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NCSBN NCLEX ACTUAL LATEST 2025
EXAM WITH COMPLETE EXAM
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NCLEX BRAND NEW EXAM
Is a process of learning a different culture to adapt to a new or changing environment. - ANSWER- Acculturation. It is a subjective perspective of the person's heritage and a sense of belonging to a group - ANSWER- Ethnic identity Include meditation, relaxation techniques, imagery, music therapy, massage, touch, laughter, humor, & spiritual measures (prayer). - ANSWER- Low-risk therapies: Because of their health & dietary practices, Native Americans, Latino Americans, Hispanic Americans, & African Americans. - ANSWER- High risk of obesity & diabetes mellitus Surgery is not prohibited, but the administration of blood and blood products is forbidden. This religious group believes the soul cannot live after death. Administration of medication is an acceptable practice except if the medication is derived from blood products. - ANSWER- Jehovah's Witnesses
Believers adhere to dietary kosher laws. In this religion, the dairy-meat combination is unacceptable. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven-hoofed, and ritually slaughtered. - ANSWER- Orthodox Judaism include whole medical systems, mind-body medicine, biologically based practices, manipulative & body-based practices, & energy medicine. - ANSWER- Five categories of complementary and alternative medicine (CAM) Focused, maintains strong control, makes decisions, & addresses all problems. Dominates group & commands, rather than seeks suggestions or input. Manager addresses problem (quality improvement) with taff, designs a plan without input, & wants all problems reported directly back to her - ANSWER- Autocratic leader Participative & would likely meet with each staff person individually to determine staff member's perception of problem. Would also speak with the staff about any issues & ask the staff for input with developing a plan. - ANSWER- Democratic leader Passive and nondirective. Would state what the problem was & inform staff that the staff needed to come up with a plan to "fix it." - ANSWER- Laissez-faire leader Assessment findings include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck & hand vein distention, altered LOC, & decreased hematocrit. - ANSWER- Overhydration or fluid overload & occurs when fluid intake or fluid retention Avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, & tomatoes - ANSWER- Common food sources of potassium:
toxins, such as acetylsalicylic acid (aspirin); malnutrition; severe diarrhea. Intestinal secretion high in bicarbonate & may be lost through enteric drainage tubes, an ileostomy, or diarrhea. - ANSWER- Metabolic acidotic Nausea & vomiting. Loss of gastric acid, cause pH & HCO3 to increase. Symptoms experienced would include hypoventilation & tachycardia. - ANSWER- Metabolic alkalosis Decreased pH and an increased CO2. Hypoventalation & COPD - ANSWER- Respiratory acidotic Increased pH & decreased CO2. Hyperventalation, Lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, numbness & tingling of extremities. Hyperventilation (tachypnea) occurs. - ANSWER- Respiratory alkalotic Sample for PT & INR level to determine anticoagulation status & risk for bleeding
- ANSWER- Warfarin (Coumadin) aPTT monitors the effects. Anticoagulant used most often during hemodialysis. Monitors extent of anticoagulation checking PTT, which is appropriate measure heparin effect. Protamine sulfate is antidote. - ANSWER- Heparin Dark green leafy vegetables good source iron, oranges are a good source of vitamin C, which enhances iron absorption. - ANSWER- Iron deficiency anemia foods in diet: May lack B12 in diet. - ANSWER- Vegans Include fruits & vegetables - ANSWER- Low sodium foods:
Highly processed or refined foods (tomato soup, instant oatmeal), Saltwater fish & shellfish. Smoked foods, - ANSWER- High Sodium foods: Water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea. - ANSWER- Clear liquid diet: Pulling, Vegetable juice, Pureed vegetables, plain ice cream, sherbet, breakfast drinks, milk, pudding & custard, soups that are strained, refined cooked cereals, & strained vegetable juices. - ANSWER- Full liquid diet: Pork products rich in this vitamin. Other good food sources include nuts, whole grain cereals, & legumes. - ANSWER- High Thiamine foods On the left side, with the head lower than the feet. This position used to minimize effect of air traveling as a bolus to lungs by trapping it in right side of heart. - ANSWER- Suspects air embolism. Should immediately place client in which position? Assess for known allergies to eggs to prevent anaphylaxis. - ANSWER- Fat emulsion (lipids) Signs include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul's respirations, diuresis, & coma when severe. If has these symptoms, blood glucose level should be checked immediately. - ANSWER- Hyperglycemia: Temperature and weight: Temperature monitored to detect infection, potential complication of therapy. Infection also could result in sepsis because catheter in blood vessel. Weight monitored for effectiveness nutritional therapy & detect hypervolemia. - ANSWER- Parenteral nutrition; PN monitor
Completely immobile, lost protective reflexe shift body weight. Reposition every 2 hours. Use bed cradle protect toes from breakdown due to weight from linen. Protective pads can be applied heels & elbows reduce friction & shear. Appropriate perineal care essential keep waste products from excoriating skin. Reduce skin dryness & irritation adding superfatty solution (such as baby oil or castile soap) daily bath water. Drying agents such as alcohol avoided because dry skin can crack & break down. - ANSWER- Potential skin integrity problems for unconscious client Head kept 30- to 45-degree angle. Head & neck not be angled either anteriorly or laterally, kept in neutral (midline) position. Promotes venous return through jugular veins, which will help prevent rise in ICP. Sensitive to loud noises. Control environmental noise by others helpful. Seizures potential complication may occur for up to 1 year after surgery. Must take anticonvulsant medications, keep track of doses. Family learn seizure precautions & accompany during ambulation if dizziness/seizures tend to occur. Suture line kept dry until sutures removed to prevent infection. - ANSWER- Craniotomy/postcraniotomy Normal 285 to 295 mOsm/kg H2O. Higher value indicates dehydration; lower value indicates overhydration. - ANSWER- Normal serum osmolality Place on bed rest (as prescribed) in quiet setting. Stimulants; caffeine & nicotine prohibited; decaffeinated coffee/tea may be used. Lights dim minimize environmental stimulation. Any activity increases blood pressure or impedes venous return from brain prohibited; pushing, pulling, sneezing, coughing, or straining. Nurse provide physical care minimize increases BP. For same reason, visitors, radio, television, & reading materials prohibited or limited. - ANSWER- Aneurysm precautions Manage constipation; high-fiber diet, bulk formers, & stool softeners. Fluid intake 2000 mL/day recommended. Initiate bowel program every-other-day basis. Done approximately 45 minutes after largest meal of day take advantage of gastrocolic reflex. Glycerin suppository, bisacodyl suppository, or digital stimulation used
initiate process. Laxatives & enemas avoided whenever possible because lead to dependence. - ANSWER- Multiple sclerosis Reticular activating system in conjunction with cerebral hemispheres responsible for arousal. - ANSWER- Chronic insomnia IV dislodged from vein & is lying in subcutaneous tissue. Pallor, coolness, & swelling are results of IV fluid being deposited in tissue. Corrective action is remove catheter & start new IV line at another site. - ANSWER- Infiltrated IV Discomfort at site, redness, warmth, & swelling proximal to catheter. If phlebitis occurs, discontinue IV line & insert new IV line at different site. Apply warm moist compresses to area speed resolution of inflammation. Notify (HCP). Document occurrence, actions taken, & client response. - ANSWER- Phlebitis at IV site: Produces a rash, redness, & itching. - ANSWER- An allergic reaction at IV site: Characterized by ecchymosis, swelling, & leakage at IV insertion site, as well as hard & painful lumps at site. - ANSWER- Hematoma Dyspnea, a swollen tongue, & cyanosis. - ANSWER- Hypersensitivity reaction: Taught minor activity restrictions apply with this type of catheter. Protect site during bathing & should carry or wear Medic-Alert ID. Have repair kit in home for use as needed because catheter is for long-term use. - ANSWER- PICC line Before beginning administration IV solution, assess whether chest radiograph reveals central catheter is in proper place. Portable chest X-ray. - ANSWER- Central venous catheter insertion:
Described as a scratchy, leathery heart sound. - ANSWER- Pericardial friction rub Tests the six cardinal positions of gaze - ANSWER- Assess for muscle weakness in eyes Visual acuity & cranial nerve II (optic). - ANSWER- Snellen eye chart Close eyes & then lightly touching areas of face & testing corneal reflexes assess cranial nerve V (trigeminal). - ANSWER- Testing sensory function tested insupine position. Flexes head (gently moves head to chest) & there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if passively flexes hip & knee in response to neck flexion & reports pain in vertebral column. - ANSWER- Positive Brudzinski's sign Blood leaves embryo through two umbilical arteries. Oxygenated, blood returned by one umbilical vein. Arteries carry deoxygenated blood & waste products from fetus, umbilical vein carries oxygenated blood & provides oxygen & nutrients to fetus. - ANSWER- Fetal circulation Connects umbilical vein to inferior vena cava - ANSWER- Ductus venosus Is temporary opening between right & left atria. - ANSWER- Foramen ovale Joins the aorta & pulmonary artery - ANSWER- Ductus arteriosus
Uterine enlargement, Hegar's sign , Goodell's sign , Chadwick's sign, ballottement, Braxton Hicks contractions, & positive pregnancy test for presence of HCG. - ANSWER- Probable signs of pregnancy Fetal heart rate detected by electronic device (Doppler transducer), active fetal movements palpable by examiner, & outline fetus by radiography or ultrasonography. - ANSWER- Positive signs of pregnancy *Pregnancy avoided for 1-3 months. Vaccine administered subcutaneous route.Exposure immunosuppressed individuals avoided. *Hypersensitivity reaction can occur if client has allergy to eggs. - ANSWER- Rubella virus vaccine Postpartum Three classic signs are hypertension, generalized edema, & proteinuria. - ANSWER- Classic signs of preeclampsia Can trigger disseminated intravascular coagulation (DIC). Evidence of bleeding, such as in gums, petechiae, & purpura should be reported to HCP if noted on assessment. - ANSWER- Severe preeclampsia Considered a risk factor for disseminated intravascular coagulation (DIC). - ANSWER- Dead fetus syndrome Isoniazid plus rifampin (Rifadin) will be required for 9 months. - ANSWER- Pregnant client tuberculosis is suspected; sputum culture obtained & identifies Mycobacterium tuberculosis When the cervix is dilated completely & ends with birth of the neonate. - ANSWER- Second Stage of Labor begins
pregnancy symptom. (Sudden onset painless vaginal bleeding) - ANSWER- Placenta previa Oxygen administered, 8 to 10 L/min, by face mask. Oxygen used decrease hypoxia. Kept on bed rest with head of bed slightly elevated reduce dyspnea. Morphine sulfate may be prescribed, not initial nursing action. IV also required, & vital signs need to be monitored, but these actions would follow administration of oxygen. - ANSWER- Pulmonary embolism is suspected Infection of bladder. Should consume 3000 mL of fluids per day if not contraindicated. - ANSWER- Cystitis May present clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. - ANSWER- Newborn infant with respiratory distress syndrome Bluish discoloration of hands & feet, is associated with immature peripheral circulation, & common in first few hours of life. - ANSWER- Acrocyanosis Craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, & respiratory distress. Hypotonia, irritability, & poor sucking reflex. - ANSWER- Fetal alcohol syndrome May exhibit hyperirritability, vomiting, diarrhea, or uncoordinated sucking & swallowing ability. Quiet environment with minimal stimuli & handling would help establish appropriate sleep-rest cycles in newborn as well. - ANSWER- Fetal alcohol syndrome
Used as prophylactic treatment for ophthalmia neonatorum, which is caused by bacterium Neisseria gonorrhoeae. Preventive treatment of gonorrhea is required by law - ANSWER- Erythromycin ophthalmic ointment Central nervous system depressant & relaxes smooth muscle, including uterus. Used to halt preterm labor contractions & used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, & elevated serum magnesium levels. - ANSWER- MagnesiumSulfate Glucocorticoid, given increase production of surfactant to stimulate fetal lung maturation. Administered clients preterm labor at 28 to 32 weeks of gestation if labor can be inhibited for 48 hours. - ANSWER- Betamethasone (Celestone) Opioid analgesic. - ANSWER- Nalbuphine (Nubain) Given to Rh-negative clients to prevent sensitization. - ANSWER- Rho(D) immune globulin (RhoGAM) Prostaglandin given ripen & soften cervix & stimulate uterine contraction - ANSWER- Dinoprostone (Cervidil vaginal insert) Respiratory Distress Syndrome serious lung disorder caused by immaturity & inability to produce surfactant, resulting in hypoxia & acidosis. Common premature infants & may be due to lung immaturity: result of surfactant deficiency. Mainstay treatment administration exogenous surfactant, administered by intratracheal route - ANSWER- Beractant (Survanta)
Confirmatory test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspirate & biopsy. - ANSWER- Leukemia Malignancy lymph nodes. Presence of giant, multinucleated cells (Reed-Sternberg cells) is classic characteristic of this disease. - ANSWER- Hodgkin's disease Never be administered in the presence of oliguria or anuria. Checks amount urine output before administration. - ANSWER- potassium chloride Also known as congenital aganglionosis or megacolon. Pellet or ribbon-like stools: foul-smelling is clinical manifestation of disorder. Delayed passage or absence of meconium stool in neonatal period also a sign. Bowel obstruction in neonatal period, abdominal pain & distention, & failure to thrive also clinical manifestations. - ANSWER- Hirschsprung's disease Projectile vomiting, irritability, hunger & crying, constipation, & signs dehydration including decrease urine output. - ANSWER- Pyloric stenosis Invagination of section of intestine into distal bowel. Most common cause of bowel obstruction children aged 3 months to 6 years. Severe abdominal pain; crampy & intermittent, child draw in knees to chest. Vomiting may be present, but not projectile. Bright red blood & mucus passed through rectum & commonly described as currant jelly-like stools - ANSWER- Intussusception Preoperative period, child observed presence loose teeth to decrease risk aspiration during surgery. Bleeding during surgery controlled via packing & suction as needed. Frequent swallowing, restlessness, fast/thready pulse, & vomiting bright red blood are signs of bleeding. Bad mouth odor normal after tonsillectomy & may be relieved by drinking more liquids. - ANSWER- Tonsillectomy (Surgical removal tonsils)
condition eyes not aligned because lack coordination of extraocular muscles. May in child when complains frequent headaches, squints, tilts head to see. Other manifestations include crossed eyes, closing one eye to see, diplopia, photophobia, loss of binocular vision, or impairment of depth perception. - ANSWER- Strabismus Decreased wheezing in child with asthma may be interpreted incorrectly as positive sign when may actually signal inability move air. "Silent chest" is an ominous sign during an asthma episode. - ANSWER- Child with asthma Highly communicable disorder. Not transmitted airborne route. Usually transferred by hands. Use contact & standard precaution during care (wearing gloves & gown) reduce nosocomial transmission of RSV. Isolated private room or room with another infant with RSV infection. Cool humidified oxygen delivered relieve dyspnea, hypoxemia, & insensible water loss from tachypnea. - ANSWER- Respiratory syncytial virus (RSV) Acute stage: fever, conjunctival hyperemia, red throat, swollen hands, rash, & enlargement cervical lymph nodes. Subacute stage, cracking lips & fissures, desquamation skin on tips of fingers & toes, joint pain, cardiac manifestation, & thrombocytosis. Convalescent stage, appear normal, but signs inflammation may be present. - ANSWER- Kawasaki disease Narrowing or stricture of aortic valve. Signs of exercise intolerance, chest pain, & dizziness when standing for long periods. - ANSWER- Aortic stenosis Failure fetal ductus arteriosus (artery connecting aorta & pulmonary artery) to close. Characteristic machinery-like murmur is present, & infant may show signs of heart failure - ANSWER- Patent ductus arteriosus Abnormal opening between the atria - ANSWER- Atrial septal defect
Congenital defect involving abnormal placement urethral orifice of penis. Urethral orifice located below glans penis along ventral surface. Should not be circumcised because dorsal foreskin tissue used for surgical repair of hypospadias. - ANSWER- Hypospadias Congenital defect abnormal placement urethral orifice of penis. Urethral opening located anywhere on dorsum of penis. Anatomical characteristic facilitates entry bacteria into urine. - ANSWER- Epispadias Chronic disability characterized by impaired muscle movement & posture - ANSWER- Cerebral palsy Inflammation brain occurs as a result of viral illness or central nervous system infection. - ANSWER- Encephalitis Infectious process central nervous system. - ANSWER- Meningitis Congenital condition results in moderate to severe retardation. More likely to develop acute leukemia than average child - ANSWER- Down syndrome Not able extend leg when thigh is flexed anteriorly at hip. Raise child's leg with knee flexed & then extend the leg at knee & assess for pain; resistance is noted or pain is felt, result is positive Kernig's sign. - ANSWER- Kernig's sign Neck flexion causes adduction & flexion movements lower extremities children & adolescents - ANSWER- Brudzinski's sign (extension) posturing characterized: rigid extension & pronation of arms & legs. Abnormal extension upper extremities with internal rotation of upper arms &
wrists & extension of lower extremities with some internal rotation. Indicates damage in diencephalon, midbrain, or pons - ANSWER- Decerebrate posturing (flexion) posturing; Abnormal flexion of upper extremities & extension of lower extremities with possible plantar flexion of feet. Indicates lesion in cerebral hemisphere or disruption of the corticospinal tracts. - ANSWER- Decorticate posturing supportive care, monitoring & managing cerebral edema. Decrease stimuli environment quiet & dimmed lighting would decrease stress on cerebral tissue & neuron responses. - ANSWER- Reye's syndrome Assess hip instability. Abducts thigh & applies gentle pressure forward over greater trochanter. A "clicking" sensation indicates dislocated femoral head moving into acetabulum. - ANSWER- Ortolani maneuver confirmed by a p24 antigen assay, virus culture of HIV, or polymerase chain reaction. - ANSWER- Detection of HIV in infants Contains neomycin. History of anaphylactic reaction neomycin considered a contraindication to IPV. - ANSWER- Inactivated polio vaccine (IPV) Administered subcutaneously outer aspect of upper arm - ANSWER- (MMR) vaccine Transmitted airborne particles or direct contact with infectious droplets. Airborne droplet precautions required, & should wear masks. Private room if hospitalized, & door remains closed. Standard precautions used. Needs rest. consideration in rubeola is eye care. Child usually has photophobia, suggest parent keep child out of brightly lit areas. - ANSWER- Rubeola (measles)
