NCLEX-RN V12.35 National Council Licensure Examination Doc 2022/2023

NO.206 A primigravida with a blood type A negative is at 28 weeks' gestation. Today her physician has ordered a RhoGAM injection. Which statement by the client demonstrates that more teaching is needed related to this therapy? A. "I'm getting this shot so that my baby won't develop antibodies against my blood, right?" B. "I understand that if my baby is Rh positive I'll be getting another one of these injections." C. "This shot should help to protect me in future pregnancies if this baby is Rh positive, like my husband." D. "This shot will prevent me from becoming sensitized to Rh-positive blood." Answer: A Explanation: (A) RhoGAM is given to Rh-negative mothers to prevent the maternal Rh immune response to fetal Rh-positive antigens. (B) If the infant is Rh positive, the mother will receive another dose postdelivery to prevent maternal sensitization. (C) Prevention of maternal sensitization will protect future pregnancies because the mother's blood will be free of antibodies against her fetus. (D) RhoGAM prevents maternal sensitization to Rh-positive blood. NO.207 A client who has gout is most likely to form which type of renal calculi? A. Struvite stones B. Staghorn calculi C. Uric acid stones D. Calcium stones Answer: C Explanation: (A) The presence of urinary tract infection is a factor in the formation of struvite stones. (B) Staghorn calculi is the other name for struvite stones associated with urinary tract infection. (C) Clients who have gout form uric acid stones. (D) Clients who have increased urinary excretion of calcium form calcium stones. NO.208 A 55-year-old man is admitted to the hospital with complaints of fatigue, jaundice, anorexia, and clay-colored stools. His admitting diagnosis is "rule out hepatitis." Laboratory studies reveal elevated liver enzymes and bilirubin. In obtaining his health history, the nurse should assess his potential for exposure to hepatitis. Which of the following represents a high-risk group for contracting this disease? A. Heterosexual males B. Oncology nurses C. American Indians D. Jehovah's Witnesses Answer: B Explanation: (A) Homosexual males, not heterosexual males, are at high risk for contracting hepatitis. (B) Oncology nurses are employed in high-risk areas and perform invasive procedures that expose them to potential sources of infection. (C) The literature does not support the idea that any ethnic groups are at higher risk. (D) There is no evidence that any religious groups are at higher risk. NO.209 A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching concerning the warfarin therapy? A. "If you forget to take your morning dose, double the night time dose." B. "You should take aspirin instead of acetaminophen (Tylenol) for headaches." C. "Carry a medications alert card with you at all times." D. "You should use a straight-edge razor when shaving your arms and legs." Answer: C Explanation: (A) Warfarin must always be taken exactly as directed. Clients should be instructed never to skip or double up on their dosage. (B) Aspirin decreases platelet aggregation, which would potentiate the effects of the coumadin. (C) Healthcare providers need to be aware of persons on warfarin therapy prior to the initiation of any diagnostic tests and/or surgery to help prevent bleeding complications. (D) An electric razor should be used to prevent accidental cutting, which can lead to bleeding. NO.210 A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to: A. Be comforted when he is held B. Cry C. Not notice that his mother has left D. Withdraw and become listless Answer: B Explanation: (A) It will be difficult to comfort a 2 year old with a headache without his mother. (B) This baby probably will cry, which should be prevented because it will increase his intracranial pressure (ICP). Asking the mother to wait until the baby is asleep may help. (C) An awake 2 year old will notice when his mother leaves. (D) An older child may withdraw when feeling afraid, but a 2 year old will probably show more aggressive behavior. NO.211 A laboring client presents with a prolapsed cord. The nurse should immediately place the client in what position? A. Reverse Trendelenburg B. Fowler's C. Trendelenburg D. Sims' Answer: C Explanation: (A) Reverse Trendelenburg position increases pressure on the perineum. This position will not relieve cord pressure. (B) Fowler's position increases perineal pressure. Cord pressure would not be relieved. (C) Trendelenburg position will decrease perineal pressure. Cord compression will be decreased and increase in fetal blood flow occurs. (D) Sims' position does not relieve pressure on cord or perineum. NO.212 Parents of children receiving chemotherapy should be warned that alopecia is a side effect and that: A. Children seldom show concern about losing their hair B. The hair will come out gradually, and the loss will not be noticeable for some time C. It is best for girls to choose a wig similar to their hair style and color before the hair falls out D. The parents will soon get used to seeing their children without hair, and it will no longer bother them Answer: C Explanation: (A) Children may become depressed with a changed appearance and not want to look at themselves or have others see them. (B) The hair will fall out in clumps, causing patchy baldness that is quite noticeable and traumatic to children and their families. (C) Having a wig that looks like a girl's own hair can be a psychological boost to children and is helpful in fostering later adjustments to hair loss. (D) Families may become accustomed to seeing their children without hair, but the loss is traumatic to them and will continue to bother them. NO.213 A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 lb from her 7th to 8th month; her face and hands indicate edema. She is diagnosed as having PIH and referred to the high-risk prenatal clinic. The client's weight increase is most likely due to: A. Overeating and subsequent obesity B. Obesity prior to conception C. Hypertension due to kidney lesions D. Fluid retention Answer: D Explanation: (A) Overeating can lead to obesity, but not to edema. (B) There is no indication of obesity prior to pregnancy. PIH is more prevalent in the underweight than in the obese in this age group. (C) Hypertension can be due to kidney lesions, but it would have been apparent earlier in the pregnancy. (D) The weight gain in PIH is due to the retention of sodium ions and fluid and is one of the three cardinal symptoms of PIH. NO.214 The nurse is caring for a 3-month-old girl with meningitis. She has a positive Kernig's sign. The nurse expects her to react to discomfort if she: A. Dorsiflexes her ankle B. Flexes her spine C. Plantiflexes her wrist D. Turns her head to the side Answer: B Explanation: (A) Discomfort with ankle dorsiflexion is not expected with meningitis. (B) Spinal flexion, flexing the neck or the hips with legs extended, causes discomfort if the meninges are irritated. (C) Discomfort with wrist flexion is not expected with meningitis. (D) Rotating the cervical spine may cause discomfort with meningitis, but pain with flexion is more indicative of meningeal irritation. NO.215 A client suspects that she is pregnant. She reports two missed menstrual periods. The first day of her last menstrual period was August 3. Her estimated date of confinement would be: A. November 7 B. November 10 C. May 7 D. May 10 Answer: D Explanation: (A) Wrong calculation (B) Wrong calculation (C) Wrong calculation (D) Nagele's rule is: Expected Date of Confinement = Last Menstrual Period - 3 months + 7 days + 1 year NO.216 A 10-year-old boy has been diagnosed with Legg-Calve Perthes disease. Which of the client's responses would indicate compliance during initial therapy? A. Drinking large amounts of milk B. Not bearing weight on affected extremity C. Walking short distances 3 times/day D. Putting self on weight reduction diet Answer: B Explanation: (A) This condition causes aseptic necrosis of the head of the femur in the acetabulum. Drinking large quantities of milk at this time cannot hasten recovery. (B) The aim of treatment is to keep the head of the femur in the acetabulum. Non-weight-bearing is essential. Activity causes microfractures of the epiphysis. (C) In addition to non-weightbearing, clients are often placed on bedrest, which helps to reduce inflammation. Later, active motion is encouraged. (D) Weight is not generally an issue with this disease. Slipped femoral capital epiphysis, which is most frequently observed in obese pubescent children, usually requires a weight reduction diet. NO.217 A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, "Why did this happen to my baby?" is: A. "It's God's will. It was probably for the best. There was something probably wrong with your baby." B. "You're young. You can have other children later." C. "I know your other children will be a great comfort to you." D. "I can see you're upset. Would you like to see and hold your baby?" Answer: D Explanation: (A) The mother and the father require support; the nurse should not minimize their grief in this situation. (B) Attachment to this infant occurs during the pregnancy for both the mother and father. Another child cannot replace this child. (C) Attachment to this infant occurs during the pregnancy for both the mother and father. Siblings will not replace their feelings or minimize their loss of this infant. (D) Holding and viewing the infant decreases denial and may facilitate the grief process. The nurse should prepare family members for how the infant appears ("she is bruised") and provide support. NO.218 A 16-year-old client with anorexia nervosa is on an inpatient psychiatric unit. She has a fear of gaining weight and is refusing to eat sufficient amounts to maintain body weight for her age, height, and stature. To assist with the problem of powerlessness and plan for the client to no longer need to withhold food to feel in control, the nurse uses the following strategy: A. Establish a structured environment with routine tasks and activities. Also, serve meals at the same time each day. B. Distract the client during meals to get her to eat because she must take in sufficient amounts to keep from starving. C. Do frequent room checks to be sure that the client is not hiding food or throwing it away. D. Listen attentively and participate in in-depth discussions about food, because these actions may encourage her to eat. Answer: A Explanation: (A) Anorexia nervosa clients feel out of control. Providing a structured environment offers safety and comfort and can help them to develop internal control, thus reducing their need to control by selfstarvation. (B) Distraction does not focus on the client's need for control. (C) Doing frequent room checks reinforces feelings of powerlessness and the need to continue with the dysfunctional behavior. (D) Participating in long discussions about food does not make the client want to eat, but rather this strategy allows her to indulge in her preoccupation and to continue with the dysfunctional behavior. NO.219 The nurse is caring for a 2-year-old girl with a subdural hematoma of the temporal area as a result of falling out of bed and notices that she has a runny nose. The nurse should: A. Call the doctor immediately B. Help her to blow her nose carefully C. Test the discharge for sugar D. Turn her to her side Answer: C Explanation: (A) The nasal discharge could be due to a cold. It is necessary to gather additional assessment data to identify a possible cerebrospinal fluid leak. (B) If the discharge is cerebrospinal fluid, it would not be safe to encourage the girl to blow her nose. (C) Cerebrospinal fluid is positive for sugar; mucus is not. (D) Turning her to her side will have no effect on her "runny nose." It is necessary to gather further assessment data. NO.220 Which of the following menu choices would indicate that a client with pressure ulcers understands the role diet plays in restoring her albumin levels? A. Broiled fish with rice B. Bran flakes with fresh peaches C. Lasagna with garlic bread D. Cauliflower and lettuce salad Answer: A Explanation: (A) Broiled fish and rice are both excellent sources of protein. (B) Fresh fruits are not a good source of protein. (C) Foods in the bread group are not high in protein. (D) Most vegetables are not high in protein; peas and beans are the major vegetables higher in protein. NO.221 The nurse would be sure to instruct a client on the signs and symptoms of an eye infection and hemorrhage. These signs and symptoms would include: A. Blurred vision and dizziness B. Eye pain and itching C. Feeling of eye pressure and headache D. Eye discharge and hemoptysis Answer: B Explanation: (A) Although blurred vision may occur, dizziness would not be associated with an infection or hemorrhage. (B) Eye pain is a symptom of hemorrhage within the eye, and itching is associated with infection. (C) Nausea and headache would not be usual symptoms of eye hemorrhage or infection. (D) Some eye discharge might be anticipated if an infection is present; hemoptysis would not.