NCLEX-RN Dumps Updated Jan 18, 2024 Practice Test and 865 unique questions
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NEW QUESTION # 462
A newborn infant is exhibiting signs of respiratory distress. Which of the following would the nurse recognize as the earliest clinical sign of respiratory distress?
- A. Cyanosis
- B. Increased respirations
- C. Decreased respirations
- D. Sternal and subcostal retractions
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Cyanosis is a late clinical sign of respiratory distress. (B) Rapid respirations are normal in a newborn.
(C) The newborn has to exert an extra effort for ventilation, which is accomplished by using the accessory muscles of ventilation. The diaphragm and abdominal muscles are immature and weak in the newborn. (D) Decreased respirations are a late clinical sign. In the newborn, decreased respirations precede respiratory failure.
NEW QUESTION # 463
A 45-year-old client has a permanent colostomy. Which of the following foods should he avoid?
- A. Corn beef and cabbage and boiled potatoes
- B. Oatmeal, whole-wheat toast, and milk
- C. Tuna on whole-wheat bread and iced tea
- D. Peanut butter and jelly sandwich and milk
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A, C, D) These foods are allowed with a colostomy. (B) Gasforming foods such as cabbage should be avoided.
NEW QUESTION # 464
A laboratory technique specific for diagnosing Lyme disease is:
- A. Polymerase chain reaction
- B. Decreased serum calcium level
- C. Heterophil antibody test
- D. Increased serum potassium level
Answer: A
Explanation:
Section: Questions Set A
Explanation:
(A) Polymerase chain reaction is the laboratory technique specific for Lyme disease. (B) Heterophil antibody test is used to diagnose mononucleosis. (C) Lyme disease does not decrease the serum calcium level. (D) Lyme disease does not increase the serum potassium level.
NEW QUESTION # 465
On the third postpartum day, the nurse would expect the lochia to be:
- A. Rubra
- B. Serosa
- C. Scant
- D. Alba
Answer: A
Explanation:
Explanation
(A) This discharge occurs from delivery through the 3rd day. There is dark red blood, placental debris, and clots. (B) This discharge occurs from days 4-10. The lochia is brownish, serous, and thin. (C) This discharge occurs from day 10 through the 6thweek. The lochia is yellowish white. (D) This is not a classification of lochia but relates to the amount of discharge.
NEW QUESTION # 466
A 68-year-old woman is admitted to the hospital with chronic obstructive pulmonary disease (COPD). She is started on an aminophylline infusion. Three days later she is breathing easier. A serum theophylline level is drawn. Which of the following values represents a therapeutic level?
- A. 4 µ g/mL
- B. 25 µ g/mL
- C. 30 µ g/mL
- D. 14 µ g/mL
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) The therapeutic blood level range of theophylline is 10-20 mg/mL. Therapeutic drug monitoring determines effective drug dosages and prevents toxicity. (B, D) This value is a toxic level of the drug. (C) This value is a nontherapeutic level of the drug.
NEW QUESTION # 467
A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will teach her to:
- A. Take more frequent naps
- B. Use artificial tears
- C. Limit activities which require focusing (close vision)
- D. Wear a patch over one eye
Answer: D
Explanation:
(A)
Limiting activities requiring close vision will not alleviate the discomfort of double vision.
(B)
Frequent naps may be comforting, but they will not prevent double vision. (C) Artificial tears are necessary in the absence of a corneal reflex, but they have no effect on diplopia.
(D)
An eye patch over either eye will eliminate the effects of double vision during the time the eye patch is worn. An eye patch is safe for a person with an intact corneal reflex.
NEW QUESTION # 468
A mother is unsure about the type of toys for her 17-month-old child. Based on knowledge of growth and development, what toy would the nurse suggest?
- A. Various large colored blocks to teach visual discrimination
- B. A large toy with movable parts to improve pincer grasp
- C. A pull toy to encourage locomotion
- D. A mobile to improve hand-eye coordination
Answer: C
Explanation:
Explanation
(A) Increased locomotive skills make push-pull toys appropriate for the energetic toddler. (B) Infants progress from reflex activity through simple repetitive behaviors to imitative behavior. Hand-eye coordination forms the foundation of other movements. (C) At age 8 months, infants begin to have pincer grasp. Toys that help infants develop the pincer grasp are recommended for this age group. (D) Various large colored blocks are suggested toys for infants 6-12 months of age to help visual stimulation.
NEW QUESTION # 469
A 2-year-old child is recovering from surgery. Considering growth and development according to Erikson, the nurse identifies which of the following play activities as most appropriate?
- A. Watching Sesame Street on television
- B. Listening to a story about the Muppets
- C. Assembling a puzzle with large pieces
- D. Being taken for a wheelchair ride
Answer: C
Explanation:
(A) A 2-year-old child is in the stage of autonomy, according to Erikson. Assembling a puzzle with large pieces enables her to "do it herself." (B) A wheelchair ride would probably be fun, but it is not directed toward helping the child to achieve autonomy. (C) Listening to a story may be fun and educational, but it is not directed toward helping the child to achieve autonomy. (D) Watching television may be a favorite activity, but it does not foster autonomy.
NEW QUESTION # 470
The nurse should know that according to current thinking, the most important prognostic factor for a client with breast cancer is:
- A. Client's level of estrogen-progesterone receptor assays
- B. Axillary node status
- C. Tumor size
- D. Client's previous history of disease
Answer: B
Explanation:
Explanation
(A) Although tumor size is a factor in classification of cancer growth, it is not an indicator of lymph node spread. (B) Axillary node status is the most important indicator for predicting how far the cancer has spread. If the lymph nodes are positive for cancer cells, the prognosis is poorer. (C) The client's previous history of cancer puts her at an increased risk for breast cancer recurrence, especially if the cancer occurred in the other breast. It does not predict prognosis, however. (D) The estrogen-progesterone assay test is used to identify present tumors being fedfrom an estrogen site within the body. Some breast cancers grow rapidly as long as there is an estrogen supply such as from the ovaries. The estrogen-progesterone assay test does not indicate the prognosis.
NEW QUESTION # 471
Following her surgery, a 5-year-old child will return to the pediatric unit with a long-arm cast. She experienced a supracondylar fracture of the humerus near the elbow. Which nursing action is most essential during the first
24 hours after surgery and cast application?
- A. Discharge teaching
- B. Pain management
- C. Mobilization of the child
- D. Assessment of neurovascular status
Answer: D
Explanation:
Section: Questions Set D
Explanation:
(A) Mobilization is important but not absolutely essential. (B) Discharge teaching should be initiated prior to surgery as well as during the postoperative period. (C) Assessment and management of pain are necessary and high in priority. (D) Neurovascular status of the extremity is of primary importance. The risk of circulatory impairment exists with any cast application. This type of fracture is common in children. A high incidence of neurovascular complications exists with fractures near the elbow.
NEW QUESTION # 472
A 9-year-old child was in the garage with his father, who was repairing a lawnmower. Some gasoline ignited and caused an explosion. His father was killed, and the child has split-thickness and full-thickness burns over 40% of his upper body, face, neck, and arms. All of the following nursing diagnoses are included on his care plan. Which of these nursing diagnoses should have top priority during the first 24-48 hours postburn?
- A. Pain related to tissue damage from burns
- B. Potential for impaired gas exchange related to edema of respiratory tract
- C. Potential for infection related to contamination of wounds
- D. Fluid volume deficit related to increased capillary permeability
Answer: B
Explanation:
(A, B, C) These answers are all correct; however, maintenance of airway is the top priority.
(D) Persons burned about the face and neck during an explosion are also likely to suffer burns of the respiratory tract, which can lead to edema and respiratory arrest.
NEW QUESTION # 473
A postoperative TURP client is ordered continuous bladder irrigations. Later in the evening on the first postoperative day, he complains of increasing suprapubic pain. When assessing the client, the nurse notes diminished flow of bloody urine and several large blood clots in the drainage tubing. Which one of the following should be the initial nursing intervention?
- A. Change the Foley catheter.
- B. Administer a prescribed narcotic analgesic.
- C. Irrigate the Foley catheter.
- D. Call the physician about the problem.
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) The physician should be notified as problems arise, but in this case, the nurse can attempt to irrigate the Foley catheter first and call the physician if irrigation is unsuccessful. Notifying the physician of problems is a subsequent nursing intervention. (B) This answer is correct. Assessing catheter patency and irrigating as prescribed are the initial priorities to maintain continuous bladder irrigation. Manual irrigation will dislodge blood clots that have blocked the catheter and prevent problems of bladder distention, pain, and possibly fresh bleeding. (C) The Foley catheter would not be changed as an initial nursing intervention, but irrigation of the catheter should be done as ordered to dislodge clots that interfere with patency. (D) Even though the client complains of increasing suprapubic pain, administration of a prescribed narcotic analgesic is not the initial priority. The effect of the medication may mask the symptoms of a distended bladder and lead to more serious complications.
NEW QUESTION # 474
The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years. Which of the following data is most likely significant in relation to the cause of the low blood pressure?
- A. Serum potassium 3.3
- B. Pulse rate 150 bpm
- C. Pedal pulses 11 (weak)
- D. Twenty-four-hour intake 1000 mL/day for past 2 days
Answer: D
Explanation:
Section: Questions Set G
Explanation:
(A, D) Decreased pulse volume and increased pulse rate are signs of an acute hypotensive episode. (B) Inadequate fluid volume when taking vasodilators can result in a drop in blood pressure when vasodilation starts to physiologically occur as an action of the drug. (C) A potassium level of 3.3 would not be associated with a significant drop in blood pressure.
NEW QUESTION # 475
The nurse is notified that a 27-year-old primigravida diagnosed with complete placenta previa is to be admitted to the hospital for a cesarean section. The client is now at 36 weeks' gestation and is presently having bright red bleeding of moderate amount. On admission, the nursing intervention that the nurse should give the highest priority to is:
- A. Insert an indwelling catheter into her bladder
- B. Start an IV infusion in the client's arm
- C. Shave the client's abdomen and arrange her lab work
- D. Determine the status of the fetus by fetal heart tones
Answer: D
Explanation:
Explanation
(A) These nursing actions are necessary prior to the cesarean section, but not immediately necessary to maintain physiological equilibrium. (B) Determining the physiological status of the fetus would constitute the highest priority in evaluating and maintaining fetal life. (C) These nursing actions are necessary prior to the cesarean section, but not immediately necessary to maintain physiological equilibrium. (D) These nursing actions are necessary prior to the cesarean section, but not immediately necessary to maintain physiological equilibrium.
NEW QUESTION # 476
An 18-year-old girl is admitted to the hospital with a depressed skull fracture as a result of a car accident. If the nurse were to observe a rising pulse rate and lowering blood pressure, the nurse would suspect that the client:
- A. Is having intracranial bleeding
- B. Has a sudden and severe increase in intracranial pressure
- C. Is beginning to experience a dangerously high level of anxiety
- D. Has sustained an internal injury in addition to the head injury
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Widening pulse pressure (high systolic and low diastolic) with compensatory slowing of pulse rate are late signs of increasing ICP. (B) Rising pulse rate and lowering blood pressure are indicative of hypovolemia due to hemorrhage. (C) High anxiety, in the absence of hemorrhage, would result in a high pulse rate and a high blood pressure. (D) Intracranial bleeding results in increased ICP. A change in level of consciousness is an early sign of increasing ICP, and vital sign changes are late signs of increasing ICP.
NEW QUESTION # 477
A client is diagnosed with Mycobacterium tuberculosis. He is placed in respiratory isolation, intubated, and receives mechanical ventilation. When performing suctioning, the nurse should:
- A. Suction for a maximum of 20 seconds
- B. Hyperoxygenate before and after suctioning
- C. Maintain clean technique during suctioning
- D. Suction for a maximum of 30 seconds
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) The maximum time for suctioning is 10-15 seconds. (B) Supplemental O2should be administered before and after suctioning to reduce hypoxia. (C) The maximum time for suctioning is 10-15 seconds. (D) Strict sterile technique should be used during suctioning.
NEW QUESTION # 478
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