RealVCE NCLEX-RN Real Exam Question Answers Updated [Dec 01, 2021]
Easily To Pass New NCLEX NCLEX-RN Dumps with 865 Questions
NEW QUESTION 393
A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse's best response is:
- A. "There's really no need to stay with her. She's going to sleep for several hours after the treatment."
- B. "Visitors are not allowed. We will telephone you to inform you of her progress."
- C. "Yes, you may visit. She may experience temporary drowsiness, confusion, or memory loss after each treatment."
- D. "You'll have to get permission from the physician to visit. Clients are pretty sick after the first treatment."
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) It is within the nurse's realm of practice to grant visiting privileges according to hospital policy. ECT treatments do not make clients sick. (B) Visitors are allowed and encouraged, particularly family members.
(C) Clients are usually awake within 1 hour posttreatment. Drowsiness wanes as the anesthetic wears off.
(D) A family member is encouraged to stay with the client after return to the unit. The nurse has used an opportunity to do family teaching and allay fears by explaining temporary side effects of the treatment.
NEW QUESTION 394
A young boy tells the nurse, "I don't like my Dad to kiss or hug my Mom. I love my Mom and want to marry her." The nurse recognizes this stage of growth and development as:
- A. Superego
- B. Ego
- C. Electra complex
- D. Oedipus complex
Answer: D
Explanation:
Explanation
(A) The Electra complex is the erotic attachment of the female child to the father. (B) The Oedipus complex is characterized by jealousy toward the parent of the same sex and erotic attachment to the parent of the opposite sex. (C) The superego as described by Freud is the part of personality that is associated with internalized parental and societal control. (D) The ego as described by Freud is the part of personality that is associated with reality assessment.
NEW QUESTION 395
A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will:
- A. Wash her hands before and after voiding
- B. Limit her fluid intake after 6 PM so that there is not a great deal of urine in her bladder while she sleeps
- C. Maintain a fluid intake of at least 2000 mL daily
- D. Drink at least 8 oz of cranberry juice daily
Answer: B
Explanation:
Explanation
(A) Cranberry juice helps to maintain urine acidity, thereby retarding bacterial growth. (B) A generous fluid intake will help to irrigate the bladder and to prevent bacterial growth within the bladder. (C) Hand washing is an effective means of preventing pathogen transmission. (D) Restricting fluid intake would contribute to urinary stasis, which in turn would contribute to bacterial growth.
NEW QUESTION 396
The health team needs to realize that the compulsive concern with cleanliness that a client with severe anxiety exhibits is most likely an attempt to:
- A. Avoid going to psychotherapy
- B. Increase his self-image by showing higher standards than the fellow clients
- C. Manipulate the health team members
- D. Reduce his anxiety
Answer: D
Explanation:
(A) These behaviors are attempts to relieve anxiety. (B) Avoidance is not a pattern in the obsessive client. (C) Although these behaviors may seem to manipulate others, that is not the purpose behind the activity. (D) Inflated self-esteem is not a characteristic of the severely anxious client.
NEW QUESTION 397
The serial sevens test is often used to determine delirium and dementia. This test aids in assessing which of the following?
- A. Memory
- B. Abstract thinking
- C. Ability to focus and concentrate thoughts
- D. Judgment
Answer: C
Explanation:
Explanation
(A) This answer is incorrect. The test measures the abilities to concentrate and calculate. The use of proverbs is the most common way to test abstraction. (B) This answer is correct. The serial sevens test is a common test of calculation ability. It is difficult for the demented or delirious client to perform. (C) This answer is incorrect. The test for judgment should predict whether the individual will behave in a socially accepted manner. (D) This answer is incorrect. In testingmemory, the nurse would attempt to get the client either to recall recent events or to think about past events.
NEW QUESTION 398
In evaluating the laboratory results of a client with severe pressure ulcers, the nurse finds that her albumin level is low. A decrease in serum albumin would contribute to the formation of pressure ulcers because:
- A. A decreased serum albumin level indicates kidney disease.
- B. The proteins needed for tissue repair are diminished.
- C. A decreased serum albumin causes fluid movement into the blood vessels, causing dehydration.
- D. The iron stores needed for tissue repair are inadequate.
Answer: B
Explanation:
(A)
Serum albumin levels indicate the adequacy of protein stores available for tissue repair.
(B)
Serum albumin does not measure iron stores. (C) Serum albumin levels do not measure kidney function. (D) A decreased serum albumin level would cause fluid movement out of blood vessels, not into them.
NEW QUESTION 399
A 55-year-old client is admitted with a diagnosis of renal calculi. He presented with severe right flank pain, nausea, and vomiting. The most important nursing action for him at this time is:
- A. Straining of all urine
- B. Intake and output measurement
- C. Daily weights
- D. Administration of O2 therapy
Answer: A
Explanation:
(A) Intake and output measurements are important but must be accompanied by straining urine. (B) Daily weights would not provide for identification of calculi. (C) Straining urine provides for assessment of calculi and evaluation of calculi descent through ureters and urethra. (D) O2therapy should not be necessary for renal calculi.
NEW QUESTION 400
At 32 weeks' gestation, a client is scheduled for a fetal activity test (nonstress test). She calls the clinic and asks the RN, "How do I prepare for the test I am scheduled for?" The RN will most likely inform her of the following instructions to help prepare her for the test:
- A. "You will have to remain as still as you possibly can."
- B. "Do not eat any food or drink any liquids before the test is started."
- C. "You need to know that an IV is always started before the test."
- D. "You will need to drink 6 to 8 glasses of water to fill your bladder."
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) An IV line is not started in a nonstress test, because this test is used as an indicator of fetal well-being.
This test measures fetal activity and heart rate acceleration. (B) The bladder does not have to be full prior to this test. It is not a sonogram test where a full bladder enables other structures to be scanned. (C) It has been proved that eating or drinking liquids prior to the test can assist in increasing fetal activity. (D) Any maternal activity will interfere with the results of the test.
NEW QUESTION 401
A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician?
- A. Hematocrit 60%
- B. Bleeding time of 4 minutes
- C. White blood cell (WBC) count 10,000 WBCs/mm3
- D. pH 7.39
Answer: A
Explanation:
(A) Normal pH of arterial blood gases for an infant is 7.35-7.45. (B) Normal white blood cell count in an infant is 6,000-17,500 WBCs/mm3. (C) Normal hematocrit in infant is 28%-42%. A 60% hematocrit may indicate polycythemia, a common complication of cyanotic heart disease. (D) Normal bleeding time is 2-7 minutes.
NEW QUESTION 402
After the RN is finished the initial assessment of a newborn baby and after the initial bonding between the newborn and the mother has taken place in the delivery room, the RN will bring the newborn to the well-baby nursery. Before the newborn is taken from the delivery room and brought to the well-baby nursery, the RN makes sure that which of the following interventions was completed?
- A. The nurse instills prophylactic ointment in the conjunctival sacs of the newborn's eyes.
- B. The nurse counts the instruments and sponges with the scrub nurse.
- C. The nurse makes sure the mother and her newborn have been tagged with identical bands.
- D. The physician verifies the exact time of birth.
Answer: C
Explanation:
(A) The delivery room personnel are responsible for verifying time of birth. (B) The scrub and circulating nurses count sponges and instruments. (C) This intervention is done in the nursery. (D) Tagging the mother and infant with identical bands is of utmost importance. The mother wears one band, and the newborn wears two. Identical numbers on the three bands provide identification for the newborn and the birth mother. Every time the newborn is brought to the mother after delivery, those bands are checked to be sure that the numbers are identical.
NEW QUESTION 403
A 48-year-old client presents with a long history of severedepression unrelieved by medication. He is admitted to the hospital for electroconvulsive therapy. Familymembers are very concerned about this therapy and are requesting information about aftereffects of the treatment. The nurse informs the family that he will:
- A. Have transient memory loss, confusion, andheadache
- B. Have insomnia for the first few days
- C. Be alert and oriented immediately after the treatment
- D. Require no special care after the procedure
Answer: A
Explanation:
(A) This answer is correct. The client will be confused and have a memory loss, which is usually temporary, after electroconvulsive shock therapy. (B) This answer is incorrect. The client will experience transient memory loss, look bewildered, and be confused initially. (C) This answer is incorrect. The client will sleep immediately following the treatment. (D) This answer is incorrect. Vital signs are taken at least hourly after treatment. The client is monitored for hypotension, tachycardia, respiratory problems, and possible seizure activity.
NEW QUESTION 404
A 4-year-old boy is brought to the emergency room with bruises on his head, face, arms, and legs. His mother states that he fell down some steps. The nurse suspects that he may have been physically abused. In accordance with the law, the nurse must:
- A. Confront the child's mother
- B. Tell the physician her concerns
- C. Talk to the child's father
- D. Report her suspicions to the authorities
Answer: D
Explanation:
Explanation
(A) Although the nurse probably would talk to the physician about these concerns, the nurse is not required by law to do so. (B) All healthcare workers are required by the Federal Child Abuse Prevention and Treatment Act of 1974 to report suspected and actual cases of child abuse and/or neglect. (C) Talking to the child's father may or may not help the child, and the nurse is not required by law to do so. (D) Confrontation may not be indicated; the nurse is not required by law to confront the child's mother with these suspicions.
NEW QUESTION 405
A 35-year-old primigravida comes to the clinic for her first prenatal visit. The midwife, on examining the client, suspects that she is approximately 11 weeks pregnant. The pregnancy is positively confirmed by finding:
- A. FHR by ultrasound
- B. Breast tenderness and enlargement
- C. Chadwick's sign
- D. Enlargement of the uterus
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Chadwick's sign is a presumptive sign of pregnancy. The coloration may not subside from past pregnancy or could be caused by other situations that create vasocongestion. (B) FHR (movement) observed on ultrasound is a positive diagnosis of pregnancy. (C) Enlargement of the uterus may be due to fibroids or infection. It is considered a probable sign. (D) Breast tenderness and enlargement is a presumptive sign because it may be due to other conditions, such as premenstrual changes.
NEW QUESTION 406
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. "Why don't you finish talking to her, and I'll wait."
- B. "She may be here, but I can't see her."
- C. "I don't see your mother in the room. Let's talk about how you're feeling."
- D. "OK, I'll come back later when you're feeling more like taking your medicine."
Answer: C
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 407
A 34-year-old client who is gravida 1, para 0 has a history of infertility and conceived this pregnancy while taking fertility drugs. She is at 32 weeks' gestation and is carrying triplets. She is complaining of low back pain and a feeling of pelvic pressure. Her cervical exam reveals a long, closed cervix. The nurse notes that the client is experiencing mild uterine contractions every 7-8 minutes after the nurse has placed her on the fetal monitor. Her condition should indicate that:
- A. She may be in preterm labor because this is more common with multiple pregnancies
- B. She most likely has a urinary tract infection (UTI) because this is common with pregnancy
- C. Her cervix shows she will likely deliver soon
- D. The nurse should not be alarmed because mild uterine activity is common at 32 weeks' gestation
Answer: A
Explanation:
(A) Her cervical exam is normal. There are no cervical changes at this time. (B) Braxton Hicks contractions may be common throughout pregnancy, but they are not regular. (C) Rhythmical contractions in conjunction with low back pain and pelvic pressure at 32 weeks in a woman carrying triplets are of great concern. She may be in preterm labor. (D) UTIs are common in pregnancy due to the enlarging uterus compressing the ureters and the stasis of urine. The woman would be more likely to complain of urinary frequency and urgency, fever or chills, and malodorous urine with a UTI.
NEW QUESTION 408
......
Latest NCLEX-RN Study Guides 2021 - With Test Engine PDF: https://www.realvce.com/NCLEX-RN_free-dumps.html
Get New NCLEX-RN Practice Test Questions Answers : https://drive.google.com/open?id=1BgY4zC9stSCSIjMM2Qg_Oemv5WLJltwP