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The Preparation Guide for NCLEX-RN Exam
NCLEX-RN Exam Study guide
There is a brief overview for the NCLEX-RN Exam
The NCLEX-RN® exam is the licensure examination administered by the National League for Nursing (NLN) for the purpose of determining the competency of nursing personnel. The test is based on the national core curriculum standards for nursing and requires a knowledge and application of basic nursing principles. The exam consists of three parts: Part 1: Multiple choice questions, Part 2: Essay, and Part 3: Clinical skills. The multiple-choice questions cover the four major categories: assessing, planning, implementing, and evaluating care; nursing diagnoses and evaluation; health promotion, maintenance, and illness prevention; and health assessment, planning, implementation, and evaluation. You'll need to know the difference between a nursing diagnosis and problem list, and why it's important to identify problems and interventions. NCLEX-RN Dumps are the preferred study tools for any nurse looking to pass the test.
NEW QUESTION 309
A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:
- A. Ineffective airway clearance
- B. High risk for infection
- C. Altered oral mucous membrane
- D. Activity intolerance
Answer: A
Explanation:
Section: Questions Set D
Explanation:
(A) The laryngectomy client should be able to gradually increase activities without difficulty. (B) The laryngectomy client may have copious amounts of secretions and require suctioning for the first 24-48 hours.
The cannula will require cleaning even after the first 24 hours because mucus collects in it. (C) The client does have a potential for infection, but it is not a more importantnursing priority than the ineffective airway clearance.
(D) This problem is not a more important nursing priority than ineffective airway clearance. The client's mouth may become dry, but good oral care should take care of the dryness.
NEW QUESTION 310
A nurse is taking a maternal history for a client at her first prenatal visit. Her pregnancy test was positive, she has two living children, she had one spontaneous abortion, and one infant died at the age of 3 months. Which of the following best describes the client at the present?
- A. Gravida 4, para 3, ab 0
- B. Gravida 5, para 4, ab 0
- C. Gravida 4, para 2, ab 1
- D. Gravida 5, para 3, ab 1
Answer: D
Explanation:
Explanation
(A) This individual has been pregnant four times, delivered two children, and had one abortion. (B) Your client has been pregnant five times, delivered three children, and had one abortion. (C) This individual has been pregnant five times, delivered four children, and has not had an abortion. (D) This individual has been pregnant four times, delivered three children, and has not had an abortion.
NEW QUESTION 311
Discharge teaching for the client who has a total gastrectomy should include which of the following?
- A. Follow-up visits every 3 weeks for the first 6 months
- B. Need for the client to increase fluid intake to 3000 mL/day
- C. B12 injections needed for the rest of the client's life
- D. Need to eat three full meals with plenty of fiber per day
Answer: C
Explanation:
Explanation
(A) There will be no need to increase fluid intake excessively, because dumping syndrome could present a problem. (B) Followup visits every 3 weeks are not a standard recommendation. Follow-up visits will be highly individualized. (C) With removal of the stomach, intrinsic factor will no longer be produced. Intrinsic factor is necessary for vitamin B12 absorption. Parenteral injections of B12 will be needed on a monthly basis for the rest of the person's life. (D) Smaller, more frequent meals, rather than large, bulky meals, are recommended to prevent problems with dumping syndrome.
NEW QUESTION 312
A mother is unsure about the type of toys for her 17-month-old child. Based on knowledge of growth and development, what toy would the nurse suggest?
- A. Various large colored blocks to teach visual discrimination
- B. A mobile to improve hand-eye coordination
- C. A large toy with movable parts to improve pincer grasp
- D. A pull toy to encourage locomotion
Answer: D
Explanation:
(A)
Increased locomotive skills make push-pull toys appropriate for the energetic toddler.
(B)
Infants progress from reflex activity through simple repetitive behaviors to imitative behavior. Hand-eye coordination forms the foundation of other movements. (C) At age 8 months, infants begin to have pincer grasp. Toys that help infants develop the pincer grasp are recommended for this age group. (D) Various large colored blocks are suggested toys for infants 6-12 months of age to help visual stimulation.
NEW QUESTION 313
Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include:
- A. Cleanse area around the meatus twice a day
- B. Change the catheter tubing and bag every 48 hours
- C. Empty the catheter drainage bag at least daily
- D. Maintain fluid intake of 1200-1500 mL every day
Answer: A
Explanation:
Explanation
(A) Catheter site care is to be done at least twice daily to prevent pathogen growth at the catheter insertion site.
(B) Catheter drainage bags are usually emptied every 8 hours to prevent urine stasis and pathogen growth. (C) Tubing and collection bags are not changed this often, because research studies have not demonstrated the efficacy of this practice. (D) Fluid intake needs to be in the 2000-2500 mL range if possible to help irrigate the bladder and prevent infection.
NEW QUESTION 314
A physician's order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a microdrip tubing set. How many drops per minute should the nurse administer?
- A. 1 gtt/min
- B. 5 gtt/min
- C. 50 gtt/min
- D. 100 gtt/min
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) This answer is a miscalculation. (B) This answer is a miscalculation. (C)50 gtt/min. (D) This answer is a miscalculation.
NEW QUESTION 315
When planning care for the passive-aggressive client, the nurse includes the following goal:
- A. Allow the client to give excuses if he forgets to give staff information.
- B. Allow the client to express anger by using "I" messages, such as "I was angry when . . .," etc.
- C. Allow the client to have time away from therapeutic responsibilities.
- D. Allow the client to use humor, because this may be the only way this client can express self.
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Ceasing to use humor and sarcasm is a more appropriate goal, because this client uses these behaviors covertly to express aggression instead of being open with anger. (B) Use of "I" messages demonstrates proper use of assertive behavior to express anger instead of passive-aggressive behavior.
(C) Client is expected to complete share of work in therapeutic community because he has often obstructed other's efforts by failing to do his share. (D) Client has used conveniently forgetting or withholding information as a passive-aggressive behavior, which is not acceptable.
NEW QUESTION 316
A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately:
- A. 16 weeks
- B. 10 weeks
- C. 20 weeks
- D. 30 weeks
Answer: C
Explanation:
Explanation
(A) At 10 weeks, the fundus is located slightly above the symphysis pubis. (B) At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus. (C) At 20 weeks, the fundus is located approximately at the umbilicus. (D) At 30 weeks, the fundal height is about 30 cm, or 10 cm above the umbilicus.
NEW QUESTION 317
A 66-year-old female client has smoked 2 packs of cigarettes per day for 20 years. Her arterial blood gases on room air are as follows: pH 7.35; PO2 70 mm Hg; PCO2 55 mm Hg; HCO3 32 mEq/L. These blood gases reflect:
- A. Compensated metabolic acidosis
- B. Compensated respiratory acidosis
- C. Uncompensated respiratory acidosis
- D. Compensated respiratory alkalosis
Answer: B
Explanation:
(A) In compensated metabolic acidosis, the pH level is normal, the PCO2level is decreased, and the HCO3level is decreased. The client's primary alteration is an inability to remove excess acid via the kidneys. The lungs compensate by hyperventilating and decreasing PCO2. (B) In compensated respiratory acidosis, the pH level is normal, the PCO2level is elevated, and the HCO3level is elevated. The client's primary alteration is an inability to remove CO2from the lungs, so over time, the kidneys increase reabsorption of HCO3to buffer the CO2. (C) In compensated respiratory alkalosis, the pH level is normal, the PCO2level is decreased, and the HCO3level is decreased. The client's primary alteration is hyperventilation, which decreases PCO2. The client compensates by increasing the excretion of HCO3from the body. (D) In uncompensated respiratory acidosis, the pH level is decreased, the PCO2level is increased, and the HCO3level is normal. The client's primary alteration is an inability to remove CO2from the lungs. The kidneys have not compensated by increasing HCO3reabsorption.
NEW QUESTION 318
Which classification of drugs is contraindicated for the client with hypertrophic cardiomyopathy?
- A. Antidysrhythmics
- B. Vasodilators
- C. Positive inotropes
- D. Diuretics
Answer: C
Explanation:
(A) Positive inotropic agents should not be administered owing to their action of increasing myocardial contractility. Increased ventricular contractility would increase outflow tract obstruction in the client with hypertrophic cardiomyopathy. (B) Vasodilators are not typically prescribed but are not contraindicated. (C) Diuretics are used with caution to avoid causing hypovolemia. (D) Antidysrhythmics are typically needed to treat both atrial and ventricular dysrhythmias.
NEW QUESTION 319
A 72-year-old male client had the Foley catheter that was inserted during the transurethral resection of his prostate removed today. He is concerned about the urinary incontinence he is having since removal of the Foley catheter. The nurse explains that:
- A. He should not be concerned about it because it will resolve quickly
- B. This is related to the bladder spasms and will soon stop
- C. The nurse will keep him dry, and he should notify the nurse when this happens
- D. This is usually temporary
Answer: D
Explanation:
Explanation
(A) This problem is temporary, but it may take some time to resolve, especially in an older man. (B) This problem is usually temporary, but it may take some time to resolve. (C) Keeping the client dry will not relieve his anxiety about his incontinence. (D) The bladder spasms are not the cause of the client's incontinence.
NEW QUESTION 320
A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy:
- A. Increases levels of unconjugated bilirubin, thereby preventing kernicterus (brain damage)
- B. Assists the baby's clotting mechanism
- C. Breaks down bilirubin in the skin into substances that can be excreted in stool or urine
- D. Prevents the development of ophthalmia neonatorum
Answer: C
Explanation:
Section: Questions Set E
Explanation:
(A) The instillation of erythromycin ophthalmic preparation, not phototherapy, prevents ophthalmia neonatorum.
(B) The administration of vitamin K (AquaMEPHYTON) assists the infant's clotting mechanism. (C) Excessive bilirubin accumulates when the infant's liver cannothandle the increased load caused by the breakdown of red blood cells postnatally. This excessive bilirubin seeps out of the blood and into the tissues, staining them yellow. Phototherapy accelerates the removal of bilirubin from the skin by breaking it down into substances that can be excreted in stool or urine. (D) Phototherapy decreases levels of unconjugated bilirubin, thereby preventing kernicterus.
NEW QUESTION 321
The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?
- A. Diuresis by her second or third postpartum day
- B. Diaphoresis by her third postpartum day
- C. Pulse rate of 50-70 bpm by her third postpartum day
- D. Vaginal discharge or rubra, serosa, then rubra
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Bradycardia is an expected assessment during the postpartum period. (B) Diuresis can occur during labor and the postpartum period and is an expected physiological adaptation. (C) A return of rubra after the serosa period may indicate a postpartal complication. (D) Diaphoresis, especially at night, is an expected physiological change and does not indicate an infectious process. Bradycardia, diuresis, and diaphoresis are normal postpartum physiological responses to adjust the cardiac output and blood volume to the nonpregnant state.
NEW QUESTION 322
A 4 year old has an imaginary playmate, which concerns the mother. The nurse's best response would be:
- A. "Just ignore the behavior and it should disappear by age 8."
- B. "I understand your concern and will assist you with a referral."
- C. "Try not to worry because you will just upset your child."
- D. "This is appropriate behavior for a preschooler and should not be a concern."
Answer: D
Explanation:
(A) This is normal for a preschooler, and a referral is not appropriate. (B) Telling a parent not to worry is unhelpful. This response does not address the mother's concern. (C) This response is incorrect. The behavior is normal and will usually disappear by the time the child enters school. (D) This behavior is normal development for a preschooler.
NEW QUESTION 323
A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take his medicine after she leaves. The nurse looks around the room and sees that she and the client are the only ones in the room. The nurse's most therapeutic response will be:
- A. "OK, I'll come back later when you're feeling more like taking your medicine."
- B. "I don't see your mother in the room. Let's talk about how you're feeling."
- C. "Why don't you finish talking to her, and I'll wait."
- D. "She may be here, but I can't see her."
Answer: B
Explanation:
Section: Questions Set F
Explanation:
(A) This response uses the principle of reality orientation by the nurse telling the client that he or she does not see anything, but it does recognize his feelings. (B) This response does not make it clear that the nurse does not see anyone else in the room, and the nurse leaves the client alone to continue hallucinating. (C) This response leaves room for doubt; the nurse is further confusing the client by this statement. (D) This response reinforces the hallucination and implies that the nurse sees his mother, too.
NEW QUESTION 324
Medication is administered to a client who has been placed in restraints after a sudden violent episode, and his EPSs subside. Restraints can be removed when:
- A. A therapeutic alliance has been established, and violent behavior subsides
- B. The nurse deems that removal of restraints is necessary
- C. The violent behavior subsides, and the client agrees to behave
- D. The physician orders it
Answer: A
Explanation:
(A) The physicianmayorder release of restraints, but prior to that, the client must meet criteria for release. (B) While the client is still restrained, but after violent behavior has subsided, a therapeutic bridge is built. This alliance encourages dialogue between nurse and client, allowing the client to determine causative factors, feelings prior to loss of control, and adaptive alternatives to violence. (C) If the client only "agrees to behave" after violent behavior subsides, he has developed no insight into cause and effect of violence or his response to stress. (D)Removal of restraints occurs only when the client meets the criteria for release, not just because the nurse says it is necessary.
NEW QUESTION 325
When teaching a sex education class, the nurse identifies the most common STDs in the United States as:
- A. Gonorrhea
- B. Herpes genitalis
- C. Chlamydia
- D. Syphilis
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Chlamydia trachomatis infection is the most common STD in the United States. The Centers for Disease Control and Prevention recommend screening of all high-risk women, such as adolescents and women with multiple sex partners. (B) Herpes simplex genitalia is estimated to be found in 5-20 million people in the United States and is rising in occurrence yearly. (C) Syphilis is a chronic infection caused by Treponema pallidum. Over the last several years the number of people infected has begun to increase. (D) Gonorrhea is a bacterial infection caused by the organism Neisseria gonorrhoeae. Although gonorrhea is common, chlamydia is still the most common STD.
NEW QUESTION 326
A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low, intermittent suction with orders to "Irrigate NG tube with sterile saline q1h and prn." The rationale for using sterile saline, as opposed to using sterile water to irrigate the NG tube is:
- A. Saline will reduce the risk of severe, colicky abdominal pain during NG irrigation.
- B. Saline will increase peristalsis in the bowel.
- C. Water will deplete electrolytes resulting in metabolic acidosis.
- D. Water is not isotonic and will increase restlessness and insomnia in the immediate postoperative period.
Answer: C
Explanation:
Section: Questions Set G
Explanation:
(A) Water is a hypotonic solution and will deplete electrolytes and cause metabolic acidosis when used for nasogastric irrigation. (B) Irrigating with saline does not cause abdominal discomfort. Severe, colicky abdominal pain is a symptom of intestinal obstruction. (C) Irrigating with water will not cause restlessness or insomnia in the postoperative client. Restlessness and insomnia can be emotional complications of surgery.
(D) A nasogastric tube placed in the stomach is used to decompress the bowel. Irrigating with saline ensures a patent, well-functioning tube. Irrigating with saline will not increase peristalsis.
NEW QUESTION 327
A client had a transurethral resection of the prostate yesterday. He is concerned about the small amount of blood that is still in his urine. The nurse explains that the blood in his urine:
- A. Is normal and he need not be concerned about it
- B. Can be removed by irrigating the bladder
- C. Should not be there on the second day
- D. Will stop when the Foley catheter is removed
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Some hematuria is usual for several days after surgery. (B) The client will continue to have a small amount of hematuria even after the Foley catheter is removed. (C) Some hematuria is usual for several days after surgery. The client should not be concerned about it unless it increases. (D) Irrigating the bladder will not remove the hematuria. Irrigation is done to remove blood clots and facilitate urinary drainage.
NEW QUESTION 328
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