NCLEX RN EXAM 75 Questions & Answers Latest Update 2023

1. A client is having psychological counseling for problems communicating with his mother. Which model of stress is the most useful in reference to this stressor? C. Transaction-Based Model 2.A female having her first child is experiencing which type of crisis event? B. maturational 3.Nursing care for a client undergoing chemotherapy includes assessment for signs of bone marrow depression. Which finding accounts for some of the symptoms related to bone marrow depression? D. thrombocytopenia 4. A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is under way and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate? D. No action is necessary. 5.A serious complication of a total hip replacement is displacement of the prosthesis. What is the primary sign of displacement? A. pain on movement and weight bearing 6. Which of the following instructions should a nurse give a client who is about to undergo pelvic ultrasonography? D. "Drink plenty of water." 7.Which of the following is not a reason for pelvic ultrasonography? C. to measure renal size 8. Which physiologic mechanism best describes the function of the sodium-potassium pump? A. active transport 9. Laboratory tests reveal the following electrolyte values for Mr. Smith: Na 135 mEq/L, Ca 8.5 mg/dL, Cl 102 mEq/L, and K 2.0 mEq/L. Which of the following values should the nurse report to the physician because of its potential risk to the client? B. K 10. A client receiving drug therapy with furosemide and digitalis requires careful observation and care. In planning care for this client, the nurse should recognize that which of the following electrolyte imbalances is most likely to occur? C. hypokalemia 11. A nurse is assessing the fetal heart rate for a client who is at 38 weeks of gestation. When using an ultrasound device, the nurse hears blood rushing through the umbilical vessels in synchronization with the fetal heartbeat. Which of the following terms should the nurse use to document this finding? a. Funic soufflé 12. A nurse manager in a newborn nursery is reviewing infection control procedures with a group of newly hired nurses. Which of the following instructions should the nurse manager include in the teaching? a. Allow parents to enter the nursery if they are wearing a mask 13. A nurse is caring for a client who is 8 hr postpartum following vaginal delivery and is unable to void. Which of the following interventions should the nurse use to promote voiding? b. Insert an indwelling urinary catheter 14. A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching? a. Transmission can occur via the saliva and urine of the newborn 15. A nurse in a prenatal clinic is caring for a client who has hyperemesis gravidarum. Which of the following is the initial laboratory test used to evaluate this condition? d. Urine ketones 16. A nurse in a prenatal clinic is reviewing the laboratory results for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take? (Click on the Exhibit button for additional information about the client. There are three tabs that contain separate categories of data.) Try your best guess and judgment! d. Obtain a maternal serum alpha-fetoprotein specimen – NO, test occurs between 15-22 wks 17. A nurse is teaching a client about the basal body temperature method of contraception. Which of the following statements should the nurse include in the teaching? b. You should take your temperature before getting up for the day 18. A nurse is providing education to a client who is to receive misoprostol for induction of labor. Which of the following instructions should the nurse include in the teaching? c. You will lie on your side for 40 minutes after I administer the medication 19. A nurse is planning care for a client in the postpartum unit. Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment? d. The client will have adequate nutritional intake 20. A nurse in the antepartum clinic is teaching a client who is at 28 weeks of gestation and has preeclampsia. Which of the following instructions should the nurse include in the teaching? c. Count your baby’s movements daily 21. A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B Streptococcus B-hemolytic (GBS). The client is multigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse? d. We need to know if you are positive for GBS at the time of delivery 22. A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider? d. Transient circumoral cyanosis – decreased oxygenation 23. A nurse is caring for a client who is postpartum and experiencing hypovolemic shock. Which of the following findings should the nurse expect? d. Cool, clammy skin 24. A nurse is teaching a client who is at 8 weeks of gestation about self-care during pregnancy. Which of the following statements should the nurse make? d. You should take 600 mcg of folic acid per day 25. A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan? c. Maintain the client in a supine position?? Best Answer? 26. A nurse is providing teaching about expected changes during pregnancy to a client who is at 24 weeks of gestation. Which of the following information should the nurse include? c. You should anticipate nasal stuffiness 27. A nurse is assisting the provider to administer a dinoprostone (Cervidil) insert to induce labor for a client. Which of the following actions should the nurse take? c. Verify that the informed consent is obtained prior to administration 28. After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client? D. Replacement of the uterus through the vagina into a normal position 29. A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, the nurse would: B. Recheck the temperature in 4 hours 30 -A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse’s initial action should be: C. Helping the woman empty her bladder 31-A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are anxious about the condition of the fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the priority at this time? A. Anxiety 32 -A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client? C. Positive result on d-dimer study 33 -A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs of hypovolemic shock does the nurse closely monitor the client? Select all that apply. A. Tachycardia D. Diminished peripheral pulses 34- A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the physician, which of the following does the nurse specify as the first action in the event of shock? D. Placing the client in a lateral position with the bed flat 110 -A postpartum nurse provides information to a client who has delivered a healthy newborn about normal and abnormal characteristics of lochia. Which of the following findings does the nurse tells the client to report to the physician? D. Reddish lochia on postpartum day 8 35 A nurse in a physician's office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to: A. Document the findings Correct 36- A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta? B. "The placenta maintains the body temperature of my baby." Correct 37 -A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele’s rule, the nurse determines that the estimated date of delivery (EDD) is: B. July 2, 2013 Correct 38 A client has been given a prescription for lovastatin (Mevacor). Which of the following foods does the nurse instruct the client to limit consumption of while taking this medication? A. Steak Correct 39 -A nurse is reviewing the laboratory results of a client with ovarian cancer who is undergoing chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect of the chemotherapy? D. White blood cell count of 2500 cells/mm3 40 -Which finding in a client’s history indicates the greatest risk of cervical cancer to the nurse? C. Multiple sexual partners 41. When teaching new parents to prevent Sudden Infant Death Syndrome (SIDS) what is the most important practice the nurse should instruct them to do? A) Place the infant in a supine or side lying position for sleep 42. A client is admitted with a distended bladder due to the inability to void. The nurse obtains an order to catheterize the client knowing that gradual emptying is preferred over complete emptying because it A) Reduces the potential for shock 43. A client is admitted with a medical diagnosis of addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations? Hypotension, rapid weak pulse, and rapid respiratory rate 44. The nurse is conducting a drug education class for junior high school students. Which statement, provided by one of the student participants, best describes the primary characteristic of addiction? The nurse is caring for critically ill clients. Which should be monitored for the development of neutogenic shock? A client with? Spinal cord injury 45. Which statement by the community health nurse is most helpful to an adult who is in a crisis situation? You seem to be more tense these days. Would you like to talk about the problem and how you are dealing with it? 46. The nurse is teaching staff in a long term - facility home the principles of caring for clients with essential hypertension. Which comment should the nurse include in the inservice presentation about the care of clients with hypertension? Frequent blood pressure checks, including readings taken automated machines are recommended 47. A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention during the first 48 hours following admission? Monitor for increased blood pressure and pulse 48. A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat diet, low calorie diet. At dinner the nurse notes that he is trying to get other clients on the unit to give him part of their meals. what intervention should the nurse implement? Confront the client about the consequences of the behavior. 49. A child with tetrology of ballot suffers a hyper cyanotic episode. Which immediate action by the nurse can lessen the symptoms of this " TET" spell? Place child in knee-chest positionThis pressure reduces the rush of blood flow through the septal hole and improves blood circulation. 50. A client with metastatic cancer is preparing to make a decisions about end-of-life issues. When the nurse explains a durable power of attorney for health care, which description is accurate? It will identify someone that can make the decisions for you health care if you are ever in a coma or vegetative state. 51 .After eye drops are instilled, which instruction should the nurse provide to the client? Close your eyelids 52. The nurse is preparing to administer IV fluid to a client with strict fluid restriction. IV tubing with which feature is most important for the nurse to select? A Buretrol Attachment 53. At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states “My blood pressure is usually much lower.” The nurse should tell the client to A) go get a blood pressure check within the next 48 to 72 hours 54. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is C) Manage pain 55. An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 56. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs? B) "I understand the need to use those new skills." 57. A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is NPO with IV fluids infusing at 100 mL/hour. He is experiencing excruciating abdominal pain. Based on an analysis of these data, which nursing diagnosis would receive the highest priority? A. Pain related to stimulation of nerve endings associated with obstruction of the pancreatic tract 58. 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 selfesteem by: D. Allowing him to plan, assist in, and perform his own care whenever possible 59. A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is ototoxic, the nurse would implement which of the following measures? A. Instruct the client to report any signs of tinnitus, dizziness or difficulty hearing. 60. A male client has experienced low back pain for several years. He is the primary support of his wife and six children. Although he would qualify for disability, he plans to continue his employment as long as possible. His back pain has increased recently, and he is unable to control it with nonsteroidal anti-inflammatory agents. He refuses surgery and cannot take narcotics and remain alert enough to concentrate at work. His physician has suggested application of a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following is an appropriate rationale for using a TENS unit for relief of pain? C. TENS units work on the gate-control theory of pain; biostimulation therapy of large fibers block painful stimuli. 61. A male client had a right below-the-knee amputation 4 days ago. His incision is healing well. He has gotten out of bed several times and sat at the side of the bed. Each time after returning to bed, he has experienced pain as if it were located in his right foot. Which nursing measure indicates the nurse has a thorough understanding of phantom pain and its management? B. The basis for phantom pain may occur because the nerves still carry pain sensation to the brain even though the limb has been amputated. The pain is real, intense, and should be treated. 62. A 28-year-old woman was admitted to the hospital for a thyroidectomy. Postoperatively she is taken to the postanesthesia care unit for several hours. In preparing for the client’s return to her room, which nursing measure best demonstrates the nurse’s thorough understanding of possible postthyroidectomy complications? C. A tracheostomy set, O2, and suction are available at the bedside. 63. A male client is diagnosed with hypoparathyroidism. He has been on dialysis for several years. He is experiencing symptoms such as numbness of the lips, muscle weakness, carpopedal spasms, and wheezing. Given the client’s symptoms, nursing assessment would focus on: A. Detection of tetany 64.A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain his personal hygiene without assistance. Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of: B. Aspiration and weight loss 65. A 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? A. Ineffective airway clearance related to immobility, ineffective cough, and decreased level of consciousness 66. A client had a myocardial infarction 5 days ago. His physician has ordered an echocardiogram to determine how his myocardial infarction has affected his ventricular wall motion. When the client asks if this test is painful, an appropriate response is: B. "No, but you will have to lie still and the gel that is used may be cool." 67. A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, "This is too much trouble. I would rather just have a Foley.” An appropriate response for the RN teaching him would be: A. "I know. It is a lot to learn. In the long run, though, you will be able to reduce infections if you do an intermittent catheterization program.” 68. A client’s physician has prescribed theophylline (Theo- Dur) to help control the bronchospasm associated with the client’s COPD. Instructions that should be given to the client include: A. "Call your physician if you develop palpitations, dizziness, or restlessness.” 69. A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurse instructs the client to: C. Return to the hospital immediately if he develops confusion, nausea, or vomiting 70. A male client has asthma and his physician has prescribed beclomethasone (Vanceril) 3 puffs tid in addition to his other medications. After taking his beclomethasone, the client should be instructed to: B. Drink a glass of water 71. A 70-year-old client has pneumonia and has just had a respiratory arrest. He has just been intubated with an 8- mm endotracheal tube. During auscultation of his chest, breath sounds were found to be absent on the left side. The nurse identifies the most likely cause of this as: B. Left-sided pneumothorax C. Right mainstem bronchus intubation 72. A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to: A. Prevent air from entering the pleural space B. Prevent fluid from entering the pleural space 73.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: B. Pulmonary contusions 74. A 66-year-old female client has smoked 2 packs of cigarettes per day for 20 years. Her arterial blood gases on room air are as follows: pH 7.35; PO2 70 mm Hg; PCO2 55 mm Hg; HCO3 32 mEq/L. These blood gases reflect: B. Compensated respiratory acidosis 75. A female client who has chronic obstructive pulmonary disease (COPD) has presented in the emergency department with cough productive of yellow sputum and increasing shortness of breath. On room air, her blood gases are as follows: pH 7.30 mm Hg, PCO2 60 mm Hg, PO2 55 mm Hg, HCO3 32 mEq/L. These arterial blood gases reflect: D. Uncompensated respiratory acidosis