NCLEX3RN3ACTUAL3EXAM3TEST3BANK,3REAL3QUESTIONS3&3ANSWERS3NCLEX
QUESTION31
Which3classification3of3drugs3is3contraindicated3for3the3client3with3hypertrophic3cardiomyopathy?
A.3Positive3inotropes
B.3Vasodilators
C.3Diuretics
D.3Antidysrhythmics
Answer:3A3Explanati
on:
(A)3Positive3inotropic3agents3should3not3be3administered3owing3to3their3action3of3increasing3myocardial3contract
ility.3Increased3ventricular3contractility3would3increase3outflow3tract3obstruction3in3the3client3with3hypertrophic3
cardiomyopathy.3(B)3Vasodilators3are3not3typically3prescribed3but3are3not3contraindicated.3(C)3Diuretics3are3used
3with3caution3to3avoid3causing3hypovolemi
A.3(D)3Antidysrhythmics3are3typically3needed3to3treat3both3atrial3and3ventricular3dysrhythmias.
QUESTION32
Signs3and3symptoms3of3an3allergy3attack3include3which3of3the3following?
A.3Wheezing3on3inspiration
B.3Increased3respiratory3rate
C.3Circumoral3cyanosis
D.3Prolonged3expiration
Answer:3D3Explanati
on:
(A)3Wheezing3occurs3during3expiration3when3air3movement3is3impaired3because3of3constricted3edematous3bronc
hial3lumin
A.3(B)3Respirations3are3difficult,3but3the3rate3is3frequently3normal.3(C)3The3circumoral3area3is3usually3pale.3Cyan
osis3is3not3an3early3sign3of3hypoxi
A.3(D)3Expiration3is3prolonged3because3the3alveoli3are3greatly3distended3and3air3trapping3occurs.
QUESTION33
A3client3confides3to3the3nurse3that3he3tasted3poison3in3his3evening3meal.3This3would3be3an3example3of3what3typ
e3of3hallucination?
A.3Auditory
B.3Gustatory
C.3Olfactory
D.3Visceral
Answer:3B3Explanati
on:
(A)3Auditory3hallucinations3involve3sensory3perceptions3of3hearing.3(B)3Gustatory3hallucinations3involve3sens
ory3perceptions3of3taste.3(C)3Olfactory3hallucinations3involve3sensory3perceptions3of3smell.3(D)3Visceral
hallucinations3involve3sensory3perceptions3of3sensation
,QUESTION
43Which3of3the3following3findings3would3be3abnormal3in3a3postpartal3woman?
A. Chills3shortly3after3delivery
B. Pulse3rate3of3603bpm3in3morning3on3first3postdelivery3day
C. Urinary3output3 of330003mL3on3the3second3day3after3delivery
D. An3oral3temperature3of3101F3(38.3C)3on3the3third3day3after3delivery
Answer:3D3Explanati
on:
(A)3Frequently3the3mother3experiences3a3shaking3chill3immediately3after3delivery,3which3is3related3to3a3nervou
s3response3or3to3vasomotor3changes.3 If3not3followed3 by3a3fever,3it3is3clinically3innocuous.3(B)3The3pulse3rate3d
uring3the3immediate3postpartal3period3may3be3low3but3presents3no3cause3for3alarm.3The3body3attempts3to3adapt
3to3the3decreased3pressures3intra-
abdominally3as3well3as3from3the3reduction3of3blood3flow3to3the3vascular3bed.3(C)3Urinary3output3increases3duri
ng3the3early3postpartal3period3(12–
243hours)3owing3to3diuresis.3The3kidneys3must3eliminate3an3estimated32000–
30003mL3of3extracellular3fluid3associated3with3a3normal3pregnancy.3(D)3A3temperature3of3100.4F3(38C)3may3o
ccur3after3delivery3as3a3result3of3exertion3and3dehydration3of3labor.3However,3anytemperature3greater3than3100.
4F3needs3further3investigation3to3identify3any3infectious3process.
QUESTION35
A3six-month-
old3infant3has3been3admitted3to3the3emergency3room3with3febrile3seizures.3In3the3teaching3of3the3parents,3the3nurs
e3states3that:
A. Sustained3temperature3elevation3over3103F3is3generally3related3to3febrile3seizures
B. Febrile3seizures3do3not3usually3recur
C. There3is3little3risk3of3neurological3deficit3and3mental3retardation3as3sequelae3to3febrile3seizures
D. Febrile3seizures3are3associated3with3diseases3of3the3central3nervous3system
Answer:3C3Explanati
on:
(A)3The3temperature3elevation3related3to3febrile3seizures3generally3exceeds3101F,3and3seizures3occur3during3th
e3temperature3rise3rather3than3after3a3prolonged3elevation.3(B)3Febrile3seizures3may3recur3and3are3more3likely3to
3do3so3when3the3first3seizure3occurs3in3the31st3year3of3life.3(C)3There3is3little3risk3of3neurological3deficit,3menta
l3retardation,3or3altered3behavior3secondary3to3febrile3seizures.3(D)3Febrile3seizures3are3associated3with3disease
3of3the3central3nervous3system.
QUESTION36
A3client3diagnosed3with3bipolar3disorder3continues3to3be3hyperactive3and3to3lose3weight.3Which3of3the3following3
nutritional3interventions3would3be3most3therapeutic3for3him3at3this3time?
A. Small,3frequent3feedings3of3foods3that3can3be3carried
B. Tube3feedings3with3nutritional3supplements
C. Allowing3him3to3eat3when3and3what3he3wants
D. Giving3him3a3quiet3place3where3he3can3sit3down3to3eat3meals
Answer:3A3Explanati
on:
(A)3The3manic3client3is3unable3to3sit3still3long3enough3to3eat3an3adequate3meal.3Small,3frequent3feedings3with
,finger3foods3allow3him3to3eat3during3periods3of3activity.3(B)3This3type3of3therapy3should3be3implemented3when
3other3methods3have3been3exhausted.3(C)3The3manic3client3should3not3be3in3control3of3his3treatment3plan.3This
3type3of3client3may3forget3to3eat.3(D)3The3manic3client3is3unable3to3sit3down3to3eat3full3meals.
QUESTION37
A3client3with3bipolar3disorder3taking3lithium3tells3the3nurse3that3he3has3ringing3in3his3ears,3blurred3vision,3and3di
arrhe
A.3The3nurse3notices3a3slight3tremor3in3his3left3hand3and3a3slurring3pattern3to3his3speech.3Which3of3the3following3
actions3by3the3nurse3is3appropriate?
A.3 Administer3a3stat3dose3of3lithium3as3necessary.
B.3Recognize3this3as3an3expected3response3to3lithium.
C.3 Request3an3order3for3a3stat3blood3lithium3level.
D.3 Give3an3oral3dose3of3lithium3antidote.
Answer:3C3Explanati
on:
(A) These3symptoms3are3indicative3of3lithium3toxicity.3 A3stat3dose3of3lithium3could3be3fatal.
(B) These3are3toxic3effects3of3lithium3therapy.3(C)3The3client3is3exhibiting3symptoms3of3lithium3toxicity,3whic
h3may3be3validated3by3lab3studies.3(D)3There3is3no3known3lithium3antidote.
QUESTION38
A3diagnosis3of3hepatitis3C3is3confirmed3by3a3male3client‘s3physician.3The3nurse3should3be3knowledgeable3of3the3
differences3between3hepatitis3A,3B,3and3C.3Which3of3the3following3are3characteristics3of3hepatitis3C?
A. The3potential3for3chronic3liver3disease3is3minimal.
B. The3onset3of3symptoms3is3abrupt.
C. The3incubation3period3is32–263weeks.
D. There3is3an3effective3vaccine3for3hepatitis3B,3but3not3for3hepatitis3C.
Answer:3C3Explanati
on:
(A)3Hepatitis3C3and3B3may3result3in3chronic3liver3disease.3Hepatitis3A3has3a3low3potential3for3chronic3liver3dis
ease.3(B)3Hepatitis3C3and3B3have3insidious3onsets.3Hepatitis3A3has3an3abrupt3onset.3(C)3Incubation3periods3are3a
s3follows:3hepatitis3C3is32–263weeks,3hepatitis3B3is36–203weeks,3and3hepatitis3A3is32–
63weeks.3(D)3Only3hepatitis3B3has3an3effective3vaccine.
QUESTION39
Hypoxia3is3the3primary3problem3related3to3near-
drowning3victims.3The3first3organ3that3sustains3irreversible3damage3after3submersion3in3water3is3the:
A. Kidney3(urinary3system)
B. Brain3(nervous3system)
C. Heart3(circulatory3system)
D. Lungs3(respiratory3system)
Answer:3B3Explanati
on:
A+
, (A)3The3kidney3can3survive3after3303minutes3of3water3submersion.3(B)3The3cerebral3neurons3sustain3irreversible3
damage3after34–63minutes3of3water3submersion.3(C)3The3heart3can3survive3up3to3303minutes3of3water3submersion.
(D)3The3lungs3can3survive3up3to3303minutes3of3water3submersion.
QUESTION310
Which3of3the3following3activities3would3be3most3appropriate3during3occupational3therapy3for3a3client3with3bip
olar3disorder?
A. Playing3cards3with3other3clients
B. Working3crossword3puzzles
C. Playing3tennis3with3a3staff3member
D. Sewing3beads3on3a3leather3belt
Answer:3C3Explanati
on:
(A)3This3activity3is3too3competitive,3and3the3manic3client3might3become3abusive3toward3the3other3clients.3(B)3
During3mania,3the3client‘s3attention3span3is3too3short3to3accomplish3this3task.3(C)3This3activity3uses3gross3motor
3skills,3eases3tension,3and3expands3excess3energy.3 A3staff3member3is3better3 equipped3to3interact3therapeutically
3with3clients.3(D)3This3activity3requires3the3use3of3fine3motor3skills3and3is3very3tedious.
QUESTION311
A330-year-
old3male3client3is3admitted3to3the3psychiatric3unit3with3a3diagnosis3of3bipolar3disorder.3For3the3last323months,3his3
family3describes3him3as3being3―on3the3move,‖3sleeping
3–
43hours3nightly,3spending3lots3of3money,3and3losing3approximately3103lb.3During3the3initial3
assessment3with3the3client,3the3nurse3would3expect3him3to3exhibit3which3of3the3following?
A. Short,3polite3responses3to3interview3questions
B. Introspection3related3to3his3present3situation
C. Exaggerated3 self-importance
D. Feelings3of3helplessness3and3hopelessness
Answer:3C3Explanati
on:
(A)3During3the3manic3phase3of3bipolar3disorder,3clients3have3short3attention3spans3and3may3be3abusive3toward3a
uthority3figures.3(B)3Introspection3requires3focusing3and3concentration;3clients3with3mania3experience3flight3of3id
eas,3which3prevents3concentration.
(C)3Grandiosity3and3an3inflated3sense3of3self-
worth3are3characteristic3of3this3disorder.3(D)3Feelings3of3helplessness3and3hopelessness3are3symptoms3of3the3de
pressive3stage3of3bipolar3disorder.
QUESTION312
Diabetes3during3pregnancy3requires3tight3metabolic3control3of3glucose3levels3to3prevent3perinatal3mortality.3W
hen3evaluating3the3pregnant3client,3the3nurse3knows3the3recommended3serum3glucose3range3during3pregnancy3i
s:
A. 703mg/dL3and31203mg/dL
B. 1003mg/dL3and32003mg/dL
C. 403mg/dL3and31303mg/dL
D. 903mg/dL3and32003mg/dL
A+
QUESTION31
Which3classification3of3drugs3is3contraindicated3for3the3client3with3hypertrophic3cardiomyopathy?
A.3Positive3inotropes
B.3Vasodilators
C.3Diuretics
D.3Antidysrhythmics
Answer:3A3Explanati
on:
(A)3Positive3inotropic3agents3should3not3be3administered3owing3to3their3action3of3increasing3myocardial3contract
ility.3Increased3ventricular3contractility3would3increase3outflow3tract3obstruction3in3the3client3with3hypertrophic3
cardiomyopathy.3(B)3Vasodilators3are3not3typically3prescribed3but3are3not3contraindicated.3(C)3Diuretics3are3used
3with3caution3to3avoid3causing3hypovolemi
A.3(D)3Antidysrhythmics3are3typically3needed3to3treat3both3atrial3and3ventricular3dysrhythmias.
QUESTION32
Signs3and3symptoms3of3an3allergy3attack3include3which3of3the3following?
A.3Wheezing3on3inspiration
B.3Increased3respiratory3rate
C.3Circumoral3cyanosis
D.3Prolonged3expiration
Answer:3D3Explanati
on:
(A)3Wheezing3occurs3during3expiration3when3air3movement3is3impaired3because3of3constricted3edematous3bronc
hial3lumin
A.3(B)3Respirations3are3difficult,3but3the3rate3is3frequently3normal.3(C)3The3circumoral3area3is3usually3pale.3Cyan
osis3is3not3an3early3sign3of3hypoxi
A.3(D)3Expiration3is3prolonged3because3the3alveoli3are3greatly3distended3and3air3trapping3occurs.
QUESTION33
A3client3confides3to3the3nurse3that3he3tasted3poison3in3his3evening3meal.3This3would3be3an3example3of3what3typ
e3of3hallucination?
A.3Auditory
B.3Gustatory
C.3Olfactory
D.3Visceral
Answer:3B3Explanati
on:
(A)3Auditory3hallucinations3involve3sensory3perceptions3of3hearing.3(B)3Gustatory3hallucinations3involve3sens
ory3perceptions3of3taste.3(C)3Olfactory3hallucinations3involve3sensory3perceptions3of3smell.3(D)3Visceral
hallucinations3involve3sensory3perceptions3of3sensation
,QUESTION
43Which3of3the3following3findings3would3be3abnormal3in3a3postpartal3woman?
A. Chills3shortly3after3delivery
B. Pulse3rate3of3603bpm3in3morning3on3first3postdelivery3day
C. Urinary3output3 of330003mL3on3the3second3day3after3delivery
D. An3oral3temperature3of3101F3(38.3C)3on3the3third3day3after3delivery
Answer:3D3Explanati
on:
(A)3Frequently3the3mother3experiences3a3shaking3chill3immediately3after3delivery,3which3is3related3to3a3nervou
s3response3or3to3vasomotor3changes.3 If3not3followed3 by3a3fever,3it3is3clinically3innocuous.3(B)3The3pulse3rate3d
uring3the3immediate3postpartal3period3may3be3low3but3presents3no3cause3for3alarm.3The3body3attempts3to3adapt
3to3the3decreased3pressures3intra-
abdominally3as3well3as3from3the3reduction3of3blood3flow3to3the3vascular3bed.3(C)3Urinary3output3increases3duri
ng3the3early3postpartal3period3(12–
243hours)3owing3to3diuresis.3The3kidneys3must3eliminate3an3estimated32000–
30003mL3of3extracellular3fluid3associated3with3a3normal3pregnancy.3(D)3A3temperature3of3100.4F3(38C)3may3o
ccur3after3delivery3as3a3result3of3exertion3and3dehydration3of3labor.3However,3anytemperature3greater3than3100.
4F3needs3further3investigation3to3identify3any3infectious3process.
QUESTION35
A3six-month-
old3infant3has3been3admitted3to3the3emergency3room3with3febrile3seizures.3In3the3teaching3of3the3parents,3the3nurs
e3states3that:
A. Sustained3temperature3elevation3over3103F3is3generally3related3to3febrile3seizures
B. Febrile3seizures3do3not3usually3recur
C. There3is3little3risk3of3neurological3deficit3and3mental3retardation3as3sequelae3to3febrile3seizures
D. Febrile3seizures3are3associated3with3diseases3of3the3central3nervous3system
Answer:3C3Explanati
on:
(A)3The3temperature3elevation3related3to3febrile3seizures3generally3exceeds3101F,3and3seizures3occur3during3th
e3temperature3rise3rather3than3after3a3prolonged3elevation.3(B)3Febrile3seizures3may3recur3and3are3more3likely3to
3do3so3when3the3first3seizure3occurs3in3the31st3year3of3life.3(C)3There3is3little3risk3of3neurological3deficit,3menta
l3retardation,3or3altered3behavior3secondary3to3febrile3seizures.3(D)3Febrile3seizures3are3associated3with3disease
3of3the3central3nervous3system.
QUESTION36
A3client3diagnosed3with3bipolar3disorder3continues3to3be3hyperactive3and3to3lose3weight.3Which3of3the3following3
nutritional3interventions3would3be3most3therapeutic3for3him3at3this3time?
A. Small,3frequent3feedings3of3foods3that3can3be3carried
B. Tube3feedings3with3nutritional3supplements
C. Allowing3him3to3eat3when3and3what3he3wants
D. Giving3him3a3quiet3place3where3he3can3sit3down3to3eat3meals
Answer:3A3Explanati
on:
(A)3The3manic3client3is3unable3to3sit3still3long3enough3to3eat3an3adequate3meal.3Small,3frequent3feedings3with
,finger3foods3allow3him3to3eat3during3periods3of3activity.3(B)3This3type3of3therapy3should3be3implemented3when
3other3methods3have3been3exhausted.3(C)3The3manic3client3should3not3be3in3control3of3his3treatment3plan.3This
3type3of3client3may3forget3to3eat.3(D)3The3manic3client3is3unable3to3sit3down3to3eat3full3meals.
QUESTION37
A3client3with3bipolar3disorder3taking3lithium3tells3the3nurse3that3he3has3ringing3in3his3ears,3blurred3vision,3and3di
arrhe
A.3The3nurse3notices3a3slight3tremor3in3his3left3hand3and3a3slurring3pattern3to3his3speech.3Which3of3the3following3
actions3by3the3nurse3is3appropriate?
A.3 Administer3a3stat3dose3of3lithium3as3necessary.
B.3Recognize3this3as3an3expected3response3to3lithium.
C.3 Request3an3order3for3a3stat3blood3lithium3level.
D.3 Give3an3oral3dose3of3lithium3antidote.
Answer:3C3Explanati
on:
(A) These3symptoms3are3indicative3of3lithium3toxicity.3 A3stat3dose3of3lithium3could3be3fatal.
(B) These3are3toxic3effects3of3lithium3therapy.3(C)3The3client3is3exhibiting3symptoms3of3lithium3toxicity,3whic
h3may3be3validated3by3lab3studies.3(D)3There3is3no3known3lithium3antidote.
QUESTION38
A3diagnosis3of3hepatitis3C3is3confirmed3by3a3male3client‘s3physician.3The3nurse3should3be3knowledgeable3of3the3
differences3between3hepatitis3A,3B,3and3C.3Which3of3the3following3are3characteristics3of3hepatitis3C?
A. The3potential3for3chronic3liver3disease3is3minimal.
B. The3onset3of3symptoms3is3abrupt.
C. The3incubation3period3is32–263weeks.
D. There3is3an3effective3vaccine3for3hepatitis3B,3but3not3for3hepatitis3C.
Answer:3C3Explanati
on:
(A)3Hepatitis3C3and3B3may3result3in3chronic3liver3disease.3Hepatitis3A3has3a3low3potential3for3chronic3liver3dis
ease.3(B)3Hepatitis3C3and3B3have3insidious3onsets.3Hepatitis3A3has3an3abrupt3onset.3(C)3Incubation3periods3are3a
s3follows:3hepatitis3C3is32–263weeks,3hepatitis3B3is36–203weeks,3and3hepatitis3A3is32–
63weeks.3(D)3Only3hepatitis3B3has3an3effective3vaccine.
QUESTION39
Hypoxia3is3the3primary3problem3related3to3near-
drowning3victims.3The3first3organ3that3sustains3irreversible3damage3after3submersion3in3water3is3the:
A. Kidney3(urinary3system)
B. Brain3(nervous3system)
C. Heart3(circulatory3system)
D. Lungs3(respiratory3system)
Answer:3B3Explanati
on:
A+
, (A)3The3kidney3can3survive3after3303minutes3of3water3submersion.3(B)3The3cerebral3neurons3sustain3irreversible3
damage3after34–63minutes3of3water3submersion.3(C)3The3heart3can3survive3up3to3303minutes3of3water3submersion.
(D)3The3lungs3can3survive3up3to3303minutes3of3water3submersion.
QUESTION310
Which3of3the3following3activities3would3be3most3appropriate3during3occupational3therapy3for3a3client3with3bip
olar3disorder?
A. Playing3cards3with3other3clients
B. Working3crossword3puzzles
C. Playing3tennis3with3a3staff3member
D. Sewing3beads3on3a3leather3belt
Answer:3C3Explanati
on:
(A)3This3activity3is3too3competitive,3and3the3manic3client3might3become3abusive3toward3the3other3clients.3(B)3
During3mania,3the3client‘s3attention3span3is3too3short3to3accomplish3this3task.3(C)3This3activity3uses3gross3motor
3skills,3eases3tension,3and3expands3excess3energy.3 A3staff3member3is3better3 equipped3to3interact3therapeutically
3with3clients.3(D)3This3activity3requires3the3use3of3fine3motor3skills3and3is3very3tedious.
QUESTION311
A330-year-
old3male3client3is3admitted3to3the3psychiatric3unit3with3a3diagnosis3of3bipolar3disorder.3For3the3last323months,3his3
family3describes3him3as3being3―on3the3move,‖3sleeping
3–
43hours3nightly,3spending3lots3of3money,3and3losing3approximately3103lb.3During3the3initial3
assessment3with3the3client,3the3nurse3would3expect3him3to3exhibit3which3of3the3following?
A. Short,3polite3responses3to3interview3questions
B. Introspection3related3to3his3present3situation
C. Exaggerated3 self-importance
D. Feelings3of3helplessness3and3hopelessness
Answer:3C3Explanati
on:
(A)3During3the3manic3phase3of3bipolar3disorder,3clients3have3short3attention3spans3and3may3be3abusive3toward3a
uthority3figures.3(B)3Introspection3requires3focusing3and3concentration;3clients3with3mania3experience3flight3of3id
eas,3which3prevents3concentration.
(C)3Grandiosity3and3an3inflated3sense3of3self-
worth3are3characteristic3of3this3disorder.3(D)3Feelings3of3helplessness3and3hopelessness3are3symptoms3of3the3de
pressive3stage3of3bipolar3disorder.
QUESTION312
Diabetes3during3pregnancy3requires3tight3metabolic3control3of3glucose3levels3to3prevent3perinatal3mortality.3W
hen3evaluating3the3pregnant3client,3the3nurse3knows3the3recommended3serum3glucose3range3during3pregnancy3i
s:
A. 703mg/dL3and31203mg/dL
B. 1003mg/dL3and32003mg/dL
C. 403mg/dL3and31303mg/dL
D. 903mg/dL3and32003mg/dL
A+
