[2021] NCLEX-RN All-in-One Exam Guide Practice To your NCLEX-RN Exam!
Preparations of NCLEX-RN Exam 2021 NCLEX Certification Unlimited 865 Questions
NEW QUESTION 418
A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from:
- A. Rolling from his back to his tummy
- B. Crying
- C. Falling asleep
- D. Sucking his thumb
Answer: B
Explanation:
(A) A child with a subdural hematoma has increased ICP. Crying may significantly increase this pressure. (B) Adequate sleep is essential, but it is important that the child can be aroused from sleep after head injury. (C) This child is free to roll from his back to his abdomen. (D) Thumb-sucking serves to reduce anxiety and should not be prevented at this time.
NEW QUESTION 419
A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening complications may occur initially, so the nurse will monitor him closely for serum:
- A. Sodium level of 136 mEq/L
- B. Potassium level of 3.1 mEq/L
- C. Chloride level of 99 mEq/L
- D. Potassium level of 6.3 mEq/L
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) The chloride level is within acceptable limits. (B) The sodium level is within acceptable limits. (C) This value indicates hypokalemia, rather than the hyperkalemia that occurs during diabetic ketoacidosis. (D) When diabetic ketoacidosis exists, intracellular dehydration occurs and potassium leaves the cells and enters the vascular system, thus increasing the serum level beyond an acceptable range. When insulin and fluids are administered, cell walls are repaired and potassium is transported back into the cells.
Normal serum potassium levels range from 3.5-5.0 mEq/L.
NEW QUESTION 420
Morphine sulfate 4 mg IV push q2h prn for chest pain was ordered for a client in the emergency room with severe chest pain. The nurse administering the morphine sulfate knows which of the following therapeutic actions is related to the morphine sulfate?
- A. Increased level of consciousness
- B. Increased rate and depth of respirations
- C. Increased peripheral vasodilation
- D. Increased perception of pain
Answer: C
Explanation:
(A) Morphine sulfate, a narcotic analgesic, causes sedation and a decrease in level of consciousness. (B) The side effects of morphine sulfate include respiratory depression. (C) Morphine sulfate causes peripheral vasodilation, which decreases afterload, producing a decrease in the myocardial workload. (D) Morphine sulfate alters the perception of pain through an unclear mechanism. This alteration promotes pain relief.
NEW QUESTION 421
A 40-year-old client is admitted to the coronary care unit with chest pain and shortness of breath. The physician diagnosed an anterior wall myocardial infarction.
What tests should the nurse anticipate?
- A. Lactic dehydrogenase, CPK
- B. Sedimentation rate, WBC count
- C. Reticulocyte count, creatinine phosphokinase (CPK)
- D. Aspartate transaminase, alanine transaminase
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Reticulocyte count measures the number of immature erythrocytes. CPK is an enzyme released from injured myocardial tissue. (B) Aspartate transaminase is an enzyme released from injured myocardial tissue. Alanine transaminase is an enzyme released for general tissue destruction, which is specific for liver injury. (C) Sedimentation rate is a nonspecific test for inflammation. (D) Lactic dehydrogenase and CPK are enzymes released from injured myocardial tissue.
NEW QUESTION 422
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. Altered family process related to physical abuse
- C. Fear related to retaliation by the father
- D. Ineffective coping
Answer: B
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 423
The client will be more comfortable and the results more accurate when the nurse prepares the client for Leopold's maneuvers by having her:
- A. Force fluids 1 hour prior to procedure
- B. Lie on her left side
- C. Empty her bladder
- D. Place her arms over her head
Answer: C
Explanation:
Explanation
(A) A full bladder would cause discomfort and possible urinary incontinence during the exam. (B) The left side-lying position would not accommodate the exam. The head of the exam table or bed can be slightly elevated to prevent supine hypotension. (C) Arms extended over the head would cause the abdomen to be tighter and less easily palpable. (D) Forcing fluids would encourage a full bladder, which is not desired for the exam.
NEW QUESTION 424
A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self- mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room.
The nurse should respond to this behavior by:
- A. Walking up to the client and touching her on the arm to get her attention
- B. Communicating a desire to assist the client to regain control, offering a one-to-one session in a quiet area
- C. Placing her in seclusion until the behavior is under control
- D. Confronting the client, letting her know the consequences for getting angry and disrupting the unit
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Threatening a client with punitive action is violating a client's rights and could escalate the client's anger. (B) Angry clients need respect for personal space, and physical contact may be perceived as a threatening gesture escalating anger. (C) Client lacks sufficient self-control to limit own maladaptive behavior; she may need assistance from staff. (D) Confronting an angry client may escalate her anger to further acting out, and consequences are for acting out anger aggressively, not for getting angry or feeling angry.
NEW QUESTION 425
Morphine sulfate 4 mg IV push q2h prn for chest pain was ordered for a client in the emergency room with severe chest pain. The nurse administering the morphine sulfate knows which of the following therapeutic actions is related to the morphine sulfate?
- A. Increased level of consciousness
- B. Increased rate and depth of respirations
- C. Increased peripheral vasodilation
- D. Increased perception of pain
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Morphine sulfate, a narcotic analgesic, causes sedation and a decrease in level of consciousness. (B) The side effects of morphine sulfate include respiratory depression. (C) Morphine sulfate causes peripheral vasodilation, which decreases afterload, producing a decrease in the myocardial workload. (D) Morphine sulfate alters the perception of pain through an unclear mechanism. This alteration promotes pain relief.
NEW QUESTION 426
A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours' postburn?
- A. Alteration in airway integrity secondary to edema of neck and face, which in turn is secondary to alteration in skin integrity
- B. Alteration in sensation secondary to third-degree burn
- C. Alteration in comfort secondary to alteration in skin integrity
- D. Fluid volume deficit secondary to alteration in skin integrity
Answer: A
Explanation:
Explanation
(A) Fluid deficit is a high priority not only during the first 8 hours postburn, but also during the first 36 hours postburn. (B) Alteration in comfort is a high priority during the entire length of the client's hospitalization and on discharge. (C) Alteration in sensation is a high priority during the first 48-72 hours postburn. Lack of sensation may be indicative of lack of circulation. (D) Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure to continually assess this client's airway status could result in poor ventilation and oxygenation, in addition to an inability to intubate the client secondary to excessive edema formation in the neck.
NEW QUESTION 427
As soon as a child has been diagnosed as "hearing impaired," special education should begin. Which of the following special education tasks is the most difficult for a severely hearing-impaired child?
- A. Signing
- B. Speech
- C. Lip reading
- D. Auditory training
Answer: B
Explanation:
(A) With the slight and mild hard of hearing, auditory training is beneficial. (B) Speech is the most difficult task because it is learned by visual and auditory stimulation, imitation, and reinforcement. (C, D) Lip reading and signing are aimed at establishing communicative skills, but they are learned more easily by visual stimulation.
NEW QUESTION 428
Other drugs may be ordered to manage a client's ulcerative colitis. Which of the following medications, if ordered, would the nurse question?
- A. 6-Mercaptopurine
- B. Loperamide (Imodium)
- C. Psyllium
- D. Methylprednisolone sodium succinate (Solu-Medrol)
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Methylprednisolone sodium succinate is used for its anti-inflammatory effects. (B) Loperamide would be used to control diarrhea. (C) Psyllium may improve consistency of stools by providing bulk. (D) An immunosuppressant such as 6-mercaptopurine is used for chronic unrelenting Crohn's disease.
NEW QUESTION 429
The health team needs to realize that the compulsive concern with cleanliness that a client with severe anxiety exhibits is most likely an attempt to:
- A. Reduce his anxiety
- B. Manipulate the health team members
- C. Increase his self-image by showing higher standards than the fellow clients
- D. Avoid going to psychotherapy
Answer: A
Explanation:
Explanation
(A) These behaviors are attempts to relieve anxiety. (B) Avoidance is not a pattern in the obsessive client. (C) Although these behaviors may seem to manipulate others, that is not the purpose behind the activity. (D) Inflated self-esteem is not a characteristic of the severely anxious client.
NEW QUESTION 430
The postpartum nurse should include which of the following instructions to breast-feeding mothers?
- A. Daily caloric intake should be increased by 500 cal.
- B. Wash the nipples with soap and water before and after each feeding.
- C. Limit feeding times for several days to avoid nipple soreness.
- D. Breast milk is totally digestible by the baby because it contains lactose.
Answer: A
Explanation:
Section: Questions Set E
Explanation:
(A) Limiting initial feeding times will only delay nipple soreness as well as the establishment of the letdown reflex, thus encouraging engorgement from clogged ducts and ductules. (B) Soap should be avoided because it may be excessively drying, predisposing nipples to cracking. (C) For optimal milk production, an additional
500 kcal over maintenance levels are needed daily. (D) Lipase, not lactose, emulsifies the fat in breast milk, making it almost totally digestible by infants.
NEW QUESTION 431
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. Rubella vaccine at the next visit"
- B. Rh-immune globulin at the next visit"
- C. Rh-immune globulin within 3 days of delivery"
- D. Rubella vaccine after delivery on the day of discharge"
Answer: D
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 432
The most appropriate method of evaluating whether the diet of a child with cystic fibrosis is meeting his caloric needs is:
- A. Careful monitoring of weight loss or gain
- B. Keeping a strict account of the number of calories ingested
- C. Carefully recording amounts and types of foods ingested
- D. Keeping a careful account of the amount of pancreatic enzymes ingested
Answer: A
Explanation:
Explanation
(A) Consistent weight gain, even if it is slow, is an indication that the child is eating and digesting sufficient calories. (B) Recording how much the child eats is useful, but it is not an indicator of how well his body is using the foods consumed. (C) Counting calories will indicate how much he is eating, but it will not reflect whether or not the foods are properly digested. (D) Keeping track of the enzyme intake will indicate compliance with medication but not whether the child is getting sufficient calories.
NEW QUESTION 433
The child with iron poisoning is given IV deforoxamine mesylate (Desferal). Following administration, the child suffers hypotension, facial flushing, and urticaria. The initial nursing intervention would be to:
- A. Take all vital signs, and report to the physician
- B. Stop the medication, and begin a normal saline infusion
- C. Assess urinary output, and if it is 30 mL an hour, maintain current treatment
- D. Discontinue the IV
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) The IV line should not be discontinued because other IV medications will be needed. (B) Stop the medication and begin a normal saline infusion. The child is exhibiting signs of an allergic reaction and could go into shock if the medication is not stopped. The line should be kept opened for other medication.
(C) Taking vital signs and reporting to the physician is not an adequate intervention because the IV medication continues to flow. (D) Assessing urinary output and, if it is 30 mL an hour, maintaining current treatment is an inappropriate intervention owing to the child's obvious allergic reaction.
NEW QUESTION 434
A type I diabetic client delivers a male newborn. The newborn is 45 minutes old. What is the primary nursing goal in the nursery during the first hours for this newborn?
- A. Monitor intake and output
- B. Bonding
- C. Maintain normal blood sugar
- D. Maintain normal nutrition
Answer: C
Explanation:
Explanation
(A) Bonding is necessary but would not be the priority with this newborn in the nursery. (B) The infant will be at risk for hypoglycemia because of excess insulin production. (C) Normal nutrition is a goal for all newborns.
(D) Monitoring intake and output is necessary but is not the most critical nursing goal.
NEW QUESTION 435
A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea, vomiting, and sore throat for the past several days. In caring for a young child with symptoms of influenza, the mother must be cautioned about:
- A. Giving clear liquids too soon
- B. The possibility of pneumonia as a complication
- C. Giving aspirin and bismuth subsalicylate (Pepto-Bismol) to treat the symptoms
- D. Allowing the child to come in contact with other children for 3 days
Answer: C
Explanation:
Explanation
(A) Aspirin should never be given to children with influenza because of the possibility of causing Reye's syndrome. Pepto- Bismol is also classified as a salicylate and should be avoided. (B) Depending on the severity of symptoms, the child may be receiving IV therapy or clear liquids. (C) The disease has a 1-3 day incubation period and affected children are most infectious 24 hours before and after the onset of symptoms.
(D) Although viral pneumonia can be a complication of influenza, this would not be an initial priority.
NEW QUESTION 436
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