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NURSING 101 ACTUALTESTS NCLEX-RN - P1 WITH ACTUAL

ANSWERS, EXAMS OF NURSING

Number: NCLEX

Passing Score:

800 Time Limit:

120 min File

Version: 12.

NCLEX-RN

QUESTION 1

A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to

determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using

Nägele's rule

is:

A. March 27

B. February 1

C. February 27

D. January 3

Correct Answer:

C Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A)March 27 is a miscalculation. (B) February 1 is a miscalculation. (C) February 27 is the correct answer. To calculate the estimated date of

confinement using Nagele's rule, subtract 3 months from the date that the last menstrual cycle began and then add 7 days to the result. (D)

January 3 is a miscalculation.

QUESTION 2

The nurse practitioner determines that a client is approximately 9 weeks' gestation. During the visit, the practitioner informs the client about

symptoms of physical changes that she will experience during her first trimester, such as:

A. Nausea and vomiting

B. Quickening

C. A 68 lb weight gain

D. Abdominal enlargement

Correct Answer:

A Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) Nausea and vomiting are experienced by almost half of all pregnant women during the first 3 months of pregnancy as a result of elevated

human chorionic gonadotropin levels and changed carbohydrate metabolism. (B) Quickening is the mother's perception of fetal movement and

generally does not occur until 1820

D. She needs to be placed on a restrictive diet immediately.

Correct Answer:

B Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) She is probably not compliant with her diet and exercise program. Recommended weight gain during second and third trimesters is

approximately 12 lb. (B) Because of her excessive weight gain of 10 lb in 2 months, she needs re-evaluation of her eating habits and

reinforcement of proper dietary habits for pregnancy. A 2200-calorie diet is recommended for most pregnant women with a weight gain of

2730 lb over the 9-month period. With rapid and excessive weightgain, PIH should also be suspected. (C) She does not need to increase her

caloric intake, but she does need to re-evaluate dietary habits. Ten pounds in 2 months is excessive weight gain during pregnancy, and health

teaching is warranted. (D) Restrictive dieting is not recommended during pregnancy.

QUESTION 5

Diabetes during pregnancy requires tight metabolic control of glucose levels to prevent perinatal mortality. When evaluating the pregnant

client, the nurse knows the recommended serum glucose range during pregnancy is:

A. 70 mg/dL and 120 mg/dL

B. 100 mg/dL and 200 mg/dL

C. 40 mg/dL and 130 mg/dL

D. 90 mg/dL and 200 mg/dL

Correct Answer:

A Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) The recommended range is 70120 mg/dL to reduce the risk of perinatal mortality. (B, C, D) These levels are not recommended. The

higher the blood glucose, the worse the prognosis for the fetus. Hypoglycemia can also have detrimental effects on the fetus.

QUESTION 6

When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What

action should the nurse take?

A. Continue monitoring because this is a normal occurrence.

B. Turn client on right side.

C. Decrease IV

fluids. D. Report to physician or midwife.

Correct Answer:

D Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) This is not a normal occurrence. Late decelerations need prompt intervention for immediate infant recovery. (B) To increase O2 perfusion

to the unborn infant, the mother should be placed on her left side. (C) IV fluids should be increased, not decreased. (D) Immediate action is

warranted, such as reporting findings, turning mother on left side, administering O2, discontinuing oxytocin (Pitocin), assessing maternal

blood pressure and the labor process, preparing for immediate cesarean delivery, and explaining plan of action to client.

QUESTION 7

The predominant purpose of the first Apgar scoring of a newborn is to:

A. Determine gross abnormal motor function

B. Obtain a baseline for comparison with the infant's future adaptation to the environment

C. Evaluate the infant's vital functions

D. Determine the extent of congenital malformations

Correct Answer:

C Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) Apgar scores are not related to the infant's care, but to the infant's physical condition. (B) Apgar scores assess the current physical

condition of the infant and are not related to future environmental adaptation. (C) The purpose of the Apgar system is to evaluate the

physical condition of the newborn at birth and to determine if there is an immediate need for resuscitation. (D) Congenital malformations are

not one of the areas assessed with Apgar scores.

QUESTION 8

A pregnant woman at 36 weeks' gestation is followed for PIH and develops proteinuria. To increase protein in her diet, which of the following

foods will provide the greatest amount of protein when added to her intake of 100 mL of milk?

A. Fifty milliliters light cream and 2 tbsp corn syrup

B. Thirty grams powdered skim milk and 1 egg

B. Yearly checkups performed by physician

C. Ultrasounds every 3 years

D. Monthly breast self-examination

Correct Answer:

D Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) Mammograms are less effective than breast self-examination for the diagnosis of abnormalities in younger women, who have denser

breast tissue. They are more effective forwomen older than 40. (B) Up to 15% of early-stage breast cancers are detected by physical

examination; however, 95% are detected by women doing breast self-examination. (C) Ultrasound is used primarily to determine the

location of cysts and to distinguish cysts from solid masses. (D) Monthly breast self-examination has been shown to be the most effective

method for early detection of breast cancer. Approximately 95% of lumps are detected by women themselves.

QUESTION 11

Which of the following risk factors associated with breast cancer would a nurse consider most significant in a client's history?

A. Menarche after age 13

B. Nulliparity

C. Maternal family history of breast cancer

D. Early menopause

Correct Answer:

C Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) Women who begin menarche late (after 13 years old) have a lower risk of developing breast cancer than women who have begun earlier.

Average age for menarche is 12.5 years. (B) Women who have never been pregnant have an increased risk for breast cancer, but a positive

family history poses an even greater risk. (C) A positive family history puts a woman at an increased risk of developing breast cancer. It is

recommended that mammography screening begin 5 years before the age at which an immediate female relative was diagnosed with breast

cancer. (D) Early menopause decreases the risk of developing breast cancer.

QUESTION 12

The nurse should know that according to current thinking, the most important prognostic factor for a client with breast cancer is:

A. Tumor size

B. Axillary node status

C. Client's previous history of disease

D. Client's level of estrogen-progesterone receptor assays

Correct Answer:

B Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) Although tumor size is a factor in classification of cancer growth, it is not an indicator of lymph node spread. (B) Axillary node status is the

most important indicator for predicting how far the cancer has spread. If the lymph nodes are positive for cancer cells, the prognosis is poorer.

(C) The client's previous history of cancer puts her at an increased risk for breast cancer recurrence, especially if the cancer occurred in the

other breast. It does not predict prognosis, however. (D) The estrogen-progesterone assay test is used to identify present tumors being

fedfrom an estrogen site within the body. Some breast cancers grow rapidly as long as there is an estrogen supply such as from the ovaries.

The estrogen-progesterone assay test does not indicate the prognosis.

QUESTION 13

A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2 months, his family describes

him as being "on the move," sleeping 34 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial assessment

with the client, the nurse would expect him to exhibit which of the following?

A. Short, polite responses to interview questions

B. Introspection related to his present situation

C. Exaggerated self-importance

D. Feelings of helplessness and hopelessness

Correct Answer:

C Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) During the manic phase of bipolar disorder, clients have short attention spans and may be abusive toward authority figures. (B)

Introspection requires focusing and concentration; clients with mania experience flight of ideas, which prevents concentration. (C) Grandiosity

and an inflated sense of self-worth are characteristic of this disorder. (D) Feelings of helplessness and hopelessness are symptoms of the

depressive stage of bipolar disorder.

QUESTION 14

A. "I don't think you are worthless. I'm glad to see you, and we will help you."

B. "Don't you think this is a sign of your illness?"

C. "I know with your wife and new baby that you do have a lot to live for."

D. "You've been feeling sad and alone for some time now?"

Correct Answer:

D Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) This response does not acknowledge the client's feelings. (B) This is a closed question and does not encourage communication. (C) This

response negates the client's feelings and does not require a response from the client. (D) This acknowledges the client's implied thoughts and

feelings and encourages a response.

QUESTION 17

Which of the following statements relevant to a suicidal client is correct?

A. The more specific a client's plan, the more likely he or she is to attempt suicide.

B. A client who is unsuccessful at a first suicide attempt is not likely to make future attempts.

C. A client who threatens suicide is just seeking attention and is not likely to attempt suicide.

D. Nurses who care for a client who has attempted suicide should not make any reference to the word "suicide" in order to protect the client's

ego.

Correct Answer:

A Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) This is a high-risk factor for potential suicide. (B) A previous suicide attempt is a definite risk factor for subsequent attempts. (C) Every

threat of suicide should be taken seriously. (D) The client should be asked directly about his or her intent to do bodily harm. The client is

never hurt by direct, respectful questions.

QUESTION 18

The day following his admission, the nurse sits down by a male client on the sofa in the dayroom. He was admitted for depression and

thoughts of suicide. He looks at the nurse and says, "My life is so bad no one can do anything to help me." The most helpful initial response by

the nurse would be:

A. "It concerns me that you feel so badly when you have so many positive things in your life."

B. "It will take a few weeks for you to feel better, so you need to be patient."

C. "You are telling me that you are feeling hopeless at this point?"

D. "Let's play cards with some of the other clients to get your mind off your problems for now."

Correct Answer:

C Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) This response does not acknowledge the client's feelings and may increase his feelings of guilt. (B) This response denotes false

reassurance. (C) This response acknowledges the client's feelings and invites a response. (D) This response changes the subject and does

not allow the client to talk about his feelings.

QUESTION 19

A long-term goal for the nurse in planning care for a depressed, suicidal client would be to:

A. Provide him with a safe and structured environment.

B. Assist him to develop more effective coping mechanisms.

C. Have him sign a "no-suicide" contract.

D. Isolate him from stressful situations that may precipitate a depressive episode.

Correct Answer:

B Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) This statement represents a short-term goal. (B) Long-term therapy should be directed toward assisting the client to cope effectively with

stress. (C) Suicide contracts represent short- term interventions. (D) This statement represents an unrealistic goal. Stressful situations cannot

be avoided in reality.

QUESTION 20

After 3 weeks of treatment, a severely depressed client suddenly begins to feel better and starts interacting appropriately with other clients

and staff. The nurse knows that this client has an increased risk for:

A. Suicide

B. Exacerbation of depressive symptoms

C. Violence toward others

D. Psychotic behavior

Explanation

Explanation/Reference:

Explanation:

(A) These delusions are related to the belief that an individual has an incurable illness. (B) These delusions are related to feelings of self-

importance and uniqueness. (C) These delusions are related to feelings of being conspired against. (D) These delusions are related to denial

of self- existence.

QUESTION 23

A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of hallucination?

A. Auditory

B. Gustatory

C. Olfactory

D. Visceral

Correct Answer:

B Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) Auditory hallucinations involve sensory perceptions of hearing. (B) Gustatory hallucinations involve sensory perceptions of taste. (C)

Olfactory hallucinations involve sensory perceptions of smell. (D) Visceral hallucinations involve sensory perceptions of sensation.

QUESTION 24

A schizophrenic client has made sexual overtures toward her physician on numerous occasions. During lunch, the client tells the nurse, "My

doctor is in love with me and wants to marry me." This client is using which of the following defense mechanisms?

A. Displacement

B. Projection

C. Reaction formation

D. Suppression

Correct Answer:

B Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) Displacement involves transferring feelings to a more acceptable object. (B) Projection involves attributing one's thoughts or feelings

to another person. (C) Reaction formation involves transforming an unacceptable impulse into the opposite behavior. (D) Suppression

involves the intentional exclusion of unpleasant thoughts or experiences.

QUESTION 25

Hypoxia is the primary problem related to near-drowning victims. The first organ that sustains irreversible damage after submersion in water is

the:

A. Kidney (urinary system)

B. Brain (nervous system)

C. Heart (circulatory system)

D. Lungs (respiratory system)

Correct Answer:

B Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) The kidney can survive after 30 minutes of water submersion. (B) The cerebral neurons sustain irreversible damage after 46 minutes of

water submersion. (C) The heart can survive up to 30 minutes of water submersion. (D) The lungs can survive up to 30 minutes of water

submersion.

QUESTION 26

One of the most dramatic and serious complications associated with bacterial meningitis is Waterhouse- Friderichsen syndrome, which is:

A. Peripheral circulatory collapse

B. Syndrome of inappropriate antiduretic hormone

C. Cerebral edema resulting in hydrocephalus

D. Auditory nerve damage resulting in permanent hearing loss

Correct Answer:

A Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) Waterhouse-Friderichsen syndrome is peripheral circulatory collapse, which may result in extensive and diffuse intravascular coagulation

and thrombocytopenia resulting in death. (B) Syndrome of inappropriate antidiuretic hormone is a complication of meningitis, but it is not

Waterhouse-Friderichsen syndrome. (C) Cerebral edema resulting in hydrocephalus is a complication of meningitis, but it is not Waterhouse-

Friderichsen syndrome. (D) Auditory nerve damage resulting in

QUESTION 29

A laboratory technique specific for diagnosing Lyme disease is:

A. Polymerase chain reaction

B. Heterophil antibody test

C. Decreased serum calcium level

D. Increased serum potassium level

Correct Answer:

A Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) Polymerase chain reaction is the laboratory technique specific for Lyme disease. (B) Heterophil antibody test is used to diagnose

mononucleosis. (C) Lyme disease does not decrease the serum calcium level. (D) Lyme disease does not increase the serum potassium level.

QUESTION 30

The nurse would expect to include which of the following when planning the management of the client with Lyme disease?

A. Complete bed rest for 68 weeks

B. Tetracycline treatment

C. IV amphotericin B

D. High-protein diet with limited fluids

Correct Answer:

B Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) The client is not placed on complete bed rest for 6 weeks. (B) Tetracycline is the treatment of choice for children with Lyme disease who are

over the age of 9.

(C) IV amphotericin B is the treatment for histoplasmosis. (D) The client is not restricted to a high-protein diet with limited fluids.

QUESTION 31

A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess

adequacy of fluid resuscitation in the burned child?

A. Blood

pressure B. Serum potassium level

C. Urine output

D. Pulse rate

Correct Answer:

C Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) Blood pressure can remain normotensive even in a state of hypovolemia. (B) Serum potassium is not reliable for determining adequacy of

fluid resuscitation.

(C) Urine output, alteration in sensorium, and capillary refill are the most reliable indicators for assessing adequacy of fluid resuscitation. (D)

Pulse rate may vary for many reasons and is not a reliable indicator for assessing adequacy of fluid resuscitation.

QUESTION 32

Proper positioning for the child who is in Bryant's traction is:

A. Both hips flexed at a 90-degree angle with the knees extended and the buttocks elevated off the bed

B. Both legs extended, and the hips are not flexed

C. The affected leg extended with slight hip flexion

D. Both hips and knees maintained at a 90-degree flexion angle, and the back flat on the bed

Correct Answer:

A Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) The child's weight supplies the countertraction for Bryant's traction; the buttocks are slightly elevated off the bed, and the hips are

flexed at a 90-degree angle. Both legs are suspended by skin traction. (B) The child in Buck's extension traction maintains the legs extended

and parallel to the bed. (C) The child in Russell traction maintains hip flexion of the affected leg at the prescribed angle with the leg

extended. (D) The child in "9090" traction maintains both hips and knees at a 90-degree flexion angle and the back is flat on the bed.

QUESTION 33

A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia,

which include:

C. There is little risk of neurological deficit and mental retardation as sequelae to febrile seizures

D. Febrile seizures are associated with diseases of the central nervous system

Correct Answer:

C Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) The temperature elevation related to febrile seizures generally exceeds 101F, and seizures occur during the temperature rise rather than

after a prolonged elevation. (B) Febrile seizures may recur and are more likely to do so when the first seizure occurs in the 1st year of life.

(C) There is little risk of neurological deficit, mental retardation, or altered behavior secondary to febrile seizures. (D) Febrile seizures are

associated with disease of the central nervous system.

QUESTION 36

A child is admitted to the emergency room with her mother. Her mother states that she has been exposed to chickenpox. During the

assessment, the nurse would note a characteristic rash:

A. That is covered with vesicular scabs all in the macular stage

B. That appears profusely on the trunk and sparsely on the extremities

C. That first appears on the neck and spreads downward

D. That appears especially on the cheeks, which gives a"slapped-cheek" appearance

Correct Answer:

B Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) A rash with vesicular scabs in all stages (macule, papule, vesicle, and crusts). (B) A rash that appears profusely on the trunk and sparsely

on the extremities.

(C) A rash that first appears on the neck and spreads downward is characteristic of rubeola and rubella. (D) A rash, especially on the cheeks,

that gives a "slapped- cheek" appearance is characteristic of roseola.

QUESTION 37

The priority nursing goal when working with an autistic child is:

A. To establish trust with the child

B. To maintain communication with the family

C. To promote involvement in school activities

D. To maintain nutritional requirements

Correct Answer:

A Section: (none)

Explanation

Explanation/Reference:

Explanation:

(A) The priority nursing goal when working with an autistic child is establishing a trusting relationship. (B) Maintaining a relationship with the

family is important but having the trust of the child is a priority. (C) To promote involvement in school activities is inappropriate for a child who

is autistic. (D) Maintaining nutritional requirements is not the primary problem of the autistic child.

QUESTION 38

The child with iron poisoning is given IV deforoxamine mesylate (Desferal). Following administration, the child suffers hypotension, facial

flushing, and urticaria. The initial nursing intervention would be to:

A. Discontinue the IV

B. Stop the medication, and begin a normal saline infusion

C. Take all vital signs, and report to the physician

D. Assess urinary output, and if it is 30 mL an hour, maintain current treatment

Correct Answer:

B Section: (none)

Explanation

Explanation/Reference:

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.

QUESTION 39

When teaching a mother of a 4-month-old with diarrhea about the importance of preventing dehydration, the nurse would inform the mother

about the importance of feeding her child:

A. Fruit juices

B. Diluted carbonated drinks