[Nov 30, 2023] Get New NCLEX-RN Certification Practice Test Questions Exam Dumps
Real NCLEX-RN Exam Dumps Questions Valid NCLEX-RN Dumps PDF
NEW QUESTION # 139
What is the most effective method to identify early breast cancer lumps?
- A. Mammograms every 3 years
- B. Monthly breast self-examination
- C. Yearly checkups performed by physician
- D. Ultrasounds every 3 years
Answer: B
Explanation:
(A) Mammograms are less effective than breast self-examination for the diagnosis of abnormalities in younger women, who have denser breast tissue. They are more effective forwomen older than 40. (B) Up to 15% of early-stage breast cancers are detected by physical examination; however, 95% are detected by women doing breast self-examination. (C) Ultrasound is used primarily to determine the location of cysts and to distinguish cysts from solid masses. (D) Monthly breast self-examination has been shown to be the most effective method for early detection of breast cancer. Approximately 95% of lumps are detected by women themselves.
NEW QUESTION # 140
The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on a fullstrength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the following?
- A. The feeding is infusing into the trachea.
- B. The client aspirated tube feeding.
- C. The nurse has placed the suction catheter in the esophagus.
- D. This is a normal finding.
Answer: B
Explanation:
(A)
Once the feeding tube placement is confirmed in the stomach, aspiration can occur if the client's stomach becomes too full. When suctioning the trachea, if secretions resemble tube feeding, the client has aspirated the feeding. (B) Because the trachea provides direct access to a client's airway, it would not be possible to place the catheter in the esophagus.
(C)
Blue-colored sputum is never considered a normal finding and should be reported and documented. (D) The nurse confirmed placement of the feeding tube in the stomach prior to initiating the tube feeding; therefore, it is highly unlikely that the feeding tube would be located in the trachea.
NEW QUESTION # 141
A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should:
- A. Explain that his vital signs will be checked frequently after the test
- B. Practice with him so he will be able to hold his breath for 1 minute
- C. Explain that he will be receiving a laxative to prevent a distended bowel from applying pressure on the liver
- D. Explain that he will be kept NPO for 24 hours before the exam
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) There is no NPO restriction prior to a liver biopsy. (B) The client would need to hold his breath for 5-10 seconds. (C) There is no pretest laxative given. (D) Following the test, the client is watched for hemorrhage and shock.
NEW QUESTION # 142
When a client with pancreatitis is discharged, the nurse needs to teach him how to prevent another occurrence of acute pancreatitis. Which of the following statements would indicate he has an understanding of his disease?
- A. "I will report any changes in bowel movements to my doctor."
- B. "I will not eat any raw or uncooked vegetables."
- C. "I will limit my alcohol to one cocktail per day."
- D. "I will look into attending Alcoholics Anonymous meetings."
Answer: D
Explanation:
Explanation
(A) Raw or uncooked vegetables are all right to eat postdischarge. (B) This client must avoid any alcohol intake. (C) The client displays awareness of the need to avoid alcohol. (D) This action would be pertinent only if fatty stools associated with chronic hepatitis were the problem.
NEW QUESTION # 143
A male infant is to be discharged home this morning. Which instruction related to his cord care should be included in his mother's discharge teaching plan?
- A. Clean the umbilical cord with alcohol at each diaper change.
- B. Keep the umbilical area moist with Vaseline until the stump falls off.
- C. Keep the umbilical area covered at all times with the diaper.
- D. Clean the umbilical cord daily with soap and water during the bath.
Answer: A
Explanation:
(A) The umbilical area should be kept dry for healing to occur. Moisture is conducive to bacterial growth and therefore could lead to infection at the site. (B) The diaper should be folded below the cord to allow the cord stump to be exposed to the air for healing. (C) The umbilical cord should be swabbed with alcohol at each diaper change to remove urine and stool and to facilitate the desiccation process through drying. (D) Soap and water should not be used to clean the umbilical area because the area could retain moisture, thus making it susceptible to bacterial growth and infection.
NEW QUESTION # 144
A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?
- A. "My husband told me this morning that he wants a divorce. I am upset, but I cannot discuss the matter with him until after my company's board meeting today."
- B. "I felt a lump in my breast 2 weeks ago. I put off getting it checked until after my sister's wedding."
- C. "My son died 3 years ago. I still cannot bring myself to clean out his room."
- D. "I did not get the raise because my boss does not like me."
Answer: A
Explanation:
(A) This statement is an example of adaptive rationalization. She is coping with her disappointment by rationalizing. This is adaptive because no harm is done to self or others. It is used to protect her ego. (B) This is an example of maladaptive suppression. She is suppressing the seriousness of the lump. It is maladaptive because delaying treatment will cause harm to her. (C) The client's actions are an example of maladaptive denial. She is denying her son's death by not facing his possessions. Until she faces his death, she cannot face reality. (D) This is an example of adaptive suppression. She realizes the impact of her husband's statement but delays discussion until she can devote her full attention to the matter.
NEW QUESTION # 145
With a geriatric client, the nurse should also assess whether he has been obtaining a yearly vaccination against influenza. Why is this assessment important?
- A. Older clients have less effective immune systems.
- B. Influenza is growing in our society.
- C. Older clients have more exposure to the causative agents.
- D. Older clients generally are sicker than others when stricken with flu.
Answer: A
Explanation:
Explanation
(A) Although influenza is common, the elderly are more at risk because of decreased effectiveness of their immune system, not because the incidence is increasing. (B) Older clients have the same degree of illness when stricken as other populations. (C) As people age, their immune system becomes less effective, increasing their risk for influenza. (D) Older clients have no more exposure to the causative agents than do school-age children, for example.
NEW QUESTION # 146
A 3-year-old child was hospitalized for acute laryngotracheobronchitis. During her hospitalization, the child was placed under an oxygen mist tent. The nurse's frequent monitoring of the child's temperature frightened her parents. Which response by the nurse would be most appropriate?
- A. Rapid temperature elevations can occur in children.
- B. Checking the temperature will prevent febrile seizures.
- C. Monitoring the temperature prevents undue chilling.
- D. Taking the child's temperature can prevent airway obstruction.
Answer: C
Explanation:
Section: Questions Set D
Explanation:
(A) The refrigerated cool mist tent creates a cool, moist environment. The child as well as bedding and clothing may become dampened. Monitoring the temperature of the child will ensure warmth and prevent chilling. (B) Only a low-grade fever is expected in laryngotracheobronchitis. (C) Febrile seizures are not expected with the low-grade fever. (D) Inflammation of the mucosal lining in the respiratory tract can cause airway obstruction.
However, monitoring the child's temperature would not prevent airway obstruction.
NEW QUESTION # 147
In teaching the client about proper umbilical cord care, the nurse recommends that:
- A. The cord clamp be left on until the cord stump separates
- B. The area be cleansed at diaper changes with alcohol and inspected for redness or drainage
- C. Petrolatum be placed around the cord after the sponge bath
- D. A belly binder be applied to prevent umbilical hernia
Answer: B
Explanation:
Section: Questions Set F
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 # 148
An alcoholic client who is completing the inpatient segment of a substance abuse program was placed on disulfiram (Antabuse) drug therapy. What should the nurse include in the discharge instructions?
- A. If disulfiram is taken and alcohol ingested, the client experiences nausea, vomiting and elevated blood pressure.
- B. The effects of disulfiram can be triggered by alcohol 5 days to 2 weeks after the drug is discontinued.
- C. Disulfiram is most effective when prescribed as late as possible in a recovery program.
- D. Disulfiram works on the desensitization principle.
Answer: B
Explanation:
Explanation
(A) When alcohol is ingested with disulfiram therapy, the client experiences nausea, vomiting, and a potentially serious drop in blood pressure. (B) Disulfiram is most successful when used early in the recovery process while the individual makes major lifestyle changes necessary for long-term recovery. (C) Disulfiram works on the classical conditioning principle. (D) The effects of disulfiram can be felt when alcohol is ingested 1-2 weeks after disulfiram is discontinued.
NEW QUESTION # 149
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. Speech
- B. Lip reading
- C. Auditory training
- D. Signing
Answer: A
Explanation:
Explanation/Reference:
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 # 150
A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor and delivery are the ischial spines because:
- A. Ischial spines are the widest diameter of the pelvis
- B. Ischial spines are the narrowest diameter of the pelvis
- C. They measure pelvic floor
- D. They represent the inlet of birth canal
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) The fetal descent, or station, is determined by the relationship of the presenting part to the spine. (B) Ischial spines are the narrowest measurement. (C) Ischial spines measure the pelvic outlet. (D) Pelvic floor measurement is not related to fetal descent.
NEW QUESTION # 151
A 48-year-old client is being seen in her physician's office for complaints of indigestion, heartburn, right upper quadrant pain, and nausea of 4 days' duration, especially after meals. The nurse realizes that these symptoms may be associated with cholecystitis and therefore would check for which specific sign during the abdominal assessment?
- A. Rebound tenderness
- B. Turner's sign
- C. Murphy's sign
- D. Cullen's sign
Answer: C
Explanation:
Explanation
(A) This sign is a faint blue discoloration around the umbilicus found in clients who have hemorrhagic pancreatitis. (B) This sign indicates areas of inflammation within the peritoneum, such as with appendicitis. It is a deep palpation technique used on a nontender area of the abdomen, and when the palpating hand is removed suddenly, the client experiences a sharp, stabbing pain at an area of peritoneal inflammation. (C) This sign is considered positive with acute cholecystitis when the client is unable to take a deep breath while the right upper quadrant is being deeply palpated. The client will elicit a sudden, sharp gasp, which means the gallbladder is acutely inflamed. (D) This is a sign of acute hemorrhagic pancreatitis and manifests as a green or purple discoloration in the flanks.
NEW QUESTION # 152
A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent:
- A. Clot formation
- B. Scrotal edema
- C. Bladder spasms
- D. Prostatic infection
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) The purpose of bladder irrigation is not to prevent bladder spasms, but to drain the bladder and decrease clot formation and obstruction. (B) A three-way system of bladder irrigation will cleanse the bladder and prevent formation of blood clots. A catheter obstructed by clots or other debris will cause prostatic distention and hemorrhage. (C) Scrotal edema seldom occurs after TURP. Bladder irrigation will not prevent this complication. (D) Prostatic infection seldom occurs after TURP. Bladder irrigation will not prevent this complication.
NEW QUESTION # 153
Clients receiving antipsychotic drug therapy will often exhibit extrapyramidal side effects that are reversible with which of the following agents ordered by the physician?
- A. Anti-Parkinsonian drugs
- B. Tricyclic agents
- C. Anticholinergics
- D. Phenothiazines
Answer: C
Explanation:
Explanation
(A) This answer is incorrect. Phenothiazines are antipsychotic drugs and produce the symptoms. (B) This answer is correct. Anticholinergic agents are often used prophylactically for extrapyramidal symptoms. They balance cholinergic activity in the basal ganglia of the brain. (C) This answer is incorrect. Anti- Parkinsonian drugs would increase the symptoms. (D) This answer is incorrect. Tricyclic agents are used for symptoms of depression.
NEW QUESTION # 154
Which of the following should be included in discharge teaching for a client with hepatitis C?
- A. He should use disposable dishes for eating and drinking.
- B. He should avoid alcoholic beverages during his recovery period.
- C. He should take aspirin as needed for muscle and joint pain.
- D. He may become a blood donor when his liver enzymes return to normal.
Answer: B
Explanation:
Explanation
(A) Aspirin is hepatotoxic, may increase bleeding, and should be avoided. (B) Blood should not be donated by a client who has had hepatitis C because of the possibility of transmission of disease. (C) Alcohol is detoxified in the liver. (D) Hepatitis C is not spread through the oral route.
NEW QUESTION # 155
A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching concerning the warfarin therapy?
- A. "If you forget to take your morning dose, double the night time dose."
- B. "Carry a medications alert card with you at all times."
- C. "You should use a straight-edge razor when shaving your arms and legs."
- D. "You should take aspirin instead of acetaminophen (Tylenol) for headaches."
Answer: B
Explanation:
Explanation
(A) Warfarin must always be taken exactly as directed. Clients should be instructed never to skip or double up on their dosage. (B) Aspirin decreases platelet aggregation, which would potentiate the effects of the coumadin. (C) Healthcare providers need to be aware of persons on warfarin therapy prior to the initiation of any diagnostic tests and/or surgery to help prevent bleeding complications. (D) An electric razor should be used to prevent accidental cutting, which can lead to bleeding.
NEW QUESTION # 156
A child receiving chemotherapeutic drugs experiences a loss of appetite directly related to the therapy. Which of the following strategies should be most effective in encouraging the child to eat?
- A. Schedule procedures immediately after eating so that the child will not be tired or in pain at mealtime.
- B. Provide a well-balanced diet at usual times, and restrict dessert if the child fails to eat well.
- C. Offer the child a diet with a wider variety of foods and with more seasoning than her usual diet.
- D. Offer the child smaller meals more frequently than usual, and include as many of her favorite foods as possible.
Answer: D
Explanation:
(A) Because the child's appetite is capricious at best, regular servings may be overwhelming. Praise the child for what is eaten. (B) The child will soon learn that procedures follow meals and may play with food rather than eat it to avoid or delay the procedure. (C) Young children usually do not like highly seasoned foods and may need the security of usual foods. Such a change may actually increase anorexia. (D) Small servings appear more achievable to the child, and the inclusion of favorite foods can add a sense of security.
NEW QUESTION # 157
Which of the following activities would be most appropriate during occupational therapy for a client with bipolar disorder?
- A. Working crossword puzzles
- B. Playing cards with other clients
- C. Sewing beads on a leather belt
- D. Playing tennis with a staff member
Answer: D
Explanation:
Section: Questions Set A
Explanation:
(A) This activity is too competitive, and the manic client might become abusive toward the other clients. (B) During mania, the client's attention span is too short to accomplish this task. (C) This activity uses gross motor skills, eases tension, and expands excess energy. A staff member is better equipped to interact therapeutically with clients. (D) This activity requires the use of fine motor skills and is very tedious.
NEW QUESTION # 158
When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the nurse take?
- A. Report to physician or midwife.
- B. Decrease IV fluids.
- C. Turn client on right side.
- D. Continue monitoring because this is a normal occurrence.
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) This is not a normal occurrence. Late decelerations need prompt intervention for immediate infant recovery. (B) To increase O2 perfusion to the unborn infant, the mother should be placed on her left side.
(C) IV fluids should be increased, not decreased. (D) Immediate action is warranted, such as reporting findings, turning mother on left side, administering O2, discontinuing oxytocin (Pitocin), assessing maternal blood pressure and the labor process, preparing for immediate cesarean delivery, and explaining plan of action to client.
NEW QUESTION # 159
Which of the following signs might indicate a complication during the labor process with vertex presentation?
- A. Contraction lasting 60 seconds
- B. Fetal tachycardia to 170 bpm during a contraction
- C. Nausea and vomiting at 8-10 cm dilation
- D. Appearance of dark-colored amniotic fluid
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Fetal tachycardia may indicate fetal hypoxia; however, 170 bpm is only mild tachycardia. (B) Nausea and vomiting occur frequently during transition and are not a complication. (C) Contractions frequently last
60-90 seconds during the transitional phase of labor and are not considered a complication as long as the uterus relaxes completely between contractions. (D) Passage of meconium in a vertex presentation is a sign of fetal distress; this may be normal in a breech presentation owing to pressure on the presenting part.
NEW QUESTION # 160
Which of the following would have the physiological effect of decreasing intracranial pressure (ICP)?
- A. Administration of hypo-osmolar fluids
- B. Increased core body temperature
- C. Decreased PaCO2
- D. Decreased serum osmolality
Answer: C
Explanation:
Explanation
(A) An increase in core body temperature increases metabolism and results in an increase in ICP. (B) Decreased serum osmolality indicates a fluid overload and may result in an increase in ICP. (C) Hypo-osmolar fluids are generally voided in the neurologically compromised. Using IV fluids such as D5W results in the dextrose being metabolized, releasing free water that is absorbed by the brain cells, leading to cerebral edema.
(D) Hypercapnia and hypoventilation, which cause retention of CO2 and lead to respiratory acidosis, both increase ICP. CO2 is the most potent vasodilator known.
NEW QUESTION # 161
A client calls the prenatal clinic to schedule an appointment. She states she has missed three menstrual periods and thinks she might be pregnant. During her first visit to the prenatal clinic, it is confirmed that she is pregnant. The registered nurse (RN) learns that her last menstrual period began on June 10. According to Nagele's rule, the estimated date of confinement is:
- A. August 30
- B. June 3
- C. March 17
- D. January 10
Answer: C
Explanation:
Explanation
(A) Using Nagele's rule, count back 3 calendar months from the first day of the last menstrual period. The answer is March 10. Then add 7 days and 1 year, which would be March 17 of the following year. (B, C, D) This date is incorrect.
NEW QUESTION # 162
A client had a renal transplant 3 months ago. He has suddenly developed graft tenderness, an increased white blood cell count, and malaise. The client is experiencing which type of rejection?
- A. Hyperchronic
- B. Hyperacute
- C. Acute
- D. Chronic
Answer: C
Explanation:
Explanation
(A) The sudden development of fever, graft tenderness, increased white blood count, and malaise are signs and symptoms of an acute rejection that commonly occurs at 3 months. (B) Chronic rejection occurs slowly over a period of months to years and mimics chronic renal failure. (C) Hyperacute rejection occurs immediately after surgery up to 48 hours postoperatively. (D) Hyperchronic rejection is not a type of rejection.
NEW QUESTION # 163
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