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1 Exam : NCLEX -RN Title : National Council Licensure Examination(NCLEX -RN) Vendor : NCLEX Version : V12.35 2 NO.1 A. depressed client is seen a.t the menta.l hea.lth center for follow -u.p a.fter a.n a.ttempted su.icide 1 week a.go. She ha.s ta.ken ph enelzine s u.lfa.te (Na.rdil), a. monoa.mine oxida.se (MA.O) inhibitor, for 7 stra.ight da.ys. She sta.tes tha.t she is not feeling a.ny better. The n u.rse expla.ins tha.t the dru.g mu.st a.ccu.mu.la.te to a.n effective level before symptoms a.re tota.lly relieved. Symptom relief is expected to occ u.r within: A. 10 da.ys B. 2-4 weeks C. 2 months D. 3 months A.nswer: B Expla.na.tio n: (A) This a.nswer is incorrect. It ca.n ta.ke u.p to 1 month for thera.pe u.tic effect of the medica.tion. (B) This a.nswer is correct. Beca. u.se MA.O inhibitors a.re slow to a.ct, it ta.kes 2-4 weeks before improvement of symptoms is noted. (C) This a.nswer is incorrect. It ca.n ta.ke u.p to 1 month for thera.pe u.tic effect of the medica.tion. (D) This a.nswer is incorrect. Thera.pe u.tic effects of the medica .tion a.re noted within 1 month of dru.g thera.py. NO.2 Cystic fibrosis is tra.nsmitted a.s a.n a.u.tosoma.l recessive tra.it. This mea.ns tha.t: A. Mothers ca.rry the gene a.nd pa.ss it to their sons B. Fa.thers ca.rry the gene a.nd pa.ss it to their da.u.ghter s C. Both pa.rents m u.st ha.ve the disea.se for a. child to ha.ve the disea.se D. Both pa.rents m u.st be ca.rriers for a. child to ha.ve the disea.se A.nswer: D Expla.na.tio n: (A.) Cystic fibrosis is not a.n X -linked or sex -linked disea.se. (B) The only cha.ra.c teristic on the Y chromosome is the tra.it for ha.iry ea.rs. (C) Both pa.rents do not need to ha.ve the disea.se bu.t mu.st be ca.rriers. (D) If a. tra.it is recessive, two genes (one from ea.ch pa.rent) a.re necessa.ry to prod u.ce a.n a.ffected child. NO.3 A. 24-yea.r -old client presents to the emergency depa.rtment protesting "I a.m God." The nu.rse identifies this a.s a.: A. Delu.sion B. Illu.sion C. Ha.ll u.cina.tion D. Conversion A.nswer: A. Expla.na.tion: (A.) Del u.sion is a. fa.lse belief. (B) Ill u.sion is the mi srepresenta.tion of a. rea.l, externa.l sensory 3 experience. (C) Ha.ll u.cina.tion is a. fa.lse sensory perception involving a.ny of the senses. (D) Conversion is the expression of intra.psychic conflict thro u.gh sensory or motor ma.nifesta.tions. NO.4 In a. cu.te episodes of ma.nia., lithi u.m is effective in 1-2 weeks, b u.t it ma.y ta.ke u.p to 4 weeks, or 4 even a. few months, to trea.t symptoms fu.lly. Sometimes a.n a.ntipsychotic a.gent is prescribed du.ring the first few da.y s or weeks of a.n a.c u.te episode to ma.na.ge severe beha.viora.l excitement a.nd a.c u.te psychotic symptoms. In a.ddition to the lithi u.m, which one of the following medica.tions might the physicia.n prescribe? A. Dia.zepa.m (Va.li u.m) B. Ha.loperidol (Ha.ldol) C. Sertra.line (Zoloft) D. A.lpra.zola.m (Xa.na.x) A.nswer: B Expla.na.tion: (A.) Dia.zepa.m is a.n a.ntia.nxiety medica.tion a.nd is not designed to redu.ce psychotic symptoms. (B) Ha.loperidol is a.n a.ntipsychotic medica.tion a.nd ma.y be u.sed u.ntil the li thiu.m ta.kes effect. (C) Sertra.line is a.n a.ntidepressa.nt a.nd is u.sed prima.rily to red u.ce symptoms of depression. (D) A.lpra.zola.m is a.n a.ntia.nxiety medica.tion a.nd is not designed to red u.ce psychotic symptoms. NO.5 A. violent client rema.ins in restra.ints for severa.l hou.rs. Which of the following interventions is most a.ppropria.te while he is in restra.ints? A. Give flu.ids if the client req u.ests them. B. A.ssess skin integrity a.nd circu.la.tion of extremities before a.pplying restra.ints a.nd a.s they a.re removed. C. Mea.s u.re vita.l signs a.t lea.st every 4 hou.rs. D. Relea.se restra.ints every 2 hou.rs for client to exercise. A.nswer: D Expla.na.tio n: (A.) Fl u.ids (no u.rishment) sho u.ld be offered a.t reg u.la.r interva.ls whether the client req u.ests (or refu.ses) them or not. (B) Skin integrity a.nd circu.la.tion of the extremities shou.ld be checked regu.la.rly while the client is restra.ined, not only before restra.ints a.re a.pplied a.nd a.fter they a.re removed. (C) Vita.l signs sho u.ld be c hecked a.t lea.st every 2 ho u.rs. If the client rema.ins a.gita.ted in restra.ints, vita.l signs shou.ld be monitored even more closely, perha.ps every 1-2 hou.rs. (D) Restra.ints sho u.ld be relea.sed every 2 ho u.rs for exercise, one extremity a.t a. time, to ma.inta.in m u.scle tone, skin a.nd joint integrity, a.nd circ u.la.tion. NO.6 The pedia.tricia.n ha.s dia.gnosed tinea. ca.pitis in a.n 8 - yea.r -old girl a.nd ha.s pla.ced her on ora.l griseof u.lvin. The nu.rse shou.ld empha.size which of these instr u.ctions to the mother a.nd/or child? A. A.dminister ora.l griseof u.lvin on a.n empty stoma.ch for best resu.lts. B. Discontin u.e dru.g thera.py if food ta.stes fu.nny. C. Ma.y discontin u.e medica.tion when the child experiences symptoma.tic relief. D. Observe for hea.da .ches, dizziness, a.nd a.norexia.. A.nswer: D Expla.na.tio 5 n: (A.) Giving the dru.g with or a.fter mea.ls ma.y a.lla.y ga.strointestina.l discomfort. Giving the dru.g with a. fa.tty mea.l (ice crea.m or milk) increa.ses a.bsorption ra.te. (B) Griseof u.lvin ma.y a.lter ta.ste sensa.tions 6 a.nd thereby decrea.se the a.ppetite. Monitoring of food inta.ke is importa.nt, a.nd ina.deq u.a.te nu.trient inta.ke shou.ld be reported to the physicia.n. (C) The child ma.y experience sympto ma.tic relief a.fter 48- 96 ho u.rs of thera.py. It is importa.nt to stress contin u.ing the dr u.g thera.py to prevent rela.pse ( u.su.a.lly a.bo u.t 6 weeks). (D) The incidence of side effects is low; however, hea.da.ches a.re common. Na. u.sea., vomiting, dia .rrhea., a.nd a.norexia. ma.y occ u.r. Dizziness, a.ltho u.gh u.ncommon, sho u.ld be reported to the physicia.n. NO.7 A. client with cirrhosis of the liver becomes coma.tose a.nd is sta.rted on neomycin 300 mg q6h via. na.soga.stric t u.be. The ra.tiona.le for this thera.py is to: A. Prevent systemic infection B. Promote diu.resis C. Decrea.se a.mmonia. forma.tion D. A.cidify the sma.ll bowel A.nswer: C Expla.na.tio n: (A.) Neomycin is a.n a.ntibiotic, b u.t this is not the Ra.tiona.le for a.dministering it to a. client in hepa.tic coma.. (B) Diu.retics a.nd sa.lt-free a.lbu.min a.re u.sed to promote diu.resis in clients with cirrhosis of the liver. (C) Neomycin destroys the ba.cteria. in the intestines. It is the ba.cteria. in the bowel tha.t brea.k down protein into a.mmoni a.. (D) La.ct u.lose is a.dministered to crea.te a.n a.cid environment in the bowel. A.mmonia. lea.ves the blood a.nd migra.tes to this a.cidic environment where it is tra.pped a.nd excreted. NO.8 A. 5-yea.r -old ha.s ju.st ha.d a. tonsillectomy a.nd a.denoi dectomy. Which of these nu.rsing mea.s u.res shou.ld be incl u.ded in the postopera.tive ca.re? A. Enco u.ra.ge the child to cou.gh u.p blood if present. B. Give wa.rm clea.r liq u.ids when f u.lly a.lert. C. Ha.ve child ga.rgle a.nd do toothbr u.shing to remove old bloo d. D. Observe for evidence of bleeding. A.nswer: D Expla.na.tio n: (A.) The nu.rse shou.ld disco u.ra.ge the child from cou.ghing, clea.ring the throa.t, or pu.tting objects in his mou.th. These ma.y ind u.ce bleeding. (B) Cool, clea.r liq u.ids ma.y be given whe n child is f u.lly a.lert. Wa.rm liq u.ids ma.y dislodge a. blood clot. The n u.rse sho u.ld a.void red - or brown -colored liqu.ids to disting u.ish fresh or old blood from ingested liq u.id sho u.ld the child vomit. (C) Ga.rgles a.nd vigoro u.s toothbr u.shing co u.ld initia.te bleeding. (D) Postopera.tive hemorrha.ge, tho u.gh u.nu.su.a.l, ma.y occ u.r. The n u.rse sho u.ld observe for bleeding by looking directly into the throa.t a.nd for vomiting of bright red blood, contin u.ou.s swa.llowing, a.nd cha.nges in vita.l s igns. NO.9 A.n 80 -yea.r -old ma.le client with a. history of a.rteriosclerosis is experiencing severe pa.in in his left leg tha.t sta.rted a.pproxima.tely 20 minu.tes a.go. When performing the a.dmission a.ssessment, the nu.rse wou.ld expect to observe whic h of the following: A. Both lower extremities wa.rm to tou.ch with 2_peda.l pu.lses 7 B. Both lower extremities cya.notic when pla.ced in a. dependent position IT Certification Guaranteed, The Easy Way! 8 C. Decrea.sed or a.bsent peda.l p u.lse in the left leg D. The left leg wa.rmer to tou.ch tha.n the right leg A.nswer: C Expla.na.tio n: (A.) This sta.tement describes a. norma.l a.ssessment finding of the lower extremities. (B) This a.ssessment finding reflects problems ca.u.sed by veno u.s insu.fficiency. (C) Decrea.sed or a.bsentpeda .l pu.lses reflect a. problem ca. u.sed by a.rteria.l ins u.fficiency. (D) The leg tha.t is experiencing a.rteria.l insu.fficiency wou.ld be cool to to u.ch d u.e to the decrea.sed circ u.la.tion. NO.10 A. 16 -month -old infa.nt is being prepa.red for tetra.logy of Fa.llot repa.ir. In the n u.rsing a.ssessment, which la.b va.lu.e shou.ld elicit fu.rther a.ssessment a.nd requ.ires notifica.tion of physicia.n? A. pH 7.39 B. White blood cell (WBC) co u.nt 10,000 WBCs/mm3 C. Hema.tocrit 60% D. Bleeding time of 4 minu.tes A.nswer: C Expla.na.tio n: (A.) Norma.l pH of a.rteria.l blood ga.ses for a.n infa.nt is 7.35 -7.45. (B) Norma.l white blood cell cou.nt in a.n infa.nt is 6,000 -17,500 WBCs/mm3. (C) Norma.l hema.tocrit in infa.nt is 28% -42%. A. 60% hema.tocrit ma.y indica.te polycythe mia., a. common complica.tion of cya.notic hea.rt disea.se. (D) Norma.l bleeding time is 2-7 min u.tes. NO.11 A. ma.le client is experiencing extreme distress. He begins to pa.ce u.p a.nd down the corridor. Wha.t nu.rsing intervention is a.ppropria.te when comm u.nica.ting with the pa.cing client? A. A.sk him to sit down. Spea.k slowly a.nd u.se short, simple sentences. B. Help him to recognize his a.nxiety. C. Wa.lk with him a.s he pa.ces. D. Increa.se the level of his s u.pervision. A.nswer: C Expla.na.tio n: (A.) The n u.rse sho u.ld not a.sk him to sit down. Pa.cing is the a.ctivity he ha.s chosen to dea.l with his a.nxiety. The n u.rse dea.ling with this client sho u.ld spea.k slowly a.nd with short, simplesentences. (B) The client ma.y a.lrea.dy recognize the a.nxiety a.nd is a.ttempting to dea.l with it. (C) Wa.lk with the client a.s he pa.ces. This gives s u.pport while he u.ses a.nxiety -genera.ted energy. (D) Increa.sing the level of su.pervision ma.y be a.ppropria.te a.fter he stops pa.cing. It wou.ld minimize self -inju.ry a.nd/or loss of control. NO.12 Prior to a.n a.mniocentesis, a. feta.l u.ltra.so u.nd is done in order to: A. Eva.l u.a.te feta.l lu.ng ma.t u.rity IT Certification Guaranteed, The Easy Way! 9 B. Eva.l u.a.te the a.mo u.nt of a.mniotic fl u.id C. Loca.te the position of the pla.centa. a.nd fetu.s D. Ensu.re tha.t the fet u.s is ma.t u.re enou.gh to perform the a.mniocentesis A.nswer: C IT Certification Guaranteed, The Easy Way! 1 0 Expla.na.tion: (A.) A.mniocentesis ca.n be performed to a.ssess for l u.ng ma.t u.rity. Feta.l u.ltra.so u.nd ca.n be u.sed for gesta.tiona.l da.ting, a.lth ou.gh it does not sepa.ra.tely determine l u.ng ma.t u.rity. (B) U.ltra.so u.nd ca.n eva.l u.a.te a.mniotic fl u.id vol u.me, which ma.y be u.sed to determine congenita.l a.noma.lies. (C) A.mniocentesis involves remova.l of a.mniotic fl u.id for eva.l u.a.tion. Th e needle, inserted thro u.gh the a.bdomen, is gu.ided by u.ltra.so u.nd to a.void needle inju.ries, a.nd the test eva.l u.a.tes the position of the pla.centa. a.nd the fet u.s. (D) A.mniocentesis ca.n be performed a.s ea.rly a.s the 15th -17th week of pregna.nc y. NO.13 A. 25 -yea.r -old client believes she ma.y be pregna.nt with her first child. She sched u.les a.n obstetric exa.mina.tion with the nu.rse pra.ctitioner to determine the sta.t u.s of her possible pregna.ncy. Her la.st menstr u.a.l period bega.n Ma.y 20, a.nd her estima.ted da.te of confinement u.sing Na.gele's r u.le is: A. Ma.rch 27 B. Febr u.a.ry 1 C. Febr u.a.ry 27 D. Ja.nu.a.ry 3 A.nswer: C Expla.na.tio n: (A.)Ma.rch 27 is a. misca.lc u.la.tion. (B) Febr u.a.ry 1 is a. misca.lc u.la.tion. (C) Febr u.a.ry 27 is the corre ct a.nswer. To ca.lc u.la.te the estima.ted da.te of confinement u.sing Na.gele's ru.le, su.btra.ct 3 months from the da.te tha.t the la.st menstr u.a.l cycle bega.n a.nd then a.dd 7 da.ys to the res u.lt. (D) Ja.n u.a.ry 3 is a. misca.lc u.la.tion. NO.14 A. client is now pregna.nt for the second time. Her first child weighed 4536 g a.t delivery. The client's gl u.cose tolera.nce test shows eleva.ted blood s u.ga.r levels. Beca. u.se she only shows signs of dia.betes when she is pregna.nt, she is cla.ssified a.s ha .ving: A. Insu.lin-dependent dia.betes B. Type II dia.betes mellit u.s C. Type I dia.betes mellit u.s D. Gesta.tiona.l dia.betes mellit u.s A.nswer: D Expla.na.tio n: (A.) Insu.lin-dependent dia.betes mellit u.s, a.lso known a.s type I dia.betes, u.su.a.lly a.ppea.rs befor e the a.ge of 30 yea.rs with a.n a.br u.pt onset of symptoms req u.iring ins u.lin for ma.na.gement. It is not rela.ted to onset d u.ring pregna.ncy. (B) Non -insu.lin-dependent dia.betes (type II dia.betes) u.su.a.lly a.ppea.rs in older a.du.lts. It ha.s a. slow onset a.nd progression of symptoms. (C) This type of dia.betes is the sa.me a.s insu.lin-dependent dia.betes. (D) Gesta.tiona.l dia.betes mellit u.s ha.s its onset of symptoms d u.ring pregna.ncy a.nd u.su.a.lly disa.ppea.rs a.fter delivery. These symptom s a.re u.su.a.lly mild a.nd not life threa.tening, a.ltho u.gh they a.re a.ssocia.ted with increa.sed feta.l morbidity a.nd other feta.l complica.tions. IT Certification Guaranteed, The Easy Way! 1 1 NO.15 A. 44-yea.r -old fema.le client is receiving externa.l ra.dia.tion to her sca.p u.la. for meta.sta.s is of IT Certification Guaranteed, The Easy Way! 12 brea.st ca.ncer. Tea.ching rela.ted to skin ca.re for the client wo u.ld inclu.de which of the following? A. Tea.ch her to completely clea.n the skin to remove a.ll ointments a.nd ma.rkings a.fter ea.ch trea.tment . B. Tea.ch her to cover broken skin in the trea.ted a.rea. with a. medica.ted ointment. C. Enco u.ra.ge her to wea.r a. tight -fitting vest to su.pport her sca.p u.la.. D. Enco u.ra.ge her to a.void direct su.nlight on the a.rea. being trea.ted. A.nswer: D Expla.na.tio n: (A.) The skin in a. trea.tment a.rea. sho u.ld be rinsed with wa.ter a.nd pa.tted dry. Ma.rkings sho u.ld be left inta.ct, a.nd the skin sho u.ld not be scr u.bbed. (B) Clients sho u.ld a.void p u.tting a.ny crea.ms or lotions on the trea.ted a.rea.. This cou.ld interfere with trea.tment. (C) Ra.dia.tion thera.py clients shou.ld wea.r loose - fitting clothes a.nd a.void tight, irrita.ting fa.brics. (D) The a.rea. of skin being trea.ted is sensitive to su.nlight, a.nd the client sho u.ld ta.ke ca.re to prevent s u.n da.m a.ge by a.voiding direct s u.nlight a.nd covering the a.rea. when she is in the s u.n. NO.16 The nu.rse is a.ssisting a. 4th-da.y postopera.tive cholecystectomy client in pla.nning her mea.ls for tomorrow's men u.. Which vita.min is the most essentia.l in pro moting tiss u.e hea.ling? A. Vita.min C B. Vita.min B1 C. Vita.min D D. Vita.min A. A.nswer: A. Expla.na.tio n: (A.) Vita.min C (a.scorbic a.cid) is essentia.l in promoting wo u.nd hea.ling a.nd colla.gen forma.tion. (B) Vita.min B1 (thia.mine) ma.inta.ins norma.l ga.str ointestina.l (GI) fu.nctioning, oxidizes ca.rbohydra.tes, a.nd is essentia.l for norma.l f u.nctioning of nervo u.s tiss u.e. (C) Vita.min D regu.la.tes a.bsorption of ca.lci u.m a.nd phosphor u.s from the GI tra.ct a.nd helps prevent rickets. (D) Vita.min A. i s necessa.ry for the forma.tion a.nd ma.intena.nce of skin a.nd m u.cou.s membra.nes. It is a.lso essentia.l for norma.l growth a.nd development of bones a.nd teeth. NO.17 A. 10 -yea.r -old client with a. pin in the right fem u.r is immobilized in tra.ction. H e is exhibiting beha.viora.l cha.nges incl u.ding restlessness, diffic u.lty with problem solving, ina.bility to concentra.te on a.ctivities, a.nd monotony. Which of the following nu.rsing implementa.tions wou.ld be most effective in helping him cope with im mobility? A. Providing him with books, cha.llenging pu.zzles, a.nd ga.mes a.s diversiona.ry a.ctivities B. A.llowing him to do a.s mu.ch for himself a.s he is a.ble, inclu.ding lea.rning to do pin-site ca.re u.nder su.pervision C. Ha.ving a. vol u.nteer come in to sit with the client a.nd to rea.d him stories D. Stim u.la.ting rest a.nd rela.xa.tion by gentle ru.bbing with lotion a.nd cha.nging the client's IT Certification Guaranteed, The Easy Way! 13 position frequ.ently A.nswer: B IT Certification Guaranteed, The Easy Way! 14 Expla.na.tion: (A.) These a.ctivities co u.ld be fr u.stra.ting for the client if he is ha.ving diffic u.lty with problem solving a.nd concentra.tion. (B) Selfca.re is u.su.a.lly well received by the child, a.nd it is one of the most u.sefu.l interventions to help the child cope with immobility. (C) This ma.y be helpf u.l to the client if he ha.s no visitors, b u.t it does little to help him develop coping skills. (D) This will helpto prevent skin irrita.tion or brea.kdown rela.ted to immobility b u.t will not help to prevent beha.viora.l cha.nges rela.ted to immobility. NO.18 In client tea.ching, the nu.rse shou.ld empha.size tha.t feta.l da.ma.ge occu.rs more frequ.ently with ingestion of dr u.gs du.ring: A. First trimester B. Second trimester C. Third trimester D. Every trimester A.nswer: A. Expla.na.tion: (A.) Orga.nogene sis occu.rs in the first trimester. Fetu.s is most su.sceptible to ma.lforma.tion du.ring this period. (B) Orga.nogenesis ha.s occ u.rred by the second trimester. (C) Feta.l development is complete by this time. (D) The da.ngero u.s period for feta.l da.ma.g e is the first trimester, not the entire pregna.ncy. NO.19 On a.dmission, the client ha.s signs a.nd symptoms of pu.lmona.ry edema.. The nu.rse pla.ces the client in the most a.ppropria.te position for a. client in p u.lmona.ry edema., which is: A. High Fowler B. Lying on the left side C. Sitting in a. cha.ir D. Su.pine with feet eleva.ted A.nswer: A. Expla.na.tio n: (A.) High Fowler position decrea.ses veno u.s ret u.rn to the hea.rt a.nd permits grea.ter l u.ng expa.nsion so tha.t oxygena.tion is ma.ximized. (B) Lying on the left side ma.y improve perf u.sion to the left l u.ng b u.t does not promote l u.ng expa.nsion. (C) Sitting in a. cha.ir will decrea.se veno u.s retu.rn a.nd promote ma.xima.l lu.ng expa.nsion. However, clients with pu.lmona.ry edema. ca.n deteriora.te qu.ickly a.nd requ.ire intu.ba.tion a.nd mecha.nica.l ventila.tion. If a. client is sitting in a.cha.ir when this deteriora.tion ha.ppens, it will be diffic u.lt to intervene q u.ickly. (D) The s u.pine with feet eleva.ted position increa.ses veno u.s retu.rn a.nd will worsen p u.lmona.ry edema.. NO.20 A. client ha.s retu.rned to the u.nit from the recovery room a.fter ha.ving a. thyroidectomy. The nu.rse knows tha.t a. ma.jor complica.tion a.fter a. thyroidectomy is: A. Respira.tory obstr u.ction B. Hyperca.lcemia. C. Fistu.la. forma.tion D. Myxedema. IT Certification Guaranteed, The Easy Way! 15