NCLEX Exam NCLEX-PN ALL QUESTIONS AND ANSWERS GRADED A+

NCLEX Exam NCLEX-PN ALL QUESTIONS AND ANSWERS GRADED A+ Haloperidol (Haldol) - Answer acute episodes of mania, lithium is effective in 1-2 weeks, but it may take up to 4 weeks, or even a few months treat symptoms fully. Sometimes an antipsychotic agent is prescribed the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms. In addition to the lithium, which one of the following medications might the physician prescribe? NO.1 A depressed client is seen at the mental health center for follow-up after an attempted suicide 1 week ago. She has taken phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor, for 7 straight days. She states that she is not feeling any better. The nurse explains that the drug must accumulate to an effective level before symptoms are totally relieved. Symptom relief is expected to occur within: - Answer 2-4 weeks months months B Explanation: NO.2 Cystic fibrosis is transmitted as an autosomal recessive trait. This means that - Answer Both parents must be carriers for a child to have the disease Delusion - Answer NO.3 A 24-year-old client presents to the emergency department protesting "I am God. The nurse identifies this as a Release restraints every 2 hours for client to exercise. - Answer NO.5 A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints? Observe for headaches, dizziness, and anorexia - Answer NO.6 The 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? Decrease ammonia formation - Answer n.7 A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h nasogastric tube. The rationale for this therapy is to: Observe for evidence of bleeding. - Answer NO.8 A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures should be included in the postoperative care? Decreased absent pedal pulse in the left leg - Answer NO.9 An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his left leg that started approximately 20 minutes ago. When performing the admission assessment, the nurse would expect to observe which of the following: Hematocrit 60% - Answer NO.10 A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician? 7.39 Walk him as he paces. - Answer NO.11 A male client is experiencing extreme distress. He begins to pace up and down the corridor. What nursing intervention is appropriate when communicating with the pacing client? Walk with him as he paces. - Answer NO.11 A male client is experiencing extreme distress. He begins to pace up and down the corridor. What nursing intervention is appropriate when communicating with the pacing client? Locate the position of the placenta and fetus - Answer NO.12 Prior to an amniocentesis, a fetal ultrasound is done in order to February 27 - Answer NO.13 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 Nagele's rule is: Gestational diabetes mellitus - Answer NO.14 A client is now pregnant for the second time. Her first child weighed 4536 g at delivery. The client's glucose tolerance test shows elevated blood sugar levels. Because she only shows signs of diabetes when she is pregnant, she is classified as having: Vitamin C - Answer NO.16 The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue healing? Allowing him to do as much for himself as he is able, including learning to do pin-site care under supervision - Answer NO.17 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? First trimester - Answer NO.18 In client teaching, the nurse should emphasize that fetal damage occurs more frequently with ingestion of drugs during: High Fowler - Answer NO.19 On admission, the client has signs and symptoms of pulmonary edema. The nurse places the client in the most appropriate position for a client in pulmonary edema, which is: Respiratory obstruction - Answer NO.20 A client has returned to the unit from the recovery room after having a thyroidectomy. The nurse knows that a major complication after a thyroidectomy is: Mother calls infant by name. - Answer NO.2 The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase? Respect the client's family's wishes. - Answer NO.22 A female client has just died. Her family is requesting that all nursing staff leave the room. The family's religious leader has arrived and is ready to conduct a ceremony for the deceased in the room, requesting that only family members be present. The nurse assigned to the client should perform the appropriate nursing action, which might include: Wear a patch over one eye - Answer NO.23 A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will teach her to Level of consciousness - Answer NO.24 One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is: Urine output - Answer NO.25 Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who suffered partial- and fullthickness burns to 25% of her body? Headache and facial flushing - Answer NO.26 A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report: Phenytoin (Dilantin) - Answer NO.27 A client states to his nurse that I was told by the doctor not to take one of my drugs because it seems to have caused decreasing blood cells. Based on this information, which drug might the nurse expect to be discontinued? Administer the morning lithium dose as scheduled - Answer NO.28 A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should: Maintaining an adequate level of hydration - Answer NO.29 The primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed toward: You've been feeling sad and alone for some time now? - Answer NO.30 Three weeks following discharge, male client is readmitted to the psychiatric unit for depression. His wife stated that he had threatened to kill himself with a handgun. As the nurse admits him to the unit, he says, "I wish I were dead because I am worthless to everyone; I guess I am just no good." Which response by the nurse is most appropriate at this time? Move furniture out of the way and place a blanket under his head - Answer NO.32 The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take? Immerse both legs in cool water - Answer NO.33 An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action? Serum electrolytes - Answer NO.34 The nurse notes scattered crackles in both lungs and 1+ pitting edema when assessing a cardiac client. The physician is notified and orders furosemide (Lasix) 80 mg IV push stat. Which of the following diagnostic studies is monitored to assess for a major complication of this therapy? When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices. - Answer NO.35 A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements? I Provide time for play and becoming acquainted. - Answer NO.36 A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful? Diminished or absent femoral pulses - Answer NO.37 Diagnostic assessment findings for an infant with possible coarctation of the aorta would include: Urine retention or a distended bladder - Answer NO.38 During a client's first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus. A family member who is having marital problems and is regularly abusing alcohol - Answer NO.39 An 80-year-old widow is living with her son and daughter- in-law. The home health nurse has been making weekly visits to draw blood for a prothrombin time test. The client is taking 5 mg of coumadin per day. She appears more debilitated, and bruises are noted on her face. Elder abuse is suspected. Which of the following are signs of persons who are at risk for abusing an elderly person? Complaints of shortness of breath - Answer NO.40 A 32-year-old female client is being treated for Guillain- Barre synd rome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation? The disorder is a threat to his physical well-being - Answer NO.41 Plans for the care of a client with an ulcer caused by emotional problems need to take into consideration that: Large amounts of salt in your diet can cause you to retain fluid, which increases your blood pressure. - Answer NO.42 A 55-year-old man has recently been diagnosed with hypertension. His physician orders a low sodium diet for him. When he asks, "What does salt have to do with high blood pressure?" the nurse's initial response would be: Six to 10 treatments are common. Are you concerned about permanent effects? - Answer NO.43 A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2- week period. Her husband asks, "Isn't that a lot? The nurse's best response is: Potassium level of 6.3 mEq/L - Answer NU.44 A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening complications may occur initially, so the nurse will monitor him closely for serum: Lecithin-sphingomyelin ratio - Answer NO.45 A 27-year-old primigravida at 32 weeks' gestation has been diagnosed with complete placenta previa. Conservative management including bed rest is the proper medical management. The goal for fetal survival is based on fetal lung maturity. The test used to determine fetal lung maturity is: Dinitrophenylhydrazine Within therapeutic range - Answer NO.46 One week ago, a 21-year-old client with a diagnosis of bipolar disorder was started on lithium 300 mg po qid. A lithium level is ordered. The client's level is 1.3 mEq/L. The nurse recognizes that this level is considered to be When exercise is increased, insulin needs are decreased - Answer NO.47 When discussing the relationship between exercise and insulin requirements, a 26-year-old client with IDDM should be instructed that: Evisceration - Answer NO.48 A client had a hemicolectomy performed 2 days ago. Today, when the nurse assesses the incision, a small part of the abdominal viscera is seen protruding through the incision. This complication of wound healing is known as Headache - Answer NO.49 A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure? Have the client void before the procedure - Answer NO.50 Which nursing implication is appropriate for a client undergoing a paracentesis? procedure I know you're feeling frightened right now, but I want you to know that I don't see anyone in the corner." - Answer NO.51 A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, "The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart. The nurse's best response is: Orthopneic - Answer NO.52 To facilitate maximum air exchange, the nurse should position the client in: Serum potassium is low. The nurse should administer KCI as ordered - Answer NO.53 A 48-year-old client is in the surgical intensive care unit after having had three-vessel coronary artery bypass surgery yesterday. She is extubated, awake, alert and talking. She is receiving digitalis for atrial arrhythmias. This morning serum electrolytes were drawn. Which abnormality would require immediate intervention by the nurse after contacting the physician? Validate that he is not allergic to iodine or shellfish - Answer NO.54 A male client is scheduled to have angiography of his left leg. The nurse needs to include which of the following when preparing the client for th