New 2021 NCLEX-RN exam questions Welcome to download the newest PassLeaderVCE NCLEX-RN PDF dumps (865 Q&As)
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NEW QUESTION 16
A postoperative TURP client is ordered continuous bladder irrigations. Later in the evening on the first postoperative day, he complains of increasing suprapubic pain. When assessing the client, the nurse notes diminished flow of bloody urine and several large blood clots in the drainage tubing. Which one of the following should be the initial nursing intervention?
- A. Call the physician about the problem.
- B. Change the Foley catheter.
- C. Administer a prescribed narcotic analgesic.
- D. Irrigate the Foley catheter.
Answer: D
Explanation:
Explanation
(A) The physician should be notified as problems arise, but in this case, the nurse can attempt to irrigate the Foley catheter first and call the physician if irrigation is unsuccessful. Notifying the physician of problems is a subsequent nursing intervention. (B) This answer is correct. Assessing catheter patency and irrigating as prescribed are the initial priorities to maintain continuous bladder irrigation. Manual irrigation will dislodge blood clots that have blocked the catheter and prevent problems of bladder distention, pain, and possibly fresh bleeding. (C) The Foley catheter would not be changed as an initial nursing intervention, but irrigation of the catheter should be done as ordered to dislodge clots that interfere with patency. (D) Even though the client complains of increasing suprapubic pain, administration of a prescribed narcotic analgesic is not the initial priority. The effect of the medication may mask the symptoms of a distended bladder and lead to more serious complications.
NEW QUESTION 17
Children often experience visual impairments. Refractive errors affect the child's visual activity. The main refractive error seen in children is myopia. The nurse explains to the child's parents that myopia may also be described as:
- A. Nearsightedness
- B. Cataracts
- C. Farsightedness
- D. Lazy eye
Answer: A
Explanation:
Explanation
(A) Cataracts are not considered refractive errors. Cataracts canbe described as opacity of the lens.
(B)Hyperopiais the term forfarsightedness. One can see objects at a distance more clearlythan close objects.
(C)Myopiais the term for nearsightedness.Objects that are close in distance are more clearly seen. (D) Lazyeye refers to strabismus or misalignment of the eyes.
NEW QUESTION 18
A male client is undergoing cardiac tests. He has been instructed to wear a Holter monitor. The nurse knows she has included the appropriate information in her teaching when the client tells her:
- A. "Damage to his heart muscle will be recorded by the monitor."
- B. "He is to refrain from activities that cause chest pain."
- C. "He should remove the electrodes for bathing."
- D. "He is to keep a record of everything he does during the day."
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) The client should leave the electrodes in place during the entire time the test is ordered. He should not even remove the electrodes for bathing. (B) The Holter monitor will record cardiac electrical activity but will not record damage to his myocardium. (C) The client should keep a record of all of his activities so the physician can correlate the ECG findings with his activities. (D) The client should continue doing his regular activities. The purpose of the Holter monitor is to record heart activity during routine activities.
NEW QUESTION 19
A 40-year-old client has been admitted to the hospital with severe substernal chest pain radiating down his left arm. The nurse caring for the client establishes the following priority nursing diagnosis-Alteration in comfort, pain related to:
- A. Increased excretion of lactic acid due to myocardial hypoxia
- B. Increased blood flow through the coronary arteries
- C. Decreased stimulation of the sympathetic nervous system
- D. Decreased secretion of catecholamines secondary to anxiety
Answer: A
Explanation:
Explanation
(A) Anaerobic metabolism results because the decreased blood supply to the myocardium causes a release of lactic acid. Lactic acid is an irritant to the myocardial neural receptors, producing chest pain. (B) Chest pain is caused by a decrease in the O2 supply to the myocardial cells. Treatment modalities for chest pain are aimed toward increasing the blood flow through coronary arteries. (C) Chest pain causes an increase in the stimulation of the sympathetic nervous system. This stimulation increases the heart rate and blood pressure, causing an increase in myocardial workload aggravating the chest pain. (D) Chest pain and anxiety cause increased secretion of catecholamines by stimulating the sympathetic nervous system. This stimulation increases chest pain by increasing the workload of the heart.
NEW QUESTION 20
The nurse would assess the client's correct understanding of the fertility awareness methods that enhance conception, if the client stated that:
- A. "My sexual partner and I should have intercourse when my cervical mucosa is thick and cloudy."
- B. "My sexual partner and I should have sexual intercourse on day 14 of my cycle regardless of the length of the cycle."
- C. "I should douche immediately after intercourse."
- D. "At ovulation, my basal body temperature should rise about 0.5F."
Answer: D
Explanation:
(A)
At ovulation, the cervical mucus is increased, stretchable, and watery clear. (B) Under the influence of progesterone, the basal body temperature increases slightly after ovulation.
(C)
To enhance fertility, measures should be taken that promote retention of sperm rather than removal. (D) Ovulation, the optimal time for conception, occurs 14+2 days before the next menses; therefore, the date of ovulation is directly related to the length of the menstrual cycle.
NEW QUESTION 21
A male client is experiencing extreme distress. He begins to pace up and down the corridor. What nursing intervention is appropriate when communicating with the pacing client?
- A. Walk with him as he paces.
- B. Increase the level of his supervision.
- C. Ask him to sit down. Speak slowly and use short, simple sentences.
- D. Help him to recognize his anxiety.
Answer: A
Explanation:
(A) The nurse should not ask him to sit down. Pacing is the activity he has chosen to deal with his anxiety. The nurse dealing with this client should speak slowly and with short, simplesentences. (B) The client may already recognize the anxiety and is attempting to deal with it. (C) Walk with the client as he paces. This gives support while he uses anxiety-generated energy. (D) Increasing the level of supervision may be appropriate after he stops pacing. It would minimize self-injury and/or loss of control.
NEW QUESTION 22
A client is experiencing visual problems at school. She has complained of difficulty seeing the blackboard and squinting. She no longer likes to participate in physical activities such as softball. The client has displayed possible classic symptoms of which refractive error?
- A. Astigmatism
- B. Hyperopia
- C. Amblyopia
- D. Myopia
Answer: D
Explanation:
(A) Visual images are blurred and distorted. (B) Symptoms are headaches, burning eyes, fatigue, squinting, and difficulty reading. (C) These symptoms are classic for myopia. (D) Amblyopia is not a refractive error. It is a loss of vision in one or both eyes.
NEW QUESTION 23
A client with emphysema is placed on diuretics. In order to avoid potassium depletion as a side effect of the drug therapy, which of the following foods should be included in his diet?
- A. Liver
- B. Tomatoes
- C. Celery
- D. Potatoes
Answer: D
Explanation:
Section: Questions Set A
Explanation:
(A) Celery is high in sodium. (B) Potatoes are high in potassium. (C) Tomatoes are high in sodium. (D) Liver is high in iron.
NEW QUESTION 24
Assessment of a client reveals a 30% loss of preillness weight, lanugo, and cessation of menses for 3 months. Her vital signs are BP 90/50, P 96 bpm, respirations 30, and temperature 97 οF. She admits to the nurse that she has induced vomiting 3 times this morning, but she had to continue exercising to lose "just 5 more lb." Her symptoms are consistent with:
- A. Gastritis
- B. Pregnancy
- C. Anorexia nervosa
- D. Bulimia
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Presenting behaviors collectively are inconsistent with depression. (B) A preillness weight loss of 30%, lanugo, and cessation of menses are inconsistent with bulimia. (C) Symptoms and vital signs do not indicate the presence of infection. (D) All symptoms and vital signs are consistent with anorexia nervosa.
NEW QUESTION 25
During burn therapy, morphine is primarily administered IV for pain management because this route:
- A. Allows for discontinuance of the medication if respiratory depression develops
- B. Avoids causing additional pain from IM injections
- C. Delays absorption to provide continuous pain relief
- D. Facilitates absorption because absorption from muscles is not dependable
Answer: D
Explanation:
Explanation
(A) Absorption would be increased, not decreased. (B) IM injections should not be used until the client is hemodynamically stable and has adequate tissue perfusion. Medications will remain in the subcutaneous tissue with the fluid that is present in the interstitial spaces in the acute phase of the thermal injury. The client will have a poor response to the medication administered, and a "dumping" of the medication can occur when the medication and fluid are shifted back into the intravascular spaces in the next phase of healing. (C) IV administration of the medication would hasten respiratory compromise, if present. (D) The desire to avoid causing the client additional pain is not a primary reason for this route of administration.
NEW QUESTION 26
Two weeks after a client's admission for depression, the physician orders a consult for electroconvulsive therapy (ECT). Which of the following conditions, if present, would be a contraindication for ECT?
- A. Surgically repaired herniated lumbar disk
- B. Brain tumor or other space-occupying lesion
- C. History of frequent urinary tract infections
- D. History of mitral valve prolapse
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) A contraindication for ECT is a space-occupying lesion such as a brain tumor. During ECT, intracranial pressure increases. Therefore, ECT would not be prescribed for a client whose intracranial pressure is already elevated. (B) Any cardiac dysrhythmias or complications that arise during ECT are usually attributed to the IV anesthetics used, not to preexisting cardiac structural conditions. (C) Musculoskeletal injuries during ECT are extremely rare because of the IV use of centrally acting muscle relaxers. (D) A history of any kind of infection would not contraindicate the use of ECT. In fact, concurrent treatment of infections with ECT is not uncommon.
NEW QUESTION 27
A client calls the prenatal clinic to schedule an appointment. She states she has missed three menstrual periods and thinks she might be pregnant. During her first visit to the prenatal clinic, it is confirmed that she is pregnant. The registered nurse (RN) learns that her last menstrual period began on June 10. According to Nagele's rule, the estimated date of confinement is:
- A. August 30
- B. June 3
- C. January 10
- D. March 17
Answer: D
Explanation:
Explanation
(A) Using Nagele's rule, count back 3 calendar months from the first day of the last menstrual period. The answer is March 10. Then add 7 days and 1 year, which would be March 17 of the following year. (B, C, D) This date is incorrect.
NEW QUESTION 28
The physician of a client diagnosed with alcoholism orders neomycin 0.5 g q6h to prevent hepatic coma.
Neomycin decreases serum ammonia levels by:
- A. Decreasing the uptake of vitamin D, thereby drawing more water into the colon
- B. Decreasing nitrogen-forming bacteria in the intestines
- C. Acidifying colon contents by causing ammonia retention in the colon
- D. Irritating the bowel and promoting evacuation of stool
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Neomycin interferes with protein synthesis in the bacterial cell, causing bacterial death. Neomycin reduces the growth of the ammonia-producing bacteria in the intestines and is used for the treatment of hepatic coma. (B) This choice describes the action of lactulose, another drug commonly used to decrease systemic ammonia levels. (C) Neomycin's action doesnotdecrease uptake of vitamin D to reduce serum ammonia levels. (D) Bowel irritation with diarrhea is more likely to occur with administration of lactulose rather than of neomycin. Besides, diarrhea is a side effect of a drug, not the action of the drug.
NEW QUESTION 29
The most important goal in the care plan for a child who was hospitalized with an accidental overdose would be to:
- A. Teach parents appropriate safety precautions
- B. Instruct parents in use of ipecac
- C. Determine child's activity pattern
- D. Reduce mother's sense of guilt
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) This goal is not the most important. (B) There is always some guilt when an accident occurs; however, the priority is to be sure future accidents are prevented. (C) Ipecac is not used for caustic alkali and acid ingestions. (D) Determining the parent's knowledge about safety hazards and teaching appropriate preventive measures are likely to prevent recurrence of accidents.
NEW QUESTION 30
An infant weighing 15 lb has just been treated for severe diarrhea in the hospital. Discharge instructions by the nurse will include maintenance fluid requirements for the pediatric client. Which of the following values best indicates the nurse's understanding of normal fluid requirements for this infant?
- A. 330 mL/day
- B. 680 mL/day
- C. 960 mL/day
- D. 240 mL/day
Answer: B
Explanation:
Section: Questions Set E
Explanation:
(A, C, D) These answers are incorrect. (B) Normal fluid requirement for this pediatric client is based on the fact that 0-10 kg of weight equals 100 mL/kg per day. This infant weighs 15 pounds (6.8 kg). Thus, 100 mL X 6.8
680 mL/day.
NEW QUESTION 31
The child with iron poisoning is given IV deferoxamine mesylate (Desferal). Following administration, the child suffers hypotension, facial flushing, and urticaria. The initial nursing intervention would be to:
- A. Take all vital signs, and report to the physician
- B. Stop the medication, and begin a normal saline infusion
- C. Assess urinary output, and if it is 30 mL an hour, maintain current treatment
- D. Discontinue the IV
Answer: B
Explanation:
Section: Questions Set A
Explanation:
(A) The IV line should not be discontinued because other IV medications will be needed. (B) Stop the medication and begin a normal saline infusion. The child is exhibiting signs of an allergic reaction and could go into shock if the medication is not stopped. The line should be kept opened for other medication. (C) Taking vital signs and reporting to the physician is not an adequate intervention because the IV medication continues to flow. (D) Assessing urinary output and, if it is 30 mL an hour, maintaining current treatment is an inappropriate intervention owing to the child's obvious allergic reaction.
NEW QUESTION 32
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NCLEX-RN exam questions from PassLeaderVCE dumps: https://www.passleadervce.com/NCLEX-Certification/reliable-NCLEX-RN-exam-learning-guide.html (865 Q&As)
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