NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED

NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question andAnswers NEWEST EXAM SOLUTION DOWNLOAD A+ Question 1 A c. What document should be in guiding the care of this client? A) Client Self Determination Act B) Physician's treatment orders C) Advance Directives. D) Clinical Pathway protocols Review Information: The correct answer is: C) Advance Directives. This documentspecifies the client's wishes Question 2 You are the of a health care team that consists of one licensed NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ practical/vocational nurse, one nursing assistant, a nursing student and yourself. To whom is it appropriate to assigncomplete care for A) Yourself B) The nursing student C) The licensed vocational nurse D) The nursing assistant Review Information: The correct answer is:A) Yourself. While the nurse may delegate a bed bath for a stable client, this care should be performedby an RN for a new admission. Only tasks that do not require independent judgment should be delegated. Question 3 NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ A mother brings her the clinic, complaining that the child seems to be .The nurse expectsto find which of the following on the initial history and physical assessment? A) Increased temperature and lethargy B) Rash and restlessness C) Increased sleeping and listlessness D) Diarrhea and poor skin turgor Review Information: The correct answer is: B) Rash and restlessness. Question 4 As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by theparents require follow-up and are consistent with the diagnosis? A) "The child has been listless and has lost weight." NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ B) "Her urine is dark yellow and small in amounts." C) "Clothes are becoming tighter across her abdomen." D+) "We notice muscle weakness and some unsteadiness." Review Information: The correct answer is:C) "Clothes are becoming tighter across herabdomen.". One of the most common signs of neuroblastoma is increasing abdominal girth. The parents'' report that clothing is tight is significant, and should be followed by additionalassessments. Question 5 A 16 year-old presents to the emergency department. The triage nurse finds that this teenager is legally married and signed the consent form for treatment. What would be theappropriate INITIAL action by the nurse? A) Refuse to see the client until a parent or legal guardian can be contacted NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ B) Withhold treatment until telephone consent can be obtained from the spouse C) Refer the client to a community pediatric hospital emergency room D) Assess and treat in the same manner as any adult client Review Information: The correct answer is:D) Assess and treat in the same manner asany adult client. Minors may become known as an "emancipated minor" through marriage, pregnancy,high school graduation, independent living or service in the military. Therefore, this client, who is married, has the legal capacity of an adult. Question 6 A newly admitted elderly client is severely dehydrated. When planning care for thisclient, which one of the following is an appropriate task for an Unlicensed AssistivePersonnel (UAP)? A) Obtain a history of fluid loss NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ B) Report output of less than 30 ml/hr C) Monitor response to IV fluids D) Check skin turgor every four hours Review Information: The correct answer is:B) Report output of less than 30 ml/hr. When directing a UAP, the nurse must communicate clearly about each delegated task with specific instructions on what must be reported. Because the RN is responsible for allcare-related decisions,only implementation tasks should be assigned because they do not require independent judgment. Question 7 The nurse is assessing a 4 year-old for possible rheumatic fever. Which of the followingwould the nurse suspect is related to this diagnosis? A) Diagnosis of chickenpox six months ago B) Exposure to strep throat in daycare last month NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ C) Treatment for ear infection two months ago D) Episode of fungal skin infection last week Review Information: The correct answer is:B) Exposure to strep throat in daycare lastmonth. Evidence supports a strong relationship between infection with Group A streptococci andsubsequent rheumatic fever (usually within 2-6 weeks). Therefore, the history of playmates recovering from strep throat would indicate that the child diagnosed with rheumatic fever most likely also had strep throat. Sometimes, such an infection has no clinical symptoms. Question 8 When the nurse becomes aware of feeling reluctant to interact with a manipulative client,the BEST action by the nurse is to A) Discuss the feeling of reluctance with an objective peer or supervisor B) Limit contacts with the client to avoid reinforcing the manipulative behavior NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ C) Confront the client regarding the negative effects of his/her behavior on others D) Develop a behavior modification plan that will promote more functional behavior Review Information: The correct answer is:A) Discuss the feeling of reluctance with anobjective peer or supervisor. The nurse who is experiencing stress in the therapeutic relationship can gain objectivity through supervision. The nurse must attempt to discover attitudes and feelings in the selfthat influence the nurse-client relationship. Question 9 A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action A) May result in charges of unlawful seclusion and restraint B) Leaves the nurse vulnerable for charges of assault and battery NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ C) Was appropriate in view of the client's history of violence D) Was necessary to maintain the therapeutic milieu of the unit Review Information: The correct answer is:A) May result in charges of unlawfulseclusion and restraint. Seclusion should only be used when there is an immediate threat of violence orthreatening behavior. Question 10 A client has been admitted to the Coronary Care Unit with a Myocardial Infarction.Which of the following nursing diagnosis should have PRIORITY? A) Pain related to ischemia B) Risk for altered elimination: constipation C) Risk for complication: dysrhythmias D) Anxiety NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Review Information: The correct answer is:A) Pain related to ischemia. Pain is related to ischemia, and relief of pain will decrease myocardial oxygen demands,reduce blood pressure and heart rate and relieve anxiety. Pain also stimulates the sympathetic nervous system and increased preload, further increasing myocardial demands. Question 11 The nurse manager who is responsible for hiring professional nursing staff is required tocomply with the Americans with Disabilities Act. The provisions of the law require the nurse manager to A) Maintain an environment free from hazards B) Provide reasonable accommodations for disabled individuals C) Make all necessary accommodations for disabled individuals NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ D) Consider only physical disabilities in making employment decisions Review Information: The correct answer is:B) Provide reasonable accommodations fordisabled individuals. The law is designed to permit persons with disabilities access to job opportunities. Employers must evaluate an applicant's ability to perform the job and not discriminate onthe basis of a disability. Employers also must make "reasonable accommodations. Question 12 The mother of a school-aged child in a long leg cast asks the nurse how to relieve itchinginside the cast. Which of the following is appropriate for the nurse to suggest as a remedy? A) Scratching the outside of the cast vigorously, applying pressure over the area B) Blowing a hair dryer or heat lamp on the cast over the area that is itching C) Using a long, smooth piece of wood to gently scratch the affected area NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ D) Applying an ice pack over the area of the cast that is affected Review Information: The correct answer is:D) Applying an ice pack over the area of thecast that is affected. Applying ice is a safe method of relieving the itching. Question 13 Which of the following BEST describes the application of time management strategies inthe role of the nurse manager? A) Scheduling staff efficiently to cover client needs B) Assuming a fair share of the client care as a role model C) Setting daily goals to prioritize work D) Delegating tasks to reduce work load Review Information: The correct answer is:C) Setting daily goals to prioritize work. NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Time management strategies must include setting priorities and meeting goals. Question 14 The clinic nurse assesses a toddler with a tentative diagnosis of neuroblastoma.Symptoms the nurse observes that suggest this problem include A) Lymphedema and nerve palsy B) Hearing loss and ataxia C) Headaches and vomiting D) Abdominal mass and weakness Review Information: The correct answer is:D) Abdominal mass and weakness. Clinical manifestations of neuroblastoma include an irregular abdominal mass thatcrosses the midline, weakness, pallor, anorexia, weight loss and irritability. NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Question 15 A fifteen year-old client has been placed in a Milwaukee Brace. Which one of thefollowing statements from the client indicates the need for additional teaching? A) "I will only have to wear this for six months." B) "I should inspect my skin daily." C) "The brace will be worn day and night." D) "I can take it off when I shower." Review Information: The correct answer is:A) "I will only have to wear this for sixmonths.". The brace must be worn long-term, usually for 1-2 years. Question 16 NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the scheduleover the past few months. The manager considers self-scheduling knowing that A) Quality of care will improve B) Staff turnover should decrease C) Flexible scheduling will occur D) Team morale will improve Review Information: The correct answer is:D) Team morale will improve. Nurses are more satisfied with autonomy and control. The nurse manager becomes thefacilitator of scheduling rather than the decision-maker of the schedule. Question 17 A client is admitted to the emergency room following an acute asthma attack. Which ofthe following assessments would be expected by the nurse? NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ A) Diffuse expiratory wheezing B) Loose, productive cough C) No relief from inhalant D) Fever and chills Review Information: The correct answer is:A) Diffuse expiratory wheezing. In asthma, the airways are narrowed - creating difficulty getting air in and a wheezingsound. Question 18 The nurse manager hears a physician loudly criticizing one of the staff nurses in the hearing of others. The employee does not respond to the physician's complaints. Thenurse manager's FIRST action should be A) Walk up to the physician and quietly ask that this unacceptable behavior stop NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ B) Allow the staff nurse to handle this situation without interference C) Notify the Nursing Director and Medical Staff Chief of a breech of professionalconduct D) Request an immediate private meeting with the physician and staff nurse Review Information: The correct answer is:D) Request an immediate private meetingwith the physician and staff nurse. Assertive communication respects the needs of all parties to express themselves, but notat the expense of others. The nurse manager needs first to protect clients and other staff from this display and come to the assistance of the nurse employee. Question 19 A client voluntarily admits herself to the hospital due to suicidal ideation. The client hasbeen on the unit for two days and is now demanding to be released. The MOST appropriate action is for the nurse to A) Tell the client that she cannot be released because she is still suicidal NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ B) Inform the client that she can be released only if she signs a no suicide contract C) Discuss with the client the decision to leave and prepare for her discharge D) Instruct her regarding her right to sign out upon receipt of the physician's dischargeorder Review Information: The correct answer is:C) Discuss with the client the decision toleave and prepare for her discharge. Clients voluntarily admitted to the hospital have a right to demand and obtain release.Discussing the decision allows opportunity for other interventions. Question 20 A client is admitted with infective endocarditis (IE). Which symptom would alert thenurse to a complication of this condition? A) Dyspnea NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ B) Heart murmur C) Macular rash D) Hemorrhage Review Information: The correct answer is:B) Heart murmur. Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off, causing emboli and leaving ulcerations on the valve leaflets. Theseemboli produce symptoms of cardiac murmur, fever, anorexia, malaise and neurologic sequelae of emboli. Furthermore, the vegetations may travel to various organs such as spleen, kidney, coronary artery, brain and lungs and obstruct blood flow. Question 21 A nurseadmits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based on the fact that the MOST likely cause of this problemstems from the infant's inability to A) Stabilize thermoregulation NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ B) Maintain alveolar surface tension C) Begin normal pulmonary blood flow D) Regulate intracardiac pressure Review Information: The correct answer is:B) Maintain alveolar surface tension. Respiratory distress syndrome is primarily a disease related to developmental delay inlung maturation. Although many factors lead to the development of the problem, the central factor relates to the lack of a normally functioning surfactant system due to immaturity in lung development. Question 22 NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ An 18 year-old client is admitted to intensive care from the emergency room following adiving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse's PRIORITY assessment should be A) Response to stimuli B) Bladder control C) Respiratory function D) Muscle weakness Review Information: The correct answer is: C) Respiratory function. Spinal injury at the C-2 level results in quadriplegia. While the client will experience allof the problems identified, respiratory assessment is a priority. Question 23 The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ for the nurse to includein the plan of care? A) Hourly urine output B) White blood count C) Blood glucose every four hours D) Temperature every two hours Review Information: The correct answer is:A) Hourly urine output. Clients who have had an episode of decreased glomerular perfusion are at risk for pre- renal failure. This is caused by any abnormal decline in kidney perfusion that reduces glomerular perfusion. Pre-renal failure occurs when the effective arterial blood volumefalls. Examples of this phenomena include a drop in circulating blood volume as in a cardiac arrest state or in low cardiac perfusion states such as congestive heart failure associated with a cardiomyopathy. Close observation of hourly urinary output is necessary for early detection of this condition. Question 24 NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ The nurse admitting a 5 month-old who vomited nine times in the past six hours shouldobserve for signs of A) Metabolic acidosis B) Metabolicalkalosis C) Respiratoryacidosis D) Respiratoryalkalosis Review Information: The correct answer is:B) Metabolic alkalosis. Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excessloss and lead to metabolic alkalosis. Question 25 A child is injured on the school playground and appears to have a fractured leg. TheFIRST action the school nurse should take is A) Call for emergency transport to the hospital NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ B) Immobilize the limb and joints above and below the injury C) Assess the child and the extent of the injury D) Apply cold compresses to the injured area Review Information: The correct answer is:C) Assess the child and the extent of theinjury. When applying the nursing process, assessment is the first step in providing care. The 5"Ps" of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis). Question 26 As the nurse interviews the parents of a child with asthma, it is a PRIORITY to ask about A) Household pets NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ B) New furniture C) Lead based paint D) Plants such as cactus Review Information: The correct answer is:A) Household pets. Animal dander is a very common allergen affecting persons with asthma. Other triggersmay include pollens, carpeting and household dust. Question 27 An 80 year-old client was admitted with a diagnosis of possible cerebral vascular accident. Blood pressure has ranged from 180/110 to 160/100. Over the past several hours, the nurse noted increasing lethargy. Which of the following assessments should thenurse report IMMEDIATELY to the physician? A) Slurred speech NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ B) Incontinence C) Muscle weakness D) Rapid pulse Review Information: The correct answer is:A) Slurred speech. Changes in speech patterns and level of conscious can be indicators of continued intercranial bleeding. Treatment options may change based on further diagnostic tests. Question 28 A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratchinghis bottom and wetting the bed at night." Based on these complaints, the nurse would INITIALLY assess for A) Allergies B) Hyperactivity NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ C) Regression D) Pinworms Review Information: The correct answer is:D) Pinworms. Signs of pinworm infection include intense perianal itching, poor sleep patterns, generalirritability, restlessness, bed-wetting, distractibility and short attention span. Question 29 A 72 year-old client with osteomyelitis requires a six week course of intravenous antibiotics. In planning for home care, the MOST important action by the nurse is A) Investigating the client's insurance coverage for home IV antibiotic therapy B) Determining if there are adequate hand washing facilities in the home C) Assessing the client's ability to participate in self care and/or the reliability of a caregiver NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ D) Selecting the appropriate venous access device Review Information: The correct answer is:C) Assessing the client''s ability toparticipate in self care and/or the reliability of a caregiver. The cognitive ability of the client as well as the availability and reliability of a caregivermust be assessed to determine if home care is a feasible option. Question 30 The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. The BESTresponse by the nurse is A) "Folic acid should be taken before and after conception." B) "Multivitamin supplements are recommended during pregnancy." C) "A well balanced diet promotes normal fetal development." D) "Increased dietary iron improves the health of mother and fetus." NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Review Information: The correct answer is:A) "Folic acid should be taken before andafter conception.". The American Academy of Pediatrics recommends that all childbearing women increasefolic acid from dietary sources and/or supplements. There is evidence that increased amounts of folic acid prevents neural tube defects. Question 31 The nurse is caring for a newborn with a neural tube defect. The BEST covering for thelesion is A) Telfadressingwithantibioticointment B) Moist sterile nonadherent dressing C) Dry sterile dressing D) Sterile occlusive pressure dressing Review Information: The correct answer is:B) Moist sterile nonadherent dressing. NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Before surgical closure the sac is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. Dressings are changed frequently to keepthem moist. Question 32 A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important toprevent lead poisoning? A) Use ready-to-feed commercial infant formula B) Boil the tap water for 10 minutes prior to preparing the formula C) Let tap water run for 2 minutes before adding to concentrate D) Buy bottled water labeled "lead free" to mix the formula Review Information: The correct answer is:C) Let tap water run for 2 minutes beforeadding to concentrate. NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Use of lead-contaminated water to prepare formula is a major source of poisoning in infants. Drinking water may be contaminated by lead from old lead pipes or lead solderused insealing water pipes. Letting tap water run for several minutes will diminish the lead contamination. Question 33 A client is admitted to the rehabilitation unit following a CVA and mild dysphagia. TheMOST appropriate intervention for this client is A) Position client in upright position while eating B) Place client on a clear liquid diet C) Tilt head back to facilitate swallowing reflex D) Offer finger foods such as crackers or pretzels Review Information: The correct answer is:A) Position client in upright position whileeating. An upright position facilitates proper chewing and swallowing. NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Question 34 The nurse explains an autograft to a client scheduled for excision of a skin tumor. Thenurse knows the client understands the procedure when the client says, "I will receivetissue from A) a tissue bank." B) a pig." C) my thigh." D) synthetic skin." Review Information: The correct answer is:C) my thigh.". Autografts are done with tissue transplanted from the client''s own skin. NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Question 35 The nurse is caring for a newborn with tracheoesophageal fistula. Which of the followingnursing diagnoses is a PRIORITY? A) Risk for dehydration B) Ineffective airway clearance C) Altered nutrition D) Risk for injury Review Information: The correct answer is:B) Ineffective airway clearance. The most common form of TEF is one in which the proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primarybronchus by a short fistula at or near the bifurcation. Thus, a priority is maintaining an open airway, preventing aspiration. Other nursing diagnoses are then addressed. Question 36 NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The MOST important reason for the nurse to elevate the casted legis to A) Promote the client's comfort B) Reduce the drying time C) Decrease irritation to the skin D) Improve venous return Review Information: The correct answer is:D) Improve venous return.Elevating the leg both improves venous return and reduces swelling. Question 37 A nurse is working with family members of a newly diagnosed client with Alzheimer'sdisease. Which of the following interventions is MOST helpful? A) Teachingrelaxationtechniques NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ B) Implementing a daily exercise routine C) Improving daily nutritional intake D) Suggestingcommunicationstrategies Review Information: The correct answer is:D) Suggesting communication strategies. Since Alzheimer''s disease is a progressive chronic illness that greatly challenges caregivers, the nurse can be of greatest assistance in helping family to identify language changes, and select verbal and nonverbal communication strategies to minimize aberrantbehavior. Question 38 The nurse is teaching a client with non-insulin dependent diabetes mellitus about theprescribed diet. The nurse should teach the client to A) Maintain previous calorie intake B) Keep a candy bar available at all times NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ C) Reduce carbohydrates intake to 25% of total calories D) Keep a regular schedule of meals and snacks Review Information: The correct answer is:D) Keep a regular schedule of meals andsnacks. Currently, calorie-controlled diets with strict mealplans are rarely suggested for clientswho have diabetes. Try to incorporate schedule or food changes into clients'' existing dietary patterns. Help clients learn to read labels and identify specific canned foods, frozen entrees, or other foods which are acceptable and those which should be avoided. Question 39 The mother of a two month-old baby calls the nurse at a well-baby clinic two days afterthe first DTaP immunization. She reports that the baby feels very warm, has cried NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ inconsolably for as long as three hours, and has had several shaking spells. The responseof the nurse should be to A) instruct the mother to call 911 for an ambulance to transport the infant B) suggest that these are expected reactions and to begin every 4 hour antipyretics C) tell the mother to take the infant immediately to the nearest emergency room D) give instructions to bring the infant to the clinic now Review Information: The correct answer is:A)instruct the mother to call 911 for anambulance to transport the infant The exhibited findings of the infant indicate a severe reaction to the immunizations. Immediate attention is needed & an ambulance with trained staff needs to transport because of the risk of grand mal seizures from potential encephalopathy which is a critical reaction. The mother would need to be instructed after this acute reaction to inform the provider of this reaction to the first dose of DTaP. Based on the need and riskinvolved to the infant, the health care provider may decide that further DTaP immunizations are contraindicated for life. The clinic nurse would need to document in the notes for this infant: the instructions given, findings NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ reported by the mother and specific follow-up needs for the next clinic visit in relation to teaching and evaluation ofthe outcome of this event. Question 40 The nurse is teaching a class on HIV prevention. Which of the following should beemphasized as increasing risk? A) Donating blood B) Using public bathrooms C) Unprotected sex D) Touching a person with AIDS Review Information: The correct answer is:C) Unprotected sex. Because HIV is spread through exposure to bodily fluids, unprotected intercourse andshared drug paraphernalia remain the highest risk for infection. NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Question 41 A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has short palpebral fissures, thinned upper lip, and hypoplastic philtrum of the upper lip. The mother states that the child seems to have problems in learning to countand recognizing basic colors. Based on this data, the nurse suspects that the child is MOST likely showing the effects of A) Congenitalabnormalities B) Chronic toxoplasmosis C) Fetal alcohol syndrome D) Lead poisoning Review Information: The correct answer is:C) Fetal alcohol syndrome. Major features of fetal alcohol syndrome consist of facial and associated physical features, such as short palpebral fissure, hypoplastic philtrum, thinned upper lip, short, upturned nose. Behavioral problems, cognitive impairment and psychosocial deficits arealso associated with this NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ syndrome. Question 42 The nurse is performing the admission assessment of a client with an acute episode ofasthma. Which of the following assessments would the nurse anticipate finding? A) Prolonged inspiration B) Expiratorywheezes C) Expectorating large amounts of purulent mucous D) Lethargy Review Information: The correct answer is:B) Expiratory wheezes. Asthma is characterized by expiratory wheezes caused by obstruction of the airways. Wheezes are a high pitched musical sounds produced by air moving through narrowedairways. Clients often associate wheezes with the feeling of tightness in the chest. NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Question 43 The nurse is planning a meal plan that would provide the most iron for a child withanemia. Which of the following dinner menus would be BEST? A) Fish sticks, french fries, banana, cookies, milk B) Ground beef patty, lima beans, wheat roll, raisins, milk C) Chicken nuggets, macaroni, peas, cantaloupe, milk D) Peanut butter and jelly sandwich, apple slices, milk Review Information: The correct answer is:B) Ground beef patty, lima beans, wheatroll, raisins, milk. Iron rich foods include red meat, fish, egg yolks, green leafy vegetables, legumes, wholegrains, dried fruits such as raisins. This dinner is the best choice, high in iron and is appropriate for a toddler. NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Question 44 A ten year-old client is recovering from a splenectomy following a traumatic injury. Theclients laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The BEST approach for the nurse to use is to A) Limit milk and milk products B) Encourage bed activities and games C) Plan nursing care around lengthy rest periods D) Promote a diet rich in iron Review Information: The correct answer is:C) Plan nursing care around lengthy restperiods. The initial priority for this client is rest due to the inability of red blood cells to carryoxygen. NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Question 45 The nurse planning care for a 12 year-old child with sickle cell disease in a vaso- occlusive crisis of the elbow should include which one of the following as a PRIORITY? A) Limit fluids B) Client controlled analgesia C) Cold compresses to elbow D) Passive range of motion exercise Review Information: The correct answer is:B) Client controlled analgesia. Management of a crisis is directed towards supportive and symptomatic treatment. The priority of care is pain relief. In a 12 year-old child, client controlled analgesia promotesmaximum comfort. Question 46 As the nurse provides discharge teaching to the parents of a 15 month-old NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ child with Kawasaki Disease who has received immunoglobulin therapy, which one of the followinginstructions would be MOST appropriate? A) High doses of aspirin will be continued for some time B) Complete recovery is expected within several days C) Active range of motion exercises should be done frequently D) The measles, mumps and rubella vaccine should be delayed Review Information: The correct answer is:D) The measles, mumps and rubella vaccineshould be delayed. Discharge instructions for a child with Kawasaki Disease should include immunoglobulintherapy may interfere with the body''s ability to form appropriate amounts of antibodies and live immunizations should be delayed. Question 47 The nurse is giving instructions to the parents of a child with Cystic Fibrosis. The nursewould emphasize that pancreatic enzymes should be taken NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ A) Once each day B) Three times daily after meals C) With each meal or snack D) Each time carbohydrates are eaten Review Information: The correct answer is:C) With each meal or snack. Pancreatic enzymes should be taken with each meal and every snack to allow fordigestion of all foods that are eaten. Question 48 The nurse is assessing an eight month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infantbe MOST likely to exhibit? A) Lethargy B) Irritability NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ C) Negative Moro D) Depressed fontanel Review Information: The correct answer is:B) Irritability. Signs of IICP (increased intracranial pressure) in infants include bulging fontanel, instability, high-pitched cry, andcries when held. Vital sign changes include pulse that is variable, i.e., rapid, slow and bounding, or feeble. Respirations are more often slow, deep, and irregular. Question 49 The nurse is performing a physical assessment on a toddler. Which of the followingshould be the FIRST action? A) Performtraumaticprocedures B) Use minimal physical contact C) Proceed from head to toe NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ D) Explain the exam in detail Review Information: The correct answer is:B) Use minimal physical contact. The nurse should approach the toddler slowly and use minimal physical contact initially so as to gain the toddler''s cooperation. Be flexible in the sequence of the exam, and giveonly brief simple explanations just prior to the action. Question 50 A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of the following symptoms noted on the initial nursing assessment is expected? A) Recent weight gain B) Physical growth delay C) Protruding eyeballs D) Sudden onset of irritability Review Information: The correct answer is:C) Protruding eyeballs. NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Exophthalmos or protruding eyeballs is a distinctive characteristic of Graves'' Disease. Question 51 When assessing a client admitted to the hospital for diabetic acidosis, which of thefollowing clinical manifestations would the nurse expect? A) A blood pH level above 7.5 B) Arterial blood PCO2 above 40 C) Blood pH level below 7.3 D) Arterial blood PCO2 below 10 Review Information: The correct answer is:C) Blood pH level below 7.3. In the absence of insulin, which facilitates the transport of glucose into the cell, the bodybreaks down fats and proteins to supply energy ketones, a by- product of fat metabolism. These accumulate causing metabolic acidosis (pH 7.3). NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Question 52 The nurse is explaining the proper use of syrup of ipecac to a group of parents. For whichof the following accidental poisonings is the treatment appropriate? A) Ovencleaner B) Draincleaner C) Kerosene D) Chewable vitamins Review Information: The correct answer is:D) Chewable vitamins. Of the above choices, poisoning with vitamins is the only case in which it is safe toinduce vomiting with syrup of ipecac. Question 53 NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ A two year-old child is brought to the pediatrician's office with a chief complaint of milddiarrhea for two days. Nutritional counseling by the nurse should include which one of the following statements? A) Place the child on clear liquids and gelatin for 24 hours B) Continue with the regular diet and include oral rehydration fluids C) Give bananas, apples, rice and toast as tolerated D) Place NPO for 24 hours, then rehydrate with milk and water Review Information: The correct answer is:B) Continue with the regular diet andinclude oral rehydration fluids. Current recommendations for mild to moderate diarrhea are to maintain a normal dietwith rehydration fluids. Question 54 NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The nurseis concerned that the client is unable to coordinate the release of the medication with the inhalation phase. The nurse's BEST recommendation for the client is A) Nebulized treatments for home care B) Adding a spacer device to the MDI canister C) Asking a family member to assist the client with the MDI D) Request a visiting nurse to follow the client at home Review Information: The correct answer is:B) Adding a spacer device to the MDIcanister. The majority of pulmonary medications for COPD are delivered by inhalation.This isoften preferred over oral administration because a lower drug dose is needed and systemic side effects are reduced. In addition, the onset of action of bronchodilator medication given via inhalation is faster. Question 55 NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Which of the following manifestations observed by the school nurse confirms thepresence of pediculosis capitis in students? A) Scratching the head more than usual B) Flakes evident on a student's shoulders C) Oval pattern occipital hair loss D) Whitish oval specks sticking to the hair Review Information: The correct answer is:D) Whitish oval specks sticking to the hair. Diagnosis of pediculosis capitis is made by observation of the white eggs (nits) firmly attached to the hair shafts. Treatment includes shampoo application, such as lindane forchildren over 2 years of age, and meticulous combing and removal of all nits. Question 56 NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. Whilewaiting for an ambulance, the BEST action the nurse would suggest to the parents is A) Administer syrup of ipecac B) Offer small amounts of water C) Have the child drink milk D) Give ginger ale or cola Review Information: The correct answer is:B) Offer small amounts of water. Small amounts of water will dilute the corrosive substance prior to gastric lavage. Question 57 A client is scheduled for an IVP (Intravenous Pyelogram). Which of the following datafrom the client's history indicate a potential hazard for this test? A) Reflex incontinence NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ B) Allergic to shellfish C) Claustrophobia D) Hypertension Review Information: The correct answer is:B) Allergic to shellfish. It is important to know if the client has an allergy to iodine or shellfish. If the client does, they may havean allergic reaction to the IVP contrast dye injected during the procedure. Question 58 A high school nurse is advising a class of unwed pregnant students that the MOSTimportant action they can perform to deliver a healthy child is A) Maintaining good nutrition B) Staying in school NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ C) Keeping in contact with the child's father D) Getting adequate sleep Review Information: The correct answer is:A) Maintaining good nutrition. Nurses canserve a pivotal role in providing nutritional education and case management interventions. Weight gain during pregnancy is one of the strongest predictors of infantbirth weight. Specifically, teens need to increase their intake of protein, vitamins, and minerals including iron. Pregnant teens who gain between 26 and 35 pounds have the lowest incidence of low-birth-weight babies. Question 59 The nurse is preparing a handout on infant feeding to be distributed to families visitingthe clinic. Which of the following should be included in the teaching materials? A) Solid foods are introduced one at a time beginning with cereal B) Finely ground meat should be started early to provide iron C) Egg white is added early to increase protein intake NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ D) Solid foods should be mixed with formula in a bottle Review Information: The correct answer is:A) Solid foods are introduced one at a timebeginning with cereal. Solid foods should be added one at a time between 4-6 months. If the infant is able totolerate the food, another may be added in a week. Iron fortified cereal is the recommended first food. Question 60 The nurse is caring for a client with sickle cell disease who is scheduled to receive a unitof packed red blood cells. Which of the following is an appropriate action for the nurse when administering the infusion? A) Storing the packed red cells in the medicine refrigerator while starting IV NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ B) Slow the rate of infusion if the client develops fever or chills C) Limit the infusion time of each of the unit to a maximum of four hours D) Assess vital signs every 15 minutes throughout the entire infusion Review Information: The correct answer is:C) Limit the infusion time of each of theunit to a maximum of four hours. Infuse the specified amount of blood within 4 hours. If the infusion will exceed this time,the blood should be divided into appropriately sized quantities. Question 61 A client with a documented pulmonary embolism has the following arterial blood gases:PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 7.45, SaO2 - 87%, HCO3 - 22. Based on thisdata, what is the FIRST nursing action? A) Review other lab data B) Notify the physician NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ C) Administer oxygen D) Calm the client Review Information: The correct answer is:C) Administer oxygen. The client has a low PCO2 due to increased respiratory rate from the hypoxemia andsigns of respiratory alkalosis. Immediate intervention is indicated. Question 62 A client diagnosed with hepatitis C discusses his health history with the admitting nurse.The nurse should recognize which of the following as the MOST important data? A) RecenttraveltoCentralAmerica NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ B) Ingestion of raw shellfish last week C) Multiple sex partners D) Blood transfusion 15 years ago Review Information: The correct answer is:D) Blood transfusion 15 years ago. The client who was transfused prior to blood screening for hepatitis C may showsymptoms many years later. Question 63 A client is recovering from a thyroidectomy. While monitoring the client's initial postoperative condition, which of the following should the nurse report immediately? A) Tetanyandparesthesia B) Mild stridor and hoarseness C) Irritability and insomnia NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ D) Headache and nausea Review Information: The correct answer is: A) Tetany and paresthesia. Because the parathyroid gland may be damaged in this surgery, secondary hypocalcemia may occur. Symptoms of hypoparathyroidism include tetany, paresthesia, muscle crampsand seizures. Question 64 A client is admitted with a right upper lobe infiltrate, and also to rule out tuberculosis.The isolation precautions the nurse would institute include A) Positive pressure ventilation NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ B) Gown and gloves C) Particulate respirator mask D) Barrier precautions Review Information: The correct answer is:C) Particulate respirator mask. Tight fitting, high-efficiency masks are required when caring for clients who havesuspected communicable disease of the airborne variety. Question 65 A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for thenurse to include at the change of shift report? A) The client lost 2 pounds B) The client's potassium level is 4 mEq/liter. C) The client's urine output was 1500 cc in five hours D) The client is to receive another dose of Lasix at 10 PM NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Review Information: The correct answer is:C) The client's urine output was 1500 cc infive hours. Although all of these may be correct information to include in report, the essential piecewould be the urine output. Question 66 The nurse is caring for a client with a colostomy. During a teaching session, the nurserecommends that the pouch be emptied A) When it is one third to one half full B) Prior to meals C) After each fecal elimination D) At the same time each day NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Review Information: The correct answer is:A) When it is one third to one half full.If the pouch becomes more than half full it may separate from the flange. Question 67 A couple asks the nurse about risks of several birth control methods. The MOSTappropriate response by the nurse would be A) Norplant is safe and may be removed easily B) Oral contraceptives should not be used by smokers C) Depo-Provera is convenient with few side effects D) The IUD gives protection from pregnancy and infection Review Information: The correct answer is:B) Oral contraceptives should not be usedby smokers. The use of oral contraceptives in a pregnant woman who smokes increases her risk ofcardiovascular problems. NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Question 68 Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness ofthis treatment? A) An increase in appetite B) A decrease in fluid retention C) A decrease in lethargy D) A reduction in jaundice Review Information: The correct answer is:C) A decrease in lethargy. Lactulose produces and acid environment in the bowel and trapsammonia in the gut; the laxativeeffect then aids in removing the ammonia from the body. This decreases the effects ofhepatic encephalopathy, including lethargy and confusion. NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Question 69 The mother of a 3 month-old infant tells the nurse that she wants to change from formulatowhole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition? A) Solid foods should be introduced at 3-4 months B) Whole milk is difficult for a young infant to digest C) Fluoridated tap water should be used to dilute milk D) Supplemental apple juice can be used between feedings Review Information: The correct answer is:B) Whole milk is difficult for a younginfant to digest. Cow''s milk is not given to infants younger than 1 year because the tough, hard curd isdifficult to digest. Also it contains little iron and creates a high renal solute load. NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Question 70 The nurse is assessing a 55 year-old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk forthrombusformation in the post-operative period? A) Estrogen replacement therapy B) 10% less than ideal body weight C) Hypersensitivity to heparin D) History of hepatitis Review Information: The correct answer is:A) Estrogen replacement therapy. Estrogen increases the hypercoagualability of the blood and increased the risk fordevelopment of thrombophlebitis. Question 71 NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ The nurse is planning discharge for a 90 year-old client with musculo-skeletal weakness.Which of the following interventions would be MOST effective in preventing falls? A) Place nightlights in bedroom B) Wear eyeglasses at all times C) Install grab bars in the bathroom D) Teach muscle strengthening exercises Review Information: The correct answer is:A) Place nightlights in bedroom. Because more falls occur in the bedroom than any other location, begin there. However, work in partnership with the client and family so they are willing to move furniture, lampcords, and storage areas; add lighting; remove throw rugs; and decrease other environmental hazards. Question 72 While obtaining the history of a two week-old infant during the well- baby exam, the nurse finds that the neonatal screening for NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ phenylketonuria (PKU) was done when theinfant was less than 24 hours- old. It is a PRIORITY for the nurse to A) Schedule the infant for a repeat test in two weeks B) Obtain a repeat blood test at this point C) Contact the hospital of birth for the results D) Document that the test results are pending Review Information: The correct answer is:B) Obtain a repeat blood test at this point. Testing for PKU is most reliable when protein has been ingested. A repeat blood specimen must be obtained by the third week of life if the initial specimen was takenfrom an infant less than 24 hours-old. Question 73 Two hours after the normal spontaneous vaginal delivery of a woman who is gravida 4 para 4, the nurse notes that the fundus is boggy and displaced slightly above and to the left of the umbilicus. The appropriate INITIAL nursing action is to NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ A) Assess lochia for color and amount B) Monitor pulse and blood pressure C) Call the physician immediately D) Ask the woman to empty her bladder Review Information: The correct answer is:D) Ask the woman to empty her bladder. A full bladder can displace the uterus and prevent contraction. After the woman emptiesthe bladder, the fundus should be assessed again. Question 74 An 8 year-old client is admitted to the hospital for surgery. The child's parent reports several allergies. Which of the following should all health care personnel be aware of? A) Shellfish B) Molds NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ C) Balloons D) Perfumed soap Review Information: The correct answer is:C) Balloons. Allergy to balloons indicates a latex allergy. All personnel in contact with the child willneed to be aware of this condition and use non-latex gloves. Question 75 The nurse is caring for a client who is post-op following a thoracotomy. The client hastwo chest tubes in place,connected to one chest drain. The nursing assessment reveals NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ bubbling in the water seal chamber when the client coughs. What is the MOSTappropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Continue to monitor the client to see if the bubbling increases D) Instruct the client to try to avoid coughing Review Information: The correct answer is:C) Continue to monitor the client to see if thebubbling increases. Bubbling associated with coughing after lung surgery is to be expected as small amountsof air escape the pleural space when pressures inside the chest increase with coughing. Monitoring is the only nursing action required. Question 76 The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax)for a Herpes Simplex Virus type 2 infection. The nurse NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ should instruct the client to A) Complete the entire course of the medication for an effective cure B) Begin treatment with acyclovir at the onset of symptoms of recurrence C) Stop treatment if she thinks she may be pregnant to prevent birth defects D) Continue to take prophylactic doses for at least five years after the diagnosis Review Information: The correct answer is:B) Begin treatment with acyclovir at the onsetof symptoms of recurrence. When the client is aware of early symptoms, such as pain, itching or tingling, treatment isvery effective. Question 77 An eight year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which one of thefollowing is the BEST choice? NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ A) Bologna sandwich, pudding, milk B) Frankfurter, baked potato, milk C) Chicken strips, corn on the cob, milk D) Grilled cheese sandwich, apple, milk Review Information: The correct answer is:C) Chicken strips, corn on the cob, milk.This menu is lowest in sodium. Ideally, low fat milk would be available. Question 78 The nurse is teaching parents about accidental poisoning in children. Which of thefollowing should be emphasized? A) Start treatment before calling the Poison Control Center B) Empty the child's mouth in any case of possible poisoning C) Do not move the child if a toxic substance was inhaled D) Induce vomiting if the poison is a hydrocarbon NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Review Information: The correct answer is:B) Empty the child''s mouth in any case ofpossible poisoning. Emptying the mouth of poison interferes with further ingestion and should be done firstto limit contact with the substance. Question 79 Which of the following symptoms contraindicate the use of haloperidol (Haldol) andwarrant withholding the dose? A) Drowsiness, lethargy, and inactivity B) Dry mouth, nasal congestion, and blurred vision C) Rash, blood dyscrasias, severe depression D) Hyperglycemia, weight gain, and edema NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Review Information: The correct answer is:C) Rash, blood dyscrasias, severe depression. Rash and blood dyscrasias are side effects of anti- psychotic drugs. A historyof severe depression is a contraindication to the use of neuroleptics. Question 80 The nurse is planning care for a 14 year-old client returning from scoliosis correctivesurgery. Which of the following actions should receive PRIORITY in the plan? A) Antibiotic therapy for 10 days B) Teach client isometric exercises for legs C) Assess movement and sensation of extremities D) Assist to stand up at bedside within the first 24 hours Review Information: The correct answer is:C) Assess movement and sensation ofextremities. Following corrective surgery for scoliosis, neurological status requires NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ special attentionand assessment, especially that of the extremities. Question 81 A three year-old child diagnosed as having celiac disease attends a day care center. Whichof the following would be an appropriate snack? A) Cheese crackers B) Peanut butter sandwich C) Potato chips D) Vanillacookies Review Information: The correct answer is:C) Potato chips. Children with celiac disease should eat a gluten free diet. Gluten is found mainly in grains of wheat and rye and in smaller quantities in barley and oats. Corn, rice, soybeansand potatoes are digestible in persons with celiac disease. NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Question 82 The nurse is caring for a 14 month-old just diagnosed with Cystic Fibrosis. The parents state this is the first child in either family with this disease, and ask about the risk to future children. The BEST response by the nurse is based on the knowledge that there is a A) 1 in 4 chance for each child to carry that trait B) 1 in 4 risk for each child to have the disease C) 1 in 2 chance of avoiding the trait and disease D) 1 in 2 chance that each child will have the disease Review Information: The correct answer is:B) 1 in 4 risk for each child to have thedisease. Cystic Fibrosis is an autosomal recessive transmission pattern. In this situation, both parents must be carriers of the trait for the disease since neither one of them has the disease. Therefore, for each pregnancy, there is a 25% chance of the child having the disease, 50% chance of carrying the trait and a 25% chance of having neither the trait orthe disease. NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Question 83 A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute.What should the nurse do FIRST? A) Notify the physician B) Administer the prn dose of Albuterol C) Apply oxygen at 2 liters per nasal cannula D) Repeat the peak flow reading in 30 minutesReview Information: The correct answer is: B) Administer the prn dose of Albuterol. Peak flow monitoring during exacerbations of asthma is recommended for clients with moderate-to-severe persistent asthma to determine the severity of the exacerbation and to NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ guide the treatment. A peak flow reading of less than 50% of the client''s baseline readingis a medical alert condition and a short-acting beta-agonist must be taken immediately. Question 84 What nursing observation signifies that a client has attained the stage of concreteoperations (Piaget)? A) Explores his environment using sight and movement B) Can think in mental images or word pictures C) Makes the moral judgment that "stealing is wrong" D) Reasons that homework is time-consuming but necessary Review Information: The correct answer is:C) Makes the moral judgment that "stealingis wrong". The stage of concrete operations is depicted by logical thinking and moral judgments. NURS6401 NCSBN TEST BANK-for the NCLEX-RN &NCLEX-PN UPDATED 2022/2023 Question and Answers NEWEST EXAM SOLUTION DOWNLOAD A+ Question 85 The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of thefollowing lab reports should the nurse review FIRST? A) Protime (PT) and partial thromboplastin time (PTT) B) Red blood cell and white blood cell counts C) Blood urea nitrogen and creatinine clearance D) Liverenzymes(ASTandALT) Review Information: The correct answer is:D) Liver enzymes (AST and ALT). Because acetaminophen is toxic to the liver and causes hepatic cellular ne