[Nov 25, 2021] SurePassExams NCLEX-RN Exam Practice Test Questions (Updated 865 Questions)
Pass NCLEX NCLEX-RN Exam Info and Free Practice Test
NEW QUESTION 198
A group of nursing students at a local preschool day care center are going to screen each
child's fine and gross motor, language, and social skills. The students will use which one of the most widely used screening tests?
- A. Revised Prescreening Developmental Questionnaire
- B. Goodenough Draw-a-Person Screening Test
- C. Denver Development Screening Test
- D. Caldwell Home Inventory
Answer: C
Explanation:
(A) The Revised Prescreening Developmental Questionnaire is more age appropriate and offers simplified parent scoring and easier comparison. It is used by parents instead of professionals. (B) The Goodenough Draw-a-Person test is used to assess intellectual development. (C) The Denver Developmental Screening Test is one of the most widely used screening tests. It offers a concise, easy-to-administer, systematic approach to assessing the preschool child. It is widely used because of its reliability and validity. (D) The Caldwell Home Inventory is used to assess the home environment in areas of social, emotional, and cognitive supports.
NEW QUESTION 199
A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:
- A. Changing tracheostomy dressing only as necessary using one-half strength hydrogen peroxide to cleanse the site
- B. Avoiding manipulation of the tracheostomy including cuff deflation
- C. Reporting any signs of crepitus immediately to the physician
- D. Deflating the cuff for 10 minutes every other hour instead of 5 minutes every hour
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) The tracheal cuff should not be deflated within the first 24 hours following surgery. (B) To minimize bleeding, any manipulation, including cuff deflation, should be avoided. (C) Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician. (D) The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.
NEW QUESTION 200
The nurse is notified that a 27-year-old primigravida diagnosed with complete placenta previa is to be admitted to the hospital for a cesarean section. The client is now at 36 weeks' gestation and is presently having bright red bleeding of moderate amount. On admission, the nursing intervention that the nurse should give the highest priority to is:
- A. Start an IV infusion in the client's arm
- B. Insert an indwelling catheter into her bladder
- C. Determine the status of the fetus by fetal heart tones
- D. Shave the client's abdomen and arrange her lab work
Answer: C
Explanation:
Explanation
(A) These nursing actions are necessary prior to the cesarean section, but not immediately necessary to maintain physiological equilibrium. (B) Determining the physiological status of the fetus would constitute the highest priority in evaluating and maintaining fetal life. (C) These nursing actions are necessary prior to the cesarean section, but not immediately necessary to maintain physiological equilibrium. (D) These nursing actions are necessary prior to the cesarean section, but not immediately necessary to maintain physiological equilibrium.
NEW QUESTION 201
The following medications were noted on review of the client's home medication profile. Which of the medications would most likely potentiate or elevate serum digoxin levels?
- A. Quinidine
- B. Theophylline
- C. Thyroid agents
- D. KCl
Answer: A
Explanation:
Explanation
(A) Hypokalemia can cause digoxin toxicity. Administration of KCl would prevent this. (B) Thyroid agents decrease digoxin levels. (C) Quinidine increases digoxin levels dramatically. (D) Theophylline is not noted to have an effect on digoxin levels.
NEW QUESTION 202
A male client is diagnosed with hypoparathyroidism. He has been on dialysis for several years. He is experiencing symptoms such as numbness of the lips, muscle weakness, carpopedal spasms, and wheezing.
Given the client's symptoms, nursing assessment would focus on:
- A. Evidence of depression
- B. Detection of premature cataract formation
- C. Detection of tetany
- D. Detection of hypocalcemia to prevent seizures
Answer: C
Explanation:
Section: Questions Set D
Explanation:
(A) Assessment should focus on detection of tetany, which is the most common symptom of hypoparathyroidism. Left undetected and untreated, tetany resulting from hypocalcemia can progress to seizures. (B) Hypocalcemia is difficult to detect on nursing assessment alone. Abdominal cramping may be an indication of hypocalcemia, but laboratory data are required to confirm diagnosis. (C) Depression can be a symptom of hypoparathyroidism, but it is not definitive. (D) Premature cataract formation can occur, but it also is not specific to parathyroidism and poses no immediate danger to the client.
NEW QUESTION 203
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 at the next visit"
- B. Rh-immune globulin within 3 days of delivery"
- C. Rubella vaccine at the next visit"
- D. Rubella vaccine after delivery on the day of discharge"
Answer: D
Explanation:
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 204
During the active phase of rheumatic fever, the nurse teaches parents of a child with acute rheumatic fever to assist in minimizing joint pain and promoting healing by:
- A. Immobilizing the joints in functional position using splints, rolls, and pillows
- B. Massaging the joints briskly with lotion or liniment after bath
- C. Applying warm water bottle or heating pads over involved joints
- D. Putting all joints through full range-of-motion twice daily
Answer: A
Explanation:
(A) Any movement of the joint causes severe pain. (B) Touching or moving the joint causes severe pain. (C) Immobilization in a functional position allows the joint to rest and heal. (D) Pressure from the warm water bottle or pads can cause severe pain or burning of the skin.
NEW QUESTION 205
A 10-month-old infant's mother says that he takes fresh whole milk eagerly, but that when she offered him baby foods at 6 months of age, he pushed them out of his mouth. Because he has gained weight appropriately, she has quit trying to get him to eat other foods. The nurse's response is based on the knowledge that:
- A. Milk intake should be limited to no more than four 8-oz bottles per day and should be followed by iron- enriched cereal or other solid foods or juices
- B. He should be started on iron-enriched cereal, meat, vegetables, fruits, and juices prior to bottle feeds.
Milk intake should be limited to 1 qt/day - C. It is acceptable to continue to give him whole milk and to delay giving solid foods as long as he takes a vitamin supplement daily
- D. Milk is an excellent food and will meet his nutritional needs adequately until he is ready to eat solid foods
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) If the infant is given the bottle first, he will be less likely to be hungry enough to eat the solid foods. (B) Milk is deficient in iron, vitamin C, zinc, and fluoride. It does not provide an adequate diet. (C) The vitamin supplement will help, but the infant needs an iron supplement. (D) Giving the solid food when the infant is hungriest will increase the likelihood that he will eat. The more solid food he takes, the less milk he will desire.
NEW QUESTION 206
A 48-year-old male client is hospitalized with mild ascites, bruising, and jaundice. He has a 20-year history of alcohol abuse. The client is diagnosed with cirrhosis. His serum ammonia level is high, indicating hepatic encephalopathy. He has esophageal varices. Which of the following may cause the varices to rupture?
- A. Ingestion of barbiturates
- B. Ingestion of antacids
- C. Lifting heavy objects
- D. Walking briskly
Answer: C
Explanation:
(A) Lifting heavy objects will increase intrathoracic pressure, thus placing the client at risk for rupturing esophageal varices. (B, C, D) This activity will not cause an increase in intrathoracic pressure.
NEW QUESTION 207
A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:
- A. Provide an indicator of respiratory effort
- B. Provide a means to measure chest drainage
- C. Prevent air from entering the pleural space
- D. Prevent fluid from entering the pleural space
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) A chest tube extends from the pleural space to a collection device. The tube is placed below the surface of the saline so that air cannot enter the pleural space. (B) Fluid may enter the pleural space as a result of injury or disease. A chest tube may drain fluid from the pleural space, but the water seal is not involved in this. (C) Chest drainage should be measured, but the water seal is not involved in this. (D) Fluctuations in the tube in the water-sealed bottle will give an indication of respiratory effort, but that is not the purpose of the water seal.
NEW QUESTION 208
When providing dietary teaching to an individual who has diabetes mellitus, type II, the nurse discusses the importance of consuming the recommended daily allowance of which of the following electrolytes?
- A. Magnesium
- B. Sodium
- C. Potassium
- D. HCO3
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Potassium intake that meets the recommended daily allowance is important, especially in clients who have a history of cardiac disease. (B) Low levels of magnesium can cause an increase in resistance to insulin and can lead to carbohydrate intolerance. (C) Sodium is an important electrolyte for all clients but has no direct effect on diabetes mellitus. (D) Bicarbonate plays an important role in acid-base balance. It is equally necessary for maintenance of all body functions.
NEW QUESTION 209
A child has a nursing diagnosis of fluid volume excess related to compromised regulatory mechanisms. Which of the following nursing interventions is the most accurate measure to include in his care?
- A. Check urine specific gravity of each voiding.
- B. Observe for edema.
- C. Monitor intake and output.
- D. Weigh the child twice daily on the same scale.
Answer: D
Explanation:
Explanation
(A) Although all of these interventions are important aspects of care, weight is the most sensitive indicator of fluid balance. (B) Although monitoring intake and output is important, weight is a more accurate indicator of fluid status. (C) Urine specific gravity does not necessarily indicatefluid volume excess. (D) Edema may not be apparent, yet the client may have fluid volume excess.
NEW QUESTION 210
Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, "Begin oxytocin induction at 1 mU/min." The nurse should:
- A. Increase the dosage by 2 mU/min increments at 15-minute intervals
- B. Question the order
- C. Maintain the dosage when duration of contractions is 40-60 seconds and frequency is at 212-4 minute intervals
- D. Begin the oxytocin induction as ordered
Answer: B
Explanation:
(A)
Oxytocin stimulates labor but should not be used until CPD (cephalopelvic disproportion) is ruled out in a dysfunctional labor. (B) This answer is the correct protocol for oxytocin administration, but the medication should not be used until CPD is ruled out.
(C)
This answer is the correct manner to interpret effective stimulation, but oxytocin should not be used until CPD is ruled out. (D) This answer is the appropriate nursing action because the scenario presents adysfunctional labor pattern that may be caused by CPD. Oxytocin administration is contraindicated in CPD.
NEW QUESTION 211
In acute episodes of mania, lithium is effective in 1-2 weeks, but it may take up to 4 weeks, or even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms. In addition to the lithium, which one of the following medications might the physician prescribe?
- A. Diazepam (Valium)
- B. Sertraline (Zoloft)
- C. Alprazolam (Xanax)
- D. Haloperidol (Haldol)
Answer: D
Explanation:
(A) Diazepam is an antianxiety medication and is not designed to reduce psychotic symptoms. (B) Haloperidol is an antipsychotic medication and may be used until the lithium takes effect. (C) Sertraline is an antidepressant and is used primarily to reduce symptoms of depression. (D) Alprazolam is an antianxiety medication and is not designed to reduce psychotic symptoms.
NEW QUESTION 212
Parents should be taught not to prop the bottle when feeding their infants. In addition to the risk of choking, it puts the infant at risk for:
- A. Asthma
- B. Conjunctivitis
- C. Tonsillitis
- D. Otitis media
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Because the eustachian tube is short and straight in the infant, formula that pools in the back of the throat attacks bacteria which can enter the middle ear and cause an infection. (B) Asthma is not associated with propping the bottle. (C) Conjunctivitis is an eye infection and not associated with propping the bottle. (D) Tonsillitis is usually a result of pharyngitis and not propping the bottle.
NEW QUESTION 213
In assessing cardiovascular clients with progression of aortic stenosis, the nurse should be aware that there is typically:
- A. Systemic venous engorgement
- B. Increased pressure in the pulmonary veins and pulmonary edema
- C. Decreased pulmonary blood flow and cyanosis
- D. Increased left ventricular systolic pressures and hypertrophy
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) These signs are seen in pulmonic stenosis or in response to pulmonary congestion and edema and mitral stenosis. (B) These signs are seen primarily in mitral stenosis or as a late sign in aortic stenosis after left ventricular failure. (C) These signs are seen primarily in right-sided heart valve dysfunction. (D) Left ventricular hypertrophy occurs to increase muscle mass and overcome the stenosis; left ventricular pressures increase as left ventricular volume increases owing to insufficient emptying.
NEW QUESTION 214
Following her surgery, a 5-year-old child will return to the pediatric unit with a long-arm cast. She experienced a supracondylar fracture of the humerus near the elbow. Which nursing action is most essential during the first
24 hours after surgery and cast application?
- A. Assessment of neurovascular status
- B. Mobilization of the child
- C. Discharge teaching
- D. Pain management
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Mobilization is important but not absolutely essential. (B) Discharge teaching should be initiated prior to surgery as well as during the postoperative period. (C) Assessment and management of pain are necessary and high in priority. (D) Neurovascular status of the extremity is of primary importance. The risk of circulatory impairment exists with any cast application. This type of fracture is common in children. A high incidence of neurovascular complications exists with fractures near the elbow.
NEW QUESTION 215
A female client at 37 weeks' gestation has just undergone a nonstress test. The results were two fetal movements with a corresponding increase in fetal heart rate (FHR) of 15 bpm lasting 15 seconds within a
20-minute period. Her results would be classified as:
- A. Non-reactive; needs follow-up contraction stress test
- B. Reactive; needs follow-up contraction stress test
- C. Non-reactive; no contraction stress test required
- D. Reactive; no contraction stress test required
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) A contraction stress test is unnecessary following a reactive (normal) nonstress test. (B) The results are considered reactive, indicating that the fetus is not showing distress. Therefore, a contraction stress test, which is a more in-depth test for fetal distress, is unnecessary. (C) A nonreactive test would show fewer than two fetal movements or a failure of the FHR to increase at least 15 bpm with the movements in a 20-minute period. (D) A contraction stress test should follow a nonreactive nonstress test to validate fetal distress.
NEW QUESTION 216
The client tells the nurse, "I have pain in my left shoulder."
This is considered:
- A. Evaluation process
- B. Subjective information
- C. Objective information
- D. Complaining
Answer: B
Explanation:
(A) Evaluation process follows a nursing intervention. (B) Objective information can be measured. (C) Subjective information is provided by a person. (D) Client is reporting a symptom that needs to be assessed.
NEW QUESTION 217
In assessing cardiovascular clients with progression of aortic stenosis, the nurse should be aware that there is typically:
- A. Systemic venous engorgement
- B. Increased pressure in the pulmonary veins and pulmonary edema
- C. Decreased pulmonary blood flow and cyanosis
- D. Increased left ventricular systolic pressures and hypertrophy
Answer: D
Explanation:
Explanation
(A) These signs are seen in pulmonic stenosis or in response to pulmonary congestion and edema and mitral stenosis. (B) These signs are seen primarily in mitral stenosis or as a late sign in aortic stenosis after left ventricular failure. (C) These signs are seen primarily in right-sided heart valve dysfunction. (D) Left ventricular hypertrophy occurs to increase muscle mass and overcome the stenosis; left ventricular pressures increase as left ventricular volume increases owing to insufficient emptying.
NEW QUESTION 218
The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have:
- A. Nicotine withdrawal
- B. A birth defect
- C. A low birth weight
- D. Anemia
Answer: C
Explanation:
Section: Questions Set F
Explanation:
(A) Women who smoke during pregnancy are at increased risk for miscarriage, preterm labor, and IUGR in the fetus. (B) Although smoking produces harmful effects on the maternal vascular system and the developing fetus, it has not been directly linked to fetal anomalies. (C) Smoking during pregnancy has not been directly linked to anemia in the fetus. (D) Smoking during pregnancy has not been linked to nicotine withdrawal symptoms in the newborn.
NEW QUESTION 219
The cardiac client who exhibits the symptoms of disorientation, lethargy, and seizures may be exhibiting a toxic reaction to:
- A. Digoxin (Lanoxin)
- B. Nitroglycerin IV (Tridil)
- C. Lidocaine (Xylocaine)
- D. Quinidine gluconate or sulfate (Quinaglute,Quinidex)
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Side effects of digoxin include headache, hypotension, AV block, blurred vision, and yellow-green halos. (B) Side effects of lidocaine include heart block, headache, dizziness, confusion, tremor, lethargy, and convulsions. (C) Side effects of quinidine include heart block, hepatotoxicity, thrombocytopenia, and respiratory depression. (D) Side effects of nitroglycerin include postural hypotension, headache, dizziness, and flushing.
NEW QUESTION 220
The nurse writes the following nursing diagnosis for a client in acute renal failure - Impaired gas exchange related to:
- A. Increased levels of vitamin D
- B. Decreased production of renin
- C. Decreased red blood cell production
- D. Increased red blood cell production
Answer: C
Explanation:
Section: Questions Set G
Explanation:
(A) Red blood cell production is impaired in renal failure owing to impaired erythropoietin production. This causes a decrease in the delivery of oxygen to the tissue and impairs gas exchange. (B) The conversion of vitamin D to its physiologically active form is impaired in renal failure. (C) In renal failure, a decrease in red blood cell production occurs owing to an impaired production of erythropoietin, leading to impaired gas exchange at the cellular level. (D) The decreased production of renin in renal failure causes an increased production of aldosterone causing sodium and water retention.
NEW QUESTION 221
A 32-year-old female client is being treated for Guillain-Barre syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation?
- A. Complaints of a headache
- B. Loss of superficial and deep tendon reflexes
- C. Complaints of shortness of breath
- D. Facial paralysis
Answer: C
Explanation:
Section: Questions Set D
Explanation:
(A) Headaches are not associated with Guillain-Barre syndrome. (B) Loss of superficial and deep tendon reflexes is expected with this diagnosis. (C) Complaints of shortness of breath must be further evaluated. Forty percent of all clients have some detectable respiratory weakness and should be prepared for a possible tracheostomy. Pneumonia is also a common complication of this syndrome. (D) Facial paralysis is expected and is not considered abnormal.
NEW QUESTION 222
A client was not using his seat belt when involved in a car accident. He fractured ribs 5, 6, and 7 on the left and developed a left pneumothorax. Assessment findings include:
- A. Decreased breath sounds on the left and chest pain with movement
- B. Rhonchi and frothy sputum
- C. Crackles and paradoxical chest wall movement
- D. Wheezing and dry cough
Answer: A
Explanation:
Section: Questions Set C
Explanation:
(A) Crackles are caused by air moving through moisture in the small airways and occur with pulmonary edema.
Paradoxical chest wall movement occurs with flail chest when a segment of the thorax moves outward on inspiration and inward on expiration. (B) Decreased breath sounds occur when a lung is collapsed or partially collapsed. Chest pain with movement occurs with rib fractures. (C) Rhonchi are caused by air moving through large fluid-filled airways. Frothy sputum may occur with pulmonary edema. (D) Wheezing is caused by fluid in large airways already narrowed by mucus or bronchospasm. Dry cough could indicate a cardiac problem.
NEW QUESTION 223
......
Pass Your NCLEX Exam with NCLEX-RN Exam Dumps: https://www.surepassexams.com/NCLEX-RN-exam-bootcamp.html
NCLEX-RN Exam Dumps PDF Updated Dump from SurePassExams Guaranteed Success: https://drive.google.com/open?id=1PXwzuVrX2HoBoz8UX9nICrE0zRFtMiJm