NCLEX NGN Pre-Test Questions and Answers 100% pass

NCLEX NGN Pre-Test Questions and Answers 100% pass A child who is HIV-positive is scheduled to receive a mumps, measles, and rubella (MMR) vaccine. The laboratory results show the CD4+ as 1000 cells/mm3. Which nursing action is appropriate? Administering the vaccine Contacting the primary health care provider Asking the laboratory to repeat the CD4+ test Informing the child's mother that the vaccine must not be administered at this time - ANS- A The normal CD4+ count is 500 to 1600 cells/mm3. Because this child's CD4+ count is 1000 cells/mm3, the nurse would administer the vaccine. A child with osteosarcoma who required amputation of a lower limb is experiencing phantom limb pain. The nurse attempts to comfort the child by providing which explanation? The pain is a normal, temporary condition The pain occurs because nerves have been cut This pain will go away once a prosthesis is used Pain medication may be needed for life to alleviate the discomfort - ANS- A Phantom limb pain is a temporary condition that some people who undergo amputation experience. This sensation of burning, aching, or cramping in the missing limb is most distressing to the client. The child should be reassured that the condition is normal. A client has recently been diagnosed with deep vein thrombosis of the right leg. Which of the following interventions of the nurse immediately implement? a. Elevating the foot of the bed 6 inches b. Placing ice packs on and under the right leg c. Documenting the need for hourly calf measurements d. Performing the need for hourly calf measurements - ANS- A DVT treatment includes bed rest, leg elevation, and application of warm, moist heat. Elevation decreases the venous pressure with relieves edema and pain. ROM cause cause the thrombus to mobilize to the lungs causing PEs. A client hospitalized on a mental health unit with schizophrenia tells the nurse, "The voices in my head say that I'm worthless and that I don't deserve to be alive." What is the nurse's priority concern for this client? Ineffective coping skills Perceptual disturbances Chronic low self-esteem Risk for self-directed violence - ANS- D A client in a manic state emerges from her room wearing provocative clothing and quickly enters the dayroom. She announces to the group that she is the star of a burlesque show and will begin her performance shortly. Which is the priority nursing action? Ask the client to go to her room and to change her clothes Tell the client firmly that burlesque shows are not allowed in the nursing unit Tell the client that her bathroom privileges are being suspended because of her behavior Quietly and firmly assist the client to her room and help her dress in appropriate clothes - ANS- D A client who has just received a diagnosis of asthma says to the nurse, "This is just another nail in my coffin." Which response by the nurse is therapeutic? "Do you think that having asthma will kill you?" "You seem very distressed at learning that you have asthma." "I'm not going to work with you if you can't view this as a challenge rather than a 'nail in your coffin.'" "Asthma is a very treatable condition, but it's important to learn how to properly administer your medications. Let's practice with your inhalant." - ANS- B A client who is 8 weeks pregnant reads her electronic medical record via a patient portal. She contacts the clinic and asks the nurse to explain a "positive Hegar sign." Which is the best answer for the nurse to provide? "You are able to feel fetal movement." "A soft blowing sound can be heard with a stethoscope." "The lower part of your uterus is softer than when you are not pregnant." "You are experiencing irregular painless contractions during the pregnancy." - ANS- C Softening and compressibility of the lower uterine segment, occurring around the sixth week of pregnancy, is called the Hegar sign. A client who is delusional says to the nurse, "Terrorists have been sent here to kill me." How should the nurse respond to the client? "No one is going to kill you." "Your medication is making you feel like this." "Are you worried that people are trying to hurt you?" "What makes you think that terrorists were sent to hurt you?" - ANS- C A client who was sexually assaulted a year ago is self-contained and calm while discussing the assault. The client says to the nurse, "It still doesn't seem real." The nurse is considering requesting a referral to a mental health professional because which defense mechanism has been used for an extensive period of time? Denial Projection Rationalization Intellectualization - ANS- A A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should take which action first? a. Asses the clear fluid for protein b. Check the clear fluid for glucose c. Place cotton calls or dry gauze loosely in the ears d. Use an otoscope to assess the tympanic membrane for rupture - ANS- B CSF contains glucose not protein. A client with a diagnosis of preeclampsia suddenly begins to exhibit seizure activity. Which is the first action on the part of the nurse? a. Calling the physician b. Inserting an oral airway c. Turning the client on her side d. Noting the time of the seizure - ANS- C A client with a manic disorder monopolizes group therapy. What should the nurse leading the group say to the client? "Leave the room." "Go to the nurses' station until our group therapy session is finished." "I will recommend that group therapy be eliminated from your treatment plan." "Thank you for your comments. Now, try to stop talking and listen to the others." - ANS- D A client with diabetes mellitus who is scheduled to have blood drawn for determination of the glycosylated hemoglobin (HbA1c) level asks the nurse why the test is necessary if he is performing blood glucose monitoring at home. Which is the best response for the nurse to provide? a. Detect diabetic complications b. Assess long-term glycemic control c. Determine whether the client is at risk for hypoglycemia d Determine whether the prescribed insulin dosage is correct - ANS- B A client with skeletal traction applied to the right leg complains of severe pain in the leg. The nurse realigns the client's position, but this intervention does not relieve the pain. Which action would the nurse take next? Providing pin care Calling the primary health care provider Removing some of the traction weights Medicating the client with the prescribed analgesic - ANS- B The nurse realigns the client and, if this is ineffective, calls the primary health care provider. The nurse never removes traction weights unless this is specifically prescribed by the primary health care provider. Severe leg pain, once traction has been established, indicates a problem. The client should be medicated after an attempt has been made to identify and treat the cause of the pain.