This page was exported from Free valid test braindumps [ http://free.validbraindumps.com ] Export date:Sat Apr 5 14:12:21 2025 / +0000 GMT ___________________________________________________ Title: [Feb-2023] NCLEX-RN Exam Dumps - Free Demo & 365 Day Updates [Q433-Q452] --------------------------------------------------- [Feb-2023] NCLEX-RN Exam Dumps - Free Demo & 365 Day Updates Free Sales Ending Soon - Use Real NCLEX-RN PDF Questions Do you know how to register for the NCLEX exam? The steps to follow are: You must take the exam.You must return the registration card with a copy of your diploma. There are no differences in the steps to follow for registration and application.You must pay the examination fee.You must complete the application for the exam.You must obtain a Registration Card from the NCSBN.   QUESTION 433A 16-year-old student has a long history of bronchial asthma and has experienced several severe asthmatic attacks during the school year. The school nurse is required to administer 0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How does the school nurse evaluate the effectiveness of this intervention?  Increased pulse rate  Increased expectorate of secretions  Decreased inspiratory difficulty  Increased respiratory rate Explanation/Reference:Explanation:(A) A side effect of epinephrine is fatal ventricular fibrillation owing to its effects on cardiac stimulation. (B) Medications used to treat asthma are designed to decrease bronchospasm, not to increase expectorate of secretions. (C) Epinephrine decreased inspiratory difficulty by stimulating α-, β1, and β2-receptors causing sympathomimetic stimulation (e.g., bronchodilation). (D) The person with asthma fights to inspire sufficient air thus increasing respiratory rate.QUESTION 434The nurse is teaching a client how to perform monthly testicular self-examination (TSE) and states that it is best to perform the procedure right after showering. This statement is made by the nurse based on the knowledge that:  The client is more likely to remember to perform the TSE when in the nude  When the scrotum is exposed to cool temperatures, the testicles become large and bulky  The scrotum will be softer and more relaxed after a warm shower, making the testicles easier to palpate  The examination will be less painful at this time Explanation/Reference:Explanation:(A) Nudity is not a trigger for reminding males to perform TSE. (B) Testicles become more firm when exposed to cool temperatures, but not large and bulky. (C) The testicles will be lower and more easily palpated with warmer temperatures. A protective mechanism of the body to protect sperm production is for the scrotum to pull closer to the body when exposed to cooler temperatures. (D) The examination should not be painful.QUESTION 435A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin.The nurse’s first intervention should be to:  Check FHT  Notify the attending physician  Turn off the IV oxytocin  Prepare for the delivery because the client is probably in transition Explanation(A) FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. (B) The physician should be notified, but this is not the first intervention the nurse should do. (C) The standard of care for an induction according to the Association of Women’s Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. (D) Contractions lasting 60-90 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor.QUESTION 436A nurse is taking a maternal history for a client at her first prenatal visit. Her pregnancy test was positive, she has two living children, she had one spontaneous abortion, and one infant died at the age of 3 months.Which of the following best describes the client at the present?  Gravida 4, para 2, ab 1  Gravida 5, para 3, ab 1  Gravida 5, para 4, ab 0  Gravida 4, para 3, ab 0 Explanation/Reference:Explanation:(A) This individual has been pregnant four times, delivered two children, and had one abortion. (B) Your client has been pregnant five times, delivered three children, and had one abortion. (C) This individual has been pregnant five times, delivered four children, and has not had an abortion. (D) This individual has been pregnant four times, delivered three children, and has not had an abortion.QUESTION 437A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?  Ineffective airway clearance related to immobility, ineffective cough, and decreased level of consciousness  Altered cerebral tissue perfusion related to pathophysiological changes that decrease blood flow  Potential for injury related to impaired mobility and seizures  Impaired verbal communication related to aphasia Explanation/Reference:Explanation:(A) An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. (B) Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is secondary to maintenance of an effective airway. (C) While prevention of injury is important, it is secondary to maintaining an effective airway and cerebral tissue perfusion. (D) Impaired verbal communication is not life threatening in the acute phase of recovery. It is the lowest priority of the nursing diagnoses listed.QUESTION 438A client is being discharged from the hospital today. The discharge teaching for care of her colostomy included which of the following basic principles for protecting the skin around her stoma:  Taping a pouch that is leaking  Cutting the skin barrier 112 inches larger than the stoma  Changing the pouch only when leakage occurs  Using a skin sealant under pouch adhesives Explanation(A) When a pouch seal leaks, the pouch should be immediately changed, not taped. Stool held against the skin can quickly result in severe irritation. (B) The skin barrier should be cut only slightly larger than the stoma (one-half inch). (C) The client should be taught to change pouches whenever possible before leakage occurs.(D) When skin sealant is used under the tape, the outermost layer of the epidermis remains intact. When no skin sealant is used, this layer is removed when the tape is removed.QUESTION 439A 35-year-old client is admitted to the hospital for elective tubal ligation. While the nurse is doing preoperative teaching, the client says, “The anesthesiologist said she was going to give me balanced anesthesia. What exactly is that?” The best explanation for the nurse to give the client would be that balanced anesthesia:  Is a type of regional anesthesia  Uses equal amounts of inhalation agents and liquid agents  Does not depress the central nervous system  Is a combination of several anesthetic agents or drugs producing a smooth induction and minimal complications Explanation(A) Regional anesthesia does not produce loss of consciousness and is indicated for excision of moles, cysts, and endoscopic surgeries. (B) Varying amounts of anesthetic agents are used when employing balanced anesthesia. Amounts depend on age, weight, condition of the client, and surgical procedure. (C) General anesthesia is a drug-induced depression of the central nervous system that produces loss of consciousness and decreased muscle activity. (D) Balanced anesthesia is a combination of a number of anesthetic agents that produce a smooth induction, appropriate depth of anesthesia, and appropriate muscle relaxation with minimal complications.QUESTION 440A client has been uncomfortable in crowds all her life. After the birth of her child, she hasbeen housebound unless her husband can accompany her to the grocery store and for medical appointments. His schedule will not allow for this, and he has insisted that she must be more independent. Her anxiety has increased to the point of panic. The client has been diagnosed with agoraphobia. Which statement is true about this disorder?  The behavior is not considered disabling.  More men suffer from agoraphobia than women.  The fears are persistent, and avoidance is used as the coping mechanism.  Agoraphobia moves into remission when treated with chlorpromazine. (A) Agoraphobia is the most pervasive and serious phobic disorder. (B) Women compose 70%-85% of agoraphobia sufferers. (C) Agoraphobia is an acute disorder that immobilizes the sufferer with extreme anxiety. (D) Chlorpromazine is not a drug used to treat phobias.QUESTION 441A primigravida with a blood type A negative is at 28 weeks’ gestation. Today her physician has ordered a RhoGAM injection. Which statement by the client demonstrates that more teaching is needed related to this therapy?  “I’m getting this shot so that my baby won’t develop antibodies against my blood, right?”  “I understand that if my baby is Rh positive I’ll be getting another one of these injections.”  “This shot should help to protect me in future pregnancies if this baby is Rh positive, like my husband.”  “This shot will prevent me from becoming sensitized to Rh-positive blood.” Section: Questions Set EExplanation:(A) RhoGAM is given to Rh-negative mothers to prevent the maternal Rh immune response to fetal Rh-positive antigens. (B) If the infant is Rh positive, the mother will receive another dose postdelivery to prevent maternal sensitization. (C) Prevention of maternal sensitization will protect future pregnancies because the mother’s blood will be free of antibodies against her fetus. (D) RhoGAM prevents maternal sensitization to Rh-positive blood.QUESTION 442The 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:  Behavior is not normal, and a child psychiatrist should be consulted.  Mother is lying to protect herself.  Lying is normal behavior for a preschool child who is learning to separate fantasy from reality.  Behavior indicates a developmental delay, because preschoolers should be able to tell right from wrong. 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.QUESTION 443A 27-year-old male client is admitted to the acute care mental health unit for observation. He has recently lost his job, and his wife told him yesterday that she wants a divorce. The client is placed on suicide precautions. In assessing suicide potential, the nurse should pay close attention to the client’s:  Level of insight  Thought processes  Mood and affect  Abstracting abilities (A) Assessing the client’s level of insight is an important part of the mental status exam (MSE), but it does not reflect suicide potential. (B) Assessing the client’s thought processes is an important part of the MSE, but it does not reflect suicide potential. (C) Assessing the client’s mood and affect is an important part of the MSE, and it can be a very valuable indicator of suicide potential. Frequently a client who has decided to proceed with suicide plans will exhibit a suddenly improved mood and affect. (D) Assessing a client’s abstracting abilities is an important part of the MSE, but it does not reflect suicide potential.QUESTION 444A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:  Activity intolerance  Ineffective airway clearance  High risk for infection  Altered oral mucous membrane Explanation(A) The laryngectomy client should be able to gradually increase activities without difficulty. (B) The laryngectomy client may have copious amounts of secretions and require suctioning for the first 24-48 hours.The cannula will require cleaning even after the first 24 hours because mucus collects in it. (C) The client does have a potential for infection, but it is not a more importantnursing priority than the ineffective airway clearance. (D) This problem is not a more important nursing priority than ineffective airway clearance. The client’s mouth may become dry, but good oral care should take care of the dryness.QUESTION 445The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on oral griseofulvin. The nurse should emphasize which of these instructions to the mother and/or child?  Administer oral griseofulvin on an empty stomach for best results.  Discontinue drug therapy if food tastes funny.  May discontinue medication when the child experiences symptomatic relief.  Observe for headaches, dizziness, and anorexia. 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) Griseofulvin may alter taste sensations and thereby decrease the appetite. Monitoring of 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 of therapy. It is important to stress continuing the drug therapy to prevent relapse (usually about 6 weeks). (D) The incidence of side effects is low; however, headaches are common. Nausea, vomiting, diarrhea, and anorexia may occur.Dizziness, although uncommon, should be reported to the physician.QUESTION 446The 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?  The client aspirated tube feeding.  The nurse has placed the suction catheter in the esophagus.  This is a normal finding.  The feeding is infusing into the trachea. Explanation/Reference: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.QUESTION 447A psychotic client who believes that he is God and rules all the universe is experiencing which type of delusion?  Somatic  Grandiose  Persecutory  Nihilistic Section: Questions Set AExplanation:(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.QUESTION 448In evaluating the laboratory results of a client with severe pressure ulcers, the nurse finds that her albumin level is low. A decrease in serum albumin would contribute to the formation of pressure ulcers because:  The proteins needed for tissue repair are diminished.  The iron stores needed for tissue repair are inadequate.  A decreased serum albumin level indicates kidney disease.  A decreased serum albumin causes fluid movement into the blood vessels, causing dehydration. Section: Questions Set BExplanation:(A) Serum albumin levels indicate the adequacy of protein stores available for tissue repair. (B) Serum albumin does not measure iron stores. (C) Serum albumin levels do not measure kidney function. (D) A decreased serum albumin level would cause fluid movement out of blood vessels, not into them.QUESTION 449A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following nutritional interventions would be most therapeutic for him at this time?  Small, frequent feedings of foods that can be carried  Tube feedings with nutritional supplements  Allowing him to eat when and what he wants  Giving him a quiet place where he can sit down to eat meals Explanation(A) The manic client is unable to sit still long enough to eat an adequate meal. Small, frequent feedings with finger foods allow him to eat during periods of activity. (B) This type of therapy should be implemented when other methods have been exhausted. (C) The manic client should not be in control of his treatment plan. This type of client may forget to eat. (D) The manic client is unable to sit down to eat full meals.QUESTION 450An infant with a congenital heart defect is being discharged with an order for the administration of digoxin elixir every 12 hours. The parents need to be taught when administering digoxin to the infant that:  If the infant vomits within 30 minutes of the digoxin administration, repeat the dose  They need to mix it with formula so the infant swallows it easily  If the infant vomits two or more consecutive doses or becomes listless or anorexic, notify thephysician  If a dose of digoxin is skipped for more than 6 hours, a new timetable for administration must be developed Explanation(A) Occasionally the child may vomit. They should not repeat the dose because the amount of digoxin that was absorbed is un-known, and serum levels of digoxin that are too high are more dangerous than those that are temporarily too low. (B) To ensure that the entire dose of digoxin is received, never mix it with food or formula. (C) Vomiting, anorexia, and listlessness are all signs of digoxin toxicity and should be reported to the physician immediately. (D) If a dose is forgotten for more than 6 hours, the nurse should advise the parents to skip that dose and to continue the next dose as scheduled.QUESTION 451A 6-month-old infant who was diagnosed at 4 weeks of age with a ventricular septal defect, was admitted today with a diagnosis of failure to thrive. His mother stated that he had not been eating well for the past month. A cardiac catheterization reveals congestive heart failure. All of the following nursing diagnoses are appropriate. Which nursing diagnosis should have priority?  Altered nutrition: less than body requirements related to inability to take in adequate calories  Altered growth and development related to decreased intake of food  Activity intolerance related to imbalance between oxygen supply and demand  Decreased cardiac output related to ineffective pumping action of the heart Explanation(A) Altered nutrition occurs owing to the fatigue from decreased cardiac output associated with congestive heart failure. (B) The decreased intake occurs due to fatigue from the altered cardiac output. (C) Fatigue occurs due to the decreased cardiac output. (D) The ineffective action of the myocardium leads to inadequate O2 to the tissues, which produces activity intolerance, altered nutrition, and altered growth and development.QUESTION 452A 16-year-old student has a long history of bronchial asthma and has experienced several severe asthmatic attacks during the school year. The school nurse is required to administer 0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How does the school nurse evaluate the effectiveness of this intervention?  Increased pulse rate  Increased expectorate of secretions  Decreased inspiratory difficulty  Increased respiratory rate Section: Questions Set BExplanation:(A) A side effect of epinephrine is fatal ventricular fibrillation owing to its effects on cardiac stimulation. (B) Medications used to treat asthma are designed to decrease bronchospasm, not to increase expectorate of secretions. (C) Epinephrine decreased inspiratory difficulty by stimulating α-, β1, and β2-receptors causing sympathomimetic stimulation (e.g., bronchodilation). (D) The person with asthma fights to inspire sufficient air thus increasing respiratory rate. Loading … NCLEX-RN Dumps - Pass Your Certification Exam: https://www.validbraindumps.com/NCLEX-RN-exam-prep.html --------------------------------------------------- Images: https://free.validbraindumps.com/wp-content/plugins/watu/loading.gif https://free.validbraindumps.com/wp-content/plugins/watu/loading.gif --------------------------------------------------- --------------------------------------------------- Post date: 2023-02-19 14:02:18 Post date GMT: 2023-02-19 14:02:18 Post modified date: 2023-02-19 14:02:18 Post modified date GMT: 2023-02-19 14:02:18