[Jan 30, 2024] PassTorrent NCLEX-RN Exam Practice Test Questions (Updated 865 Questions)
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NEW QUESTION # 85
The healthcare team determines that an elderly client has had progressive changes in memory over the last 2 years that have interfered with her personal, social, or occupational functioning. Her memory, learning, attention, and judgment have all been affected in some way. These symptoms describe which of the following conditions?
- A. Mania
- B. Delirium
- C. Parkinsonism
- D. Dementia
Answer: D
Explanation:
Explanation
(A) These changes are common characteristics of dementia. (B) Parkinson's disease affects the muscular system. Progressive memory changes are not presenting symptoms. (C) Delirium includes an altered level of consciousness, which is not found in dementia. (D) Mania includes symptoms of hyperactivity, flight of ideas, and delusions of grandeur.
NEW QUESTION # 86
A client was prescribed a major tranquilizer 2 months ago. One month ago she was placed on benztropine (Cogentin). What would indicate that benztropine therapy is effective?
- A. Muscle weakness
- B. Rigidity
- C. Smooth, coordinated voluntary movement
- D. Tremors
Answer: C
Explanation:
(A) Benztropine is prescribed to decrease or alleviate extrapyramidal side effects of major tranquilizers. Smooth, coordinated voluntary movement indicates minimal extrapyramidal side effects. (B) Tremors are an extrapyramidal side effect. (C) Rigidity is an extrapyramidal side effect. (D) Muscle weakness is an extrapyramidal side effect.
NEW QUESTION # 87
A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will:
- A. Maintain a fluid intake of at least 2000 mL daily
- B. Wash her hands before and after voiding
- C. Limit her fluid intake after 6 PM so that there is not a great deal of urine in her bladder while she sleeps
- D. Drink at least 8 oz of cranberry juice daily
Answer: C
Explanation:
Section: Questions Set B
Explanation:
(A) Cranberry juice helps to maintain urine acidity, thereby retarding bacterial growth. (B) A generous fluid intake will help to irrigate the bladder and to prevent bacterial growth within the bladder. (C) Hand washing is an effective means of preventing pathogen transmission. (D) Restricting fluid intake would contribute to urinary stasis, which in turn would contribute to bacterial growth.
NEW QUESTION # 88
Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?
- A. 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.
- B. She burps her baby by placing her in a sitting position, supporting her head and neck and gently massaging her back.
- C. She places her infant on her right side after feeding her.
- D. She uses the bulb syringe to help clear her baby's nose when milk is regurgitated.
Answer: A
Explanation:
Explanation/Reference:
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 # 89
Iron dextran (Imferon) is a parenteral iron preparation.
The nurse should know that it:
- A. Requires use of the Z-track method
- B. Is also called intrinsic factor
- C. Should be given SC
- D. Must be given in the abdomen
Answer: A
Explanation:
Explanation
(A) Intrinsic factor is needed to absorb vitamin B12.(B) Iron dextran is given parenterally, but Z-track in a large muscle. (C) A Ztrack method of injection is required to prevent staining and irritation of the tissue. (D) An SC injection is not deep enough and may cause subcutaneous fat abscess formation.
NEW QUESTION # 90
Parents of children receiving chemotherapy should be warned that alopecia is a side effect and that:
- A. The parents will soon get used to seeing their children without hair, and it will no longer bother them
- B. The hair will come out gradually, and the loss will not be noticeable for some time
- C. It is best for girls to choose a wig similar to their hair style and color before the hair falls out
- D. Children seldom show concern about losing their hair
Answer: C
Explanation:
(A) Children may become depressed with a changed appearance and not want to look at themselves or have others see them. (B) The hair will fall out in clumps, causing patchy baldness that is quite noticeable and traumatic to children and their families. (C) Having a wig that looks like a girl's own hair can be a psychological boost to children and is helpful in fostering later adjustments to hair loss. (D) Families may become accustomed to seeing their children without hair, but the loss is traumatic to them and will continue to bother them.
NEW QUESTION # 91
In evaluating the effectiveness of magnesium sulfate (MgSO4), which of the following might indicate that the client was developing MgSO4 toxicity?
- A. Urine output of 40 mL/hr
- B. A 21 proteinuria value
- C. A 31 patellar tendon reflex
- D. Respirations of 12 breaths/min
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Diminished (not accentuated) patellar tendon reflex is a sign of developing MgSO4 toxicity. A value of
21 is considered a normal tendon reflex; 3+ is considered brisker than normal. (B) MgSO4 is a central nervous system (CNS) depressant. It also relaxes smooth muscle. If the respiratory rate is <16 bpm magnesium toxicity may be developing. (C) Urine output of 40mL/hr is enough to allow elimination of toxic levels of magnesium. Urinary output of <100 mL in a 4-hour period may result in toxic levels of magnesium.
(D) Presence of protein in the urine is a symptom of pregnancy-induced hypertension (PIH), a clinical syndrome for which magnesium sulfate is frequently used in medical management. Protein in the urine is not induced by magnesium sulfate intake.
NEW QUESTION # 92
A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 lb from her 7th to 8th month; her face and hands indicate edema. She is diagnosed as having PIH and referred to the high-risk prenatal clinic. The client's weight increase is most likely due to:
- A. Hypertension due to kidney lesions
- B. Fluid retention
- C. Overeating and subsequent obesity
- D. Obesity prior to conception
Answer: B
Explanation:
(A) Overeating can lead to obesity, but not to edema. (B) There is no indication of obesity prior to pregnancy. PIH is more prevalent in the underweight than in the obese in this age group. (C) Hypertension can be due to kidney lesions, but it would have been apparent earlier in the pregnancy. (D) The weight gain in PIH is due to the retention of sodium ions and fluid and is one of the three cardinal symptoms of PIH.
NEW QUESTION # 93
A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She has been admitted to the pediatric unit after surgical repair of the cleft lip. Which of the following nursing interventions would be appropriate during the first 24 hours?
- A. Maintain elbow restraints in place unless she is being directly supervised.
- B. Position on side or abdomen.
- C. Offer pacifier when she cries.
- D. Clean suture line every shift.
Answer: A
Explanation:
Section: Questions Set G
Explanation:
(A) Placing the infant on her abdomen may allow for injury to the suture line. (B) Elbow restraints prevent the infant from touching the suture line and yet leaves hands free. (C) The suture line is cleaned as often as every hour to prevent crusting and scarring. (D) Sucking of a bottle or pacifier places pressure on the suture line and may delay healing and cause scarring.
NEW QUESTION # 94
Which of the following serum laboratory values would the nurse monitor during gentamicin therapy?
- A. Potassium
- B. Calcium
- C. Creatinine
- D. Sodium
Answer: C
Explanation:
Explanation
(A) A common side effect of gentamicin is nephrotoxicity. The serum laboratory test that best reflects kidney function is serum creatinine. (B) Serum sodium has no relationship to gentamicin. (C) Serum calcium has no relationship to gentamicin. (D) Serum potassium has no relationship to gentamicin. If a client has impaired renal function secondary to gentamicin administration, he or she may also have hyperkalemia as a secondary disorder.
NEW QUESTION # 95
A baby is circumcised. Immediate postoperative care should include:
- A. Keeping the baby NPO for 4 hours to avoid vomiting
- B. Changing the dressing frequently using dry, sterile gauze
- C. Taking the baby to his mother for cuddling
- D. Applying a loose diaper
Answer: C
Explanation:
(A) A pressure diaper should be applied to discourage hemorrhage. (B) The baby can be fed by his mother soon after the procedure, once it is assessed that he is not in any distress and is stable. (C) Dressing changes should not be dry. Dry dressing will stick. (D) Cuddling after the procedure will hopefully quiet the baby. Feeding is also important if his feeding was withheld prior to the procedure or it is time for a feeding.
NEW QUESTION # 96
As a nurse works with an adolescent with cystic fibrosis, the nurse begins to notice that he appears depressed and talks about suicide and feelings of worthlessness. This is an important factor to consider in planning for his care because:
- A. He needs to be confronted with his feelings and forced to work through them
- B. No threat of suicide should be ignored or challenged in any way
- C. He needs to be observed carefully for signs that his depression has been relieved
- D. It may be a bid for attention and an indication that more diversionary activity should be planned for him
Answer: B
Explanation:
(A) Threats of suicide should always be taken seriously. (B) This client has a life-threatening chronic illness. He may be concerned about dying or he may actually be contemplating suicide. (C) Sometimes clients who have made the decision to commit suicide appear to be less depressed. (D) Forcing him to look at his feelings may cause him to build a defense against the depression with behavioral or psychosomatic disturbances.
NEW QUESTION # 97
A client is 2 hours post ventriculoperitoneal shunt placement. How should the nurse position the client?
- A. Head of bed elevated 30 degrees on operative side
- B. Head of bed elevated 30 degrees on nonoperative side
- C. Bed flat on operative side
- D. Bed flat on nonoperative side
Answer: D
Explanation:
Explanation
(A) Elevation of head on nonoperative side would be the position for the late postoperative period. (B) Positioning on operative side puts pressure on the suture lines and on the shunt valve. Elevation of head in immediate postoperative period may cause rapid reduction of cerebrospinal fluid. (C) Placement on operative side puts pressure on the suture lines and shunt valve. (D) Flat position on nonoperative side in the immediate postoperative period prevents pressure on shunt valve and rapid reduction in cerebrospinal fluid.
NEW QUESTION # 98
When assessing a child with diabetes insipidus, the nurse should be aware of the cardinal signs of:
- A. Irritability relieved by feeding formula
- B. Polyuria and polydipsia
- C. Hypothermia and azotemia
- D. Anemia and vomiting
Answer: B
Explanation:
(A) Anemia and vomiting are not cardinal signs of diabetes insipidus. (B) Polyuria and
polydipsia are the cardinal signs of diabetes insipidus. (C) Irritability relieved by feeding water, not formula, is a common sign, but not the cardinal sign, of diabetes insipidus. (D) Hypothermia and azotemia are signs, but not cardinal signs, of diabetes insipidus.
NEW QUESTION # 99
The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:
- A. Immediate treatment of mild PIH includes the administration of a variety of medications
- B. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation
- C. The client may not recognize the early symptoms of PIH
- D. Self-discipline is required to control caloric intake throughout the pregnancy
Answer: C
Explanation:
Section: Questions Set B
Explanation:
(A) Mild PIH is not treated with medications. (B) Emotional stress is not the cause of blood pressure elevation in PIH. (C) Excessive caloric intake is not the cause of weight gain in PIH. (D) The client most frequently is not aware of the signs and symptoms in mild PIH.
NEW QUESTION # 100
A 56-year-old psychiatric inpatient has had recurring episodes of depression and chronic low self-esteem. She feels that her family does not want her around, experiences a sense of helplessness, and has a negative view of herself. To assist the client in focusing on her strengths and positive traits, a strategy used by the nurse would be to:
- A. Encourage or direct client to attend activities that offer simple methods to attain success
- B. Tell the client to attend all structured activities on the unit
- C. Increase the client's self-esteem by asking that she make all decisions regarding attendance in group activities
- D. Not allow any dependent behaviors by the client because she must learn independence and will have to ask for any assistance from staff
Answer: A
Explanation:
Explanation
(A) The nurse should encourage activities gradually, as client's energy level and tolerance for shared activities improve. (B) Activities that focus on strengths and accomplishments, with uncomplicated tasks, minimize failure and increase self-worth. (C) Asking a client to set a goal to make all decisions about attending group activities is unrealistic, and such decisions are not always under the client's control; this sets up the client for further failure and possibly decreased self-worth. (D) Encouragement toward independence does promote increased feelings of selfworth; however, clients may need assistance with decision making and problem solving for various situations and on an individual basis.
NEW QUESTION # 101
A school-age child with asthma is ready for discharge from the hospital. His physician has written an order to continue the theophylline given in the hospital as an oral home medication. Immediately prior to discharge, he complains of nausea and becomes irritable. His vital signs were normal except for tachycardia. What first nursing actions would be essential in this situation?
- A. Hold the child's discharge for 1 hour.
- B. Notify the physician immediately.
- C. Discharge the child as the physician ordered.
- D. Administer an antiemetic as necessary.
Answer: B
Explanation:
Section: Questions Set D
Explanation:
(A) Holding the child's discharge alone does not address the client's problem. (B) Nausea, tachycardia, and irritability are all symptoms of theophylline toxicity. The physician should benotified immediately so that a serum theophylline level can be ordered. Theophylline dose should be withheld until the physician is notified. (C) The child must be evaluated for theophylline toxicity before any discharge. (D) Cause of the nausea should be investigated before the administration of an antiemetic.
NEW QUESTION # 102
Seven days ago, a 45-year-old female client had an ileostomy. She is self-sufficient and well otherwise.
Which of the following long-term objectives would be unrealistic?
- A. She should be able to return to a regular diet.
- B. She should be able to control evacuation of her bowels.
- C. She should be able to manage her own care.
- D. She should be able to resume sexual activity.
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Because of the location of an ileostomy, the client will not be able to control the evacuation of her bowels. The ileostomy will drain liquid stool continuously. (B) The client should be able to return to a normal, well-balanced diet. She should avoid foods that cause diarrhea or excessive gas production, and she should eat small meals. (C) The client should be able to resume sexual activity. She will be able to wear a pouch. (D) The client has no other health or mental problems and should be able to manage her own ileostomy.
NEW QUESTION # 103
A male client was involved in a motor vehicle accident earlier in the day. The nurse caring for him on evenings notices that on admission to the hospital, he lost a lot of blood and required multiple blood transfusions. The nurse would anticipate which blood product would be ordered when a large blood loss has occurred?
- A. Packed red blood cells
- B. Whole blood
- C. Platelets
- D. Fresh frozen plasma
Answer: B
Explanation:
Explanation
(A) Whole blood is the transfusion component of choice when large volumes of blood need to be replaced.
Whole blood contains all blood components that are lost during active bleeding. (B) Platelet therapy is indicated for thrombocytopenia if the client's platelet count is below 15,000/mm3. (C) Infusion of fresh frozen plasma is required when the prothrombin time and partial thromboplastic time are prolonged. (D) Packed red blood cells are transfused in instances of anemia with decreases in hematocrit and hemoglobin.
NEW QUESTION # 104
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