[Jan 20, 2022] Free NCLEX Certification NCLEX-RN Official Cert Guide PDF Download
NCLEX NCLEX-RN Official Cert Guide PDF
NEW QUESTION 321
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. Increase the rate of IV fluids and start O2 by mask
- 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. Administer oxytocin (Pitocin) immediately and increase the rate of IV fluids
Answer: A
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 322
A 15-year-old child is admitted to the pediatric unit with a diagnosis of thalassemia. Which of the following would be included in educating the mother and child as part of discharge planning?
- A. Know the signs and symptoms of iron overload.
- B. Give oral iron medication every day.
- C. Keep exercise at a minimum to reduce stress.
- D. Have the child's blood pressure monitored every week.
Answer: A
Explanation:
(A) Oral iron supplements are contraindicated in thalassemia. (B) Although heart failure may be an end result of this disease, this action is unnecessary. (C) Iron overload is a potential complication of frequent blood transfusions of children with thalassemia. (D) Children should be encouraged to pursue activities related to their exercise tolerance.
NEW QUESTION 323
A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and kill her. The best verbal response to the client by the nurse at this time is:
- A. "I understand that the voices are real to you, but I want you to know I don't hear them. They are a symptom of your illness."
- B. "Just don't pay attention to the voices. They'll go away after some medication."
- C. "You can't leave here. This unit is locked and the doctor has not ordered your discharge."
- D. "We will have to put you in seclusion and restraints for a while. You could hurt someone with thoughts like that."
Answer: A
Explanation:
Explanation
(A) This response validates the client's experience and presents reality to him. (B) This nontherapeutic response minimizes and dismisses the client's verbalized experience. (C) This response can be interpreted by a paranoid client as a threat, thereby increasing the client's potential for violence and loss of control. (D) This response is also threatening. The client's behavior does not call for restraints because he has not lost control or hurt anyone. If seclusion or restraints were indicated, the nurse should never confront the client alone.
NEW QUESTION 324
A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to:
- A. Not notice that his mother has left
- B. Be comforted when he is held
- C. Withdraw and become listless
- D. Cry
Answer: D
Explanation:
Explanation
(A) It will be difficult to comfort a 2 year old with a headache without his mother. (B) This baby probably will cry, which should be prevented because it will increase his intracranial pressure (ICP). Asking the mother to wait until the baby is asleep may help. (C) An awake 2 year old will notice when his mother leaves. (D) An older child may withdraw when feeling afraid, but a 2 year old will probably show more aggressive behavior.
NEW QUESTION 325
A female client comes for her second prenatal visit. The nurse-midwife tells her, "Your blood tests reveal that you do not show immunity to the German measles." Which notation will the nurse include in her plan of care for the client? "Will need . . .
- A. Rh-immune globulin within 3 days of delivery"
- B. Rubella vaccine after delivery on the day of discharge"
- C. Rubella vaccine at the next visit"
- D. Rh-immune globulin at the next visit"
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Rh immune globulin is given to Rh-negative mothers to prevent the maternal Rh immune response. (B) Rh immune globulin is given to Rh-negative mothers to prevent the maternal Rh immune response. (C) The rubella vaccine is not given during pregnancy because of its teratogenicity. (D) Nonimmune mothers are vaccinated early in the postpartum period to prevent future infection with the rubella virus.
NEW QUESTION 326
A 45-year-old male client experiences a sense of depression because he has not yet achieved his life's goals.
His career has not been satisfying. He is still looking for the right job. His wife spends too much money, and his children seem to ignore him while being very selfish. He is tired of all of their attitudes and is considering buying a red Corvette convertible. While obtaining these data concerning the client's feelings about his life, the nurse is able to determine he is experiencing what psychological crisis according to Erikson's stages?
- A. Identity versus role confusion
- B. Generativity versus self-absorption
- C. Integrity versus despair
- D. Intimacy versus isolation
Answer: B
Explanation:
Section: Questions Set E
Explanation:
(A) Identity versus role confusion is experienced by adolescents making the transition from childhood to adulthood as they attempt to develop a sense of identity. (B) Integrity versus despair is experienced by the elderly as they reflect on their life in an attempt to find meaning. (C) Intimacy versus isolation is experienced by young adults as they establish intimate bonds of love and friendship. (D) Generativity versus self-absorption is experienced by middle-aged adults as they fulfill life goals that involve family, career, and society. The client is experiencing this crisis.
NEW QUESTION 327
A 35-year-old client is admitted to the hospital with diabetic ketoacidosis. Results of arterial blood gases are pH 7.2, PaO2 90, PaCO2 45, and HCO3 16. The nursing assessment of arterial blood gases indicate the presence of:
- A. Respiratory alkalosis
- B. Metabolic acidosis
- C. Respiratory acidosis
- D. Metabolic alkalosis
Answer: B
Explanation:
(A) Respiratory alkalosis is determined by elevated pH and low PaCO2. (B) Respiratory acidosis is determined by low pH and elevated PaCO2. (C) Metabolic alkalosis is determined by elevated pH and HCO3.(D) Metabolic acidosis is determined by low pH and HCO3.
NEW QUESTION 328
A client is having an amniocentesis. Prior to the procedure, an ultrasound is performed. In preparing the client, the nurse explains the reason for a sonogram in this situation to be:
- A. Determination of placental location
- B. Determination of multiple gestations
- C. Determination of gross anomalies
- D. Determination of fetal age
Answer: A
Explanation:
(A)
Sonography can be used to determine the presence of multiple gestation. In this question, the sonogram is used as a preparatory step for a specific invasive procedure. (B) Sonography can be used to determine the presence of gross anomalies. In this question, the sonogram is used as a preparatory step for a specific invasive procedure. (C) Prior to amniocentesis, the abdomen is scanned by ultrasound to locate the placenta, thus reducing the possibility of penetrating it with the spinal needle used to obtain amniotic fluid.
(D)
Sonography can be used to determine fetal age. In this question, the sonogram is used
as a preparatory step for a specific invasive procedure.
NEW QUESTION 329
A client is in active labor and has been admitted to the labor and delivery unit. The RN has just done a sterile vaginal exam and determines that the client is dilated 5 cm, effaced 85%, and the fetus's head is at 0 station.
She asks if she could have a lumbar epidural now. The epidural is started, and the anesthetic agent used is bupivacaine (Marcaine). After the client has received her lumbar epidural, it is important for the RN to monitor her for which of the following side effects:
- A. Hypotension
- B. Hypoglycemia
- C. Hyperglycemia
- D. Hypertension
Answer: A
Explanation:
Section: Questions Set C
Explanation:
(A) The medication bupivacaine will cause vasodilation in the vascular system, and this does not result in elevation of the ma-ternal blood pressure. (B) The medication bupivacaine will cause vasodilation in the vascular system, and this will result in lowering the maternal blood pressure. (C) Bupivacaine does not interfere with the functioning of the endocrine system. (D) Bupivacaine does not interfere with the functioning of the endocrine system.
NEW QUESTION 330
A client is going to have a pneumonectomy in the morning. She had a previous negative surgical experience, is talking rapidly, and has an increased pulse and respiratory rate. Nursing interventions for this client should include:
- A. Providing distractors such as reading or watching television
- B. Reminding her that this surgery is not as extensive as her past surgery was
- C. Providing opportunities to ask questions and talk about concerns
- D. Telling her that she should not be so nervous and assuring her that everything will be OK
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) This intervention will help to clarify any misunderstandings about the surgery and give the client an opportunity to verbalize concerns about the surgery. (B) Distractors will not alleviate the preoperative anxiety that the client is experiencing. This response actually denies the client's anxiety. (C) This intervention is false assurance and denies that anxiety is a normal response to the threat of surgery. (D) Psychological responses are not directly related to the extent of the surgery, because they are influenced by the client's past experiences.
NEW QUESTION 331
A newborn has been delivered with a meningomyelocele. The nursery nurse should position the newborn:
- A. Prone
- B. Semi-Fowler
- C. Supine
- D. Side lying
Answer: A
Explanation:
Explanation
(A) The prone position reduces pressure and tension on the sac. Primary nursing goals are to prevent trauma and infection of the sac. (B) The supine position exerts pressure on the sac. (C) Newborns usually cannot maintain side-lying position. (D) The semi- Fowler position exerts pressure on the sac.
NEW QUESTION 332
A 16-year-old client with anorexia nervosa is on an inpatient psychiatric unit. She has a fear of gaining weight and is refusing to eat sufficient amounts to maintain body weight for her age, height, and stature. To assist with the problem of powerlessness and plan for the client to no longer need to withhold food to feel in control, the nurse uses the following strategy:
- A. Distract the client during meals to get her to eat because she must take in sufficient amounts to keep from starving.
- B. Listen attentively and participate in in-depth discussions about food, because these actions may encourage her to eat.
- C. Establish a structured environment with routine tasks and activities. Also, serve meals at the same time each day.
- D. Do frequent room checks to be sure that the client is not hiding food or throwing it away.
Answer: C
Explanation:
(A)
Anorexia nervosa clients feel out of control. Providing a structured environment offers safety and comfort and can help them to develop internal control, thus reducing their need to control by self-starvation. (B) Distraction does not focus on the client's need for control.
(C)
Doing frequent room checks reinforces feelings of powerlessness and the need to continue with the dysfunctional behavior. (D) Participating in long discussions about food does not make the client want to eat, but rather this strategy allows her to indulge in her preoccupation and to continue with the dysfunctional behavior.
NEW QUESTION 333
A client hospitalized with a medical diagnosis of adjustment disorder versus personality disorder states, "Nobody cares about the clients." The nurse's most effective response would be:
- A. "How can you say that I don't care? We just met."
- B. "What makes you think the nurses don't care?"
- C. "You will feel differently about us in a few days."
- D. "You seem angry. Tell me more about how you feel."
Answer: D
Explanation:
(A) This statement is a defensive response that places the nurse in a vulnerable countertransference position, and at the same time, fails to challenge the client's "splitting" behavior. (B) This statement is a defensive response by the nurse. In addition, this type of nontherapeutic statement requests that the client explain the reasons for her behavior, a difficult task for an individual with limited insight. (C) This statement is a nontherapeutic response that both ignores the intensity of the client's emotions and the dynamics underlying "splitting" behavior. (D) By simultaneously acknowledging the client's emotional intensity and gently challenging her "splitting" behavior, the nurse addresses the client's current distortions and prepares for further interventions with angry or ambivalent feelings.
NEW QUESTION 334
The nurse knows that children are more susceptible to respiratory tract infections owing to physiological differences. These childhood differences, when compared to an adult, include:
- A. Fewer alveoli, slower respiratory rate
- B. Rounded shape of chest, smaller volume of air
- C. Diaphragmatic breathing, larger volume of air
- D. Larger number of alveoli, diaphragmatic breathing
Answer: B
Explanation:
(A) Although a child has fewer alveoli than an adult, the child's respiratory rate is faster. (B) Although a child may use diaphragmatic breathing, the adult exchanges a larger volume of air. (C) The adult has a larger number of alveoli than a child. (D) The child's chest is rounded whereas the adult chest is more of an oval shape, and the child does exchange a smaller volume of air than an adult.
NEW QUESTION 335
The nurse provides a male client with diet teaching so that he can help prevent constipation in the future.
Which food choices indicate that this teaching has been understood?
- A. Cooked oatmeal and grapefruit half
- B. Omelette and hash browns
- C. Bagel with cream cheese
- D. Pancakes and syrup
Answer: A
Explanation:
Explanation
(A) Eggs and hash browns do not provide much fiber and bulk, so they do not effectively prevent constipation.
(B) Pancakes and syrup also have little fiber and bulk, so they do not effectively prevent constipation. (C) Bagel and cream cheese do not provide intestinal bulk. (D) A combination of oatmeal and fresh fruit will provide fiber and intestinal bulk.
NEW QUESTION 336
The nurse teaches a pregnant client that a high-risk symptom occurring at any time during pregnancy that needs to be reported immediately to a healthcare provider is:
- A. Breast tenderness
- B. Abdominal pain
- C. Constipation
- D. Urinary frequency
Answer: B
Explanation:
(A) Constipation is a result of decreased peristalsis due to smooth muscle relaxation related to changing progesterone levels that occur during pregnancy. (B) Urinary frequency is a common result of the increasing size of the uterus and the resulting pressure it places on the bladder. (C) With the increased vascularity and hypertrophy of the mammary alveoli due to estrogen and progesterone level changes, the breasts will increase in size and may become tender. (D) Abdominal pain may be an indication of early spontaneous abortion, preterm delivery, or a placental abruption.
NEW QUESTION 337
Nursing assessment of early evidence of septic shock in children at risk includes:
- A. Respiratory distress, cold skin, and pale extremities
- B. Fever, tachycardia, and tachypnea
- C. Normal pulses, hypotension, and oliguria
- D. Elevated blood pressure, hyperventilation, and thready pulses
Answer: B
Explanation:
Explanation
(A) Fever, tachycardia, and tachypnea are the classic early signs of septic shock in children. (B) Respiratory distress, cold skin, and pale extremities are later signs of septic shock. (C) Elevated blood pressure, hyperventilation, and thready pulses are later signs of septic shock. (D) Normal pulses, hypotension, and oliguria are not early signs of septic shock.
NEW QUESTION 338
A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client's fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process:
- A. Decreases the time of the client's first stage of labor
- B. Prolongs the client's third stage of labor
- C. Decreases the overall time of the labor process
- D. Prolongs the client's first stage of labor
Answer: D
Explanation:
Explanation
(A) Posterior position causes a larger diameter of the fetal head to enter the pelvis than an anterior position.
Pressure on the sacral nerves is increased, and it takes the fetus a longer time to enter the pelvic inlet. (B) This position will prolong the first stage of labor. When the larger diameter of the fetal head enters the pelvis first, it will have a more difficult time accommodating to the pelvis; therefore, it will take a longer time for the fetus to move through the pelvis. (C) It will increase the time of labor because the larger diameter of the fetal head will have a more difficult time accommodating to the pelvic inlet and thus will move through the pelvis slower. (D) In the third stage of labor the placenta is delivered; therefore, the infant has been delivered.
NEW QUESTION 339
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. No problem indicated
- B. Fatigue due to stress
- C. Iron-deficiency anemia
- D. Physiological anemia
Answer: C
Explanation:
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 340
A female client has married recently. A month ago she visited her physician with complaints of burning on urination. She was given a prescription for trimethoprim- sulfamethoxazole (Bactrim) DS bid for 10 days. She was admitted through the emergency room on Saturday evening complaining of flank pain. Her temperature was 104_F. A preliminary urinalysis revealed 31 bacteria along with red and white blood cells in the urine. A preliminary diagnosis of pyelonephritis was made. During a nursing admission assessment, which statement by the client demonstrates a possible cause for pyelonephritis?
- A. "I'm afraid I may have something wrong with my bladder because I have been getting bladder infections frequently since I've been married."
- B. "I took the Bactrim for 6 or 7 days. The burning stopped, so I saved the rest of the medication for the next time."
- C. "I have not been drinking six to eight glasses of water each day as the nurse had instructed."
- D. "I recently had the flu, which could be settling in my kidneys now."
Answer: B
Explanation:
Explanation
(A) Although it is important that the client drink adequate fluids while treating a bladder infection with trimethoprimsulfamethoxazole, the failure to do so will not cause pyelonephritis. (B) A stricture or abnormality may cause the progression of bladder infection to urinary tract infection, but this is rare. There is no indication in this situation that this has occurred. (C) The most common cause of pyelonephritis is improper treatment of bladder infections. The client typically feels better after several days, discontinues the medication, and saves the remainder forthe next occurrence of a bladder infection. For this reason, it is imperative to provide client education related to completion of the prescribed medication. (D) There is no evidence that infection in another body system could cause pyelonephritis.
NEW QUESTION 341
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