Achieve the NCLEX-RN Exam Best Results with Help from NCLEX Certified Experts
Provide NCLEX-RN Practice Test Engine for Preparation
NEW QUESTION # 317
The physician of a client diagnosed with alcoholism orders neomycin 0.5 g q6h to prevent hepatic coma.
Neomycin decreases serum ammonia levels by:
- A. Decreasing the uptake of vitamin D, thereby drawing more water into the colon
- B. Acidifying colon contents by causing ammonia retention in the colon
- C. Decreasing nitrogen-forming bacteria in the intestines
- D. Irritating the bowel and promoting evacuation of stool
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Neomycin interferes with protein synthesis in the bacterial cell, causing bacterial death. Neomycin reduces the growth of the ammonia-producing bacteria in the intestines and is used for the treatment of hepatic coma. (B) This choice describes the action of lactulose, another drug commonly used to decrease systemic ammonia levels. (C) Neomycin's action doesnotdecrease uptake of vitamin D to reduce serum ammonia levels. (D) Bowel irritation with diarrhea is more likely to occur with administration of lactulose rather than of neomycin. Besides, diarrhea is a side effect of a drug, not the action of the drug.
NEW QUESTION # 318
An 8-year-old child comes to the physician's office complaining of swelling and pain in the knees. His mother says, "The swelling occurred for no reason, and it keeps getting worse." The initial diagnosis is Lyme disease.
When talking to the mother and child, questions related to which of the following would be important to include in the initial history?
- A. A decreased urinary output and flank pain
- B. A fever of over 103F occurring over the last 2-3 weeks
- C. Rashes covering the palms of the hands and the soles of the feet
- D. Headaches, malaise, or sore throat
Answer: D
Explanation:
Explanation
(A) Urinary tract symptoms are not commonly associated with Lyme disease. (B) A fever of 103F is not characteristic of Lyme disease. (C) The rash that is associated with Lyme diseasedoes not appear on the palms of the hands and the soles of the feet. (D) Classic symptoms of Lyme disease include headache, malaise, fatigue, anorexia, stiff neck, generalized lymphadenopathy, splenomegaly, conjunctivitis, sore throat, abdominal pain, and cough.
NEW QUESTION # 319
A neonate was admitted to the hospital with projectile vomiting. According to the parents, the baby had experienced vomiting episodes after feeding for the last 2 days. A medical diagnosis of hypertrophic pyloric stenosis was made. On assessment, the infant had poor skin turgor, sunken eyeballs, dry skin, and weight loss. Identify the number-one priority nursing diagnosis.
- A. Altered bowel elimination
- B. Fluid volume deficit
- C. Anxiety
- D. Altered nutrition
Answer: B
Explanation:
(A) Fluid volume deficit is the major problem. Symptoms of dehydration are evident. The effects of fluid and electrolyte balance may be life threatening. Rehydration can be accomplished effectively through IV fluids and electrolytes. (B) Vomiting may also signal a nutritional problem. However, the nutritional problem would be secondary to fluid and electrolyte disturbances. The infant may also be placed on NPO status. (C) With vomiting, a decrease in the size and number of stools is expected. (D) The infant cannot verbalize feelings of anxiety. Anxiety would not be an appropriate diagnosis.
NEW QUESTION # 320
Which of the following findings would be abnormal in a postpartal woman?
- A. Urinary output of 3000 mL on the second day after delivery
- B. Chills shortly after delivery
- C. Pulse rate of 60 bpm in morning on first postdelivery day
- D. An oral temperature of 101F (38.3C) on the third day after delivery
Answer: D
Explanation:
(A) Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous response or to vasomotor changes. If not followed by a fever, it is clinically innocuous. (B) The pulse rate during the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt to the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. (C) Urinary output increases during the early postpartal period (12-24 hours) owing to diuresis. The kidneys must eliminate an estimated 2000-3000 mL of extracellular fluid associated with a normal pregnancy. (D) A temperature of 100.4F (38C) may occur after delivery as a result of exertion and dehydration of labor. However, any temperature greater than 100.4F needs further investigation to identify any infectious process.
NEW QUESTION # 321
The nurse instructs a pregnant client (G2P1) to rest in a side-lying position and avoid lying flat on her back.
The nurse explains that this is to avoid "vena caval syndrome," a condition which:
- A. Is seen mainly in first pregnancies
- B. Occurs when blood pressure increases sharply with changes in position
- C. May require medication if positioning does not help
- D. Results when blood flow from the extremities is blocked or slowed
Answer: D
Explanation:
Explanation
(A) Blood pressure changes are predominantly due to pressure of the gravid uterus. (B) Pressure of the gravid uterus on the inferior vena cava decreases blood return from lower extremities. (C) Inferior vena cava syndrome is experienced in the latter months of pregnancy regardless of parity. (D) There are no medications useful in the treatment of interior vena cava syndrome; alleviating pressure by position changes is effective.
NEW QUESTION # 322
A 32-year-old mother of two was brought to the hospital by her husband. He reported that his wife could no longer manage the house and children. She does not sleep and talks day and night. She has purchased some very expensive clothes. The nurse noted that the client speaks rapidly and changes the subject irrationally. This is an example of:
- A. Echolalia
- B. Hallucinations
- C. Flight of ideas
- D. Delusions
Answer: C
Explanation:
Explanation
(A) Rapidly moving from one topic to another without following any logical sequence is called flight of ideas.
(B) False beliefs are delusions. (C) False sensory perceptions are hallucinations ("hearing voices"). (D) Repeating words is called echolalia.
NEW QUESTION # 323
In addition to changing the mother's position to relieve cord pressure, the nurse may employ the following measure (s) in the event that she observes the cord out of the vagina:
- A. Immediately pour sterile saline on the cord, and repeat this every 15 minutes to prevent drying.
- B. Keep the cord warm and moist by continuous applications of warm, sterile saline compresses.
- C. Cover the cord with a wet sponge.
- D. Apply a cord clamp to the exposed cord, and cover with a sterile towel.
Answer: B
Explanation:
(A) Saline should be warmed; waiting 15 minutes may not keep the cord moist. (B) This choice does not specify what the sponge was "wet" with. (C) This measure would stop circulation to the fetus. (D) The cord should be kept warm and moist to maintain fetal circulation. This measure is an accepted nursing action.
NEW QUESTION # 324
Following the delivery of a healthy newborn, a client has developed thrombophlebitis and is receiving heparin IV. What are the signs and symptoms of a heparin overdose for which the nurse would need to observe during postpartum care of the client?
- A. Epistaxis, hematuria, dysuria
- B. Hematuria, ecchymosis, and epistaxis
- C. Dysuria
- D. Vertigo, hematuria, ecchymosis
Answer: B
Explanation:
Section: Questions Set D
Explanation:
(A) Dysuria is not a common symptom of heparin overdose. (B) Although epistaxis and hematuria are common symptoms of heparin overdose, dysuria is not. (C) Vertigo is not a common symptom of heparin overdose. (D) Hematuria, ecchymosis, and epistaxis are the most common signs and symptoms of a heparin overdose.
Others are thrombocytopenia, elevated liver enzymes, and local injection site complications.
NEW QUESTION # 325
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. 1 g sodium
- B. High carbohydrate, low cholesterol
- C. High protein, high carbohydrate
- D. Tyramine-free
Answer: D
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 # 326
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. Lip reading
- B. Auditory training
- C. Signing
- D. Speech
Answer: D
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 # 327
A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will:
- A. Drink at least 8 oz of cranberry juice daily
- B. Limit her fluid intake after 6 PM so that there is not a great deal of urine in her bladder while she sleeps
- C. Maintain a fluid intake of at least 2000 mL daily
- D. Wash her hands before and after voiding
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Cranberry juice helps to maintain urine acidity, thereby retarding bacterial growth. (B) A generous fluid intake will help to irrigate the bladder and to prevent bacterial growth within the bladder. (C) Hand washing is an effective means of preventing pathogen transmission. (D) Restricting fluid intake would contribute to urinary stasis, which in turn would contribute to bacterial growth.
NEW QUESTION # 328
A female client was recently diagnosed with gastric cancer. She entered the hospital and had a total gastrectomy with esophagojejunostomy. Her postoperative recovery was uneventful. On conducting discharge teaching, the nurse discusses changes in bodily function and lifestyle changes with the client. In order to prevent pernicious anemia, the nurse stresses that the client must:
- A. Increase the amount of iron in her diet
- B. Receive monthly blood transfusions
- C. Eat small quantities several times daily until she is able to tolerate food in moderate portions
- D. Understand the need for Vitamin B12 replacement therapy
Answer: D
Explanation:
Section: Questions Set E
Explanation:
(A) Monthly blood transfusions are not indicated postgastrectomy. (B) Increasing iron in the client's diet may cause irritation and will not alleviate pernicious anemia. (C) It may be necessary that the client eat small meals several times per day, but this measure has no relevance to prevention of pernicious anemia. (D) Pernicious anemia is caused by lack of Vitamin B12, and replacement therapy will be necessary because the client's stomach has been removed.
NEW QUESTION # 329
An infant weighing 15 lb has just been treated for severe diarrhea in the hospital. Discharge instructions by the nurse will include maintenance fluid requirements for the pediatric client. Which of the following values best indicates the nurse's understanding of normal fluid requirements for this infant?
- A. 960 mL/day
- B. 330 mL/day
- C. 680 mL/day
- D. 240 mL/day
Answer: C
Explanation:
Section: Questions Set E
Explanation:
(A, C, D) These answers are incorrect. (B) Normal fluid requirement for this pediatric client is based on the fact that 0-10 kg of weight equals 100 mL/kg per day. This infant weighs 15 pounds (6.8 kg). Thus, 100 mL X 6.8
680 mL/day.
NEW QUESTION # 330
A husband and wife and their two children, age 9 and age 5, are requesting family therapy. Which of the following strategies is most therapeutic for the nurse to use during the initial interaction with a family?
- A. Allow family members to assume the seats as they choose.
- B. Encourage the mother to speak for the children.
- C. Interpret immediately what seems to be going on within the family.
- D. Always allow the most vocal person to state the problem first.
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) One will always hear what the most vocal person has to say. It is best to start with the quietest family member to encourage that person to express emotions. (B) All family members are encouraged to speak for themselves. (C) In the initial family assessment, only data collection occurs; interpretations are made later. (D) Allowing family members to choose their own seats will assist the nurse in assessing the family system and in determining who feels closer to whom.
NEW QUESTION # 331
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. Pain management
- B. Mobilization of the child
- C. Assessment of neurovascular status
- D. Discharge teaching
Answer: C
Explanation:
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 # 332
The mother of a preschooler reports to the nurse that he frequently tells lies. The admission assessment of the child indicates possible child abuse. The nurse knows that his:
- A. Lying is normal behavior for a preschool child who is learning to separate fantasy from reality.
- B. Behavior is not normal, and a child psychiatrist should be consulted.
- C. Mother is lying to protect herself.
- D. Behavior indicates a developmental delay, because preschoolers should be able to tell right from wrong.
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Because preschoolers often tell "stories" as they learn to differentiate fantasy from reality, the child's behavior is normal. (B) The nurse has no reason to believe the child's mother is lying, because children of his age often tell lies. (C) The child's lying is actually "storytelling" as he learns to separate fantasy from reality, a normal developmental task for his age group. (D) The child's behavior is consistent with his age and does not indicate a developmental delay.
NEW QUESTION # 333
Nursing care of the infant prior to surgical closure of a meningomyelocele would include:
- A. Aspirate any fluid from sac
- B. Cover sac with saline-soaked sterile dressing
- C. Do not apply dressing; keep sac open to air
- D. Cover sac with dry sterile dressing
Answer: B
Explanation:
(A) A dry, sterile dressing would adhere to the sac, causing tissue damage. (B) A saline-soaked sterile dressing protects the sac from contamination by air and prevents drying. (C) A sac open to air causes drying and potential for contamination. (D) This intervention is not an independent nursing action.
NEW QUESTION # 334
......
Detailed New NCLEX-RN Exam Questions for Concept Clearance: https://actualtests.trainingquiz.com/NCLEX-RN-training-materials.html
