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NCLEX-PN Pre-Test Exam

Question No : 1 Teaching the client with gonorrhea how to prevent reinfection and further spread is an example of: A. primary prevention. B. secondary prevention. C. tertiary prevention. D. primary health care prevention. Answer: B


Explanation: Secondary prevention targets the reduction of disease prevalence and disease morbidity through early diagnosis and treatment. Question No : 2 Which of the following foods is a complete protein? A. corn B. eggs C. peanuts

D. sunflower seeds

Answer: B


Explanation: Eggs are a complete protein. The remaining options are incomplete proteins.


Question No : 3 Broccoli, oranges, dark greens, and dark yellow vegetables can be eaten to: A. supplement vitamin pills. B. balance body molecules. C. cure many diseases. D. help improve body defenses. Answer: D


Explanation: Controversy over what types of food to eat and not eat is still under investigation. Certain foods can help improve body defenses to possibly prevent certain diseases.


Question No : 4 The major electrolytes in the extracellular fluid are: A. potassium and chloride. B. potassium and phosphate. C. sodium and chloride. D. sodium and phosphate. Answer: C


Explanation: Sodium and chloride are the major electrolytes in the extracellular fluid.


Question No : 5 Which of the following nursing diagnoses might be appropriate as Parkinson’s disease progresses and complications develop? A. Impaired Physical Mobility B. Dysreflexia C. Hypothermia D. Impaired Dentition Answer: A


Explanation: The client with Parkinson’s disease can develop a shuffling gait and rigidity, causing impaired physical mobility. The other diagnoses do not necessarily relate to a client with Parkinson’s disease. Question No : 6 Which of the following is an inappropriate item to include in planning care for a severely neutropenic client? A. Transfuse neutrophils (granulocytes) to prevent infection. B. Exclude raw vegetables from the diet. C. Avoid administering rectal suppositories. D. Prohibit vases of fresh flowers and plants in the client’s room. Answer: A


Explanation: Granulocyte transfusion is not indicated to prevent infection. Produced in the bone marrow, granulocytes normally comprise 70% of all WBCs. They are subdivided into three types based on staining properties: neutrophils, eosinophils, and basophils. They can be beneficial in a selected population of infected, severely granulocytopenic clients (less than 500/mm3) who do not respond to antibiotic therapy and who are expected to experience prolonged suppression of granulocyte production.Physiological Adaptation Question No : 7 A primary belief of psychiatric mental health nursing is: A. most people have the potential to change and grow. B. every person is worthy of dignity and respect. C. human needs are individual to each person. D. some behaviors have no meaning and cannot be understood. Answer: B Explanation: Every person is worthy of dignity and respect. Every person has the potential to change and grow. All people have basic human needs in common with others. All behavior has meaning and can be understood from the client’s perspective.Psychosocial Integrity Question No : 8 - (Topic 1) A teenage client is admitted to the hospital because of acetaminophen (Tylenol) overdose. Overdoses of acetaminophen can precipitate life-threatening abnormalities in which of the following organs? A. lungs B. liver C. kidneys D. adrenal glands Answer: B Explanation:


NCLEX NCLEX-PN : Practice Test Acetaminophen is extensively metabolized in the liver. Choices 1, 3, and 4 are incorrect because prolonged use of acetaminophen might result in an increased risk of renal dysfunction, but a single overdose does not precipitate life-threatening problems in the respiratory system, renal system, or adrenal glands.Pharmacological Therapies Question No : 9 - (Topic 1) All of the following factors, when identified in the history of a family, are correlated with poverty except: A. high infant mortality rate. B. frequent use of Emergency Departments. C. consultation with folk healers. D. low incidence of dental problems. Answer: D Explanation: Dental problems are prevalent because of the lack of preventive care and access to care. High infant mortality is one of the most significant problems correlated with poverty. Pregnant women who do not have access to care might come to the Emergency Department when in labor. Those in poverty are likely to use Emergency Departments because they may not be turned away. Those in poverty might also turn to folk healers or other persons in their community for care who might be easier to access and might not demand payment.Health Promotion and Maintenance Question No : 10 - (Topic 1)


NCLEX NCLEX-PN : Practice Test Acyclovir is the drug of choice for: A. HIV. B. HSV 1 and 2 and VZV. C. CMV. D. influenza A viruses. Answer: B Explanation: Acyclovir (Zovirax) is specific for treatment of herpes virus infections. There is no cure for herpes. Acyclovir is excreted unchanged in the urine and therefore must be used cautiously in the presence of renal impairment. Drugs that treat herpes inhibit viral DNA replication by competing with viral substrates to form shorter, ineffective DNA chains.Physiological Adaptation Question No : 11 - (Topic 1) Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complainsof dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley’s level of anxiety as: A. mild. B. moderate. C. severe. D. panic. Answer: C Explanation: The person whose anxiety is assessed as severe is unable to solve problems and has a poor grasp of what’s happening in his or her environment. Somatic symptoms such as those described by Ashley are usually present.


NCLEX NCLEX-PN : Practice Test Vital sign changes are observed. The individual with mild anxiety might report being mildly uncomfortable and might even find performance enhanced. The individual with moderate anxiety grasps less information about the situation, has some difficulty problem-solving, and might have mild changes in vital signs. The individual in panic demonstrates markedly disturbed behavior and might lose touch with reality.Psychosocial Integrity Question No : 12 - (Topic 1) Which of the following methods of contraception is able to reduce the transmission of HIV and other STDs? A. intrauterine device (IUD) B. Norplant C. oral contraceptives D. vaginal sponge Answer: D Explanation: The vaginal sponge is a barrier method of contraception that, when used with foam or jelly contraception, reduces the transmission of HIV and other STDs as well as reducing the risk of pregnancy. IUDs, Norplant, and oral contraceptives can prevent pregnancy but not the transmission HIV and STDs. Clients using the contraceptive methods in Choices 1, 2, and 3 should be counseled to use a chemical or barrier contraceptive to decrease transmission of HIV or STDs.Health Promotion and Maintenance Question No : 13 - (Topic 1)


NCLEX NCLEX-PN : Practice Test Which fetal heart monitor pattern can indicate cord compression? A. variable decelerations B. early decelerations C. bradycardia D. tachycardia Answer: A Explanation: Variable decelerations can be related to cord compression. The other patterns are not.Reduction of Risk Potential Question No : 14 - (Topic 1) The nurse teaching about preventable diseases should emphasize the importance of getting the following vaccines: A. human papilloma virus, genital herpes, measles. B. pneumonia, HIV, mumps. C. syphilis, gonorrhea, pneumonia. D. polio, pertussis, measles. Answer: D Explanation: Vaccines are one of the most effective methods of preventing and controlling certain communicable diseases. The smallpoxvaccine is not currently in use becausethe smallpox virushas been declarederadicated from the world’s population. Diseases such as polio, diphtheria, pertussis, and measles are mostly controlled by routine childhood immunization. They have not, however, been eradicated, so children need to be immunized against these diseases.Physiological Adaptation


NCLEX NCLEX-PN : Practice Test Question No : 15 - (Topic 1) Which of the following conditions is mammography used to detect? A. pain B. tumor C. edema D. epilepsy Answer: B Explanation: Mammography is used to detect tumors or cysts in the breasts, not the other conditions.Reduction of Risk Potential Question No : 16 - (Topic 1) When the nurse is determining the appropriate size of an oropharyngeal airway to insert, what part of a client’s body should she measure? A. corner of the mouth to the tragus of the ear B. corner of the eye to the top of the ear C. tip of the chin to the sternum D. tip of the nose to the earlobe Answer: A Explanation: An oropharyngeal airway is measured from the corner of the client’s mouth, to the tragus of the ear. Reduction of Risk Potential


NCLEX NCLEX-PN : Practice Test Question No : 17 - (Topic 1) Which sign might the nurse see in a client with a high ammonia level? A. coma B. edema C. hypoxia D. polyuria Answer: A Explanation: Coma might be seen in a client with a high ammonia level.Reduction of Risk Potential Question No : 18 - (Topic 1) What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36mmHg, and HCO3 24 mEq/L? A. metabolic alkalosis B. homeostasis C. respiratory acidosis D. respiratory alkalosis Answer: B Explanation: These ABG values are within normal limits. Choices 1, 3, and 4 are incorrect because the ABG values indicate none of these acid-base disturbances.Physiological Adaptation Question No : 19 - (Topic 1) Which of the following is the primary force in sex education in a child’s life?


NCLEX NCLEX-PN : Practice Test A. school nurse B. peers C. parents D. media Answer: C Explanation: Parents are the primary force in sex education in a child’s life. The school nurse is involved with formal sex education and counseling. Peers become more important in sex education during adolescence but might lack correct information. The media play a powerful role in what children learn about sex through movies, TV, and video games.Health Promotion and Maintenance Question No : 20 - (Topic 1) The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to examine? A. 6 B. 8 C. 12 D. 16 Answer: C Explanation: In general, children begin dentition around 6 months of age. During the first 2 years of life, a quick guide to the number of teeth a child should have is as follows: Subtract the number 6 from the number of months in the age of the child. In this example, the child is 18 months old, so the formula is 18 – 6 = 12. An 18-month-old child should have approximately 12 teeth.Health Promotion and Maintenance


NCLEX NCLEX-PN : Practice Test Question No : 21 - (Topic 1) Which of the following medications is a serotonin antagonist that might be used to relieve nausea and vomiting? A. metoclopramide (Reglan) B. onedansetron (Zofran) C. hydroxyzine (Vistaril) D. prochlorperazine (Compazine) Answer: B Explanation: Zofran is a serotonin antagonist that can be used to relieve nausea and vomiting. The other medications can be used for nausea and vomiting, but they have different mechanisms of action.Physiological Adaptation Question No : 22 - (Topic 1) A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as: A. plantar fasciitis. B. hallux valgus. C. hammertoe. D. Morton’s neuroma. Answer: D Explanation: Morton’s neuroma is a small mass or tumor in a digital nerve of the foot. Hallux valgus is referred to in lay terms as abunion.Hammertoe is where one toe is cocked up over another toe. Plantar fasciitis is an inflammation


NCLEX NCLEX-PN : Practice Test of, or pain in, the arch of the foot.Basic Care and Comfort Question No : 23 - (Topic 1) For a client with suspected appendicitis, the nurse should expect to find abdominal tenderness in which quadrant? A. upper right B. upper left C. lower right D. lower left Answer: C Explanation: The nurse should expect to find abdominal tenderness in the lower-right quadrant in a client with appendicitis. Physiological Adaptation Question No : 24 - (Topic 1) Assessment of a client with a cast should include: A. capillary refill, warm toes, no discomfort. B. posterior tibial pulses, warm toes. C. moist skin essential, pain threshold. D. discomfort of the metacarpals. Answer: A Explanation: Assessment for adequate circulation is necessary. Signs of impaired circulation include slow capillary refill, cool fingers or toes, and pain.Basic Care and Comfort


NCLEX NCLEX-PN : Practice Test Question No : 25 - (Topic 1) Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority? A. open leg fracture B. open head injury C. stab wound to the chest D. traumatic amputation of a thumb Answer: C Explanation: A stab wound to the chest might result in lung collapse and mediastinal shift that, if untreated, could lead to death. Treatment of an obstructed airway or a chest wound is a higher priority than hemorrhage. The principle of ABC (airway, breathing, and circulation) prioritizes care decisions.Physiological Adaptation Question No : 26 - (Topic 1) Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma? A. The clothing is the property of another and must be treated with care. B. Such care facilitates repair and salvage of the clothing. C. The clothing of a trauma victim is potential evidence with legal implications. D. Such care decreases trauma to the family members receiving the clothing. Answer: C Explanation: Trauma in any client, living or dead, has potential legal and/or forensic implications.


NCLEX NCLEX-PN : Practice Test Clothing, patterns of stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death, and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health care facilities have policies governing the collection of forensic evidence. The chain of evidence custody must be followed to ensure the integrity and credibility of the evidence. The chain of evidence custody is the pathway that evidence follows from the time it is collected until is has served its purpose in the legal investigation of an incident.Physiological Adaptation Question No : 27 - (Topic 1) Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care? A. “I should put alcohol on my baby’s cord 3–4 times a day.” B. “I should put the baby’s diaper on so that it covers the cord.” C. “I should call the physician if the cord becomes dark.” D. “I should wash my hands before and after I take care of the cord.” Answer: D Explanation: Parents should be taught to wash their hands before and after providing cord care. This prevents transferring pathogens to and from the cord. Folding the diaper below the cord exposes the cord to air and allows for drying.


NCLEX NCLEX-PN : Practice Test It also prevents wet or soiled diapers from coming into contact with the cord. Current recommendations include cleaning the area around the cord 3–4 times a day with a cotton swab but do not include putting alcohol or other antimicrobials on the cord. It is normal for the cord to turn dark as it dries.Health Promotion and Maintenance Question No : 28 - (Topic 1) A middle-aged woman tells the nurse that she has been experiencing irregular menses for the past six months. The nurse should assess the woman for other symptoms of: A. climacteric. B. menopause. C. perimenopause. D. postmenopause. Answer: C Explanation: Perimenopause refers to a period of time in which hormonal changes occur gradually, ovarian function diminishes, and menses become irregular. Perimenopause lasts approximately five years. Climacteric is a term applied to the period of life in which physiologic changes occur and result in cessation of a woman’s reproductive ability and lessened sexual activity in males. The term applies to both genders. Climacteric and menopause are interchangeable terms when used for females. Menopause is the period when permanent cessation of menses has occurred. Postmenopause refers to the period after the changes accompanying menopause are complete.Health Promotion and Maintenance


NCLEX NCLEX-PN : Practice Test Question No : 29 - (Topic 1) Which of the following might be an appropriate nursing diagnosis for an epileptic client? A. Dysreflexia B. Risk for Injury C. Urinary Retention D. Unbalanced Nutrition Answer: B Explanation: The epileptic client is at risk for injury due to the complications of seizure activity, such as possible head trauma associated with a fall. The other choices are not related to the question.Reduction of Risk Potential Question No : 30 - (Topic 1) Which of the following diseases or conditions is least likely to be associated with increased potential for bleeding? A. metastatic liver cancer B. gram-negative septicemia C. pernicious anemia D. iron-deficiency anemia Answer: C Explanation: Pernicious anemia results from vitamin B12 deficiency due to lack of intrinsic factor. This can result from inadequate dietary intake, faulty absorption from the GI tract due to a lack of secretion of intrinsic factor normally produced by gastric mucosal cells and certain disorders of the small intestine that impair absorption. The nurse should instruct the client in the need for lifelong replacement of vitamin B12, as well as the need for


NCLEX NCLEX-PN : Practice Test folic acid, rest, diet, and support.Physiological Adaptation Question No : 31 - (Topic 1) When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula? A. 2 liters/minute B. 4 liters/minute C. 6 liters/minute D. 8 liters/minute Answer: C Explanation: The highest flow rate that oxygen can be delivered via nasal cannula is 6 liters/minute. Higher flow rates must be delivered by mask.Reduction of Risk Potential Question No : 32 - (Topic 1) The kind of man who beats a woman is: A. from a minority culture in a low-income group. B. from a majority culture in a middle-income group. C. one who was never allowed to compete as a child. D. from any walk of life, race, income group, or profession. Answer: D Explanation: Batterers cannot be predicted by demographic features related to age, ethnicity, race, religious denomination, education, socioeconomic status, or class. Ninety-five percent of domestic abuse cases


NCLEX NCLEX-PN : Practice Test involve male perpetrators and female victims.Psychosocial Integrity Question No : 33 - (Topic 1) All of the following should be performed when fetal heart monitoring indicates fetal distress except: A. increase maternal fluids. B. administer oxygen. C. decrease maternal fluids. D. turn the mother. Answer: C Explanation: Decreasing maternal fluids is the only intervention that shouldnotbe performed when fetal distress is indicated.Reduction of Risk Potential Question No : 34 - (Topic 1) What interpersonal relief behavior is Ashley using? A. acting out B. somatizing C. withdrawal D. problem-solving Answer: B Explanation: Somatizing means one experiences an emotional conflict as a physical symptom. Ashley manifests several


NCLEX NCLEX-PN : Practice Test physical symptoms associated with severe anxiety. Acting out refers to behaviors such as anger, crying, laughter, and physical or verbal abuse. Withdrawal is a reaction in which psychic energy is withdrawn from the environment and focused on the self in response to anxiety. Problem-solving takes place when anxiety is identified and the unmet need is met.Psychosocial Integrity Question No : 35 - (Topic 1) A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client’s weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as: A. within normal limits, so a weight-reduction diet is unnecessary. B. lower than normal, so education about nutrient-dense foods is needed. C. indicating obesity because the BMI is 35. D. indicating overweight status because the BMI is 27. Answer: C Explanation: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. It is calculated by utilizing a chart or nomogram that plots height and weight. This client’s BMI is 35, indicating obesity. Goals of diet therapy are aimed at decreasing weight and increasing activity to healthy levels based on a client’s BMI, activity status, and energy requirements.Physiological Adaptation Question No : 36 - (Topic 1) Which of the following instructions should the nurse give a client who will be undergoing mammography?


NCLEX NCLEX-PN : Practice Test A. Be sure to use underarm deodorant. B. Do not use underarm deodorant. C. Do not eat or drink after midnight. D. Have a friend drive you home. Answer: B Explanation: Underarm deodorant should not be used because it might cause confusing shadows on the X-ray film. There are no restrictions on food or fluid intake. No sedation is used, so the client can drive herself home.Reduction of Risk Potential Question No : 37 - (Topic 1) Teaching about the need to avoid foods high in potassium is most important for which client? A. a client receiving diuretic therapy B. a client with an ileostomy C. a client with metabolic alkalosis D. a client with renal disease Answer: D Explanation: Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. Choices 1, 2, and 3 are incorrect because clients receiving diuretics with ileostomy or with metabolic alkalosis are at risk for hypokalemia and should be encouraged to eat foods high in potassium.Physiological Adaptation Question No : 38 - (Topic 1)


NCLEX NCLEX-PN : Practice Test A diet high in fiber content can help an individual to: A. lose body weight fast. B. reduce diabetic ketoacidosis. C. lower cholesterol. D. reduce the need for folate. Answer: C Explanation: Fiber-rich foods (such as grains, apples, potatoes, and beans) can help lower cholesterol.Nonpharmacological Therapies Question No : 39 - (Topic 1) When administering intravenous electrolyte solution, the nurse should take which of the following precautions? A. Infuse hypertonic solutions rapidly. B. Mix no more than 80 mEq of potassium per liter of fluid. C. Prevent infiltration of calcium, which causes tissue necrosis and sloughing. D. As appropriate, reevaluate the client’s digitalis dosage. He might need an increased dosage because IV calcium diminishes digitalis’s action. Answer: C Explanation: Preventing tissue infiltration is important to avoid tissue necrosis. Choice 1 is incorrect because hypertonic solutions should be infused cautiously and checked with the RN if there is a concern. Choice 2 is incorrect because potassium, mixed in the pharmacy per physician order, is mixed at a concentration no higher than 60 mEq/L. Physiological Adaptation


NCLEX NCLEX-PN : Practice Test Question No : 40 - (Topic 1) How often should the nurse change the intravenous tubing on total parenteral nutrition solutions? A. every 24 hours B. every 36 hours C. every 48 hours D. every 72 hours Answer: A Explanation: The nurse should change the intravenous tubing on total parenteral nutrition solutions every 24 hours, due to the high risk of bacterial growth.Health Promotion and Maintenance Question No : 41 - (Topic 1) A woman asks, “How much alcohol can I safely drink while pregnant?” The nurse’s best response is: A. “The amount of alcohol that is safe during pregnancy is unknown.” B. “Consuming one or two beers or glasses of wine a day is considered safe for a healthy pregnant woman.” C. “Drinking three or more drinks on any given occasion is the only harmful type of drinking during pregnancy.” D. “You can have a drink to help you relax and get to sleep at night.” Answer: A Explanation: The amount of alcohol that is safe during pregnancy is unknown. Fetal alcohol syndrome is a combination of mental and physical abnormalities present in infants born to mothers who have consumed alcohol during pregnancy.Psychosocial Integrity


NCLEX NCLEX-PN : Practice Test Question No : 42 - (Topic 1) A 10-month-old child is brought to the Emergency Department because he is difficult to awaken. The nurse notes bruises on both upper arms. These findings are most consistentwith: A. wearing clothing that is too small for the child. B. the child being shaken. C. falling while learning to walk. D. parents trying to awaken the child. Answer: B Explanation: Children who are shaken are frequently grasped by both upper arms. Symptoms of brain injury associated with shaking include decreased level of consciousness.Psychosocial Integrity Question No : 43 - (Topic 1) For which of the following conditions might blood be drawn for uric acid level? A. asthma B. gout C. diverticulitis D. meningitis Answer: B Explanation: Uric acid levels are indicated for clients with gout.Reduction of Risk Potential


NCLEX NCLEX-PN : Practice Test Question No : 44 - (Topic 1) A client has been diagnosed with Disseminated Intravascular Coagulation (DIC) and transferred to the medical intensive care unit (ICU) subsequent to an acute bleeding episode. In the ICU, continuous Heparin drip therapy is initiated. Which of the following assessment findings indicates a positive response to Heparin therapy? A. increased platelet count B. increased fibrinogen C. decreased fibrin split products D. decreased bleeding Answer: B Explanation: Effective Heparin therapy should stop the process of intravascular coagulation and result in increased availability of fibrinogen. Heparin administration interferes with thrombin-induced conversion of fibrinogen to fibrin. Bleeding should cease due to the increased availability of platelets and coagulation factors.Physiological Adaptation Question No : 45 - (Topic 1) Which of the following is an appropriate nursing goal for a client at risk for nutritional problems? A. provide oxygen B. promote healthy nutritional practices C. treat complications of malnutrition D. increase weight Answer: B Explanation: Promoting healthy nutritional practices is an appropriate nursing goal for a client at risk for nutritional


NCLEX NCLEX-PN : Practice Test problems. Choice 1 is incorrect because it is a nursing intervention, not a goal statement. Choice 3 is incorrect because it is a therapeutic treatment. Choice 4 is incorrect because weight gain is an appropriate goal only if the client is underweight.Basic Care and Comfort Question No : 46 - (Topic 1) Major competencies for the nurse giving end-oflife care include: A. demonstrating respect and compassion, and applying knowledge and skills in care of the family and the client. B. assessing and intervening to support total management of the family and client. C. setting goals, expectations, and dynamic changes to care for the client. D. keeping all sad news away from the family and client. Answer: A Explanation: There are many competencies that the nurse must have to care for families and clients at the end of life. Demonstration of respect and compassion as well as using knowledge and skills in the care of the client and family are major competencies.Basic Care and Comfort Question No : 47 - (Topic 1) Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes a serosanguious drainage on the dressing. The most appropriate intervention isto: A. notify the physician of the drainage. B. change the dressing.


NCLEX NCLEX-PN : Practice Test C. reinforce the dressing. D. apply an abdominal binder. Answer: C Explanation: Serosanguious drainage is expected at this time. The dressing should be reinforced. Changing a new postop dressing increases the risk of infection. An abdominal binder interferes with visualization of the dressing.Basic Care and Comfort Question No : 48 - (Topic 1) A client turns her ankle. She is diagnosed as having a Pulled Ligament. This should be documented as a: A. sprain. B. strain. C. subluxation. D. distoration. Answer: B Explanation: A strain is excessive stretching of a ligament. A sprain involves a twisting motion involving muscles.Basic Care and Comfort Question No : 49 - (Topic 1) An appropriate intervention for the client with suspected genitourinary trauma and visible blood at the urethral meatus is:


NCLEX NCLEX-PN : Practice Test A. insertion of a Foley catheter. B. in and out catheter specimen for urinalysis. C. a voided urine specimen for urinalysis. D. a urologist consult. Answer: D Explanation: A urologist consult is appropriate for a client with visible blood at the urethral meatus and suspected trauma. Choices 1 and 2 are contraindicated. A urinalysis might be ordered by the physician, but the question does not provide enough information to make Choice 3 the correct answer.Physiological Adaptation Question No : 50 - (Topic 1) A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation offingers and toes. Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image? A. administering immune globulin intravenously B. assessing the extremities for edema, redness and desquamation every 8 hours C. explaining progression of the disease to the client and his or her family D. assessing heart sounds and rhythm Answer: C Explanation: Teaching the client and family about progression of the disease includes explaining when symptoms can be expected to improve and resolve. Knowledge of the course of the disease can help them understand that no permanent disruption in physical appearance will occur that could negatively affect body image. Clients with Kawasaki disease might receive immune globulin intravenously to reduce the incidence of coronary artery lesions and aneurysms. Cardiac effects could be linked to body image, but Choice 3 is the most


NCLEX NCLEX-PN : Practice Test direct link to body image. The nurse assesses symptoms to assist in evaluation of treatment and progression of the disease.Health Promotion and Maintenance Question No : 51 - (Topic 1) A client, age 28, was recently diagnosed with Hodgkin’s disease. After staging, therapy is planned to include combination radiation therapy and systemic chemotherapy with MOPP— nitrogen mustard, vincristine (Onconvin), prednisone, and procarbazine. In planning care for this client, the nurse should anticipate which of the following side effects to contribute to a sense of altered body image? A. cushingoid appearance B. alopecia C. temporary or permanent sterility D. pathologic fractures Answer: D Explanation: Pathologic fractures are not common to the disease process. Its treatment through osteoporosis is a potential complication of steroid use. Hodgkin’s disease most commonly affects young adults (males), is spread through lymphatic channels to contiguous nodes, and also might spread via the hematogenous route to extradal sites (GI, bone marrow, skin, and other organs). A working staging classification is performed for clinical use and care. Physiological Adaptation Question No : 52 - (Topic 1) While undergoing fetal heart monitoring, a pregnant Native-American woman requests that


NCLEX NCLEX-PN : Practice Test a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse? A. “I will assist you in arranging to have a medicine woman present.” B. “We do not allow medicine women in exam rooms.” C. “That does not make any difference in the outcome.” D. “It is old-fashioned to believe in that.” Answer: A Explanation: This statement reflects cultural awareness and acceptance that receiving support from a medicine woman is important to the client. The other statements are culturally insensitive and unprofessional.Reduction of Risk Potential Question No : 53 - (Topic 1) The goals of palliative care include all of the following except: A. giving clients with life-threatening illnesses the best quality of life possible. B. taking care of the whole person—body, mind, spirit, heart, and soul. C. no interventions are needed because the client is near death. D. support of needs of the family and client. Answer: C Explanation: The goals of palliative care include choices 1, 2, and 4. Choice 3 is not part of palliative care. All aspects of medical, emotional, social, and spiritual needs of the dying client should be focused on until the end of life.Basic Care and Comfort


NCLEX NCLEX-PN : Practice Test Question No : 54 - (Topic 1) When helping a client gain insight into anxiety, the nurse should: A. help relate anxiety to specific behaviors. B. ask the client to describe events that precede increased anxiety. C. instruct the client to practice relaxation techniques. D. confront the client’s resistive behavior. Answer: B Explanation: To gain insight, the client needs to recognize causal events. The other activities focus on recognition of anxiety.Psychosocial Integrity Question No : 55 - (Topic 1) A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy’s mother indicates a need for further teachingby the nurse? A. “I should make sure he gets plenty of rest.” B. “I should get him a medic alert bracelet.” C. “I should lay him on his back during a seizure.” D. “I should loosen his clothing during a seizure.” Answer: C Explanation: A client having a seizure should be turned to the side to prevent aspiration of secretions. The other statements are correct and indicate adequate understanding of teaching.Reduction of Risk Potential


NCLEX NCLEX-PN : Practice Test Question No : 56 - (Topic 1) To remove hard contact lenses from an unresponsive client, the nurse should: A. gently irrigate the eye with an irrigating solution from the inner canthus outward. B. grasp the lens with a gentle pinching motion. C. don sterile gloves before attempting the procedure. D. ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens. Answer: D Explanation: To remove hard contact lenses, the upper and lower eyelids are gently maneuvered to help loosen the lens and slide it out of the eye. The lens must be situated on the cornea, not the sclera, before removal. An attempt to grasp a hard lens might result in a scratch on the cornea. Clean gloves are an option if drainage is present.Basic Care and Comfort Question No : 57 - (Topic 1) Which of the following foods might a client with a hypercholesterolemia need to decrease his or her intake of? A. broiled catfish B. hamburgers C. wheat bread D. fresh apples Answer: B Explanation: Due to the high cholesterol content of red meats, such as hamburger, intake needs to be decreased. The other options do not have high cholesterol content, so they do not need to be decreased.Reduction of Risk Potential


NCLEX NCLEX-PN : Practice Test Question No : 58 - (Topic 1) Nurses caring for clients who have cancer and are taking opioids need to assess for all of the following except: A. tolerance. B. constipation. C. sedation. D. addiction. Answer: D Explanation: Addiction is not of primary concern when treating the pain of terminally ill clients. Clients with cancer who are taking opioid analgesics can develop tolerance, constipation, and sedation.Basic Care and Comfort Question No : 59 - (Topic 1) Which of the following nursing actions is most effective when evaluating a kinetic family drawing? A. telling the child to draw their family doing something B. offering specific suggestions of what to include in the drawing C. discouraging the child from talking about the drawing D. noting the omission of any family members Answer: D Explanation: There are several guidelines for evaluating kinetic family drawings, including Choice 4. Effective nursing


NCLEX NCLEX-PN : Practice Test actions include asking the child to explain what each family member is doing, encouraging him or her to tell as much as possible about the drawing, noting physical intimacy or distance, noting placement of family members in the drawing, noting facial expressions of family members and noting if they are facing each other or turned away. Choice 1 is initial instruction, not evaluation. Only general encouragement should be given to avoid suggesting themes to the child.Health Promotion and Maintenance Question No : 60 - (Topic 1) A client with an ileus is placed on intestinal tube suction. Which of the following electrolytes is lost with intestinal suction? A. calcium B. magnesium C. potassium D. sodium chloride Answer: D Explanation: Duodenal intestinal fluid is rich in K+, NA+, and bicarbonate. Suctioning to remove excess fluids decreases the client’s K+ and NA+ levels.Basic Care and Comfort Question No : 61 - (Topic 1) Which of the following terms refers to soft-tissue injury caused by blunt force? A. contusion B. strain C. sprain


NCLEX NCLEX-PN : Practice Test D. dislocation Answer: A Explanation: A contusion is a soft-tissue injury caused by blunt force. It is an injury that does not break the skin, is caused by a blow and is characterized by swelling, discoloration, and pain. The immediate application of cold might limit the development of a contusion. A strain is a muscle pull from overuse, overstretching, or excessive stress. A sprain is caused by a wrenching or twisting motion. A dislocation is a condition in which the articular surfaces of the bones forming a joint are no longer in anatomic contact.Physiological Adaptation Question No : 62 - (Topic 1) Which of the following indicates a hazard for a client on oxygen therapy? A. A No Smoking sign is on the door. B. The client is wearing a synthetic gown. C. Electrical equipment is grounded. D. Matches are removed. Answer: B Explanation: A synthetic gown might generate sparks of static electricity, which can be a fire hazard, particularly in the presence of oxygen. The client on oxygen therapy should wear a cotton gown. The remaining options are appropriate safety measures.Reduction of Risk Potential Question No : 63 - (Topic 1)


NCLEX NCLEX-PN : Practice Test Erythropoietin used to treat anemia in clients with renal failure should be given in conjunction with: A. iron, folic acid, and B12. B. an increase of protein in the diet. C. vitamins A and C. D. an increase of calcium in the diet. Answer: A Explanation: The kidneys of a client in renal failure produce no erythropoietin, a hormone necessary for RBC production. Erythropoietin can be given as replacement, but the client needs adequate iron, folate, and B12 to increase the effectiveness of EPO. Choice 2 is not necessary for RBC production and can increase uremia. Choices 3 and 4 are not necessary for RBC production.Physiological Adaptation Question No : 64 - (Topic 1) When obtaining a health history on a menopausal woman, which information should a nurse recognize as a contraindication for hormone replacement therapy? A. family history of stroke B. ovaries removed before age 45 C. frequent hot flashes and/or night sweats D. unexplained vaginal bleeding Answer: D Explanation: Unexplained vaginal bleeding is a contraindication for hormone replacement therapy. Family history of stroke is not a contraindication for hormone replacement therapy. If the woman herself had a history of stroke or other blood-clotting events, hormone therapy could be contraindicated. Frequent hot flashes and/or night sweats


NCLEX NCLEX-PN : Practice Test can be relieved by hormone replacement therapy.Health Promotion and Maintenance Question No : 65 - (Topic 1) A pregnant Asian client who is experiencing morning sickness wants to take ginger to relieve the nausea. Which of the following responses by the nurse is appropriate? A. “I will call your physician to see if we can start some ginger.” B. “We don’t use home remedies in this clinic.” C. “Herbs are not as effective as regular medicines.” D. “Just eat some dry crackers instead.” Answer: A Explanation: This statement reveals cultural sensitivity. Ginger is sometimes used to relieve nausea. The other statements are culturally insensitive and do not show an awareness of herbal pharmacology.Physiological Adaptation Question No : 66 - (Topic 1) Which of the following physical findings indicates that an 11–12-month-old child is at risk for developmental dysplasia of the hip? A. refusal to walk B. not pulling to a standing position C. negative Trendelenburg sign D. negative Ortolani sign Answer: B Explanation: The nurse might be concerned about developmental dysplasia of the hip if an 11–12-


NCLEX NCLEX-PN : Practice Test month-old child doesn’t pull to a standing position. An infant who does not walk by 15 months of age should be evaluated. Children should start walking between 11–15 months of age. Trendelenberg sign is related to weakness of the gluteus medius muscle, not hip dysplasia. Ortolani sign is used to identify congenital subluxation or dislocation of the hip in infants.Health Promotion and Maintenance Question No : 67 - (Topic 1) A client with which of the following conditions is at risk for developing a high ammonia level? A. renal failure B. psoriasis C. lupus D. cirrhosis Answer: D Explanation: A client with cirrhosis is at risk for developing a high ammonia level.Reduction of Risk Potential Question No : 68 - (Topic 1) What is the primary nutritional deficiency of concern for a strict vegetarian? A. vitamin C B. vitamin B12 C. vitamin E D. magnesium


NCLEX NCLEX-PN : Practice Test Answer: B Explanation: Vitamin B12 is the primary nutritional deficiency of concern for a strict vegetarian.Health Promotion and Maintenance Question No : 69 - (Topic 1) Which of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophgeal reflux disease (GERD)? A. lettuce B. eggs C. chocolate D. butterscotch Answer: C Explanation: Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure leading to reflux and clinical symptoms of GERD. The other foods do not affect LES pressure.Basic Care and Comfort Question No : 70 - (Topic 1) A client has been taking alprazolam (Xanax) for four years to manage anxiety. The client reports taking 0.5 mg four times a day. Which statement indicates that the client understands the nurse’s teaching about discontinuing the medication? A. “I can drink alcohol now that I am decreasing my Xanax.” B. “I should not take another Xanax pill. Here is what is left of my last prescription.” C. “I should take three pills per day next week, then two pills for one week, then one pill for one week.”


NCLEX NCLEX-PN : Practice Test D. “I can expect to be sleepy for several days after stopping the medicine.” Answer: C Explanation: Xanax, like other benzodiazepines, can cause withdrawal symptoms that include agitation, insomnia, hypertension, seizures, and abdominal pain. The drug must be slowly decreased to prevent withdrawal symptoms. Psychosocial Integrity Question No : 71 - (Topic 1) A client is taking hydrocodone (Vicodin) for chronic back pain. The client has required an increase in the dose and asks whether this means he is addicted to Vicodin. The nurse should base her reply on the knowledge that: A. the client’s body has developed tolerance, requiring more drug to produce the same effect. B. the client is preoccupied with getting the drug and is experiencing loss of control, indicating drug dependence. C. addiction is the term used to describe physical dependence with withdrawal symptoms and tolerance. D. the client has a dual diagnosis of substance abuse and chronic back pain. Answer: A Explanation: Drug tolerance is characterized by the ability to ingest a larger dose without adverse effect and decreased sensitivity to the substance. Substance dependence is a severe condition indicating physical problems and disruption of the person’s social, family, and work life. The psychological behaviors related to substance use are termed addiction. Dual diagnosis is the coexistence of substance abuse and psychiatric disorders.Psychosocial Integrity


NCLEX NCLEX-PN : Practice Test Question No : 72 - (Topic 1) A safety measure to implement when transferring a client with hemiparesis from a bed to a wheelchair is: A. standing the client and walking him or her to the wheelchair. B. moving the wheelchair close to client’s bed and standing and pivoting the client on his unaffected extremity to the wheelchair. C. moving the wheelchair close to client’s bed and standing and pivoting the client on his affected extremity to the wheelchair. D. having the client stand and push his body to the wheelchair. Answer: B Explanation: Moving the wheelchair close to client’s bed and having him stand and pivot on his unaffected extremity to the wheelchair is safer because it provides support with the unaffected limb.Basic Care and Comfort Question No : 73 - (Topic 1) A client with dumping syndrome should while a client with GERD should . A. sit up 1 hour after meals; lie flat 30 minutes after meals B. lie down 1 hour after eating; sit up at least 30 minutes after eating C. sit up after meals; sit up after meals D. lie down after meals; lie down after meals Answer: B Explanation: Clients with dumping syndrome should lie down after eating to decrease dumping


NCLEX NCLEX-PN : Practice Test syndrome. GERD clients should sit up to prevent backflow of acid into the esophagus.Basic Care and Comfort Question No : 74 - (Topic 1) Which of the following organs of the digestive system has a primary function of absorption? A. stomach B. pancreas C. small intestine D. gallbladder Answer: C Explanation: The small intestine has a primary function of absorption. The remaining digestive organs have other primary functions.Physiological Adaptation Question No : 75 - (Topic 1) Which of the following neurological disorders is characterized by writhing, twisting movements of the face and limbs? A. epilepsy B. Parkinson’s C. muscular sclerosis D. Huntington’s chorea Answer: D Explanation: Huntington’s chorea is characterized by writhing, twisting movements of the face and limbs.


NCLEX NCLEX-PN : Practice Test The remaining options are neurological disorders that do not have such movements as part of their disease process.Reduction of Risk Potential Question No : 76 - (Topic 1) The nurse is teaching parents of a newborn about feeding their infant. Which of the following instructions should the nurse include? A. Use the defrost setting on microwave ovensto warm bottles. B. When refrigerating formula, don’t feed the baby partially used bottles after 24 hours. C. When using formula concentrate, mix two parts water and one part concentrate. D. If a portion of one bottle is left for the next feeding, go ahead and add new formula to fill it. Answer: A Explanation: Parents must be careful when warming bottles in a microwave oven because the milk can become superheated. When a microwave oven is used, the defrost setting should be chosen, and the temperature of the formula should be checked before giving it to the baby. Refrigerated, partially used bottles should be discarded after 4 hours because the baby might have introduced some pathogens into the formula. Returning the bottle to the refrigerator does not destroy pathogens. Formula concentrate and water are usually mixed in a 1:1 ratio of one part concentrate and one part water. Infants should be offered fresh formula at each feeding. Partially used bottles should not have fresh formula added to them. Pathogens can grow in partially used bottles of formula and be transferred to the new formula.Health Promotion and Maintenance


NCLEX NCLEX-PN : Practice Test Question No : 77 - (Topic 1) A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered? A. Advil B. Anasaid C. Clinocil D. Colace Answer: D Explanation: Colace is a stool softener that acts by pulling more water into the bowel lumen, making the stool soft and easier to evacuate.Basic Care and Comfort Question No : 78 - (Topic 1) The nurse explains to a client who underwent gastric resection that which of the following meals is most likely to cause rapid emptying of the stomach? A. a high-protein meal B. a high-fat meal C. a large meal regardless of nutrient content D. a high-carbohydrate meal Answer: D Explanation: Meals that are high in carbohydrates promote rapid gastric emptying. The other options are associated with decreased emptying time.Basic Care and Comfort


NCLEX NCLEX-PN : Practice Test Question No : 79 - (Topic 1) A batterer is usually someone who: A. grew up in a loving, secure home. B. was an only child. C. was physically or psychologically abused. D. admits he has a problem with anger. Answer: C Explanation: Many batterers report having been abused as children.Psychosocial Integrity Question No : 80 - (Topic 1) A 20-year-old obese female client is preparing to have gastric bypass surgery for weight loss. She says to the nurse, “I need this surgery because nothing else I have done has helped me to lose weight.” Which response by the nurse is most appropriate? A. “If you eat less, you can save some money.” B. “Exercise is a healthier way to lose weight.” C. “You should try the Atkins diet first.” D. “I respect your decision to choose surgery.” Answer: D Explanation: This statement is most appropriate, as it shows respect and empathy. The other statements are both insensitive and unprofessional.Physiological Adaptation Question No : 81 - (Topic 1)


NCLEX NCLEX-PN : Practice Test In teaching clients with Buck’s Traction, the major areas of importance should be: A. nutrition, ROM exercises. B. ROM exercises, transportation. C. nutrition, elimination, comfort, safety. D. elimination, safety, isotonic exercises. Answer: C Explanation: Nutrition, elimination, comfort, and safety are the major areas of importance. The diet should be high in protein with adequate fluids.Basic Care and Comfort Question No : 82 - (Topic 1) Light therapy can be effective for: A. overcoming weight problems. B. helping with allergies. C. use in alternative medical treatments. D. working with sleep patterns. Answer: D Explanation: Light therapy can be effective in treating problems associated with sleep patterns, stress, moods, jaundice in newborns, and seasonal affective disorders.Nonpharmacological Therapies Question No : 83 - (Topic 1) Assessment of the client with an arteriovenous fistula for hemodialysis should include:


NCLEX NCLEX-PN : Practice Test A. inspection for visible pulsation. B. palpation of thrill. C. percussion for dullness. D. auscultation of blood pressure. Answer: B Explanation: Thrill should be present. The client should be taught to check this daily at home. Pulsation is not typically visible. Percussion gives no information about the patency of a fistula. Blood pressure is not auscultated in a limb with an AVF. Auscultation of the AVF, for a bruit, is part of an assessment for patency.Physiological Adaptation Question No : 84 - (Topic 1) James returns home from school angry and upset because his teacher gave him a low grade on an assignment. After returning home from school, he kicks the dog. This coping mechanism is known as: A. denial. B. suppression. C. displacement. D. fantasy. Answer: C Explanation: Displacement is the transference of anger to another. Anger is displaced on the dog as a convenient object. Psychosocial Integrity Question No : 85 - (Topic 1)


NCLEX NCLEX-PN : Practice Test Which condition is associated with inadequate intake of vitamin C? A. rickets B. marasmus C. kwashiorkor D. scurvy Answer: D Explanation: Scurvy is associated with inadequate intake of vitamin C. The remaining choices refer to other nutritional deficiencies.Health Promotion and Maintenance Question No : 86 - (Topic 1) Which is the proper hand position for performing chest percussion? A. cup the hands B. use the side of the hands C. flatten the hands D. spread the fingers of both hands Answer: A Explanation: The hands are cupped for performing percussion, producing a vibration that helps loosen respiratory secretions. The other hand positions do not accomplish this task.Reduction of Risk Potential Question No : 87 - (Topic 1) Which of the following is likely to increase the risk of sexually transmitted disease?


NCLEX NCLEX-PN : Practice Test A. alcohol use B. certain types of sexual practices C. oral contraception use D. all of the above Answer: D Explanation: STDs affect certain groups in groups in greater numbers. Factors associated with risk include being younger than 25 years of age, being a member of a minority group, residing in an urban setting, being impoverished, and using crack cocaine.Physiological Adaptation Question No : 88 - (Topic 1) Why might breast implants interfere with mammography? A. They might cause additional discomfort. B. They are contraindications to mammography. C. They are likely to be dislodged. D. They might prevent detection of masses. Answer: D Explanation: Breast implants can prevent detection of masses. Choices 1, 2, and 3 are not ways in which breast implants interfere with mammography.Reduction of Risk Potential Question No : 89 - (Topic 1) A health care worker is concerned about a new mother being overwhelmed by caring for her infant. The health care worker should:


NCLEX NCLEX-PN : Practice Test A. immediately contact child protective services. B. provide the mother with literature about child care. C. consult a therapist to help the mother work out her fears. D. refer the mother to parenting classes. Answer: D Explanation: Prevention of child abuse is centered on teaching the parents how to care for their child and cope with the demands of infant care. Parenting classes can help build self-confidence, self-esteem, and coping skills. Parents benefit by understanding the developmental needs of their children, while learning how to manage their home environment more effectively. The classes also increase the parents’ social contacts and teach about community resources.Psychosocial Integrity Question No : 90 - (Topic 1) Which is the proper hand position for performing chest vibration? A. cup the hands B. use the side of the hands C. flatten the hands D. spread the fingers of both hands Answer: C Explanation: The hands are flattened over the area of the body where chest percussion is used to conduct vibration through to the chest and loosen secretions. The other hand positions do not accomplish this task.Reduction of Risk Potential


NCLEX NCLEX-PN : Practice Test Question No : 91 - (Topic 1) Which of the following lab values is associated with a decreased risk of cardiovascular disease? A. high HDL cholesterol B. low HDL cholesterol C. low total cholesterol D. low triglycerides Answer: A Explanation: High HDL cholesterol and low LDL cholesterol are associated with a decreased risk of cardiovascular disease.Reduction of Risk Potential Question No : 92 - (Topic 1) When making an occupied bed, it is important for the nurse to: A. keep the bed in the low position. B. use a bath blanket or top sheet for warmth and privacy. C. constantly keep side rails raised on both sides. D. move back and forth from one side to the other when adjusting the linens. Answer: B Explanation: Using a bath blanket or top sheet keeps the client warm and provides privacy. Keeping the bed in the low position and working above raised side rails might strain the nurse’s back. Continually moving back and forth to tuck and arrange linen is time-consuming and disorganized.Basic Care and Comfort


NCLEX NCLEX-PN : Practice Test Question No : 93 - (Topic 1) When a client informs the nurse that he is experiencing hypoglycemia, the nurse provides immediate intervention by providing: A. one commercially prepared glucose tablet. B. two hard candies. C. 4–6 ounces of fruit juice with 1 teaspoon of sugar added. D. 2–3 teaspoons of honey. Answer: D Explanation: The usual recommendation for treatment of hypoglycemia is 10–15 grams of a fast-acting simple carbohydrate, orally, if the client is conscious and able to swallow (for example, 3–4 commercially prepared glucose tablets or 4–6 oz of fruit juice). It is not necessary to add sugar to juice, even if it is labeled as unsweetened juice because the fruit sugar in juice contains enough simple carbohydrate to raise the blood glucose level. Addition of sugar might result in a sharp rise in blood sugar that could last for several hours.Physiological Adaptation Question No : 94 - (Topic 1) A client is having a seizure; his blood oxygen saturation drops from 92% to 82%. What should the nurse do first? A. Open the airway. B. Administer oxygen. C. Suction the client. D. Check for breathing. Answer: A Explanation:


NCLEX NCLEX-PN : Practice Test The nurse needs to open the airway first when the oxygen saturation drops. The other actions might be appropriate, but the airway must be patent.Reduction of Risk Potential Question No : 95 - (Topic 1) To remove a client’s gown when she has an intravenous line, the nurse should: A. temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown. B. cut the gown with scissors. C. thread the bag and tubing through the gown sleeve, keeping the line intact. D. temporarily disconnect the tubing from the intravenous container and thread it through the gown. Answer: C Explanation: Threading the bag and tubing through the gown sleeve keeps the system intact. Opening an intravenous line causes a break in a sterile system and introduces the potential for infection. Cutting a gown off is not an alternative except in an emergency. IV gowns, which open along sleeves, are widely available.Basic Care and Comfort Question No : 96 - (Topic 1) Which of the following is most likely to impact the body image of an infant newly diagnosed with Hemophilia? A. immobility B. altered growth and development C. hemarthrosis D. altered family processes


NCLEX NCLEX-PN : Practice Test Answer: D Explanation: Altered Family Processes is a potential nursing diagnosis for the family and client with a new diagnosis of Hemophilia. Infantsare aware of how their caregivers respondto their needs.Stresses can have an immediate impact on the infant’s development of trust and how others relate to them because of their diagnosis. The longterm effects of hemophilia can include problems related to immobility. Altered growth and development could not have developed in a newly diagnosed client. Hemarthrosis is acute bleeding into a joint space that is characteristic of hemophilia. It does not have an immediate effect on the body image of a newly diagnosed hemophiliac.Health Promotion and Maintenance Question No : 97 - (Topic 1) Which of the following values should the nurse monitor closely while a client is on total parenteral nutrition? A. calcium B. magnesium C. glucose D. cholesterol Answer: C Explanation: Glucose is monitored closely when a client is on total parenteral nutrition, due to high glucose concentration in the solutions. The other values are not monitored as closely.Health Promotion and Maintenance


NCLEX NCLEX-PN : Practice Test Question No : 98 - (Topic 1) A client with stress incontinence should be advised: A. to purchase absorbent undergarments. B. that Kegel exercises might help. C. that effective surgical treatments are nonexistent. D. that behavioral therapy is ineffective. Answer: B Explanation: Kegel exercises, tightening and releasing the pelvic floor muscles, might improve stress incontinence. Choice 1 is not an appropriate treatment for stress incontinence. Several effective surgical treatments exist. Lifestyle and dietary modifications can also be helpful.Physiological Adaptation Question No : 99 - (Topic 1) Diagnostic genetic counseling, for procedures such as amniocentesis and chorionic villus sampling, allows clients to make all of the following choices except: A. terminating the pregnancy. B. preparing for the birth of a child with special needs. C. accessing support services before the birth. D. completing the grieving process before the birth. Answer: D Explanation: If findings are ominous, the grieving process will not be completed before birth. If the couple elects to terminate a pregnancy based on diagnostic tests, there will be grief and concerns for future pregnancies. Couples




NCLEX NCLEX-PN : Practice Test might choose to access support services and prepare for the birth of an infant with special needs. Some fetal

conditions can be treated in utero.Health Promotion and Maintenance







Question No : 100 - (Topic 1)


A client who is experiencing infertility says to the nurse, “I feel I will be incomplete as a man/woman if I cannot have a child.” Which of the following nursing diagnoses is likely to be appropriate for this client?


A. Risk for Self Harm

B. Body Image Disturbance

C. Ineffective Role Performance

D. Powerlessness


Answer: B Explanation:


Of the nursing diagnoses listed, the client’s statement most represents Body Image Disturbance because it

directly refers to loss of the function of having a child. Nothing in the statement indicates that the client is at

risk for harming herself. Ineffective Role Performance could be correct but is not the best choice because the

statement does not reflect a disruption of the parent’s role. Powerlessness could be an appropriate nursing

diagnosis if the client described feeling powerless about the infertility.Health Promotion and Maintenance

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