NCLEX RN ACTUAL EXAM RN NCLEX ACTUAL EXAM

A+

NCLEX RN ACTUAL EXAM /RN NCLEX ACTUAL EXAM

COMPLETE 300 QUESTIONS AND CORRECT DETAILED

ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY

GRADED A+

1

QUESTION 11

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 3–4 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?

• Short, polite responses to interview questions
• Introspection related to his present situation
• Exaggerated self-importance
• Feelings of helplessness and hopelessness

Answer: C

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 12

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:

• 70 mg/dL and 120 mg/dL
• 100 mg/dL and 200 mg/dL
• 40 mg/dL and 130 mg/dL
• 90 mg/dL and 200 mg/dL 1 / 4

A+

Answer: A

Explanation:

(A) The recommended range is 70–120 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 13

When evaluating a client with symptoms of shock, it is important for the nurse to differentiate between neurogenic and hypovolemic shock. The symptoms of neurogenic shock differ from hypovolemic shock in that:

• In neurogenic shock, the skin is warm and dry
• In hypovolemic shock, there is a bradycardia
• In hypovolemic shock, capillary refill is less than 2 seconds
• In neurogenic shock, there is delayed capillary refill

Answer: A

Explanation:

(A) Neurogenic shock is caused by injury to the cervical region, which leads to loss of sympathetic control. This loss leads to vasodilation of the vascular beds, bradycardia resulting from the lack of sympathetic balance to parasympathetic stimuli from the vagus nerve, and the loss of the ability to sweat below the level of injury. In neurogenic shock, the client is hypotensive but bradycardiac with warm, dry skin. (B) In hypovolemic shock, the client ishypotensive and tachycardiac with cool skin. (C) In hypovolemic shock, the capillary refill would be>5 seconds. (D) In neurogenic shock, there is no capillary delay, the vascular beds are dilated, and peripheral flow is good.

QUESTION 14

A 55-year-old man is admitted to the hospital with complaints of fatigue, jaundice, anorexia, and clay-colored stools. His admitting diagnosis is ―rule out hepatitis.‖ Laboratory studies reveal elevated liver enzymes and bilirubin. In obtaining his health history, the nurse should assess his potential for exposure to hepatitis.Which of the following represents a high-risk group for contracting this disease?

• Heterosexual males
• Oncology nurses
• American Indians
• Jehovah‘s Witnesses

Answer: B

Explanation:

(A) Homosexual males, not heterosexual males, are at high risk for contracting hepatitis.(B) Oncology nurses are employed in high-risk areas and perform invasive procedures that expose them to potential sources of infection. (C) The literature does not support the idea that any ethnic groups are at higher risk. (D) There is no evidence that any religious groups are at higher risk.

QUESTION 15

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? 2 / 4

A+

• Displacement
• Projection
• Reaction formation
• Suppression

Answer: B

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.Which classification of drugs is contraindicated for the client with hypertrophic cardiomyopathy?

• Positive inotropes
• Vasodilators
• Diuretics
• Antidysrhythmics

Answer: A

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 hypovolemi

• (D) Antidysrhythmics are typically needed to treat both atrial and ventricular dysrhythmias.

Signs and symptoms of an allergy attack include which of the following?

• Wheezing on inspiration
• Increased respiratory rate
• Circumoral cyanosis
• Prolonged expiration

Answer: D

Explanation:

(A) Wheezing occurs during expiration when air movement is impaired because of constricted edematous bronchial lumin

• (B) Respirations are difficult, but the rate is frequently normal. (C) The circumoral area is usually pale.

Cyanosis is not an early sign of hypoxi

• (D) Expiration is prolonged because the alveoli are greatly distended and air trapping occurs.

QUESTION 3

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

• Auditory
• Gustatory
• Olfactory
• Visceral

Answer: B

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 3 / 4

A+

QUESTION

• Which of the following findings would be abnormal in a postpartal woman?

• Chills shortly after delivery
• Pulse rate of 60 bpm in morning on first postdelivery day
• Urinary output of 3000 mL on the second day after delivery
• An oral temperature of 101F (38.3C) on the third day after delivery

Answer: D

Explanation:

(A) Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous response or to vasomotor changes. If not followed by a fever, it is clinically innocuous. (B) The pulse rate during the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt to the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. (C) Urinary output increases during the early postpartal period (12–24 hours) owing to diuresis. The kidneys must eliminate an estimated 2000–3000 mL of extracellular fluid associated with a normal pregnancy. (D) A temperature of 100.4F (38C) may occur after delivery as a result of exertion and dehydration of labor. However, anytemperature greater than 100.4F needs further investigation to identify any infectious process.

QUESTION 5

A six-month-old infant has been admitted to the emergency room with febrile seizures. In the teaching of the

parents, the nurse states that:

• Sustained temperature elevation over 103F is generally related to febrile seizures
• Febrile seizures do not usually recur
• There is little risk of neurological deficit and mental retardation as sequelae to febrile seizures
• Febrile seizures are associated with diseases of the central nervous system

Answer: C

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 6

A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following nutritional interventions would be most therapeutic for him at this time?

• Small, frequent feedings of foods that can be carried
• Tube feedings with nutritional supplements
• Allowing him to eat when and what he wants
• Giving him a quiet place where he can sit down to eat meals

Answer: A

Explanation:

(A) The manic client is unable to sit still long enough to eat an adequate meal. Small, frequent feedings with

• / 4