Real NCLEX NCLEX-RN Exam Dumps with Correct 865 Questions and Answers
Valid NCLEX-RN Test Answers & NCLEX NCLEX-RN Exam PDF
Passing the NCLEX-RN exam is a requirement for licensure as a registered nurse in the United States and Canada. NCLEX-RN exam is designed to ensure that nurses are competent and safe practitioners who are able to provide high-quality care to their patients. While the exam can be challenging, there are many resources available to help individuals prepare for the test including review courses, study guides, and practice exams. With dedication and hard work, individuals can successfully pass the NCLEX-RN exam and begin their career as a registered nurse.
NEW QUESTION # 162
The nurse enters the room of a client on which a "do not resuscitate" order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, "please save her!" The nurse's action would be:
- A. Discuss with the husband that these orders are written only on clients who are not likely to recover with resuscitative efforts.
- B. Call a code and proceed with cardiopulmonary resuscitation.
- C. Call the physician and inform him that the client has expired.
- D. Remind the husband that the physician wrote an order not to resuscitate.
Answer: B
Explanation:
Explanation
(A, B, C) The last request from the husband overrides the decision not to initiate resuscitation efforts. (D) The nurse should begin cardiopulmonary resuscitation unless a living will and durable power of attorney are in force. In the meantime, the nurse should talk with the husband and notify the doctor.
NEW QUESTION # 163
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. Behavior indicates a developmental delay, because preschoolers should be able to tell right from wrong.
- B. Lying is normal behavior for a preschool child who is learning to separate fantasy from reality.
- C. Behavior is not normal, and a child psychiatrist should be consulted.
- D. Mother is lying to protect herself.
Answer: B
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 # 164
A client calls the prenatal clinic to schedule an appointment. She states she has missed three menstrual periods and thinks she might be pregnant. During her first visit to the prenatal clinic, it is confirmed that she is pregnant. The registered nurse (RN) learns that her last menstrual period began on June 10. According to Nagele's rule, the estimated date of confinement is:
- A. March 17
- B. January 10
- C. August 30
- D. June 3
Answer: A
Explanation:
Explanation
(A) Using Nagele's rule, count back 3 calendar months from the first day of the last menstrual period. The answer is March 10. Then add 7 days and 1 year, which would be March 17 of the following year. (B, C, D) This date is incorrect.
NEW QUESTION # 165
Cystic fibrosis is transmitted as an autosomal recessive trait. This means that:
- A. Mothers carry the gene and pass it to their sons
- B. Both parents must have the disease for a child to have the disease
- C. Both parents must be carriers for a child to have the disease
- D. Fathers carry the gene and pass it to their daughters
Answer: C
Explanation:
Explanation/Reference:
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.
NEW QUESTION # 166
After the RN is finished the initial assessment of a newborn baby and after the initial bonding between the newborn and the mother has taken place in the delivery room, the RN will bring the newborn to the well-baby nursery. Before the newborn is taken from the delivery room and brought to the well-baby nursery, the RN makes sure that which of the following interventions was completed?
- A. The nurse instills prophylactic ointment in the conjunctival sacs of the newborn's eyes.
- B. The nurse counts the instruments and sponges with the scrub nurse.
- C. The physician verifies the exact time of birth.
- D. The nurse makes sure the mother and her newborn have been tagged with identical bands.
Answer: D
Explanation:
Section: Questions Set C
Explanation:
(A) The delivery room personnel are responsible for verifying time of birth. (B) The scrub and circulating nurses count sponges and instruments. (C) This intervention is done in the nursery. (D) Tagging the mother and infant with identical bands is of utmost importance. The mother wears one band, and the newborn wears two.
Identical numbers on the three bands provide identification for the newborn and the birth mother. Every time the newborn is brought to the mother after delivery, those bands are checked to be sure that the numbers are identical.
NEW QUESTION # 167
The usual treatment for diabetes insipidus is with IM or SC injection of vasopressin tannate in oil. Nursing care related to the client receiving IM vasopressin tannate would include:
- A. Limit fluid intake to 500 mL/day.
- B. Weigh once a week and report to the physician any weight gain of10 lb.
- C. Store the medication in a refrigerator and allow to stand at room temperature for 30 minutes prior to administration.
- D. Hold the vial under warm water for 10-15 minutes and shake vigorously before drawing medication into the syringe.
Answer: D
Explanation:
Explanation
(A) Weight should be obtained daily. (B) Fluid is not restricted but is given according to urine output. (C) The medication does not have to be stored in a refrigerator. (D) Holding the vial under warm water for 10-15 minutes or rolling between your hands and shaking vigorously before drawing medication into the syringe activates the medication in the oil solution.
NEW QUESTION # 168
A 12-year-old girl has been diagnosed with insulindependent diabetes mellitus. Which of these principles would best guide her nutritional management?
- A. Concentrated sweets are taken during increased activity.
- B. Caloric distribution should be calculated to fit activity patterns.
- C. Food restriction is imposed to reduce weight.
- D. Fat requirements are increased owing to the possibility of ketoacidosis.
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Concentrated sweets are eliminated from diet planning. Complex carbohydrates may be taken at the time of increased activity. (B) Food restriction is not used for diabetic control of growing children. Caloric restriction may be imposed for weight control if necessary. (C) Total caloric intake and proportions of basic nutrients should be consistent from day to day. Distribution of these calories should fit the activity pattern.
Extra food is needed for increased activity. A balance of food, exercise, and insulin should be maintained.
(D) Because of the increased risk of atherosclerosis, the fat percentage of the total caloric intake is reduced.
NEW QUESTION # 169
The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on a fullstrength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the following?
- A. The nurse has placed the suction catheter in the esophagus.
- B. The client aspirated tube feeding.
- C. The feeding is infusing into the trachea.
- D. This is a normal finding.
Answer: B
Explanation:
(A)
Once the feeding tube placement is confirmed in the stomach, aspiration can occur if the client's stomach becomes too full. When suctioning the trachea, if secretions resemble tube feeding, the client has aspirated the feeding. (B) Because the trachea provides direct access to a client's airway, it would not be possible to place the catheter in the esophagus.
(C)
Blue-colored sputum is never considered a normal finding and should be reported and documented. (D) The nurse confirmed placement of the feeding tube in the stomach prior to initiating the tube feeding; therefore, it is highly unlikely that the feeding tube would be located in the trachea.
NEW QUESTION # 170
A 2-year-old child will undergo a cardiac catheterization tomorrow to evaluate his ventricular septal defect.
Based on his developmental stage, the nurse:
- A. Uses pictures to explain the procedure to the child and his parents that evening
- B. Asks the parents to explain the procedure to the child after she explains it to them
- C. Explains the procedure using simple words and sentences just before the preoperative sedation
- D. Asks the parents to leave the room while the preoperative medication and instructions are given
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) A toddler is not capable of conceptualizing about the inside of his body and is concerned about body intactness; therefore, diagrams would not be useful. Also, the previous evening is too far from the procedure for the toddler to remember the instructions. (B) A simple explanation the morning of the procedure is the best developmental strategy to use, because it focuses on the toddler's need for parental support, body intactness, and short attention span. (C) A relationship between the nurse and the child needs to develop. Also, misinformation may be given to the child if the parents explain the procedure to the child. (D) The parents are the child's support system and need to be there to strengthen the child.
NEW QUESTION # 171
A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty-eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications?
- A. Severe hypotension
- B. Fluid volume deficit
- C. Fluid volume excess
- D. Decreased cardiac output
Answer: C
Explanation:
(A) Fluid volume deficit resulting from fluid shifts to the interstitial spaces occurs in the first 48 hours. (B) Forty-eight hours to 72 hours after the burn injury and fluid resuscitation, capillary permeability is restored and fluid requirements decrease. Interstitial fluid returns rapidly to the vascular compartment, and the nurse must monitor the child for signs and symptoms of hypervolemia. (C) Increased cardiac output results as fluids shift back to the vascular compartment. (D) Hypertension is the result of hypervolemia.
NEW QUESTION # 172
A client has been instructed in how to take her nitroglycerin tablets. The nurse giving her instructions knows the client understands the information when she tells her:
- A. "I should keep the tablets in the refrigerator."
- B. "I should call the doctor if three doses of the medicine do not relieve my pain."
- C. "I should take these with water but not with milk."
- D. "I should contact my physician if I have headaches after I take this medicine."
Answer: B
Explanation:
(A) Headaches may occur after taking nitroglycerin because of vasodilation. (B) The tablets do not need to be refrigerated. The client should carry them with her. (C) The client should contact the physician if repeated doses of nitroglycerin do not relieve the discomfort. (D) Nitroglycerin tablets should be dissolved under the tongue, not swallowed.
NEW QUESTION # 173
Nursing assessment of early evidence of septic shock in children at risk includes:
- A. Respiratory distress, cold skin, and pale extremities
- B. Elevated blood pressure, hyperventilation, and thready pulses
- C. Fever, tachycardia, and tachypnea
- D. Normal pulses, hypotension, and oliguria
Answer: C
Explanation:
Explanation
(A) Fever, tachycardia, and tachypnea are the classic early signs of septic shock in children. (B) Respiratory distress, cold skin, and pale extremities are later signs of septic shock. (C) Elevated blood pressure, hyperventilation, and thready pulses are later signs of septic shock. (D) Normal pulses, hypotension, and oliguria are not early signs of septic shock.
NEW QUESTION # 174
A 70-year-old homeless woman is admitted with pneumonia. She is weak, emaciated, and febrile. The physician orders enteral feedings intermittently by nasogastric tube. When inserting the nasogastric tube, once the tube passes through the oropharynx, the nurse will instruct the client to:
- A. Tilt her head backwards
- B. Hold breath as tube passes
- C. Swallow as tube passes
- D. Cough as tube passes
Answer: C
Explanation:
(A) Head should be tilted slightly forward to facilitate insertion. (B) Swallowing assists with insertion of tube and closes off airway. (C) Client should be swallowing as tube passes; holding the breath facilitates nothing. (D) Coughing may expel tube.
NEW QUESTION # 175
A female client at 37 weeks' gestation has just undergone a nonstress test. The results were two fetal movements with a corresponding increase in fetal heart rate (FHR) of 15 bpm lasting 15 seconds within a 20-minute period. Her results would be classified as:
- A. Reactive; needs follow-up contraction stress test
- B. Reactive; no contraction stress test required
- C. Non-reactive; no contraction stress test required
- D. Non-reactive; needs follow-up contraction stress test
Answer: B
Explanation:
(A)
A contraction stress test is unnecessary following a reactive (normal) nonstress test. (B) The results are considered reactive, indicating that the fetus is not showing distress. Therefore, a contraction stress test, which is a more in-depth test for fetal distress, is unnecessary. (C) A nonreactive test would show fewer than two fetal movements or a failure of the FHR to increase at least 15 bpm with the movements in a 20-minute period.
(D)
A contraction stress test should follow a nonreactive nonstress test to validate fetal distress.
NEW QUESTION # 176
A client at 6 months' gestation complains of tiredness and dizziness. Her hemoglobin level is 10 g/dL, and her hematocrit value is 32%. Her nutritional intake is assessed as sufficient. The most likely diagnosis is:
- A. No problem indicated
- B. Iron-deficiency anemia
- C. Physiological anemia
- D. Fatigue due to stress
Answer: B
Explanation:
(A) This clinical situation is indicative of iron-deficiency anemia because the client has inadequate nutritional intake. Her blood volume is increasing faster than her red blood cell volume. Anemia is present in the second trimester when the hemoglobin level is <10.5 and the hematocrit value falls below 35%. She needs increased iron supplements with follow-up. (B) The client's values are below levels for physiological anemia. (C) The client is fatigued because of a low hemoglobin level. (D) Her hemoglobin level is low and will probably decrease even more when the blood volume peaks at 28 weeks.
NEW QUESTION # 177
To prevent fungal infections of the mouth and throat, the nurse should teach clients on inhaled steroids to:
- A. Rinse the mouth before each use to eliminate colonization of bacteria
- B. Take antacids immediately before inhalation to neutralize mucous membranes and prevent infection
- C. Rinse the mouth and gargle with warm water after each use of the inhaler
- D. Rinse the plastic holder that aerosolizes the drug with hydrogen peroxide every other day
Answer: C
Explanation:
(A) It is sufficient to rinse the plastic holders with warm water at least once per day. (B) It is important to rinse the mouth after each use to minimize the risk of fungal infections by reducing the droplets of the glucocorticoid left in the oral cavity. (C) Antacids act by neutralizing or reducing gastric acid, thus decreasing the pH of the stomach. "Neutralizing" the oral mucosa prior to inhalation of a steroid inhaler does not minimize the risk of fungal infections. (D) Rinsing prior to the use of the glucocorticoid will not eliminate the droplets left on the oral mucous membranes following the use of the inhaler.
NEW QUESTION # 178
The following nursing diagnosis is written for a comatose client with cirrhosis of the liver and secondary splenomegaly - High risk for injury: Increased susceptibility to bleeding related to:
- A. Diminished function of the Kupffer cells
- B. Increased absorption of vitamin K
- C. Thrombocytopenia due to hypersplenism
- D. Increased synthesis of the clotting factors
Answer: C
Explanation:
Section: Questions Set G
Explanation
Explanation:
(A) There is a decreased absorption of vitamin K with cirrhosis of the liver. This decrease impairs blood coagulation and the formation of prothrombin. (B) Thrombocytopenia, an increased destruction of platelets, occurs secondary to hypersplenism. (C) A diminished function of the Kupffer cells occurs with cirrhosis of the liver, causing the client to become more susceptible to infections. (D) A decrease in the synthesis of fibrinogen and clotting factors VII, IX, and X occurs with cirrhosis of the liver and increases the susceptibility to bleeding.
NEW QUESTION # 179
A psychotic client who believes that he is God and rules all the universe is experiencing which type of delusion?
- A. Persecutory
- B. Grandiose
- C. Nihilistic
- D. Somatic
Answer: B
Explanation:
Section: Questions Set A
Explanation:
(A) These delusions are related to the belief that an individual has an incurable illness. (B) These delusions are related to feelings of self-importance and uniqueness. (C) These delusions are related to feelings of being conspired against. (D) These delusions are related to denial of self-existence.
NEW QUESTION # 180
The nurse assesses a client's monitor strip and finds the following: uterine contractions every 3-4 minutes, lasting 60-70 seconds; FHR baseline 134-146 bpm, with accelerations to 158 bpm with fetal movement.
Which nursing intervention is appropriate?
- A. Turn the client to her left side.
- B. Evaluate to see if the monitor strip is reassuring.
- C. Start IV for fetal distress and administer O2 at 6-8 liters by mask.
- D. Notify physician of nonreassuring FHR pattern.
Answer: B
Explanation:
Explanation
(A) These indices are within normal parameters; therefore, the nurse does not need to contact the physician.
(B) The purpose of turning a client to her left side is to maximize uteroplacental blood flow. Based on the above assessment, there is no indication that blood flow is compromised. (C) These interventions are appropriate nursing interventions for late and prolonged decelerations. Following these interventions, the nurse should notify the physician. These indices are within normal parameters; therefore, the nurse does not need to start an IV and administer O2. (D) Variations of 20 bpm above or below the baseline FHR is considered normal. Normal FHRs range from 120-160 bpm. As the fetus moves, the FHR increases, and accelerations often occur in concert with contractions. During the active phase of labor, the frequency of uterine contractions is every 2-4 minutes, with an appropriate duration of 60 sec.
NEW QUESTION # 181
Medication is administered to a client who has been placed in restraints after a sudden violent episode, and his EPSs subside. Restraints can be removed when:
- A. A therapeutic alliance has been established, and violent behavior subsides
- B. The physician orders it
- C. The violent behavior subsides, and the client agrees to behave
- D. The nurse deems that removal of restraints is necessary
Answer: A
Explanation:
Section: Questions Set F
Explanation:
(A) The physician may order release of restraints, but prior to that, the client must meet criteria for release. (B) While the client is still restrained, but after violent behavior has subsided, a therapeutic bridge is built. This alliance encourages dialogue between nurse and client, allowing the client to determine causative factors, feelings prior to loss of control, and adaptive alternatives to violence. (C) If the client only "agrees to behave" after violent behavior subsides, he has developed no insight into cause and effect of violence or his response to stress. (D)Removal of restraints occurs only when the client meets the criteria for release, not just because the nurse says it is necessary.
NEW QUESTION # 182
A 72-year-old male client had the Foley catheter that was inserted during the transurethral resection of his prostate removed today. He is concerned about the urinary incontinence he is having since removal of the Foley catheter. The nurse explains that:
- A. This is usually temporary
- B. The nurse will keep him dry, and he should notify the nurse when this happens
- C. This is related to the bladder spasms and will soon stop
- D. He should not be concerned about it because it will resolve quickly
Answer: A
Explanation:
Explanation
(A) This problem is temporary, but it may take some time to resolve, especially in an older man. (B) This problem is usually temporary, but it may take some time to resolve. (C) Keeping the client dry will not relieve his anxiety about his incontinence. (D) The bladder spasms are not the cause of the client's incontinence.
NEW QUESTION # 183
A 27-year-old healthy primigravida is brought to the labor and birthing room by her husband at 32 weeks' gestation. She experienced a sudden onset of painless vaginal bleeding. Following an ultrasound examination, the diagnosis of bleeding secondary to complete placenta previa is made. Expected assessment findings concerning the abdomen would include:
- A. Hypertonicity of the uterus
- B. A soft relaxed abdomen
- C. A rigid, boardlike abdomen
- D. Uterine atony
Answer: B
Explanation:
Explanation
(A) A rigid, boardlike abdomen is an assessment finding indicative of placenta abruptio. (B) A cause of postbirth hemorrhage is uterine atony. With placenta previa, uterine tone is within normal range. (C) The placenta is located directly over the cervical os in complete previa. Blood will escape through the os, resulting in the uterus and abdomen remaining soft and relaxed. (D) In placenta abruptio, hypertonicity of the uterus is caused by the entrapment of blood between the placenta and uterine wall, a retroplacental bleed. This does not exist in placenta previa.
NEW QUESTION # 184
A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Naegele's rule is:
- A. February 27
- B. February 1
- C. March 27
- D. January 3
Answer: A
Explanation:
Section: Questions Set A
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 of confinement using Naegele'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.
NEW QUESTION # 185
A client had a ruptured abdominal aortic aneurysm that was repaired surgically. Her postoperative recovery progressed without complications, and she is ready for discharge. Client education in preparation for discharge began 7 days ago on her admission to the nursing unit. Evaluation of nursing care related to client education is based on evaluation of expected outcomes. Which statement made by the client would indicate that she is ready for discharge?
- A. "I will not drive but ride in the front seat of the car with a seat belt on for my first doctor's appointment."
- B. "I am allowed to exercise by walking for short periods."
- C. "Teach my husband about the diet. He'll be doing all the cooking now."
- D. "When I bathe tomorrow morning, I will be very careful not to get soap on my incision."
Answer: B
Explanation:
(A) Postoperatively, clients with major abdominal surgery are instructed to avoid driving, riding in the front seat, and wearing seat belts because any sudden impact may injure a fresh incision. She should ride in back seat without a seat belt. (B) Clients should not sit in the tub and allow the incision to soak in water because this may predispose the client to infection. A short, cool shower would be preferable. Allowing soap to come in contact with the incision would not harm it and is frequently used as postoperative wound care at home on discharge from the hospital. (C) Activity instructions include: avoid sitting for long periods and get exercise by walking. Lifting more than 5 lb of weight is also prohibited. (D) The client must also learn her diet. Her husband cooking is probably a temporary measure unless he did the cooking prior to her hospitalization.A statement such as this may indicate the need for further exploration of feelings regarding her illness, dependence, and self-care expectations.
NEW QUESTION # 186
At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her physician orders that an IV be started with 500 mL D5W mixed with 150 mg of ritodrine stat. The RN prepares the IV solution with the medication. The RN knows that clients receiving the medication ritodrine IV should be observed closely for which one of the following side effects:
- A. Hyperkalemia
- B. Increase in hematocrit and hemoglobin
- C. Hypoglycemia
- D. Tachycardia
Answer: D
Explanation:
Explanation
(A) Ritodrine is a sympathomimetic 2-adrenergic agonist that can cause an elevation of blood glucose and plasma insulin in pregnant women. Hyperglycemia can occur in women with abnormal carbohydrate metabolism because of their inability to release more insulin. (B) Hypokalemia can occur resulting from the action of the _-mimetics. It results from a displacement of the extracellular potassium into the intracellular space. (C) Ritodrine causes vasodilation of vessel walls, which can lead to hypotension. The body compensates by increasing heart rate and pulse pressure. (D) There is a lowering of serum iron resulting from the action of _-mimetics to activate hematopoiesis.
NEW QUESTION # 187
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