NCLEX NCLEX-RN Practice Verified Answers - Pass Your Exams For Sure! [2022]
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NEW QUESTION 299
A client has just received an epidural block. She is laboring on her right side. The nurse notes that her blood pressure has dropped from 132/68 to 78/42 mm Hg. The nurse's first action would be to:
- A. Administer oxytocin (Pitocin) immediately and increase the rate of IV fluids
- B. Call the physician immediately and give dopamine IM
- C. Turn her on her left side and recheck her blood pressure in 5 minutes
- D. Increase the rate of IV fluids and start O2 by mask
Answer: D
Explanation:
(A) Nursing measures to support fetal oxygenation and promote maternal blood pressure would precede calling the physician. (B) Systolic pressures below 100 mm Hg or a reduction in the systolic pressure of>30% necessitate treatment. Assessing the blood pressure in 5 minutes may allow for further fetal and/or maternal compromise. Turning the client on her left side will promote uteroplacental perfusion and is appropriate. (C) Oxytocin (Pitocin) increases the strength of uterine contractions and may cause maternal hypotension; thus it is an inappropriate drug for use in this clinical situation. IV fluids would be increased to expand the circulating blood volume and promote increased blood pressure. (D) Turning the mother to her left lateral side promotes uteroplacental perfusion.
IV fluids are administered to increase the circulating blood volume, and O2 is administered to promote fetal oxygenation and decrease the nausea accompanying the hypotension.
NEW QUESTION 300
The physician recommends immediate hospital admission for a client with PIH. She says to the nurse, "It's not so easy for me to just go right to the hospital like that." After acknowledging her feelings, which of these approaches by the nurse would probably be best?
- A. Repeat the physician's reasons for advising immediate hospitalization.
- B. Explain to the client that she is ultimately responsible for her own welfare and that of her baby.
- C. Stress to the client that her husband would want her to do what is best for her health.
- D. Explore with the client her perceptions of why she is unable to go to the hospital.
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) This answer does not hold the client accountable for her own health. (B) The nurse should explore potential reasons for the client's anxiety: are there small children at home, is the husband out of town? The nurse should aid the client in seeking support or interventions to decrease the anxiety of hospitalization.
(C) Repeating the physician's reason for recommending hospitalization may not aid the client in dealing with her reasons for anxiety. (D) The concern for self and welfare of baby may be secondary to a woman who is in a crisis situation. The nurse should explore the client's potential reasons for anxiety. For example, is there another child in the home who is ill, or is there a husband who is overseas and not able to return on short notice?
NEW QUESTION 301
An 80-year-old widow is living with her son and daughter- in-law. The home health nurse has been making weekly visits to draw blood for a prothrombin time test. The client is taking 5 mg of coumadin per day. She appears more debilitated, and bruises are noted on her face. Elder abuse is suspected. Which of the following are signs of persons who are at risk for abusing an elderly person?
- A. A friend of the family who wants to help but is minimally competent
- B. A person with adequate communication and coping skills who is employed by the family
- C. A lifelong friend of the client who is often confused
- D. A family member who is having marital problems and is regularly abusing alcohol
Answer: D
Explanation:
Explanation
(A) This answer is correct. Two risk factors are identified in this answer. (B) This answer is incorrect. Persons at risk tend to lack communication skills and effective coping patterns. (C) This answer is incorrect. Persons at risk are usually family members or those reluctant to provide care. (D) This answer is incorrect. This individual has a vested interest in providing care.
NEW QUESTION 302
A term neonate has experienced no distress at birth and has an Apgar score of 9. Her mother has asked to breastfeed her following delivery. Immediately after birth, the neonate was most susceptible to heat loss.
The most appropriate intervention to conserve heat loss and promote bonding is to:
- A. Place her to her mother's breast
- B. Place her on a heated pad
- C. Place her under the radiant warmer
- D. Dry her with blankets
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) A radiant warmer maintains an optimal thermal environment by use of a thermal skin sensor taped to the infant. The warmer limits parental attachment, so, although appropriate, it is not an intervention that promotes infant attachment. (B) Warmed blankets prevent heat loss in the neonate by conduction. In addition, tactile stimuli promote crying and lung expansion. This intervention does not promote attachment, however. (C) Skin-to-skin contact is an effective way to conserve heat after delivery and promotes parental attachment following birth in the healthy term infant. The first period of reactivity lasts approximately 30 minutes following birth. A strong sucking reflex and an active, awake newborn characterize this period. (D) Surfaces of objects warmer than the infant promote overheating by conduction, and neonatal hyperthermia may result.
NEW QUESTION 303
A client's renal calculi are identified as consisting of calcium phosphate. Which of the following diets would be appropriate?
- A. High calcium, low phosphorus
- B. Low calcium and phosphorus, acid ash
- C. Low calcium, high phosphorus
- D. Two-gram sodium diet
Answer: B
Explanation:
Section: Questions Set D
Explanation:
(A) The stones consist of calcium and phosphorus; therefore, these minerals should be avoided. A high- calcium diet is contraindicated. (B) A high-phosphorus diet is contraindicated. (C) A 2-g sodium diet is a cardiac diet. (D) A low-calcium and phosphorus diet will reduce further calculi formation.
NEW QUESTION 304
The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to:
- A. Wear gloves for the procedure
- B. Protect the outer surface of the pad from contamination
- C. Cleanse and wipe the perineum from front to back
- D. Place and adjust the pad from back to front
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Perineal hygiene is a clean procedure and does not require the client to wear gloves. A care provider should wear gloves to adhere to universal precautions. (B) The pad should be applied from front to back to prevent contamination of the birth canal or urinary tract from rectal bacteria. (C) Wiping from front to back and discarding the wipe prevents contamination of the urinary tract and birth canal from rectal bacteria. (D) The inner surface of the pad should not be touched to maintain asepsis.
NEW QUESTION 305
A nasogastric (NG) tube inserted preoperatively is attached to low, intermittent suctions. A client with an NG tube exhibits these symptoms: He is restless; serum electrolytes are Na 138, K 4.0, blood pH 7.53.
This client is most likely experiencing:
- A. Metabolic alkalosis
- B. Hyperkalemia
- C. Metabolic acidosis
- D. Hyponatremia
Answer: A
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 will develop metabolic alkalosis.
NEW QUESTION 306
When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is:
- A. Leukopenic aplastic anemia
- B. Granulocytosis and nephrosis
- C. Stephens-Johnson syndrome
- D. Folate deficiency
Answer: C
Explanation:
Explanation
(A) Stephens-Johnson syndrome is a toxic effect of phenytoin. (B) Folate deficiency is a side effect of phenytoin, but not a toxic effect. (C) Leukopenic aplastic anemia is a toxic effect of carbamazepine (Tegretol).
(D) Granulocytosis and nephrosis are toxic effects of trimethadione (Tridione).
NEW QUESTION 307
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. Observe for headaches, dizziness, and anorexia.
- B. Administer oral griseofulvin on an empty stomach for best results.
- C. May discontinue medication when the child experiences symptomatic relief.
- D. Discontinue drug therapy if food tastes funny.
Answer: A
Explanation:
Section: Questions Set E
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 308
A client is experiencing visual problems at school. She has complained of difficulty seeing the blackboard and squinting. She no longer likes to participate in physical activities such as softball. The client has displayed possible classic symptoms of which refractive error?
- A. Hyperopia
- B. Myopia
- C. Amblyopia
- D. Astigmatism
Answer: B
Explanation:
Section: Questions Set D
Explanation:
(A) Visual images are blurred and distorted. (B) Symptoms are headaches, burning eyes, fatigue, squinting, and difficulty reading. (C) These symptoms are classic for myopia. (D) Amblyopia is not a refractive error. It is a loss of vision in one or both eyes.
NEW QUESTION 309
Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client's depression alert the nurse to prioritize problems and care by addressing which of the following problems first:
- A. Nutritional status
- B. Impaired thinking
- C. Rest and activity impairment
- D. Possible harm to self
Answer: D
Explanation:
Explanation
(A) Anorexia and weight loss are problems that need attention in severe depression, but they can be addressed secondary to immediate concerns. (B) Impaired thinking and confusion are problems in severe depression that are addressed with administration of medication, through group and individual psychotherapy, and through activity therapy as motivation and interest increase. (C) Possible harm to self as with suicidal ideation; a suicide plan, means to execute plan; and/or overt gestures or an attempt must be addressed as an immediate concern and safety measures implemented appropriate to the risk of suicide. (D) Rest and activity impairment may take time and further assessment to determine client's sleep pattern and amount of psychomotor retardation with the more immediate concern for safety present.
NEW QUESTION 310
In an interview for suspected child abuse, the child's mother openly discusses her feelings.
She feels her husband is too aggressive in disciplining their child. The child's father states,
"Being a school custodian, I see kids every day that are bad because they did not get enough discipline at home. That will not happen to our child." Based on this remark, the nurse would make the following nursing diagnosis:
- A. Actual injury related to poor impulse control by the father
- B. Fear related to retaliation by the father
- C. Ineffective coping
- D. Altered family process related to physical abuse
Answer: D
Explanation:
(A) There is no evidence of fear as the child is unable to communicate. (B) There is actual injury, but the parents have not yet admitted causing the child's injuries. (C) This diagnosis is incomplete. There is no specific ineffective coping behavior identified in this nursing diagnosis. (D) Altered family process best describes the family dynamics in this situation. The parents have admitted severe disciplinary action.
NEW QUESTION 311
A client admitted with a diagnosis of possible myocardial infarction is admitted to the unit from the emergency room. The nurse's first action when admitting the client will be to:
- A. Obtain vital signs
- B. Connect the client to the cardiac monitor
- C. Ask the client if he is still having chest pain
- D. Complete the history profile
Answer: B
Explanation:
(A) Obtaining vital signs is important after connecting the client to the monitor because vital signs should be stable before the client is discharged from the emergency room. (B) All are important, but the first priority is to monitor the client's rhythm. (C) If the client is in severe pain, pain medication should be given after connecting him to the monitor and obtaining vital signs. (D) Completion of the history profile is the least important of the nursing actions.
NEW QUESTION 312
A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:
- A. Evidence of perineal irritation
- B. Temperature rose to 102_F rectally
- C. Pulse fell from 102 to 96
- D. Pulse increased from 96 to 102
Answer: B
Explanation:
(A) Perineal irritation needs to be addressed, but it is probably not necessary to call the physician. (B) This fall in pulse rate remains within normal limits and is probably insignificant. It is important to monitor for continued change. (C) This rise in pulse rate is probably not significant, but it is important to monitor for continued change. (D) This temperature is above normal limits and needs medical investigation. It may or may not be related to the head injury.
NEW QUESTION 313
An 8-week-old infant has been diagnosed with gastroesophageal reflux. The nurse is teaching the infant's mother to care for the infant at home. Which one of the following statements by the nurse is appropriate regarding the infant's home care?
- A. "Lay the infant flat on her left side after feeding."
- B. "Antacids need to be given an hour before feeding."
- C. "Play activities should be carried out before instead of after feedings."
- D. "Feed the infant every 4 hours with half-strength formula."
Answer: C
Explanation:
Section: Questions Set B
Explanation
Explanation:
(A) Elevating the child's head to a 30-degree angle is the recommended position for gastroesophageal reflux.
The supine position predisposes the child to aspiration. (B) Small, frequent feedings with thickened formula are recommended to minimize vomiting. (C) Antacids should be given at the same time as the feeding to improve their buffering action. (D) The infant should be kept still after feedings to reduce the risk of vomiting and aspiration. Vigorous activities should be carried out before feedings.
NEW QUESTION 314
A client was prescribed a major tranquilizer 2 months ago. One month ago she was placed on benztropine (Cogentin). What would indicate that benztropine therapy is effective?
- A. Smooth, coordinated voluntary movement
- B. Rigidity
- C. Muscle weakness
- D. Tremors
Answer: A
Explanation:
(A) Benztropine is prescribed to decrease or alleviate extrapyramidal side effects of major tranquilizers. Smooth, coordinated voluntary movement indicates minimal extrapyramidal side effects. (B) Tremors are an extrapyramidal side effect. (C) Rigidity is an extrapyramidal side effect. (D) Muscle weakness is an extrapyramidal side effect.
NEW QUESTION 315
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