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NCLEX-RN exam is a computerized adaptive test (CAT), which means that the difficulty of the questions is adjusted based on the test-taker’s performance. NCLEX-RN exam is composed of between 75 and 265 questions, and the test-taker must answer a minimum of 75 questions in order to pass. NCLEX-RN exam covers a wide range of topics, including pharmacology, nursing care of patients with acute and chronic illnesses, and ethical and legal considerations in nursing practice.
NEW QUESTION # 136
A client's record from the ED indicates that she overdosed on phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor. Which diet would be the most appropriate at this time?
- A. Tyramine-free
- B. High carbohydrate, low cholesterol
- C. High protein, high carbohydrate
- D. 1 g sodium
Answer: A
Explanation:
Explanation
(A) There are no data to support the need for increased carbohydrates or decreased cholesterol in the diet. (B) There is no data to support the need for increased protein or increased carbohydrates in the diet. (C) There is no assessment or laboratory data indicating that sodium should be restricted in the diet. (D) Tyramine is an amino acid activated by MAO in the liver and intestinal wall. It is released as proteins are hydrolyzed through aging, pickling, smoking, or spoilage of foods. When MAO is inhibited, tyramine levels rise, stimulating the adrenergic system to release large amounts of norepinephrine, which can produce a hypertensive crisis.
NEW QUESTION # 137
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. Jehovah's Witnesses
- B. American Indians
- C. Heterosexual males
- D. Oncology nurses
Answer: D
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 # 138
A 26-year-old client is diagnosed with an astrocytoma, a benign brain tumor. From the nurse's knowledge of the central nervous system, the nurse knows that benign tumors:
- A. Grow more rapidly than malignant tumors
- B. Can be removed surgically
- C. Do not warrant concern because they do not become malignant tumors
- D. Can be just as dangerous as malignant tumors
Answer: D
Explanation:
Explanation
(A) Both a benign and a malignant tumor can displace or destroy nearby structures or increase intracranial pressure. (B) Benign or malignant brain tumors grow at different rates depending on the type of tumor. (C) Some benign tumors do become malignant tumors. (D) Whether or not a tumor is operable depends on its location and the amount of damage its removal will cause.
NEW QUESTION # 139
The usual treatment for diabetes insipidus is with IM or SC injection of vasopressin tannate in oil. Nursing care related to the client receiving IM vasopressin tannate would include:
- A. Limit fluid intake to 500 mL/day.
- B. Weigh once a week and report to the physician any weight gain of10 lb.
- C. Store the medication in a refrigerator and allow to stand at room temperature for 30 minutes prior to administration.
- D. Hold the vial under warm water for 10-15 minutes and shake vigorously before drawing medication into the syringe.
Answer: D
Explanation:
Explanation
(A) Weight should be obtained daily. (B) Fluid is not restricted but is given according to urine output. (C) The medication does not have to be stored in a refrigerator. (D) Holding the vial under warm water for 10-15 minutes or rolling between your hands and shaking vigorously before drawing medication into the syringe activates the medication in the oil solution.
NEW QUESTION # 140
A client with bipolar disorder taking lithium tells the nurse that he has ringing in his ears, blurred vision, and diarrhea. The nurse notices a slight tremor in his left hand and a slurring pattern to his speech. Which of the following actions by the nurse is appropriate?
- A. Request an order for a stat blood lithium level.
- B. Recognize this as an expected response to lithium.
- C. Give an oral dose of lithium antidote.
- D. Administer a stat dose of lithium as necessary.
Answer: A
Explanation:
(A)
These symptoms are indicative of lithium toxicity. A stat dose of lithium could be fatal.
(B)
These are toxic effects of lithium therapy. (C) The client is exhibiting symptoms of lithium toxicity, which may be validated by lab studies. (D) There is no known lithium antidote.
NEW QUESTION # 141
A 38-year-old female client with a history of chronic schizophrenia, paranoid type, is currently an outpatient at the local mental health and mental retardation clinic. The client comes in once a week for medication evaluation and/or refills. She self-administers haloperidol 5 mg twice a day and benztropine 1 mg once a day. During a recent clinic visit, she says to the nurse, "I can't stay still at night. I toss and turn and can't fall asleep." The nurse suspects that she may be experiencing:
- A. Opisthotonos
- B. Akinesia
- C. Dystonia
- D. Akathisia
Answer: D
Explanation:
(A) Akathisia, or motor restlessness, is a reversible EPS frequently associated with the administration of antipsychotic drugs such as haloperidol. (B) Akinesia, or muscular or motor retardation, is an example of reversible EPS frequently associated with the administration of major tranquilizers such as haloperidol. (C) Acute dystonic reactions, bizarre and severe muscle contractions usually of the tongue, face, neck or extraocular muscles, are examples of EPS. (D) Opisthotonos, a severe type of whole-body dystonic reaction in which the head and heels are bent backward while the body is bowed forward, is an example of EPS.
NEW QUESTION # 142
A nurse is taking a maternal history for a client at her first prenatal visit. Her pregnancy test was positive, she has two living children, she had one spontaneous abortion, and one infant died at the age of 3 months. Which of the following best describes the client at the present?
- A. Gravida 4, para 3, ab 0
- B. Gravida 4, para 2, ab 1
- C. Gravida 5, para 3, ab 1
- D. Gravida 5, para 4, ab 0
Answer: C
Explanation:
Explanation
(A) This individual has been pregnant four times, delivered two children, and had one abortion. (B) Your client has been pregnant five times, delivered three children, and had one abortion. (C) This individual has been pregnant five times, delivered four children, and has not had an abortion. (D) This individual has been pregnant four times, delivered three children, and has not had an abortion.
NEW QUESTION # 143
A client had a myocardial infarction 5 days ago. His physician has ordered an echocardiogram to determine how his myocardial infarction has affected his ventricular wall motion. When the client asks if this test is painful, an appropriate response is:
- A. "Your physician has ordered medicine, which you will be given before you go for the test, which will make you sleepy."
- B. "Yes, but your physician will be there and will order pain medicine for you."
- C. "No, but you will have to lie still and the gel that is used may be cool."
- D. "No, but you must be able to ride on a stationary bicycle while the test is being performed."
Answer: C
Explanation:
Explanation
(A) Riding a stationary bicycle or walking on a treadmill is done during a stress test. (B) During an echocardiogram, the client must lie supine while a technician performs the test. To perform the test, the technician uses a conductive gel and a transducer to obtain ultrasound tracings of the heart. (C) A physician need not be present during an echocardiogram, and it is neither invasive nor painful. (D) There is no premedication required for an echocardiogram.
NEW QUESTION # 144
A baby who was diagnosed with pyloric stenosis has continued to have projectile vomiting. With prolonged vomiting, the infant is prone to:
- A. Respiratory acidosis
- B. Metabolic alkalosis
- C. Respiratory alkalosis
- D. Metabolic acidosis
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Respiratory acidosis is the result of problematic ventilation. Plasma pH decreases, while plasma PCO2 and plasma HCO3 increase. (B) Respiratory alkalosis results from increased respiratory rate and depth.
Plasma pH increases, while plasma PCO2 and plasma HCO3 decrease. (C) Metabolic acidosis occurs when there is strong acid gain in the body. Plasma pH, PCO2, and HCO3 decrease. (D) Increased risk for metabolic alkalosis is due to a loss of hydrogen ions; depletion of potassium, sodium, and chloride when vomiting occurs. Plasma pH and plasma PCO2 increase; plasma HCO3 may decrease and then increase to compensate.
NEW QUESTION # 145
The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury. Normal fluid intake for a child of 2 years is:
- A. 2000 mL/24 hr
- B. 1300 mL/24 hr
- C. 900 mL/24 hr
- D. 1600 mL/24 hr
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A, B, D) These values are incorrect. Normal intake for a child of 2 years is about 1600 mL in 24 hours. (C) This value is correct. Normal intake for a child of 2 years is about 1600 mL in 24 hours.
NEW QUESTION # 146
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 aspirin and bismuth subsalicylate (Pepto-Bismol) to treat the symptoms
- B. Giving clear liquids too soon
- C. The possibility of pneumonia as a complication
- D. Allowing the child to come in contact with other children for 3 days
Answer: A
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 # 147
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:
Section: Questions Set E
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 # 148
Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:
- A. Increasing sensory stimuli
- B. Maintaining seizure precautions
- C. Applying ankle and wrist restraints
- D. Restricting fluid intake
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. (B) Fluid intake should be increased to prevent dehydration. (C) Environmental stimuli should be decreased to prevent precipitation of seizures. (D) Application of restraints may cause the client to increase his or her physical activity and may eventually lead to exhaustion.
NEW QUESTION # 149
A client who was started on antipsychotic medication 2 weeks ago is preparing for discharge from the hospital.
Compliance with the medication regimen is important despite the mild side effects encountered. In order to increase the likelihood of medication compliance, the nurse would:
- A. Discuss the disease process and the importance of the medication in prevention of symptoms.
- B. Inform the client that additional side effects are to be expected and need not be reported.
- C. Discuss the importance of getting blood drawn weekly to determine medication therapeutics.
- D. Inform the client to cease taking the medication when all psychotic symptoms have cleared.
Answer: A
Explanation:
Section: Questions Set D
Explanation:
(A) This answer is correct. If the client is well informed about what reactions to expect from her medication, she is more likely to follow the treatment regimen. (B) This answer is incorrect. There are many side effects that are reversible by medication, and these must be reported to the nurse or physician. There are also more severe side effects, such as neuroleptic malignant syndrome, characterized by fever, tachycardia, and diaphoresis, which can be life threatening. (C) This answer is incorrect. There is no need for weekly blood tests if the drug regimen has been followed properly. (D) This answer is incorrect. The client should continue the medicationuntil the physician recommends any change in the drug regimen. Symptoms will usually reappear if medication is discontinued.
NEW QUESTION # 150
A mother called the physician's office to ask if it would help relieve her small daughter's abdominal pain if she gave an enema and placed a heating pad on the abdomen. Her daughter has a fever and has vomited twice.
The nurse's response is based on the knowledge that:
- A. Both heat and enemas stimulate intestinal motility and could increase the risk of perforation
- B. Heat would help to relax the abdominal muscles and relieve her pain
- C. The symptoms could easily have been caused by constipation, which an enema would relieve
- D. Complaints of stomach ache are common in young children and are generally best ignored
Answer: A
Explanation:
Section: Questions Set D
Explanation:
(A) Constipation does not cause fever or vomiting but may cause anorexia. Risk of perforation outweighs the possible benefits of an enema. (B) Heat will not relieve her symptoms but will increase intestinal motility and increase the risk of perforation. (C) Heat and enemas are contraindicated where severe abdominal pain is suspected because they increase intestinal motility and the risk of perforation. (D) Complaints accompanied by physical symptoms such as pain, anorexia, and fever should never be ignored.
NEW QUESTION # 151
In discussing the plan of care for a child with chronic nephrosis with the mother, the nurse identifies that the purpose of weighing the child is to:
- A. Determine changes in the amount of edema
- B. Impress the child with the importance of eating well
- C. Measure adequacy of nutritional management
- D. Check the accuracy of the fluid intake record
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Weighing a child with nephrosis is to assess for edema, not nutrition. (B, C) This is not the purpose for weighing the child. (D) Weight and measurement are the primary ways of evaluating edema and fluid shifts.
NEW QUESTION # 152
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