[Sep-2021] Verified NCLEX Exam Dumps with NCLEX-RN Exam Study Guide
Best Quality NCLEX NCLEX-RN Exam Questions DumpStillValid Realistic Practice Exams [2021]
NEW QUESTION 104
A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, "The doctor said I have stones that need to be removed; where are they?" The nurse knows that the best explanation for this is to tell her that:
- A. There are stones present in her kidneys
- B. There are stones present in her common bile duct
- C. There are stones present in her gallbladder
- D. There are no stones, but her gallbladder is irritated and caused her nausea, vomiting, and pain
Answer: B
Explanation:
Explanation
(A)Cholelithiasisis the correct term used to describe the presence of stones in the gallbladder.
(B)Nephrolithiasis,orrenal calculi,is the correct term used to describe the presence of stones in the kidney.
(C)Choledocholithiasisis the correct term used to describe the presence of stones in the common bile duct.
(D)Cholecystitisis the correct term used to describe inflammation of the gallbladder and can be associated with cystic duct obstructions from impacted stones.
NEW QUESTION 105
Signs and symptoms of an allergy attack include which of the following?
- A. Circumoral cyanosis
- B. Prolonged expiration
- C. Increased respiratory rate
- D. Wheezing on inspiration
Answer: B
Explanation:
(A) Wheezing occurs during expiration when air movement is impaired because of constricted edematous bronchial lumina. (B) Respirations are difficult, but the rate is frequently normal. (C) The circumoral area is usually pale. Cyanosis is not an early sign of hypoxia. (D) Expiration is prolonged because the alveoli are greatly distended and air trapping occurs.
NEW QUESTION 106
The most important goal in the care plan for a child who was hospitalized with an accidental overdose would be to:
- A. Teach parents appropriate safety precautions
- B. Instruct parents in use of ipecac
- C. Determine child's activity pattern
- D. Reduce mother's sense of guilt
Answer: A
Explanation:
Section: Questions Set G
Explanation
Explanation:
(A) This goal is not the most important. (B) There is always some guilt when an accident occurs; however, the priority is to be sure future accidents are prevented. (C) Ipecac is not used for caustic alkali and acid ingestions. (D) Determining the parent's knowledge about safety hazards and teaching appropriate preventive measures are likely to prevent recurrence of accidents.
NEW QUESTION 107
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:
(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 108
In teaching the client about proper umbilical cord care, the nurse recommends that:
- A. Petrolatum be placed around the cord after the sponge bath
- B. The cord clamp be left on until the cord stump separates
- C. A belly binder be applied to prevent umbilical hernia
- D. The area be cleansed at diaper changes with alcohol and inspected for redness or drainage
Answer: D
Explanation:
Explanation
(A) Petrolatum does not allow the cord to dry and will encourage infection. (B) Belly binders do not facilitate drying of the cord and will encourage abdominal relaxation. (C) Frequent applications of alcohol will facilitate drying and discourage infection. (D) The cord clamp can be removed in 24 hours. Leaving it on is cumbersome and could pull on the cord unnecessarily.
NEW QUESTION 109
Which of the following procedures is necessary to establish a definitive diagnosis of breast cancer?
- A. Breast tissue biopsy
- B. Thermography
- C. Mammography
- D. Diaphanography
Answer: A
Explanation:
Explanation/Reference:
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 110
A male client tells his nurse that he has had an ulcer in the past and is afraid it is "flaring up again." The nurse begins to ask him specific questions about his symptoms. The nurse knows that a symptom that might indicate a serious complication of an ulcer is:
- A. Melena
- B. Pain in the middle of the night
- C. Episodes of nausea and vomiting
- D. A bowel movement every 3-5 days
Answer: A
Explanation:
Explanation
(A) Clients with ulcers generally experience abdominal pain. It is common to have pain in the early morning hours with an ulcer. (B) Constipation is not a symptom associated with ulcers and would indicate a need to look at other factors. (C) Melena is blood in the stools. This could indicate a slow bleeding ulcer, which could result in significant amounts of blood loss over time.(D) Nausea and vomiting may be present as a result of the ulcer, especially if it is a gastric ulcer. This does not indicate an immediate life-threatening complication.
NEW QUESTION 111
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:
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 112
A 35-year-old client is receiving psychopharmacological treatment of his major depression with tranylcypromine sulfate (Parnate), a monoamine oxidase (MAO) inhibitor. The nurse teaches the client that while he is taking this type of antidepressant, he needs to restrict his dietary intake of:
- A. Tyramine
- B. Potassium-rich foods
- C. Saturated fats
- D. Tryptophan
Answer: A
Explanation:
Section: Questions Set G
Explanation:
(A) The client may need to avoid some potassium-rich foods (such as bananas, raisins, etc.). However, this is not because of the potassium content of these foods. (B) Tryptophan is an essential amino acid that is present in high concentrations in animal and fish protein. (C) The client will need to watch his dietary intake of tyramine.
Tyramine is a by-product of the conversion of tyrosine to epinephrine. Tyramine is found in a variety of foods and beverages, ranging from aged cheese to caffeine drinks. Ingestion of tyramine-rich foods while taking a MAO inhibitor may lead to an increase in blood pressure and/or a life-threatening hypertensive crisis. (D) To maintain a healthy lifestyle, restriction of dietary saturated fats is advisable.
NEW QUESTION 113
The FHR pattern in a laboring client begins to show early decelerations. The nurse would best respond by:
- A. Administering O2 at 8 L/min via face mask
- B. Notifying the physician
- C. Continuing to monitor the FHR closely
- D. Changing the client to the left lateral position
Answer: C
Explanation:
(A) Early decelerations are reassuring and do not warrant notification of the physician. (B) Because early decelerations is a reassuring pattern, it would not be necessary to change the client's position. (C) Early decelerations warrant the continuation of close FHR monitoring to distinguish them from more ominous signs. (D) O2 is not warranted in this situation, but it is warranted in situations involving variable and/or late decelerations.
NEW QUESTION 114
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. Dry her with blankets
- B. Place her under the radiant warmer
- C. Place her to her mother's breast
- D. Place her on a heated pad
Answer: C
Explanation:
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 115
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:
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 116
A client had a hemicolectomy performed 2 days ago. Today, when the nurse assesses the incision, a small part of the abdominal viscera is seen protruding through the incision. This complication of wound healing is known as:
- A. Decortication
- B. Evisceration
- C. Excoriation
- D. Dehiscence
Answer: B
Explanation:
Explanation
(A) Excoriation is abrasion of the epidermis or of the coating of any organ of the body by trauma, chemicals, burns, or other causes. (B) Dehiscence is a partial or complete separation of the wound edges with no protrusion of abdominal tissue. (C) Decortication is removal of the surface layer of an organ or structure. It is a type of surgery, such as removing the fibrinous peel from the visceral pleura in thoracic surgery. (D) Evisceration occurs when the incision separates and the contents of the cavity spill out.
NEW QUESTION 117
A female client is started on warfarin (Coumadin) 5 mg po bid. To adequately evaluate the effectiveness of the warfarin therapy, the nurse must know that this medication:
- A. Stimulates the manufacturing of platelets
- B. Dissolves any clots already formed in the arteries
- C. Interferes with the synthesis of vitamin K-dependent clotting factors
- D. Prevents the conversion of prothrombin to thrombin
Answer: C
Explanation:
Explanation
(A) Thrombolytic agents (e.g., streptokinase) directly activate plasminogen, dissolving fibrin deposits, which in turn dissolves clots that have already formed. (B) Heparin prevents the formation of clots by potentiating the effects of antithrombin III and the conversion of prothrombin to thrombin. (C) Warfarin prevents the formation of clots by interfering with the hepatic synthesis of the vitamin K-dependent clotting factors. (D) Platelets initiate the coagulation of blood by adhering to each other and the site of injury to form platelet plugs.
NEW QUESTION 118
A male client has been an insulin-dependent diabetic for approximately 30 years. He frequently indulges in highsugar foods and forgets to take his insulin. He has not experienced acute diabetic emergencies over the years but is now beginning to demonstrate symptoms of diabetic peripheral neuropathy. This distresses him because dancing is one of his favorite pastimes. He decides to question his wife's home health nurse about diabetic peripheral neuropathy. The nurse points out his noncompliance to his diabetic diet and insulin regimen. The client answers the nurse, "It has been my experience that the diabetic diet is very difficult to follow. As far as the insulin, isn't a fellow allowed to forget now and then?" The client's actions and response best demonstrate:
- A. Bargaining
- B. Depression
- C. Denial
- D. Anger
Answer: C
Explanation:
(A) Depression may be an underlying feature, but it is not evident from limited data presented here. (B) Anger is not exhibited in his response. (C) Denial is evident in the client's actions; through the years, he has had a casual approach to his illness. He only becomes concerned when bodily changes affect his present lifestyle, when in fact he should have been concerned all along. His verbal response also reflects denial. (D) There is no evidence of bargaining in the client's actions or verbal response.
NEW QUESTION 119
The nurse is developing a plan of care for a client with an electrolyte imbalance and identifies a nursing diagnosis of decreased physical mobility. Which alteration is most likely the etiology?
- A. Hypocalcemia
- B. Hypomagnesemia
- C. Hypernatremia
- D. Hypokalemia
Answer: D
Explanation:
Explanation
(A) A deficit in sodium concentration results in muscular weakness and lethargy. (B) Muscle fatigue and hypotonia are caused by hypercalcemia. (C) Muscle weakness and fatigue are classic signs of hypokalemia.
(D) Hypermagnesemia can cause muscle weakness, paralysis, and coma.
NEW QUESTION 120
A client had a vaginal delivery 3 days ago and is discharged from the hospital on the 2nd day postpartum.
She told the RN, "I need to start exercising so that I can get back into shape. Could you suggest an exercise I could begin with?'' The RN could suggest which one of the following?
- A. Leg lifts
- B. Kegel exercises
- C. Jumping jacks
- D. Push-ups
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A, B, C) This exercise is too strenuous at this time. (D) This exercise is recommended for the first few days after delivery. It helps to stimulate muscle tonus in the area of the perineum and the area around the urinary meatus and vagina.
NEW QUESTION 121
A client is receiving peritoneal dialysis. He has been taught to warm the dialyzing fluid prior to instilling it because:
- A. Warmed solution promotes a relaxed abdominal muscle
- B. Warmed solution helps keep the body temperature maintained within a normal range during instillation
- C. Warmed solution decreases the risk of peritoneal infection
- D. Warmed solution helps dilate the peritoneal blood vessels
Answer: D
Explanation:
(A) Instilling a cool solution does not significantly lower the body temperature during peritoneal dialysis. (B) Warmed solution does help dilate the peritoneal blood vessels, facilitating the exchange of fluids. (C) Warming the dialysate does not decrease the risk of peritoneal infection. Sterile technique decreases this risk. (D) Relaxing the abdominal muscles does not facilitate peritoneal dialysis.
NEW QUESTION 122
A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful?
- A. Chicken breast, rice, and green beans
- B. Pork chop, baked acorn squash, brussel sprouts
- C. Roast beef, baked potato, and diced carrots
- D. Tuna casserole, noodles, and spinach
Answer: B
Explanation:
Section: Questions Set B
Explanation:
(A) Both acorn squash and brussels sprouts are potassium-rich foods. (B) None of these foods is considered potassium rich. (C) Only the baked potato is a potassium-rich food. (D) Spinach is the only potassium-rich food in this option.
NEW QUESTION 123
A 55-year-old man is admitted to the hospital with complaints of fatigue, jaundice, anorexia, and clay-colored stools. His admitting diagnosis is "rule out hepatitis." Laboratory studies reveal elevated liver enzymes and bilirubin. In obtaining his health history, the nurse should assess his potential for exposure to hepatitis.
Which of the following represents a high-risk group for contracting this disease?
- A. Oncology nurses
- B. Jehovah's Witnesses
- C. American Indians
- D. Heterosexual males
Answer: A
Explanation:
Explanation
(A) Homosexual males, not heterosexual males, are at high risk for contracting hepatitis. (B) Oncology nurses are employed in high-risk areas and perform invasive procedures that expose them to potential sources of infection. (C) The literature does not support the idea that any ethnic groups are at higher risk. (D) There is no evidence that any religious groups are at higher risk.
NEW QUESTION 124
A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular disorder. She arrives in her room via stretcher and requires assistance to move to her bed. The nurse notes that her left leg is cold to touch.
She complains of having recently experienced muscle spasms in that leg. To determine if these muscle spasms are indicative of intermittent claudication, the nurse would begin her assessment with the following question:
- A. "Have you had any lesions of the affected leg that have been difficult to heal?"
- B. "Do you experience swelling at the end of the day in the affected and unaffected leg?"
- C. "Do your muscle spasms occur following rest, walking, or exercising?"
- D. "Would you describe the intensity, duration, and symptoms associated with your pain?"
Answer: C
Explanation:
Explanation
(A) Describing pain is an important aspect of the assessment; however, assessing activity preceding muscle spasms is equally important. (B) Edema may occur with peripheral vascular disease, but it is not of particular importance in assessing intermittent claudication. (C) Lesions may be present with peripheral vascular disease, but they are not an indication of intermittent claudication. (D) With intermittent claudication, muscle spasms occur intermittently, mainly with walking and after exercising. Rest may relieve muscle spasms.
NEW QUESTION 125
......
Authentic Best resources for NCLEX-RN: https://www.dumpstillvalid.com/NCLEX-RN-prep4sure-review.html
NCLEX-RN Test Engine Practice Exam: https://drive.google.com/open?id=1qrVRtIOMQeOe7I_GKdExW2U_jg1VWp50
