[Sep-2021] NCLEX NCLEX-RN Dumps – Reduce Your Chance of Failure in NCLEX-RN Exam
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NEW QUESTION 41
A child is to receive atropine 0.15 mg (1/400 g) as part of his preoperative medication. A vial containing atropine 0.4 mg (1/150 g)/mL is on hand. How much atropine should be given?
- A. Information given insufficient to determine the amount of atropine to be administered
- B. 2.7 mL
- C. 0.38 mL
- D. 0.06 mL
Answer: C
Explanation:
Explanation
(A, C) Information was incorrectly placed in the formula, resulting in an incorrect answer. (B) The answer is correct.
0.4 mg = 1 mL:0.15 mg 5 = mL
0.4 x = 0.15
x = 0.15/0.4
x = 0.375 or 0.38 mL
(D) Sufficient information is provided to determine the amount of atropine to administer. The amount of atropine available and the amount of atropine ordered is required to determine the amount of atropine to be given.
NEW QUESTION 42
A 6-year-old girl is visiting the outpatient clinic because she has a fever and a rash. The doctor diagnoses chickenpox. Her mother asks the nurse how many baby aspirins her daughter can have for fever. The nurse should:
- A. Advise the mother not to give her aspirin
- B. Assess the function of the client's cranial nerve VIII
- C. Check the aspirin bottle label to determine milligrams per tablet
- D. Ask if the client is allergic to aspirin before giving further information
Answer: A
Explanation:
(A) Aspirin taken during a viral infection has been implicated as a predisposing factor to Reye's syndrome in children and adolescents. Children and adolescents should not be given aspirin. (B) Allergy to aspirin is not related to Reye's syndrome. (C) Tinnitus, caused by damage to the acoustic nerve, occurs with aspirin toxicity, but this is not related to Reye's syndrome. (D) A 6-year-old child should not be given any baby aspirin.
NEW QUESTION 43
The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the client's chief complaint?
- A. "I've been having a dull pain at the upper left shoulder."
- B. "I don't remember anything in particular, I just haven't felt well."
- C. "My legs have been numb for three months."
- D. "I've only been urinating three times a day lately."
Answer: B
Explanation:
(A, B, C) These complaints are not specific signs and symptoms associated with abdominal aortic aneurysm. If symptoms are present, the aneurysm is expanding or rupture is imminent. (D) Many clients may experience no symptoms. The only symptom may be a pulsation noted in the abdomen in the reclining position.
NEW QUESTION 44
A client at 6 months' gestation complains of tiredness and dizziness. Her hemoglobin level is 10 g/dL, and her hematocrit value is 32%. Her nutritional intake is assessed as sufficient. The most likely diagnosis is:
- A. Fatigue due to stress
- B. No problem indicated
- C. Physiological anemia
- D. Iron-deficiency anemia
Answer: D
Explanation:
(A) This clinical situation is indicative of iron-deficiency anemia because the client has inadequate nutritional intake. Her blood volume is increasing faster than her red blood cell volume. Anemia is present in the second trimester when the hemoglobin level is <10.5 and the hematocrit value falls below 35%. She needs increased iron supplements with follow-up. (B) The client's values are below levels for physiological anemia. (C) The client is fatigued because of a low hemoglobin level. (D) Her hemoglobin level is low and will probably decrease even more when the blood volume peaks at 28 weeks.
NEW QUESTION 45
A female client was employed as a client care technician in a hemodialysis unit. She recently began to experience extreme fatigue, being able to sleep for 16-20 hours at a time. She also noted that her urine was tea colored, which she rationalized was a result of the vitamins she began taking to alleviate fatigue.
She was diagnosed with hepatitis B After a brief hospital stay, she is discharged to her parent's home. Her mother asks the nurse if any precautions are necessary to prevent transmission to the client's family. The nurse explains necessary precautions, which include:
- A. Laundering clothes separately in cold water with a chloride solution
- B. No necessary precautions because she is beyond the contagious phase
- C. Separate bathroom facilities if possible; if not, then cleansing daily of the facilities with a chloride solution
- D. Isolation of the client from the remainder of the family
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Isolation is not necessary, even in the acute phase. (B) Separate bathroom facilities are recommended.
If unavailable, daily cleansing with a chloride solution is recommended. (C) Precautions continue to be necessary while the client is in the active phase of hepatitis. (D) Clothes are to be laundered separately in hot water with a chloride solution.
NEW QUESTION 46
Pin care is a part of the care plan for a client who is in skeletal traction. When assessing the site of pin insertion, which one of the following findings would the nurse know as an indicator of normal wound healing?
- A. Edema
- B. Crust
- C. Erythema
- D. Exudate
Answer: B
Explanation:
Explanation
(A) Exudate (moist, active drainage) is a clinical sign of wound infection. (B) Crust (dry, scaly) is part of the normal stages of wound healing and should not be removed from around the pin site. It usually sloughs off after the underlying tissue has healed. (C) Edema (swelling) is a clinical sign of wound infection. (D) Erythema (redness) is a clinical sign of wound infection.
NEW QUESTION 47
A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom. Which nursing action is the most appropriate?
- A. Monitor muscular status.
- B. Place child on respiratory assistance.
- C. Put in a nasogastric tube and lavage the child's stomach.
- D. Teach mother poison prevention techniques.
Answer: C
Explanation:
(A) The immediate treatment for drug overdose is removal of the drug from the stomach by either forced emesis or gastric lavage. The child's unconscious state prohibits forced emesis. (B) Toxic amounts of salicylates directly affect the respiratory system, which could lead to respiratory failure. (C) The mother's anxiety is probably so high that preventive guidance will be ineffective. (D) Respiratory assistance is not needed if the child's respiratory function is unaltered.
NEW QUESTION 48
A pregnant client experiences a precipitous delivery. The nursing action during a precipitous delivery is to:
- A. Push against the perineum to stop delivery
- B. Control the delivery by guiding expulsion of fetus
- C. Cross client's legs tightly
- D. Leave the room to call the physician
Answer: B
Explanation:
Section: Questions Set C
Explanation:
(A) Controlling the rapid delivery will reduce the risk of fetal injury and perineal lacerations. (B) The nurse should always remain with a client experiencing a precipitous delivery. (C) Pushing against the perineum may cause fetal distress. (D) Crossing of legs may cause fetal distress and does not stop the delivery process.
NEW QUESTION 49
A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures should be included in the postoperative care?
- A. Have child gargle and do toothbrushing to remove old blood.
- B. Encourage the child to cough up blood if present.
- C. Observe for evidence of bleeding.
- D. Give warm clear liquids when fully alert.
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) The nurse should discourage the child from coughing, clearing the throat, or putting objects in his mouth. These may induce bleeding. (B) Cool, clear liquids may be given when child is fully alert. Warm liquids may dislodge a blood clot. The nurse should avoid red- or brown-colored liquids to distinguish fresh or old blood from ingested liquid should the child vomit. (C) Gargles and vigorous toothbrushing could initiate bleeding. (D) Postoperative hemorrhage, though unusual, may occur. The nurse should observe for bleeding by looking directly into the throat and for vomiting of bright red blood, continuous swallowing, and changes in vital signs.
NEW QUESTION 50
As a nurse in the emergency room, you receive an outside call from an elderly woman who states she has just been raped. She states, "I know I must come to the hospital, but what do I do next?" You advise her to call the police, then come to the hospital emergency room. What action by the nurse would indicate an understanding of the examination process once the victim enters the emergency room?
- A. Phone a rape counselor to begin working with the victim as soon as she enters the hospital.
- B. Inform the victim to bring insurance information with her to the hospital so she can be properly cared for.
- C. Inform the victim not to wash, change clothes, douche, brush teeth, or eat or drink anything.
- D. Do not leave the victim alone to collect her thoughts.
Answer: C
Explanation:
(A) Providing the victim with these instructions will aid in the determination of physical evidence of rape. Victims frequently feel "dirty" after rape, and their first instinct is to take care of personal hygiene before facing anyone. (B) This action is of lesser importance at this time. (C) Although this is a nursing measure appropriate in this situation, contacting a counselor can be done once the victim enters the hospital. Frequently victims call but do not follow up with the visit. (D) Once the victim enters the emergency room, it is important not to leave her alone.
NEW QUESTION 51
A postoperative prostatectomy client is preparing for discharge from the hospital the next morning. The nurse realizes that additional instructions are necessary when he states:
- A. "The isometric exercises will help to strengthen my perineal muscles and help me control my urine."
- B. "If I drink 10 to 12 glasses of fluids each day, that will help to prevent any clot formation in my urine."
- C. "If I feel as though I have developed a fever, I will take a rectal temperature, which is the most accurate."
- D. "I do not plan to do any heavy lifting until I visit my doctor again."
Answer: C
Explanation:
(A) This is correct health teaching. Drinking 10-12 glasses of clear liquid will help increase urine volumes and prevent clot formation. (B) This is correct health teaching. These types of exercises are prescribed by physicians to assist postprostatectomy clients to strengthen their perineal muscles. (C) This action is not recommended post-TURP because of the close proximity of the prostate and rectum. (D) This is correct healthcare teaching. The client should limit walking long distances, lifting heavy objects, or driving a car until these activities are cleared by the physician at the first office visit.
NEW QUESTION 52
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. Altered cerebral tissue perfusion related to pathophysiological changes that decrease blood flow
- B. Potential for injury related to impaired mobility and seizures
- C. Impaired verbal communication related to aphasia
- D. Ineffective airway clearance related to immobility, ineffective cough, and decreased level of consciousness
Answer: 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 53
An 8-year-old boy has been diagnosed with hemophilia. Which of the following diagnostic blood studies is characteristically abnormal in this disorder?
- A. Complete blood count
- B. Partial thromboplastin time
- C. Bleeding time
- D. Platelet count
Answer: B
Explanation:
(A) Partial thromboplastic time measures activity of thromboplastin, which depends on the intrinsic clotting factors deficient in children who are hemophiliacs. (B) Platelet counts are normal in hemophilia. (C) Hemophilia does not affect the complete blood count. (D) Bleeding times are normal in hemophiliacs. They measure the time interval for the bleeding from small superficial wounds to cease.
NEW QUESTION 54
When assessing residual volume in tube feeding, the feeding should be delayed if the amount of gastric contents (residual) exceeds:
- A. 30 mL
- B. 50 mL
- C. 25 mL
- D. 20 mL
Answer: B
Explanation:
Explanation
(A) A residual volume of 20 mL is not excessive. (B) A residual volume of 25 mL is not excessive. (C) A residual volume of 30 mL is not excessive. (D) Tube feedings should be withheld and physician notified for residual volumes of 50-100 mL.
NEW QUESTION 55
A 35-year-old primigravida comes to the clinic for her first prenatal visit. The midwife, on examining the client, suspects that she is approximately 11 weeks pregnant. The pregnancy is positively confirmed by finding:
- A. Enlargement of the uterus
- B. FHR by ultrasound
- C. Chadwick's sign
- D. Breast tenderness and enlargement
Answer: B
Explanation:
Explanation
(A) Chadwick's sign is a presumptive sign of pregnancy. The coloration may not subside from past pregnancy or could be caused by other situations that create vasocongestion. (B) FHR (movement) observed on ultrasound is a positive diagnosis of pregnancy. (C) Enlargement of the uterus may be due to fibroids or infection. It is considered a probable sign. (D) Breast tenderness and enlargement is a presumptive sign because it may be due to other conditions, such as premenstrual changes.
NEW QUESTION 56
A 67-year-old man had a physical examination prior to beginning volunteer work at the hospital. A routine chest x-ray demonstrated left ventricular hypertrophy. His blood pressure was 180/110. He is 45 lb overweight. His diet is high in sodium and fat. He has a strong family history of hypertension. The client is placed on antihypertensive medication; a low-sodium, low-fat diet; and an exercise regimen. On his next visit, compliance would best be determined by:
- A. No side effects from antihypertensive medication and an accurate pill count
- B. Serum blood levels of the antihypertensive medication within therapeutic range
- C. A blood pressure reading of 130/70 with a 5-lb weight loss
- D. No evidence of increased left ventricular hypertrophy on chest x-ray
Answer: C
Explanation:
Section: Questions Set D
Explanation:
(A) A blood pressure within acceptable range best demonstrates compliance, but weight loss cannot be accomplished without adherence to medication, diet, and exercise. (B) Absence of side effects does not indicate compliance with medication. Pill counts can be misleading because the client can alter pill counts prior to visit. (C) Left ventricular hypertrophy is not an accurate measure of compliance because hypertrophy frequently does not decrease even with pharmacological management. (D) Therapeutic blood levels measure the drug level at the time of the test. There is no indication of compliance several days before testing.
NEW QUESTION 57
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