) Both premature and mature infants can be at risk for hypoglycemia if their mother had gestational diabetes during pregnancy or entered the pregnancy with diabetes mellitus. These infants are exposed to high levels of maternal glucose while in utero, which causes the islets of Langerhans in the infant's liver to produce insulin. After birth when the umbilical cord is severed, the generous amount of maternal blood glucose is eliminated; however, there is continued islet cell hyperactivity in the infant's liver, which can lead to excessive insulin levels and depleted blood glucose. (C) Mature infants are born with an immature GI system. The nervous control of the stomach is incomplete at birth, salivary glands are immature at birth, and the intestinal tract is sterile. This is not the greatest risk to the premature infant. (D) Infants born before 37 weeks' gestation are at greatest risk for an insufficient amount of surfactant in the alveoli system of the lungs. Surfactant helps to prevent lung collapse and ensures stability of the respiratory system so that the infant can maintain his own respirations once the umbilical cord is severed at birth.
NEW QUESTION # 275
After an infant is delivered by cesarean delivery and placed on the warmer, the RN dries and assesses the infant. At 1 and 5 minutes after birth, the RN does the Apgar scoring of the infant. The RN knows that because this infant was delivered by cesarean section, he is at increased risk for having which one of the following:
- A. Respiratory distress syndrome
- B. Seizures
- C. Cold stress
- D. Cyanosis
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) The infant is placed on the warmer and dried after birth. Cold stress occurs when the infant is not dried and kept warm. (B) The fact that this infant was born by cesarean delivery does not place him at a greater risk for cyanosis than an infant delivered vaginally. Cyanosis occurs when infants cannot oxygenate their blood after the umbilical cord is severed. (C) Infants born by cesarean delivery are at a higher risk for developing respiratory distress syndrome because these infants do not pass through the pelvis, where the chest is compressed and fluid is able to escape from the lungs. (D) Cesarean-delivered infants are not at greater risk for seizures than infants delivered vaginally.
NEW QUESTION # 276
A 35-year-old client is admitted to the hospital for elective tubal ligation. While the nurse is doing preoperative teaching, the client says, "The anesthesiologist said she was going to give me balanced anesthesia. What exactly is that?" The best explanation for the nurse to give the client would be that balanced anesthesia:
- A. Uses equal amounts of inhalation agents and liquid agents
- B. Does not depress the central nervous system
- C. Is a combination of several anesthetic agents or drugs producing a smooth induction and minimal complications
- D. Is a type of regional anesthesia
Answer: C
Explanation:
Explanation
(A) Regional anesthesia does not produce loss of consciousness and is indicated for excision of moles, cysts, and endoscopic surgeries. (B) Varying amounts of anesthetic agents are used when employing balanced anesthesia. Amounts depend on age, weight, condition of the client, and surgical procedure. (C) General anesthesia is a drug-induced depression of the central nervous system that produces loss of consciousness and decreased muscle activity. (D) Balanced anesthesia is a combination of a number of anesthetic agents that produce a smooth induction, appropriate depth of anesthesia, and appropriate muscle relaxation with minimal complications.
NEW QUESTION # 277
A client has received preoperative teaching for the vertical partial laryngectomy that he is scheduled to have in the morning. The nurse determines that the teaching has been effective when the client states:
- A. "I will have very little difficulty swallowing after surgery."
- B. "I may also have to have a radical neck dissection done."
- C. "The quality of my voice will be excellent after surgery."
- D. "I know I will need special swallowing training after my surgery."
Answer: A
Explanation:
(A) A client with a supraglottic (horizontal partial) laryngectomy would require special swallowing training, not a vertical partial laryngectomy. (B) The quality of the client's voice will be altered but adequate for communication. (C) The client will have minimal difficulty swallowing. (D) A radical neck dissection may be done with a total laryngectomy, but not with a partial laryngectomy.
NEW QUESTION # 278
A male client has been an insulin-dependent diabetic for approximately 30 years. He frequently indulges in highsugar foods and forgets to take his insulin. He has not experienced acute diabetic emergencies over the years but is now beginning to demonstrate symptoms of diabetic peripheral neuropathy. This distresses him because dancing is one of his favorite pastimes. He decides to question his wife's home health nurse about diabetic peripheral neuropathy. The nurse points out his noncompliance to his diabetic diet and insulin regimen. The client answers the nurse, "It has been my experience that the diabetic diet is very difficult to follow. As far as the insulin, isn't a fellow allowed to forget now and then?" The client's actions and response best demonstrate:
- A. Depression
- B. Bargaining
- C. Anger
- D. Denial
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Depression may be an underlying feature, but it is not evident from limited data presented here. (B) Anger is not exhibited in his response. (C) Denial is evident in the client's actions; through the years, he has had a casual approach to his illness. He only becomes concerned when bodily changes affect his present lifestyle, when in fact he should have been concerned all along. His verbal response also reflects denial. (D) There is no evidence of bargaining in the client's actions or verbal response.
NEW QUESTION # 279
Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?
- A. A ham and cheese sandwich
- B. Saltine crackers and peanut butter
- C. Fresh fruit
- D. A milkshake
Answer: D
Explanation:
(A) Albumin, a blood volume expander, increases the circulating blood volume by exerting an osmotic pull on tissue fluids, pulling them into the vascular system. This fluid shift causes an increase in the heart rate and blood pressure. (B) Albumin, a blood volume expander, exerts an osmotic pull on fluids in the interstitial spaces, pulling the fluid back into the circulatory system. This fluid shift causes an increase in the urinary output. (C) Adventitious breath sounds and dyspnea can occur due to circulatory overload if the albumin is infused too rapidly. (D) Chills, fever, itching, and rashes are signs of a hypersensitivity reaction to albumin.
NEW QUESTION # 280
The parents of a 2-year-old child are ready to begin toilet training activities with him. His parents feel he is ready to train because he is now 2 years old. What would the nurse identify as readiness in this child?
- A. Communicating the urge to defecate or urinate
- B. The age at which the child's siblings were trained
- C. The child awakening wet from his naps
- D. Patience by the child when wearing soiled diapers
Answer: A
Explanation:
Section: Questions Set D
Explanation:
(A) Children experience impatience with soiled diapers when readiness for training is apparent. They often desire to be changed immediately. (B) A child must be able to use verbal or nonverbal skills to communicate needs. (C) A readiness indicator would be awaking dry from naps. (D) The age at which a sibling was toilet trained has no implications for training this child.
NEW QUESTION # 281
A school-age child with asthma is ready for discharge from the hospital. His physician has written an order to continue the theophylline given in the hospital as an oral home medication. Immediately prior to discharge, he complains of nausea and becomes irritable. His vital signs were normal except for tachycardia. What first nursing actions would be essential in this situation?
- A. Administer an antiemetic as necessary.
- B. Discharge the child as the physician ordered.
- C. Hold the child's discharge for 1 hour.
- D. Notify the physician immediately.
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Holding the child's discharge alone does not address the client's problem. (B) Nausea, tachycardia, and irritability are all symptoms of theophylline toxicity. The physician should benotified immediately so that a serum theophylline level can be ordered. Theophylline dose should be withheld until the physician is notified. (C) The child must be evaluated for theophylline toxicity before any discharge. (D) Cause of the nausea should be investigated before the administration of an antiemetic.
NEW QUESTION # 282
A 55-year-old man has recently been diagnosed with hypertension. His physician orders a low-sodium diet for him. When he asks, "What does salt have to do with high blood pressure?'' the nurse's initial response would be:
- A. "Salt is needed to maintain blood pressure, but too much causes hypertension."
- B. "Large amounts of salt in your diet can cause you to retain fluid, which increases your blood pressure."
- C. "Salt affects your blood vessels and causes your blood pressure to be high."
- D. "The reason is not known why hypertension is associated with a high-salt diet."
Answer: B
Explanation:
(A) This response is untrue. (B) Decreasing salt intake reduces fluid retention and decreases blood pressure. (C) Salt does not have an effect on the blood vessels themselves, but on fluid retention, which accompanies salt intake. (D) This response is untrue.
NEW QUESTION # 283
In assessing the nature of the stool of a client who has cystic fibrosis, what would the nurse expect to see?
- A. Dark brown stools
- B. Steatorrhea stools
- C. Blood-tinged stools
- D. Clay-colored stools
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Clay-colored stools indicate dysfunction of the liver or biliary tract. (B) In the early stages of cystic fibrosis, fat absorption is primarily affected resulting in fat, foul, frothy, bulky stools. (C) Dark brown stools indicate normal passage through the colon. (D) Blood-tinged stools indicate dysfunction of the gastrointestinal (GI) tract.
NEW QUESTION # 284
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. Have him breathe into a paper bag
- B. Place him in a lateral Sims' position
- C. Encourage pursed-lip breathing
- D. Increase his nasal O2 to 6 L/min
Answer: C
Explanation:
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.
NEW QUESTION # 285
A 70-year-old client is almost finished receiving her second unit of packed red blood cells. The client, who weighs 80 lb, has started complaining of being short of breath and now has crackles in the bases of her lungs.
After slowing or stopping the transfusion, the most appropriate initial nursing action would be to:
- A. Administer furosemide (Lasix) 20 mg IV push
- B. Place the client on 2 liters of O2 via nasal cannula
- C. Raise the client's head and place her feet in a dependent position
- D. Notify the physician
Answer: C
Explanation:
Section: Questions Set C
Explanation:
(A) Raising the client's head and placing her feet in a dependent position is an independent nursing action that can be taken to decrease venous return and to reduce pulmonary congestion. (B) Notifying the physician is an appropriate action that should be taken after the client is positioned to maximize her respiratory status. (C) Placing the client on O2may be done with a physician's order or according to an institution's standing orders; however, other actions should be taken first. (D) Furosemide 20 mg IV push is an appropriate medication for the client, but it must be ordered by her physician.
NEW QUESTION # 286
A 35-year-old client is admitted to the hospital for elective tubal ligation. While the nurse is doing preoperative teaching, the client says, "The anesthesiologist said she was going to give me balanced anesthesia. What exactly is that?" The best explanation for the nurse to give the client would be that balanced anesthesia:
- A. Uses equal amounts of inhalation agents and liquid agents
- B. Does not depress the central nervous system
- C. Is a combination of several anesthetic agents or drugs producing a smooth induction and minimal complications
- D. Is a type of regional anesthesia
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Regional anesthesia does not produce loss of consciousness and is indicated for excision of moles, cysts, and endoscopic surgeries. (B) Varying amounts of anesthetic agents are used when employing balanced anesthesia. Amounts depend on age, weight, condition of the client, and surgical procedure. (C) General anesthesia is a drug-induced depression of the central nervous system that produces loss of consciousness and decreased muscle activity. (D) Balanced anesthesia is a combination of a number of anesthetic agents that produce a smooth induction, appropriate depth of anesthesia, and appropriate muscle relaxation with minimal complications.
NEW QUESTION # 287
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 to hepatitis.
Which of the following represents a high-risk group for contracting this disease?
- A. Jehovah's Witnesses
- B. Oncology nurses
- C. American Indians
- D. Heterosexual males
Answer: B
Explanation:
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. (D) There is no evidence that any religious groups are at higher risk.
NEW QUESTION # 288
The cardiac client who exhibits the symptoms of disorientation, lethargy, and seizures may be exhibiting a toxic reaction to:
- A. Digoxin (Lanoxin)
- B. Lidocaine (Xylocaine)
- C. Nitroglycerin IV (Tridil)
- D. Quinidine gluconate or sulfate (Quinaglute,Quinidex)
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Side effects of digoxin include headache, hypotension, AV block, blurred vision, and yellow-green halos. (B) Side effects of lidocaine include heart block, headache, dizziness, confusion, tremor, lethargy, and convulsions. (C) Side effects of quinidine include heart block, hepatotoxicity, thrombocytopenia, and respiratory depression. (D) Side effects of nitroglycerin include postural hypotension, headache, dizziness, and flushing.
NEW QUESTION # 289
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