[May-2024] NCLEX NCLEX-RN Exam Practice Test Questions - Test4Sure
Updated Certification Exam NCLEX-RN Dumps - Practice Test Questions
NEW QUESTION # 259
When assessing a child with diabetes insipidus, the nurse should be aware of the cardinal signs of:
- A. Anemia and vomiting
- B. Irritability relieved by feeding formula
- C. Hypothermia and azotemia
- D. Polyuria and polydipsia
Answer: D
Explanation:
(A) Anemia and vomiting are not cardinal signs of diabetes insipidus. (B) Polyuria and
polydipsia are the cardinal signs of diabetes insipidus. (C) Irritability relieved by feeding water, not formula, is a common sign, but not the cardinal sign, of diabetes insipidus. (D) Hypothermia and azotemia are signs, but not cardinal signs, of diabetes insipidus.
NEW QUESTION # 260
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. They represent the inlet of birth canal
- B. Ischial spines are the widest diameter of the pelvis
- C. They measure pelvic floor
- D. Ischial spines are the narrowest diameter of the pelvis
Answer: D
Explanation:
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 # 261
The nurse is caring for a laboring client. Assessment data include cervical dilation 9 cm; contractions every
1-2 minutes; strong, large amount of "bloody show." The most appropriate nursing goal for this client would be:
- A. Maintain client's privacy.
- B. Assist with assessment procedures.
- C. Provide strategies to maintain client control.
- D. Enlist additional caregiver support to ensure client's safety.
Answer: C
Explanation:
Explanation
(A) Privacy may help the laboring client feel safer, but measures that enhance coping take priority. (B) The frequency of assessments do increase in transition, but helping the client to maintain control and cope with this phase of labor takes on importance. (C) This laboring client is in transition, the most difficult part of the first stage of labor because of decreased frequency, increased duration and intensity, and decreased resting phase of the uterine contraction. The client's ability to cope is most threatened during this phase of labor, and nursing actions aredirected toward helping the client to maintain control. (D) Safety is a concern throughout labor, but helping the client to cope takes on importance in transition.
NEW QUESTION # 262
At 38 weeks' gestation, a client is in active labor. She is using her Lamaze breathing techniques. The RN is coaching her breathing and encouraging her to relax and work with her contractions. Which one of the following complaints by the client will alert the RN that she is beginning to hyperventilate with her breathing?
- A. "I am cold."
- B. "I feel dizzy."
- C. "I have a backache."
- D. "I am nauseous."
Answer: B
Explanation:
Section: Questions Set C
Explanation:
(A) Cold is not a symptom of hyperventilation. This could be due to the temperature of the room. (B) Backache is not a symptom of hyperventilation. This is probably due to the gravid uterus and its effect on the back muscles, or it may be due to the client's position in bed. (C) Dizziness is the first symptom of hyperventilation. It occurs because the body is eliminating too much CO2. (D) Nausea is not a symptom of hyperventilation. It could be a symptom of pain.
NEW QUESTION # 263
In performing the initial nursing assessment on a client at the prenatal clinic, the nurse will know that which of the following alterations is abnormal during pregnancy?
- A. Striae gravidarum
- B. Dysuria
- C. Colostrum
- D. Chloasma
Answer: B
Explanation:
Explanation
(A) Striae gravidarum are the normal stretch marks that frequently occur on the breasts, abdomen, and thighs as pregnancy progresses. (B) Chloasma is the "mask of pregnancy" that normally occurs in many pregnant women. (C) Dysuria is an abnormal danger sign during pregnancy and may indicate a urinary tract infection.
(D) Colostrum is a yellow breast secretion that is normally present during the last trimester of pregnancy.
NEW QUESTION # 264
When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is:
- A. Folate deficiency
- B. Stephens-Johnson syndrome
- C. Granulocytosis and nephrosis
- D. Leukopenic aplastic anemia
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Stephens-Johnson syndrome is a toxic effect of phenytoin. (B) Folate deficiency is a side effect of phenytoin, but not a toxic effect. (C) Leukopenic aplastic anemia is a toxic effect of carbamazepine (Tegretol). (D) Granulocytosis and nephrosis are toxic effects of trimethadione (Tridione).
NEW QUESTION # 265
Plans for the care of a client with an ulcer caused by emotional problems need to take into consideration that:
- A. The disorder is a threat to his physical well-being
- B. His priority needs are limited to medical management
- C. There is no real psychological basis for his illness
- D. He is unable to participate in planning his care
Answer: A
Explanation:
Explanation
(A) There may be a medical emergency that takes top priority; however, the basis of the problem is emotional.
(B) The problem is a physical manifestation of an emotional conflict. (C) The bleeding ulcer can be life threatening. (D) For lifestyle change to occur, the client must participate in the planning of his care so that he is committed to changes that will have positive results.
NEW QUESTION # 266
The nurse is caring for a client with pancreatitis. Which of the following IV medications would the nurse expect the physician to prescribe for control of pain in this client?
- A. Meperidine (Demerol)
- B. Kerolac tromethamine (Toradol)
- C. Promethazine (Phenergan)
- D. Morphine sulfate
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Morphine sulfate is contraindicated in clients with pancreatitis because it may cause spasms of the sphincter of Oddi and increase pancreatic pain. (B) Ketorolac tromethamine is currently not approved by the Food and Drug Administration for IV use. (C) Promethazine is a medication that has no analgesic properties. (D) Meperidine is the drug of choice for clients with pancreatitis. It will not cause spasms at the sphincter of Oddi, which can lead to increased pancreatic pain.
NEW QUESTION # 267
A client experiencing delusions states, "I came here because there were people surrounding my house that wanted to take me away and use my body for science." The best response by the nurse would be:
- A. "I know that must be frightening for you; let the staff know when you are having thoughts that trouble you."
- B. "There were no people surrounding your house, your relatives brought you here, and no one really wants your body for science."
- C. "I need more information on why you think others want to use your body for science."
- D. "Describe the people surrounding your house that want to take you away."
Answer: A
Explanation:
(A) Focusing on the delusional content does not reinforce reality. (B) Pursuing details or more information on the delusion reinforces the false belief and further distances the client from reality. (C) Challenging the client's delusional system may force the client to defend it, and you cannot change the delusion through logic. (D) Focusing on the feeling can reinforce reality and discourage the false belief. Seeking out staff when thoughts are troublesome can help to decrease anxiety.
NEW QUESTION # 268
A client hospitalized with a medical diagnosis of adjustment disorder versus personality disorder states, "Nobody cares about the clients." The nurse's most effective response would be:
- A. "You seem angry. Tell me more about how you feel."
- B. "How can you say that I don't care? We just met."
- C. "What makes you think the nurses don't care?"
- D. "You will feel differently about us in a few days."
Answer: A
Explanation:
(A) This statement is a defensive response that places the nurse in a vulnerable countertransference position, and at the same time, fails to challenge the client's "splitting" behavior. (B) This statement is a defensive response by the nurse. In addition, this type of nontherapeutic statement requests that the client explain the reasons for her behavior, a difficult task for an individual with limited insight. (C) This statement is a nontherapeutic response that both ignores the intensity of the client's emotions and the dynamics underlying "splitting" behavior. (D) By simultaneously acknowledging the client's emotional intensity and gently challenging her "splitting" behavior, the nurse addresses the client's current distortions and prepares for further interventions with angry or ambivalent feelings.
NEW QUESTION # 269
A 2-year-old child is recovering from surgery. Considering growth and development according to Erikson, the nurse identifies which of the following play activities as most appropriate?
- A. Watching Sesame Street on television
- B. Assembling a puzzle with large pieces
- C. Being taken for a wheelchair ride
- D. Listening to a story about the Muppets
Answer: B
Explanation:
Section: Questions Set F
Explanation:
(A) A 2-year-old child is in the stage of autonomy, according to Erikson. Assembling a puzzle with large pieces enables her to "do it herself." (B) A wheelchair ride would probably be fun, but it is not directed toward helping the child to achieve autonomy. (C) Listening to a story may be fun and educational, but it is not directed toward helping the child to achieve autonomy. (D) Watching television may be a favorite activity, but it does not foster autonomy.
NEW QUESTION # 270
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. Sucking his thumb
- B. Rolling from his back to his tummy
- C. Falling asleep
- D. Crying
Answer: D
Explanation:
Explanation/Reference:
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 # 271
A client has received preoperative teaching for the vertical partial laryngectomy that he is scheduled to have in the morning. The nurse determines that the teaching has been effective when the client states:
- A. "I will have very little difficulty swallowing after surgery."
- B. "The quality of my voice will be excellent after surgery."
- C. "I may also have to have a radical neck dissection done."
- D. "I know I will need special swallowing training after my surgery."
Answer: A
Explanation:
Section: Questions Set D
Explanation:
(A) A client with a supraglottic (horizontal partial) laryngectomy would require special swallowing training, not a vertical partial laryngectomy. (B) The quality of the client's voice will be altered but adequate for communication. (C) The client will have minimal difficulty swallowing. (D) A radical neck dissection may be done with a total laryngectomy, but not with a partial laryngectomy.
NEW QUESTION # 272
The mother of a 7-year-old mental health center client reports that the client has refused to attend gymnastics for the past 2 weeks. Prior to that time, the child liked going to this class and was attending 3 times a week. In talking with the client, the nurse would:
- A. Ask her why she doesn't like gymnastics anymore
- B. Reassure her that things will get better once she begins the classes again
- C. Tell her that it is OK to be afraid of this activity
- D. Ask her to describe how things were at gymnastics before she started refusing to go
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) The child has not said that she dislikes gymnastics. (B) The nurse will be able to obtain information on what events occurred at gymnastics prior to her refusal to attend. The nurse will also gain information about the child's perception of the problem. (C) The child has not said she is afraid to go to gymnastics. (D) False reassurance is inappropriate.
NEW QUESTION # 273
A 1000-mL dose of lactated Ringer's solution is to be infused in 8 hours. The drop factor for the tubing is 10 gtt/mL. How many drops per minute should the nurse administer?
- A. 21 gtt/min
- B. 48 gtt/min
- C. 20 gtt/min
- D. 125 gtt/min
Answer: A
Explanation:
(A) This answer is a miscalculation. (B) This answer is a miscalculation. (C) This answer has not been rounded off to an even number. (D) 20.8, or 21 gtt/min.
NEW QUESTION # 274
......
NCLEX-RN exam is designed to assess the candidate's ability to apply critical thinking, problem-solving, and clinical judgment in real-life nursing situations. NCLEX-RN exam consists of multiple-choice questions that are computer-adaptive, meaning that the difficulty level of the questions varies based on the candidate's response to the previous question. NCLEX-RN exam covers four major categories: safe and effective care environment, health promotion and maintenance, psychosocial integrity, and physiological integrity.
Updated Verified NCLEX-RN dumps Q&As - Pass Guarantee or Full Refund: https://freecert.test4sure.com/NCLEX-RN-exam-materials.html