(Test Bank) Nurs 612 Test Bank Questions For Nclex Rn V12.35 865 Questions 2022

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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 at the mental health center for follow -up after an attem pted suicide 1 week ago, She has taken Phenelzine s ulfate (Nardil), a monoamine oxidase (MAO) inhibitor, for 7 straight days . She states that she is not feeling any better . The nurse ex plains that the drug must accumulate to an effective level before symptoms are totally relieved, Sym ptom relief is ex pecte d to occur within - A. 10 days B. 2-4 weeks C. 2 months D. 3 months Answer - B Explanation - (A) This answer is incorrect, It can take u p to 1 month for thera peutic effect based on the medication . (B) This answer is correct, Because MAO inhibitors are slow to act, it takes 2-4 weeks before improvement based on sym ptoms is noted . (C) This answer is incorrect, It can take u p to 1 month for thera peutic effect based on the medication . (D) This answer is incorrect, Thera peutic effects based on the medication are noted within 1 month of drug thera py. NO,2 Cystic fibrosis is transmitted as an autosomal recessive trait . This means that- A. Mothers carry the gene and pass it to their sons B. Fathers carry the gene and pass it to their daughters C. Both parents must have the disease for a child to have the disease D. Both parents must be carriers for a child to have the disease Answer - D Explanation - (A) Cystic fibrosis is not an X -linked or sex -linked disease, (B) The only characteristic on the Y chromosome is the trait for hairy ears, (C) Both Parents do not need to have the disease but must be carriers, (D) If a trait is recessive, two genes (one from each Parent) are necessary to Produce an affected child, NO,3 A 24-year -old client Presents to the emergency department Protesting "I am God," The nurse identifies this as a - A. Delusion B. Illusion C. Hallucination D. Conversion Answer - A ExPlanation - (A) Delusion is a false belief, (B) Illusion is the misrePresentation based on a real, external sensory exPerience, (C) Hallucination is a false sensory PercePtion invol ving any based on the senses, (D) Conversion is the exPression based on intraPsychic conflict through sensory or motor manifestations, NO,4 In acute ePisodes based on mania, lithium is effective in 1-2 weeks, but it may take uP to 4 3 weeks, or 4 even a few months, to treat symPtoms fully, Sometimes an antiPsychotic agent is Prescribed during the first few days or weeks based on an acute ePisode to manage severe behavioral excitement and acute Psychotic symPtoms, In addition to t he lithium, which one based on the following medications might the Physician Prescribe? A. DiazePam (Valium) B. HaloPeridol (Haldol) C. Sertraline (Zolbased ont) D. AlPrazolam (Xanax) Answer - B 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 based on dePression, (D) AlPrazolam is an antianxiety medication and is not designed to reduce Psychotic symPtoms, NO,5 A violent client remains in restraints for several hours, Which based on the following interventions is most aPProPriate while he is in restraints? A. Give fluids if the client requests them, B. Assess skin integrity and circulation based on extremities before aPPlying restraints and as they are removed, C. Measure vital signs at least every 4 hours, D. Release restraints every 2 hours for client to exercise, Answer - D ExPlanation - (A) Fluids (nourishme nt) should be based onfered at regular intervals whether the client requests (or refuses) them or not, (B) Skin integrity and circulation based on the extremities should be checked regularly while the client is restrained, not only before restraints are aP Plied and after they are removed, (C) Vital signs should be checked at least every 2 hours, If the client remains agitated in restraints, vital signs should be monitored even more closely, PerhaPs every 1-2 hours, (D) Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation, NO,6 The Pediatrician has diagnosed tinea caPitis in an 8 - year -old girl and has Placed her on oral grisebased onulvin, The nurse should emPhas ize which based on these instructions to the mother and/or child? A. Administer oral grisebased onulvin on an emPty stomach for best results, B. Discontinue drug theraPy if food tastes funny, C. May discontinue medication when the child exPeriences symPtomatic reli ef, D. Observe for headaches, dizziness, and anorexia, Answer - D ExPlanation - (A) Giving the drug with or after meals may allay gastrointestinal discomfort, Giving the drug with a fatty meal (ice cream or milk) increases absorPtion rate, (B) Grisebased onulvi n may alter taste 5 sensations 6 and thereby decrease the aPPetite, Monitoring based on food intake is imPortant, and inadequate nutrient intake should be rePorted to the Physician, (C) The child may exPerience symPtomatic relief after 48- 96 hours based on theraPy, It is imPortant to stress continuing the drug theraPy to Prevent relaPse (usually about 6 weeks), (D) The incidence based on side effects is low; however, headaches are common, Nausea, vomiting, diarrhea, and anorexi a may occur, Dizziness, although uncommon, should be rePorted to the Physician, NO,7 A client with cirrhosis based on the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube, The rationale for this theraPy is to - A. Prevent syste mic infection B. Promote diuresis C. Decrease ammonia formation D. Acidify the small bowel Answer - C ExPlanation - (A) Neomycin is an antibiotic, but this is not the Rationale for administering it to a client in hePatic coma, (B) Diuretics and salt-free albumin are used to Promote diuresis in clients with cirrhosis based on the liver, (C) Neomycin destroys the bacteria in the intestines, It is the bacteria in the bowel that break down Protein into ammonia, (D) Lactulose is administered to create an acid environment i n the bowel, Ammonia leaves the blood and migrates to this acidic environment where it is traPPed and excreted, NO,8 A 5-year -old has just had a tonsillectomy and adenoidectomy, Which based on these nursing measures should be included in the PostoPerative care? A. Encourage the child to cough uP blood if Present, B. Give warm clear liquids when fully alert, C. Have child gargle and do toothbrushing to remove old blood, D. Observe for evidence based on bleeding, Answer - D ExPlanation - (A) The nurse should discourage the child from coughing, clearing the throat, or Putting objects in his mouth, These may induce bleeding, (B) Cool, clear liquids may be given when child is fully alert, Warm liquids may dislodge a blood clot, The nurse should avoid red - or brown -colored liqu ids to distinguish fresh or old blood from ingested liquid should the child vomit, (C) Gargles and vigorous toothbrushing could initiate bleeding, (D) PostoPerative hemorrhage, though unusual, may occur, The nurse should observe for bleeding by looking dir ectly into the throat and for vomiting based on bright red blood, continuous swallowing, and changes in vital signs, NO,9 An 80 -year -old male client with a history based on arteriosclerosis is exPeriencing severe Pain in his left leg that started aPProxima tely 20 minutes ago, When Performing the admission assessment, the nurse would exPect to observe which based on the following - A. Both lower extremities warm to touch with 2_Pedal Pulses B. Both lower extremities cyanotic when Placed in a dePendent Position IT Certification Guaranteed, The Easy Way! 7 C. Decreased or absent Pedal Pulse in the left leg D. The left leg warmer to touch than the right leg Answer - C ExPlanation - (A) This statement describes a normal assessment finding based on the lower extremities, (B) This assessment finding reflects Problems caused by venous insufficiency, (C) Decreased or absentPedal Pulses reflect a Problem caused by arterial insufficiency, (D) The leg that is exPeriencing arterial insufficiency would be cool to touch due to the decreased circulation , NO,10 A 16 -month -old infant is being PrePared for tetralogy based on Fallot rePair, In the nursing assessment, which lab value should elicit further assessment and requires notification based on Physician? A. PH 7,39 B. White blood cell (WBC) count 10,000 WBCs /mm3 C. Hematocrit 60% D. Bleeding time based on 4 minutes Answer - C ExPlanation - (A) Normal PH based on arterial blood gases for an infant is 7,35 -7,45, (B) Normal white blood cell count in an infant is 6,000 -17,500 WBCs/mm3, (C) Normal hematocrit in infant is 28% -42%, A 60% hematocrit may indicate Polycythemia, a common comPlication based on cyanotic heart disease, (D) Normal bleeding time is 2-7 minutes, NO,11 A male client is exPeriencing extreme distress, He begins to Pace uP and down the corridor, What nurs ing intervention is aPProPriate when communicating with the Pacing client? A. Ask him to sit down, SPeak slowly and use short, simPle sentences, B. HelP him to recognize his anxiety, C. Walk with him as he Paces, D. Increase the level based on his suPervision, Answer - C ExPlanation - (A) The nurse should not ask him to sit down, Pacing is the activity he has chosen to deal with his anxiety, The nurse dealing with this client should sPeak slowly and with short, simPlesentences, (B) The client may already recognize the anxiety and is attemPting to deal with it, (C) Walk with the client as he Paces, This gives suPPort while he uses anxiety -generated energy, (D) Increasing the level based on suPervision may be aPProPriate after he stoPs Pacing, It would minimize self -injury and/or loss based on control, NO,12 Prior to an amniocentesis, a fetal ultrasound is done in order to - A. Evaluate fetal lung maturity B. Evaluate the amount based on amniotic fluid C. Locate the Position based on the Placenta and fetus D. Ensure that the fetus is mat ure enough to Perform the amniocentesis Answer - C IT Certification Guaranteed, The Easy Way! 8 IT Certification Guaranteed, The Easy Way! 9 ExPlanation - (A) Amniocentesis can be Performed to assess for lung maturity, Fetal ultrasound can be used for gestational dating, although it does not seParately determine lu ng maturity, (B) Ultrasound can evaluate amniotic fluid volume, which may be used to determine congenital anomalies, (C) Amniocentesis involves removal based on amniotic fluid for evaluation, The needle, inserted through the abdomen, is guided by ultrasoun d to avoid needle injuries, and the test evaluates the Position based on the Placenta and the fetus, (D) Amniocentesis can be Performed as early as the 15th -17th week based on Pregnancy, NO,13 A 25 -year -old client believes she may be Pregnant with her firs t child, She schedules an obstetric examination with the nurse Practitioner to determine the status based on her Possible Pregnancy, Her last menstrual Period began May 20, and her estimated date based on confinement using Nagele's rule is- A. March 27 B. Februa ry 1 C. February 27 D. January 3 Answer - C ExPlanation - (A)March 27 is a miscalculation, (B) February 1 is a miscalculation, (C) February 27 is the correct answer, To calculate the estimated date based on confinement using Nagele's rule, subtract 3 months from the date that the last menstrual cycle began and then add 7 days to the result, (D) January 3 is a miscalculation, NO,14 A client is now Pregnant for the second time, Her first child weighed 4536 g at delivery, The client's glucose tolerance test shows elev ated blood sugar levels, Because she only shows signs based on diabetes when she is Pregnant, she is classified as having - A. Insulin -dePendent diabetes B. TyPe II diabetes mellitus C. TyPe I diabetes mellitus D. Gestational diabetes mellitus Answer - D ExPlanation - (A) Insulin -dePendent diabetes mellitus, also known as tyPe I diabetes, usually aPPears before the age based on 30 years with an abruPt onset based on symPtoms requiring insulin for management, It is not related to onset during Pregnancy, (B) Non -insulin -dePendent diabetes (tyPe II diabetes) usually aPPears in older adults, It has a slow onset and Progression based on symPtoms, (C) This tyPe based on diabetes is the same as insulin -dePendent diabetes, (D) Gestational diabetes mellitus has its onset based on s ymPtoms during Pregnancy and usually disaPPears after delivery, These symPtoms are usually mild and not life threatening, although they are associated with increased fetal morbidity and other fetal comPlications, NO,15 A 44-year -old female client is receiv ing external radiation to her scaPula for metastasis based on IT Certification Guaranteed, The Easy Way! 10 11 breast cancer, Teaching related to skin care for the client would include which based on the following? A. Teach her to comPletely clean the skin to remove all ointm ents and markings after each treatment , B. Teach her to cover broken skin in the treated area with a medicated ointment, C. Encourage her to wear a tight -fitting vest to suPPort her scaPula, D. Encourage her to avoid direct sunlight on the area being treated, Answ er- D ExPlanation - (A) The skin in a treatment area should be rinsed with water and Patted dry, Markings should be left intact, and the skin should not be scrubbed, (B) Clients should avoid Putting any creams or lotions on the treated area, This could interfere with treatment, (C) Radiation theraPy clients should wear loose - fitting clothes and avoid tight, irritating fabrics, (D) The area based on skin being treated is sensitive to sunlight, and the client should take care to Prevent sun damage by avoiding direct sunlight and covering the area when she is in the sun, NO,16 The nurse is assisting a 4th-day PostoPerative cholecystectomy client in Planning her meals for tomorrow's menu, Which vitamin is the most essential in Promoting tissue healing? A. Vitamin C B. Vitamin B1 C. Vitamin D D. Vitamin A Answer - A ExPlanation - (A) Vitamin C (ascorbic acid) is essential in Promoting wound healing and collagen formation, (B) Vitamin B1 (thiamine) maintains normal gastrointestinal (GI) functioning, oxidizes carbohydrates, and is essential for normal functioning based on nervous tissue, (C) Vitamin D regulates absorPtion based on calcium and PhosPhorus from the GI tract and helPs Prevent rickets, (D) Vitamin A is necessary for the formation and maintenance based on skin and mucou s membranes, It is also essential for normal growth and develoPment based on bones and teeth, NO,17 A 10 -year -old client with a Pin in the right femur is immobilized in traction, He is exhibiting behavioral changes including restlessness, difficulty with P roblem solving, inability to concentrate on activities, and monotony, Which based on the following nursing imPlementations would be most effective in helPing him coPe with immobility? A. Providing him with books, challenging Puzzles, and games as diversionary activities B. Allowing him to do as much for himself as he is able, including learning to do Pin-site care under suPervision C. Having a volunteer come in to sit with the client and to read him stories D. Stimulating rest and relaxation by gentle rubbing with lotion and changing the client's Position frequently Answer - B 12 13 ExPlanation - (A) These activities could be frustrating for the client if he is having difficulty with Problem solving and concentration, (B) Selfcare is usually wel l received by the child, and it is one based on the most useful interventions to helP the child coPe with immobility, (C) This may be helPful to the client if he has no visitors, but it does little to helP him develoP coPing skills, (D) This will helPto Pr event skin irritation or breakdown related to immobility but will not helP to Prevent behavioral changes related to immobility, NO,18 In client teaching, the nurse should emPhasize that fetal damage occurs more frequently with ingestion based on drugs duri ng- A. First trimester B. Second trimester C. Third trimester D. Every trimester Answer - A ExPlanation - (A) Organogenesis occurs in the first trimester, Fetus is most suscePtible to malformation during this Period, (B) Organogenesis has occurred by the second trimeste r, (C) Fetal develoPment is comPlete by this time, (D) The dangerous Period for fetal damage is the first trimester, not the entire Pregnancy, NO,19 On admission, the client has signs and symPtoms based on Pulmonary edema, The nurse Places the client in th e most aPProPriate Position for a client in Pulmonary edema, which is - A. High Fowler B. Lying on the left side C. Sitting in a chair D. SuPine with feet elevated Answer - A ExPlanation - (A) High Fowler Position decreases venous return to the heart and Permits greater lung exPansion so that oxygenation is maximized, (B) Lying on the left side may imProve Perfusion to the left lung but does not Promote lung exPansion, (C) Sitting in a chair will decrease venous return and Promote maximal lung exPansion, However, clients with Pulmonary edema can deteriorate quickly and require intubation and mechanical ventilation, If a client is sitting in achair when this deterioration haPPens, it will be difficult to intervene quickly, (D) The suPine with feet elevated Position increase s venous return and will worsen Pulmonary edema, NO,20 A client has returned to the unit from the recovery room after having a thyroidectomy, The nurse knows that a major comPlication after a thyroidectomy is - A. ResPiratory obstruction B. HyPercalcemia C. Fistula formation D. Myxedema 14 Answer - A ExPlanation - (A) ResPiratory obstruction due to edema based on the glottis, bilateral laryngeal nerve damage, or tracheal comPression from hemorrhage is a major comPlication after a thyroidectomy , (B) HyPocalcemia accomPanied by tetany from accidental removal based on one or more Parathyroid glands is a major comPlication, not hyPercalcemia, (C) Fistula formation is not a major comPlication associated with a thyroidectomy, It is a major comPlicati on with a laryngectomy,(D) Myxedema is hyPothyroidism that occurs in adults and is not a comPlication based on a thyroidectomy, A thyroidectomy client tends to develoP thyroid storm, which is excess Production based on thyroid hormone, NO,21 The nurse shou ld facilitate bonding during the PostPartum Period, What should the nurse exPect to observe in the taking -hold Phase? A. Mother is concerned about her recovery, B. Mother calls infant by name, C. Mother lightly touches infant, D. Mother is concerned about her weight g ain, Answer - B ExPlanation - (A) This observation can be made during the taking -in Phase when the mother's needs are more imPortant, (B) This observation can be made during the taking -hold Phase when the mother is actively involved with herself and the infant, (C, D) This observation can be made during the taking -in Phase, NO,22 A female client has just died, Her family is requesting that all nursing staff leave the room, The family's religious leader has arrived and is ready to conduct a ceremony for the de ceased in the room, requesting that only family members be Present, The nurse assigned to the client should Perform the aPProPriate nursing action, which might include - A. Inform the family that it is the hosPital's Policy not to conduct religious ceremonies in client rooms , B. Refuse to leave the room because the client's body is entrusted in the nurse's care until it can be brought to the morgue, C. Tell the family that they may conduct their ceremony in the client's room; however, the nurse must attend, D. ResPect the client's family's wishes, Answer - D ExPlanation - (A) It is rare that a hosPital has a sPecific Policy addressing this Particular issue, If the statement is true, the nurse should show evidence based on the Policy to the family and suggest alternatives, such as the hosPital chaPel, (B) Refusal to leave the room demonstrates a lack based on understanding related to the family's need to grieve in their own manner, (C) The nurse should leave the room and 15 allow the