Guide (New 2023) Actual NCLEX NCLEX-RN Exam Questions
NCLEX-RN Exam Dumps Pass with Updated 2023 Certified Exam Questions
NEW QUESTION 182
A client was admitted with rib fractures and a pneumothorax, which were sustained as a result of a motor vehicle accident. A chest tube was placed on the left side to reinflate his lung, and he was transferred to a client unit. Twenty-four hours after admission he continues to have bloody sputum, develops increasing hypoxemia, and his chest x-ray shows patchy infiltrates. The nurse analyzes these symptoms as being consistent with:
- A. Tension pneumothorax
- B. Pulmonary contusions
- C. Pulmonary edema
- D. Pneumonia
Answer: B
Explanation:
(A) Pneumonia may be reflected by patchy infiltrates. In addition, fever, an increasing white blood cell count, and copious sputum production would be present. (B) Blunt chest traumacauses a bruising process in which interstitial and alveolar edema and hemorrhage occur. This is manifest by gradual deterioration over 24 hours of arterial blood gases and the continued production of bloody sputum. Patchy infiltrates are evident on chest xray 24 hours postinjury. (C) Pulmonary edema usually results from left heart failure. It is manifest by pink, frothy sputum; increasing dyspnea; tachycardia; and crackles on auscultation. (D) Tension pneumothorax is a potential complication for someone with rib fractures and a chest tube. It is manifest by diminished breath sounds on the affected side, rapidly deteriorating arterial blood gases in the presence of an open airway, and shock that is unexplained by other injuries.
NEW QUESTION 183
A client is scheduled for a magnetic resonance imaging (MRI) to locate a cerebral lesion. It is important for the nurse to find out if he has a(n):
- A. Movable metal implant
- B. Pin or screw in any bone
- C. History of seizures
- D. Allergy to seafood
Answer: A
Explanation:
Explanation
(A) Iodine is not used as a contrast medium for MRI. It is important to inquire about allergy to seafood if the client is to have an arteriogram or enhanced computer tomography. (B) MRI is safe if seizures are under control. It is more important to inquire about movable metal implants. (C) Clients with movable metal implants such as shrapnel or aneurysm clips or clients with permanent pacemakers or implanted pumps can be traumatized during an MRI. (D) Nonmovable metal prostheses or hardware will not cause trauma during an MRI.
NEW QUESTION 184
A 24-year-old woman who is gravida 1 reports, "I can't take iron pills because they make me sick." She continues, "My bowels aren't moving either." In counseling her based on these complaints, the nurse's most appropriate response would be, "It would be beneficial for you to eat . . .
- A. prunes."
- B. red meat."
- C. green leafy vegetables."
- D. eggs."
Answer: A
Explanation:
Explanation
(A) Prunes provide fiber to decrease constipation and are an excellent source of dietary iron, as the prenatal client is not taking her supplemental iron and iron-deficiency anemia is common during pregnancy. (B) Green leafy vegetables provide a source of fiber and iron; however, prunes are a better source of both. (C) Red meat is a good iron source but will not address the constipation problem. (D) Eggs are a good iron source but do not address the constipation problem.
NEW QUESTION 185
The primary reason for sending a burn client home with a pressure garment, such as a Jobst garment, is that the garment:
- A. Covers burn scars and decreases the psychological impact during recovery
- B. Increases venous return and cardiac output by normalizing fluid status
- C. Assists with ambulation
- D. Decreases hypertrophic scar formation
Answer: D
Explanation:
Explanation
(A) Tubular support, such as that received with a Jobst garment, applies tension of 10-20 mm Hg. This amount of uniform pressure is necessary to prevent or reduce hypertrophic scarring. Clients typically wear a pressure garment for 6-12 months during the recovery phase of their care. (B) Pressure garments have no ambulatory assistive properties. (C) Pressure garments can worsen the psychological impact of burn injury, especially if worn on the face. (D) Pressure garments do not normalize fluid status.
NEW QUESTION 186
Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?
- A. She uses the bulb syringe to help clear her baby's nose when milk is regurgitated.
- B. She places her infant on her right side after feeding her.
- C. She props the bottle in the crib to feed her baby, which allows her to write birth announcements and feed her baby at the same time.
- D. She burps her baby by placing her in a sitting position, supporting her head and neck and gently massaging her back.
Answer: C
Explanation:
Section: Questions Set E
Explanation:
(A) This practice is the proper use of the bulb syringe to clear the infant's airway in case of regurgitation. (B) Placing the infant on either side or on the stomach prevents aspiration of regurgitated milk. (C) "Bottle propping" is an unsafe practice because it increases the likelihood of aspiration. (D) This practice is one correct way of burping an infant.
NEW QUESTION 187
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 red blood cell production
- C. Decreased production of renin
- D. Increased red blood cell production
Answer: B
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 188
When teaching a sex education class, the nurse identifies the most common STDs in the United States as:
- A. Chlamydia
- B. Syphilis
- C. Herpes genitalis
- D. Gonorrhea
Answer: A
Explanation:
(A) Chlamydia trachomatis infection is the most common STD in the United States. The Centers for Disease Control and Prevention recommend screening of all high-risk women, such as adolescents and women with multiple sex partners. (B) Herpes simplex genitalia is estimated to be found in 5-20 million people in the United States and is rising in occurrence yearly. (C) Syphilis is a chronic infection caused by Treponema pallidum. Over the last several years the number of people infected has begun to increase. (D) Gonorrhea is a bacterial infection caused by the organism Neisseria gonorrhoeae. Although gonorrhea is common, chlamydia is still the most common STD.
NEW QUESTION 189
The child with iron poisoning is given IV deferoxamine mesylate (Desferal). Following administration, the child suffers hypotension, facial flushing, and urticaria. The initial nursing intervention would be to:
- A. Assess urinary output, and if it is 30 mL an hour, maintain current treatment
- B. Discontinue the IV
- C. Take all vital signs, and report to the physician
- D. Stop the medication, and begin a normal saline infusion
Answer: D
Explanation:
Section: Questions Set A
Explanation:
(A) The IV line should not be discontinued because other IV medications will be needed. (B) Stop the medication and begin a normal saline infusion. The child is exhibiting signs of an allergic reaction and could go into shock if the medication is not stopped. The line should be kept opened for other medication. (C) Taking vital signs and reporting to the physician is not an adequate intervention because the IV medication continues to flow. (D) Assessing urinary output and, if it is 30 mL an hour, maintaining current treatment is an inappropriate intervention owing to the child's obvious allergic reaction.
NEW QUESTION 190
A schizophrenic client who is experiencing thoughts of having special powers states that "I am a messenger from another planet and can rule the earth." The nurse assesses this behavior as:
- A. Delusions of grandeur
- B. Thought broadcasting
- C. Ideas of reference
- D. Delusions of persecution
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Clients experiencing ideas of reference believe that information from the environment (e.g., the television) is referring to them. (B) Clients experiencing delusions of persecution believe that others in the environment are plotting against them. (C) Clients experiencing thought broadcasting perceive that others can hear their thoughts. (D) Clients experiencing delusions of grandeur think that they are omnipotent and have superhuman powers.
NEW QUESTION 191
A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar puncture. In light of this procedure and developmental characteristics of this age group, which nursing measure is most appropriate?
- A. Tell the child that he will get a "stick" in his back.
- B. Emphasize those aspects of the procedure that require cooperation.
- C. Tell the child not to cry or yell.
- D. Use medical terminology when explaining the procedure to the client.
Answer: B
Explanation:
Section: Questions Set E
Explanation:
(A) The nurse should emphasize what is required to elicit cooperation and help to develop a sense of autonomy. (B) The child may express discomfort verbally and should be encouraged to express his feelings.
(C) Selecting nonthreatening words to explain a procedure will prevent misinterpretation. (D) When explaining the procedure to the parent with the child present, the nurse should use words that the child can understand to avoid misunderstanding.
NEW QUESTION 192
The nurse has been assigned a client who delivered a 6-lb, 12-oz baby boy vaginally 40 minutes ago. The initial assessment of greatest importance for this client would be:
- A. Type of episiotomy
- B. Length of her labor
- C. Character of the fundus
- D. Amount of IV fluid to be infused
Answer: C
Explanation:
Section: Questions Set D
Explanation:
The length of labor has little bearing on the fourth stage of labor. The type of labor and delivery is significant.
(B) The type of episiotomy will affect the client's comfort level. However, the nurse's assessment and implementations center on prevention of hemorrhage during the fourthstage of labor. The amount of bleeding from the episiotomy or hematoma formation is of higher priority than the type of episiotomy. (C) The amount of IV fluid to be infused is a nursing function to be attended to; however, it is lower in priority than determining if hemorrhaging is occurring. (D) Character of the fundus would be the priority nursing assessment because changes in uterine tone may identify possible postpartum hemorrhage.
NEW QUESTION 193
The nurse is admitting an infant with bacterial meningitis and is prepared to manage the following possible effects of meningitis:
- A. Constipation
- B. Sunken fontanelles
- C. Seizure
- D. Hypothermia
Answer: C
Explanation:
Section: Questions Set F
Explanation:
(A) Constipation may occur if the child is dehydrated, but it is not directly associated with meningitis. (B) It is more likely the child will have fever. (C) Seizure is often the initial sign of meningitis in children and could become frequent. (D) It is more likely the child will have bulging fontanelles.
NEW QUESTION 194
A term neonate has experienced no distress at birth and has an Apgar score of 9. Her mother has asked to breastfeed her following delivery. Immediately after birth, the neonate was most susceptible to heat loss. The most appropriate intervention to conserve heat loss and promote bonding is to:
- A. Place her on a heated pad
- B. Dry her with blankets
- C. Place her to her mother's breast
- D. Place her under the radiant warmer
Answer: C
Explanation:
Section: Questions Set E
Explanation:
(A) A radiant warmer maintains an optimal thermal environment by use of a thermal skin sensor taped to the infant. The warmer limits parental attachment, so, although appropriate, it is not an intervention that promotes infant attachment. (B) Warmed blankets prevent heat loss in the neonate by conduction. In addition, tactile stimuli promote crying and lung expansion. This intervention does not promote attachment, however. (C) Skin- to-skin contact is an effective way to conserve heat after delivery and promotes parental attachment following birth in the healthy term infant. The first period of reactivity lasts approximately 30 minutes following birth. A strong sucking reflex and an active, awake newborn characterize this period. (D) Surfaces of objects warmer than the infant promote overheating by conduction, and neonatal hyperthermia may result.
NEW QUESTION 195
The nurse would assess the client's correct understanding of the fertility awareness methods that enhance conception, if the client stated that:
- A. "My sexual partner and I should have intercourse when my cervical mucosa is thick and cloudy."
- B. "My sexual partner and I should have sexual intercourse on day 14 of my cycle regardless of the length of the cycle."
- C. "I should douche immediately after intercourse."
- D. "At ovulation, my basal body temperature should rise about 0.5F."
Answer: D
Explanation:
Explanation
(A) At ovulation, the cervical mucus is increased, stretchable, and watery clear. (B) Under the influence of progesterone, the basal body temperature increases slightly after ovulation. (C) To enhance fertility, measures should be taken that promote retention of sperm rather than removal. (D) Ovulation, the optimal time for conception, occurs 14+2 days before the next menses; therefore, the date of ovulation is directly related to the length of the menstrual cycle.
NEW QUESTION 196
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 problem solving, inability to concentrate on activities, and monotony. Which of the following nursing implementations would be most effective in helping him cope with immobility?
- A. Stimulating rest and relaxation by gentle rubbing with lotion and changing the client's position frequently
- B. Having a volunteer come in to sit with the client and to read him stories
- C. Allowing him to do as much for himself as he is able, including learning to do pin-site care under supervision
- D. Providing him with books, challenging puzzles, and games as diversionary activities
Answer: C
Explanation:
Explanation
(A) These activities could be frustrating for the client if he is having difficulty with problem solving and concentration. (B) Selfcare is usually well received by the child, and it is one of 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 prevent skin irritation or breakdown related to immobility but will not help to prevent behavioral changes related to immobility.
NEW QUESTION 197
A male client has burns over 90% of his body after an automobile accident resulting in a fire. He was trapped inside the auto and pulled out by a bystander. After several months in the hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization the nursing staff has been aware of psychological changes the client faces after burns over a large portion of his body resulting in disfigurement.
The nursing staff can best foster the client's self-esteem by:
- A. Following a standardized plan of care for burn clients formulated by a world-renowned burn center
- B. Adhering to a strict schedule of diet, exercise, and wound care
- C. Allowing him to go to physical therapy for whirlpool treatment when other clients were not in physical therapy
- D. Allowing him to plan, assist in, and perform his own care whenever possible
Answer: D
Explanation:
Explanation
(A) A regimented schedule, allowing no flexibility, will not foster the client's self-esteem. (B) Isolating the client may only enhance his feelings of social isolation due to his disfigurement. (C) Standardized care plans must be personalized and adapted to each client's situation. (D) Allowing the client control over his care will foster his self-esteem and prepare him for life outside of the hospital.
NEW QUESTION 198
A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:
- A. Pulse increased from 96 to 102
- B. Pulse fell from 102 to 96
- C. Temperature rose to 102_F rectally
- D. Evidence of perineal irritation
Answer: C
Explanation:
Explanation
(A) Perineal irritation needs to be addressed, but it is probably not necessary to call the physician. (B) This fall in pulse rate remains within normal limits and is probably insignificant. It is important to monitor for continued change. (C) This rise in pulse rate is probably not significant, but it is important to monitor for continued change. (D) This temperature is above normal limits and needs medical investigation. It may or may not be related to the head injury.
NEW QUESTION 199
Provide the 1-minute Apgar score for an infant born with the following findings: Heart rate: Above 100 Respiratory effort: Slow, irregular Muscle tone: Some flexion of extremities Reflex irritability: Vigorous cry Color: Body pink, blue extremities
- A. 0
- B. 1
- C. 2
- D. 3
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Seven out of a possible perfect score of 10 is correct. Two points are given for heart rate above 100; 1 point is given for slow, irregular respiratory effort; 1 point is given for some flex- ion of extremities in assessing muscle tone; 2 points are given for vigorous cry in assessing reflex irritability; 1 point is assessed for color when the body is pink with blue extremities (acrocyanosis). (B) For a perfect Apgar score of 10, the infant would have a heart rate over 100 but would also have a good cry, active motion, and be completely pink. (C) For an Apgar score of 8 the respiratory rate, muscle tone, or color would need to fall into the 2-point rather than the 1-point category. (D) For this infant to receive an Apgar score of 9, four of the areas evaluated would need ratings of 2 points and one area, a rating of 1 point.
NEW QUESTION 200
A client is going to have a pneumonectomy in the morning. She had a previous negative surgical experience, is talking rapidly, and has an increased pulse and respiratory rate. Nursing interventions for this client should include:
- A. Providing distractors such as reading or watching television
- B. Telling her that she should not be so nervous and assuring her that everything will be OK
- C. Providing opportunities to ask questions and talk about concerns
- D. Reminding her that this surgery is not as extensive as her past surgery was
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) This intervention will help to clarify any misunderstandings about the surgery and give the client an opportunity to verbalize concerns about the surgery. (B) Distractors will not alleviate the preoperative anxiety that the client is experiencing. This response actually denies the client's anxiety. (C) This intervention is false assurance and denies that anxiety is a normal response to the threat of surgery. (D) Psychological responses are not directly related to the extent of the surgery, because they are influenced by the client's past experiences.
NEW QUESTION 201
A 6-year-old child returned to the surgical floor 20 hours ago after an appendectomy for a gangrenous appendix. His mother tells the nurse that he is becoming more restless and is anxious. Assessment findings indicate that the child has atelectasis. Appropriate nursing actions would include:
- A. Allowing the child to remain in the position of comfort, preferably semi-or high-Fowler position
- B. Administering analgesics as ordered
- C. Remaining with the child and keeping as calm and quiet as possible
- D. Having the child turn, cough, and deep breathe every 1-2 hours
Answer: D
Explanation:
Section: Questions Set G
Explanation:
(A) Allowing the client to remain in the position of comfort will not resolve the atelectasis. This position, if left unchanged, over time may actually increase the atelectasis. (B) Analgesics will not resolve the atelectasis and may contribute to it if proper nursing actions are not taken to help resolve the atelectasis. (C) Having the client turn, cough, and deep breathe every 1-2 hours will aid in resolving the atelectasis. Surgery clients are at risk for postoperative respiratory complications because pulmonary function is reduced as a result of anesthesia and surgery. (D) Remaining with the client and keeping him calm and quiet will not affect the client's anxiety, restlessness, or help to resolve the atelectasis. The cause (atelectasis) needs to be treated, not the symptoms (anxiety and restlessness).
NEW QUESTION 202
A mother came to the pediatric clinic with her 17- month-old child. The mother would like to begin toilet training. What should the nurse teach her about implementing toilet training?
- A. Show disapproval if she does not void or defecate.
- B. Take two or three favorite toys with the child.
- C. Have a child-sized toilet seat or training potty on hand.
- D. Explain to the child she is going to "void" and "defecate."
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Giving her toys will distract her and interfere with toilet training because of inappropriate reinforcement.
(B) A child-sized toilet seat or training potty gives a child a feeling of security. (C) She should use words that are age appropriate for the child. (D) Children should be praised for cooperative behavior and/or successful evacuation.
NEW QUESTION 203
A 14-year-old teenager is hospitalized for anorexia nervosa. She is admitted to the adolescent mental health unit and placed on a behavior modification program. Nursing interventions for the teenager will most likely include:
- A. Requiring the client to eat more during meals
- B. Establishing routine tasks and activities around mealtimes
- C. Administering medications such as lithium
- D. Checking the client's room frequently
Answer: B
Explanation:
Explanation
(A) Providing a more structured, supportive environment addresses safety and comfort needs, thereby helping the anorexic client develop more internal control. (B) Medications (commonly antidepressants) are frequently ordered for the anorexic client. However, lithium (used primarily with bipolar disorder) is not commonly used to treat the anorexic client. (C) Requiring and/or demanding that the anorexic client "eat more" at mealtimes increases the client's feelings of powerlessness. (D) Like the previous strategy, checking the client's room frequently contributes to the client's feelings of powerlessness.
NEW QUESTION 204
To ensure proper client education, the nurse should teach the client taking SL nitroglycerin to expect which of the following responses with administration?
- A. Temporary blurring of vision
- B. Stinging, burning when placed under the tongue
- C. Generalized urticaria with prolonged use
- D. Urinary frequency
Answer: B
Explanation:
(A) Stinging or burning when nitroglycerin is placed under the tongue is to be expected. This effect indicates that the medication is potent and effective for use. Failure to have this response means that the client needs to get a new bottle of nitroglycerin. (B, C, D) The other responses are not expected in this situation and are not even side effects.
NEW QUESTION 205
A post-lung surgery client is placed on a chest tube drainage system. When explaining to the family how the system works, the nurse states that the water-seal bottle of a three-bottle chest drainage system serves which of the following purposes?
- A. Preventing air from entering the chest upon inspiration
- B. Collection bottle for drainage
- C. Preventing accumulation of blood around the heart
- D. Pressure regulator
Answer: A
Explanation:
Explanation
(A) There is a separate collection bottle for drainage as part of a chest drainage system. (B) In a three-bottle chest drainage system, one bottle serves only as a pressure regulator. (C) Mediastinal chest tubes prevent accumulation of blood around the heart immediately following heart surgery. (D) The purpose of the water-seal bottle in any chest drainage setup is to allow air out of the chest, but not back in. This negative pressure promotes lung expansion.
NEW QUESTION 206
A client's behavior is annoying other clients on the unit. He is meddling with their belongings and dominating the group. The best approach by the nurse is to:
- A. Have his medication increased.
- B. Ignore him and tell the other clients that these behaviors are due to his illness and that they should understand.
- C. Set limits on his behavior.
- D. Seclude him in his room.
Answer: C
Explanation:
Section: Questions Set D
Explanation:
(A) This action by the nurse would be punitive. (B) Consistent limit setting will help the client to know what is acceptable behavior. (C) This action is not within the nurse's scope of practice. (D) This could be dangerous to the client and to others and violates other clients' rights.
NEW QUESTION 207
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