2021 Realistic NCLEX-RN Dumps Exam Tips Test Pdf Exam Material
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NEW QUESTION 97
A baby is circumcised. Immediate postoperative care should include:
- A. Changing the dressing frequently using dry, sterile gauze
- B. Keeping the baby NPO for 4 hours to avoid vomiting
- C. Applying a loose diaper
- D. Taking the baby to his mother for cuddling
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) A pressure diaper should be applied to discourage hemorrhage. (B) The baby can be fed by his mother soon after the procedure, once it is assessed that he is not in any distress and is stable. (C) Dressing changes should not be dry. Dry dressing will stick. (D) Cuddling after the procedure will hopefully quiet the baby. Feeding is also important if his feeding was withheld prior to the procedure or it is time for a feeding.
NEW QUESTION 98
A nurse is performing a vaginal exam on a client in active
labor. An important landmark to assess during labor
and delivery are the ischial spines because:
- A. Ischial spines are the widest diameter of the pelvis
- B. They measure pelvic floor
- C. They represent the inlet of birth canal
- D. Ischial spines are the narrowest diameter of the pelvis
Answer: D
Explanation:
(A) The fetal descent, or station, is determined by the relationship of the presenting part to the spine. (B) Ischial spines are the narrowest measurement. (C) Ischial spines measure the pelvic outlet. (D) Pelvic floor measurement is not related to fetal descent.
NEW QUESTION 99
A 66-year-old female client has smoked 2 packs of cigarettes per day for 20 years. Her arterial blood gases on room air are as follows: pH 7.35; PO2 70 mm Hg; PCO2 55 mm Hg; HCO3 32 mEq/L. These blood gases reflect:
- A. Compensated respiratory alkalosis
- B. Compensated metabolic acidosis
- C. Compensated respiratory acidosis
- D. Uncompensated respiratory acidosis
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) In compensated metabolic acidosis, the pH level is normal, the PCO2level is decreased, and the HCO3level is decreased. The client's primary alteration is an inability to remove excess acid via the kidneys. The lungs compensate by hyperventilating and decreasing PCO2. (B) In compensated respiratory acidosis, the pH level is normal, the PCO2level is elevated, and the HCO3level is elevated. The client's primary alteration is an inability to remove CO2from the lungs, so over time, the kidneys increase reabsorption of HCO3to buffer the CO2. (C) In compensated respiratory alkalosis, the pH level is normal, the PCO2level is decreased, and the HCO3level is decreased. The client's primary alteration is hyperventilation, which decreases PCO2. The client compensates by increasing the excretion of HCO3from the body. (D) In uncompensated respiratory acidosis, the pH level is decreased, the PCO2level is increased, and the HCO3level is normal. The client's primary alteration is an inability to remove CO2from the lungs. The kidneys have not compensated by increasing HCO3reabsorption.
NEW QUESTION 100
The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this finding?
- A. Palpate these pulses again in 15 minutes.
- B. Use a Doppler to determine presence and strength of these pulses.
- C. Call the physician and notify the physician of this finding.
- D. Document the finding that the pulses are not palpable.
Answer: B
Explanation:
Explanation
(A) Palpating these pulses again in 15 minutes may only result in the same findings. (B) Any time during an assessment that the nurse is unable to palpate pulses, the nurse should then obtain a Doppler and assess for presence or absence of the pulse and pulse strength, if a pulse is present. (C) Pulses may be present and assessed through use of a Doppler. Absence of palpable pulses does not indicate absence of blood flow unless pulses cannot be located with a Doppler. (D) The nurse would only call the physician after determining that the pulses are absent by both palpation and Doppler.
NEW QUESTION 101
In healthcare settings, nurses must be familiar with primary, secondary, and tertiary levels of care. As a nurse in the community, which of the following interventions might be a primary prevention strategy?
- A. Teaching fifth-grade children the harmful effects of substance abuse
- B. Counseling a client with post-traumatic stress disorder
- C. Referring a client who has been on a detoxification unit to a rehabilitation center
- D. Crisis intervention with an intoxicated teenager whose mother just committed suicide
Answer: A
Explanation:
Section: Questions Set F
Explanation:
(A) The teenager is already coping ineffectively and requires early detection and treatment, which is secondary prevention. (B) The client must be sent to a rehabilitation unit, which requires tertiary prevention. (C) Reducing the incidence of disease through education supports primary prevention. (D) A client with identified symptoms of post-traumatic stress disorder requires intervention by treatment.
NEW QUESTION 102
A female client is anticipating a visit with her parents over the Thanksgiving holidays. She has recently begun experiencing periods of extreme shortness of breath, which her physician has labeled as panic attacks. Which of the following statements by the nurse would enhance therapeutic communication?
- A. "Tell me about your dislike for your parents."
- B. "Why do you feel this way?"
- C. "Perhaps you and I can discover what produces your anxiety."
- D. "Don't worry, everything will be all right on your visit with your parents."
Answer: C
Explanation:
(A) Asking the client to provide an explanation for her feelings is often intimidating. (B) This response is probing and may make the client feel used and valued only for the information she can provide. (C) This underrates the client's feelings and belittles her concerns. It may cause the client to stop sharing feelings for fear that they will be ridiculed. (D) The emphasis is on working with the client. It shows that there is hope for change through collaboration.
NEW QUESTION 103
Which of the following blood values would require further nursing action in a newborn who is 4 hours old?
- A. Hemoglobin 17.2 g/dL
- B. White blood cells 18,000/mm3
- C. Serum glucose 30 mg/dL
- D. Platelets 250,000/mm3
Answer: C
Explanation:
Section: Questions Set F
Explanation:
(A) The normal range for hemoglobin in the newborn is 17-19 g/dL; 17.2 g/dL is within normal limits. (B) A normal value range for platelets in the newborn is 150,000-400,000 mm3; 250,000/mm3 is within normal range. (C) A serum glucose of 30 mg/dL in the first 72 hours of life is indicative of hypoglycemia and warrants further intervention. (D) On the day of birth, a white blood cell count of 18,000-40,000/mm3 is normal in the newborn.
NEW QUESTION 104
A 24-year-old client presents to the emergency department protesting "I am God." The nurse identifies this as a:
- A. Conversion
- B. Hallucination
- C. Illusion
- D. Delusion
Answer: D
Explanation:
Section: Questions Set C
Explanation:
(A) Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion is the expression of intrapsychic conflict through sensory or motor manifestations.
NEW QUESTION 105
A 9-month-old infant visits her pediatrician for a routine visit. A developmental assessment was initiated by the nurse. Which skill would cause the nurse to be concerned about the infant's developmental progression?
- A. She sits briefly alone with assistance.
- B. She stands while holding onto furniture.
- C. She pulls herself to her feet with help.
- D. She creeps and crawls.
Answer: A
Explanation:
(A) The 9-month-old infant can sit alone for long periods. By the age of 6 months, many infants can pull themselves to a sitting position. (B, C, D) This skill represents normal development.
NEW QUESTION 106
Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?
- A. She places her infant on her right side after feeding her.
- B. She uses the bulb syringe to help clear her baby's nose when milk is regurgitated.
- C. She burps her baby by placing her in a sitting position, supporting her head and neck and gently massaging her back.
- D. She props the bottle in the crib to feed her baby,which allows her to write birth announcements and feed her baby at the same time.
Answer: D
Explanation:
Explanation
(A) This practice is the proper use of the bulb syringe to clear the infant's airway in case of regurgitation. (B) Placing the infant on either side or on the stomach prevents aspiration of regurgitated milk. (C) "Bottle propping" is an unsafe practice because it increases the likelihood of aspiration. (D) This practice is one correct way of burping an infant.
NEW QUESTION 107
A female client at 36 weeks' gestation is experiencing preterm labor. Her physician has prescribed two doses of betamethasone 12 mg IM q24h. The nurse explains that she is receiving this drug to:
- A. Prevent uterine infection
- B. Treat fetal respiratory distress syndrome
- C. Increase uteroplacental circulation
- D. Promote fetal lung maturation
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Respiratory distress syndrome occurs in the newborn, not the fetus. It may be treated postnatally with surfactant therapy. (B) Betamethasone is a corticosteroid, not an anti-infective drug; therefore, its use would not prevent uterine infection. (C) Betamethasone binds with glucocorticoid receptors in alveolar cells to increase production of surfactant, thus increasing lung maturity in the preterm fetus. (D) Betamethasone does not affect uteroplacental circulatory exchange.
NEW QUESTION 108
A 3-year-old female client is brought into the pediatric clinic because she limps. She has not been to the clinic since she was 9 months old. The nurse practitioner describes the limp as a "Trendelenburg gait." This gait is characteristic of:
- A. Fractured femur
- B. Fractured pelvis
- C. Scoliosis
- D. Dislocated hip
Answer: D
Explanation:
Explanation
(A, C, D) A Trendelenburg gait is not characteristic of any of these disorders. (B) The downward slant of one hip is a positive sign of dislocation in the weight-bearing hip. If one hip is dislocated, the child walks with a characteristic limp known as the Trendelenburg gait.
NEW QUESTION 109
While the RN is assessing a mother's perineum on her 2nd postpartum day after having a vaginal delivery, the RN notes a large ecchymotic area located to the left of the mother's perineum. Which one of the following interventions should the RN initiate at this time?
- A. Apply ice to the perineum.
- B. Encourage the client to take warm sitz baths.
- C. Inform the physician.
- D. Have the client expose the area to air.
Answer: B
Explanation:
Explanation
(A) The area is bruised and painful. This action would do nothing to help with the healing process of the perineum or to provide comfort. (B) Ice is effective immediately after birth to reduce edema and discomfort, but not on the 2nd postpartum day. (C) Sitz baths are useful if the perineum has been traumatized, because the moist heat increases circulation to the area to promote healing, relaxes tissue, and decreases edema. (D) The physician is not notified of bruising, but if a hematoma is present, then the physician is notified.
NEW QUESTION 110
Often children are monitored with pulse oximeter. The pulse oximeter measures the:
- A. O2 content of the blood
- B. PO2
- C. Affinity of hemoglobin for O2
- D. Oxygen saturation of arterial blood
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) The O2 content of whole blood is determined by the partial pressure of oxygen (PO2) and the oxygen saturation. The pulse oximeter does not measure the PO2. (B) The pulse oximeter is a noninvasive method of measuring the arterial oxygen saturation. (C) The PO2 is the amount of O2 dissolved in plasma, which the pulse oximeter does not measure. (D) The affinity of hemoglobin for O2 is the relationship between oxygen saturation and PO2 and is not measured by the pulse oximeter.
NEW QUESTION 111
Loss of appetite for a child with leukemia is a major recurrent problem. The plan of care should be designed to:
- A. Increase his appetite
- B. Help the child gain weight
- C. Make mealtimes pleasant
- D. Reinforce attempts to eat
Answer: D
Explanation:
Explanation
(A) Ignoring refusals to eat and rewarding eating attempts are the most successful means of increasing intake.
(B) This goal is not specific enough or related to the loss of appetite. (C) This goal is not possible at this time based on his illness. (D) This goal is helpful, but alone will not address his loss of appetite.
NEW QUESTION 112
A 47-year-old male client is admitted for colon surgery. Intravenous antibiotics are begun 2 hours prior to surgery. He has no known infection. The rationale for giving antibiotics prior to surgery is to:
- A. Relieve the client's concern regarding possible infection
- B. Reduce the risk of intraoperative fever
- C. Reduce the risk of wound infection from anaerobic bacteria
- D. Provide cathartic action within the colon
Answer: C
Explanation:
Section: Questions Set G
Explanation:
(A) Cathartic drugs promote evacuation of intestinal contents. (B) The client undergoing intestinal surgery is at increased risk for infection from large numbers of anaerobic bacteria that inhabit the intestines. Administering antibiotics prophylactically can reduce the client's risk for infection. (C) Antibiotics are indicated in the treatment of infections and have no effect on emotions. (D) Antipyretics are useful in the treatment of elevated temperatures. Antibiotics would have an effect on infection, which causes temperature elevation, but would not directly affect such an elevation.
NEW QUESTION 113
A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?
- A. Headache
- B. Seizure
- C. Ataxia
- D. Bulging fontanelles
Answer: A
Explanation:
(A) Bulging fontanelles are a symptom of increased intracranial pressure in infants. (B) Seizure is a late sign of increased intracranial pressure. (C) Headache is a very early symptom of increased intracranial pressure in the child. (D) Ataxia is a late sign of increased intracranial pressure.
NEW QUESTION 114
Which of the following procedures is necessary to establish a definitive diagnosis of breast cancer?
- A. Mammography
- B. Thermography
- C. Breast tissue biopsy
- D. Diaphanography
Answer: C
Explanation:
Explanation
(A) Diaphanography, also known as transillumination, is a painless, noninvasive imaging technique that involves shining a light source through the breast tissue to visualize the interior. It must be used in conjunction with a mammogram and physical examination. (B) Mammography is a useful tool for screening but is not considered a means of diagnosing breast cancers. (C) Thermography is a pictorial representation of heat patterns on the surface of the breast. Breast cancers appear as a "hot spot" owing to their higher metabolic rate.
(D) Biopsy either by needle aspiration or by surgical incision is the primary diagnostic technique for confirming the presence of cancer cells.
NEW QUESTION 115
A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should:
- A. Explain that he will be receiving a laxative to prevent a distended bowel from applying pressure on the liver
- B. Practice with him so he will be able to hold his breath for 1 minute
- C. Explain that he will be kept NPO for 24 hours before the exam
- D. Explain that his vital signs will be checked frequently after the test
Answer: D
Explanation:
(A) There is no NPO restriction prior to a liver biopsy. (B) The client would need to hold his breath for 5-10 seconds. (C) There is no pretest laxative given. (D) Following the test, the client is watched for hemorrhage and shock.
NEW QUESTION 116
Nursing care for the parents of a child with a congenital heart defect would include:
- A. Expressing to the parents after the corrective surgery has been completed successfully that all their grief feelings will resolve
- B. Acknowledging the fear and concern surrounding their child's health and assisting the parents through the grieving process as they mourn the loss of their fantasized healthy child
- C. Encouraging the parents not to tell the child about the seriousness of the congenital heart defect, so the child will function as normally as possible
- D. Identifying anger and resentment as destructive emotions that serve no purpose
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) It is important to discuss with parents the need to treat the child as they would any other children, but they must be truthful and honest with the child about the heart defect. As the child grows older, explanations can go into greater depth. (B) Parents of children with congenital heart defects go through a grieving process over the loss of their "healthy" child. The nurse needs to recognize these feelings and give the parents a role in the child's care when they are ready. (C) Anger and resentment are normal feelings that must be dealt with appropriately. (D) Parents may go through a second grieving process after the repair of the cardiac defect. During this grieving period, they mourn the loss of the "defective" child who now may be essentially "normal."
NEW QUESTION 117
A male client seeks counseling after his wife of 19 years threatened to divorce him. For most of their marriage, he has physically and verbally abused her. When asked about his behavior in the process of the nursing assessment, the client states, "I was mean to my wife because she insists on cooking meals and wearing clothes that I do not like." This defense mechanism is an example of:
- A. Rationalization
- B. Repression
- C. Regression
- D. Reaction formation
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Repression is blocking a desire from conscious expression. The client is conscious of his desires. (B) Regression is returning to an earlier form of expression, which is not demonstrated here. (C) Reaction formation is acting out the opposite of true feelings. The client felt anger concerning his wife's cooking and acted out his feelings. (D) Rationalization is unconsciously falsifying an experience by giving a "rational" explanation. The client is attempting to justify his behavior by giving an explanation.
NEW QUESTION 118
A 45-year-old client diagnosed with major depression is scheduled for electroconvulsive therapy (ECT) in the morning. Which of the following medications are routinely administered either before or during ECT?
- A. Atropine, sodium brevitol, and succinylcholine chloride (Anectine)
- B. Thioridazine (Mellaril), lithium, and benztropine
- C. Carbamazepine (Tegretol), haloperidol, and trihexyphenidyl (Artane)
- D. Sodium, potassium, and magnesium
Answer: A
Explanation:
(A) Thioridazine (an antipsychotic drug), lithium (an antimanic drug), and benztropine (an antiparkinsonism agent) are generally administered to treat schizophrenic and bipolar disorders. (B) Atropine (a cholinergic blocker), sodium brevitol (a shortacting anesthetic), and succinylcholine (a neuromuscular blocker) are administered either before or during ECT to coun teract bradycardia and to provide anesthesia and total muscle relaxation. (C) These are electrolyte substances administered to correct fluid and electrolyte imbalances in the body. (D) Carbamazepine (an anticonvulsant), haldoperidol (an antipsychotic), and trihexyphenydyl (an antiparkinsonism agent) are usually administered in psychiatric settings to control problems associated with psychotic behavior.
NEW QUESTION 119
A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?
- A. Ineffective airway clearance related to immobility, ineffective cough, and decreased level of consciousness
- B. Altered cerebral tissue perfusion related to pathophysiological changes that decrease blood flow
- C. Potential for injury related to impaired mobility and seizures
- D. Impaired verbal communication related to aphasia
Answer: A
Explanation:
Section: Questions Set D
Explanation:
(A) An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. (B) Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is secondary to maintenance of an effective airway. (C) While prevention of injury is important, it is secondary to maintaining an effective airway and cerebral tissue perfusion. (D) Impaired verbal communication is not life threatening in the acute phase of recovery. It is the lowest priority of the nursing diagnoses listed.
NEW QUESTION 120
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. A large toy with movable parts to improve pincer grasp
- B. A mobile to improve hand-eye coordination
- C. A pull toy to encourage locomotion
- D. Various large colored blocks to teach visual discrimination
Answer: C
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 121
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