[Nov 26, 2023] NCLEX-RN PDF Dumps is essential on your NCLEX-RN Exam Questions Certain Success! [Q462-Q477]

Posted On November 26, 2023

[Nov 26, 2023] NCLEX-RN PDF Dumps is essential on your NCLEX-RN Exam Questions Certain Success!

NCLEX-RN PDF Questions – Perfect Prospect To Go With NCLEX-RN Practice Exam

NEW QUESTION 462
The physician has prescribed metoclopramide (Reglan). When assessing the client, the nurse would expect to find which of the following responses?

Increase in gastric secretions

Increase in peristalsis

Disorientation

Drowsiness

Explanation
(A) Metoclopramide does not stimulate gastric secretions. (B) This response is expected with metoclopramide, in addition to increasing gastric emptying. (C) Disorientation is a symptom of metoclopramide overdose. The drug should be discontinued. (D) Drowsiness is a symptom of metoclopramide overdose and the drug should be discontinued.

NEW QUESTION 463
A female client plans to bottle-feed her newborn. Her physician has ordered bromocriptine (Parlodel) to suppress lactation. Which of the following instructions about bromocriptine should be given by the nurse?

Bromocriptine stimulates the production of prolactin.

Hypertension is a primary side effect.

Bromocriptine is generally taken for 5 days.

Her blood pressure must be stable before starting bromocriptine.

Explanation
(A) Bromocriptine inhibits the secretion of prolactin. (B) Hypotension is a side effect of this drug; hypertension is not. (C) Bromocriptine is generally taken for 14 days. (D) The administration of bromocriptine is delayed at least 4 hours postpartum and given only when the client’s blood pressure is stable, because it can cause hypotension and syncope.

NEW QUESTION 464
A client is a depressed, 48-year-old salesman. A serious concern for the nurse working
with depressed clients is the potential of suicide. The time that suicide is most likely to occur is:

In the acutely depressed state

When the depression starts to lift

In the denial phase

During a manic episode

(A) The client may be too disorganized in the acute phase to make a workable plan. (B) When the depression starts to lift, the client is able to make a workable plan. (C) There usually is not a significant denial phase related to depression. Suicide occurs in a state of despair and hopelessness. (D) Suicide is uncommon in the manic state. In this state, clients do not feel hopeless, but euphoric and overly confident.

NEW QUESTION 465
A 3-year-old female client is brought into the pediatric clinic because she limps. She has not been to the clinic since she was 9 months old. The nurse practitioner describes the limp as a “Trendelenburg gait.” This gait is characteristic of:

Scoliosis

Dislocated hip

Fractured femur

Fractured pelvis

Explanation
(A, C, D) A Trendelenburg gait is not characteristic of any of these disorders. (B) The downward slant of one hip is a positive sign of dislocation in the weight-bearing hip. If one hip is dislocated, the child walks with a characteristic limp known as the Trendelenburg gait.

NEW QUESTION 466
Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?

She uses the bulb syringe to help clear her baby’s nose when milk is regurgitated.

She places her infant on her right side after feeding her.

She props the bottle in the crib to feed her baby, which allows her to write birth announcements and feed her baby at the same time.

She burps her baby by placing her in a sitting position, supporting her head and neck and gently massaging her back.

Section: Questions Set E
Explanation:
(A) This practice is the proper use of the bulb syringe to clear the infant’s airway in case of regurgitation. (B) Placing the infant on either side or on the stomach prevents aspiration of regurgitated milk. (C) “Bottle propping” is an unsafe practice because it increases the likelihood of aspiration. (D) This practice is one correct way of burping an infant.

NEW QUESTION 467
Which of the following would differentiate acute from chronic respiratory acidosis in the assessment of the trauma client?

Increased PaCO2

Decreased PaO2

Increased HCO3

Decreased base excess

(A) Increased CO2 will occur in both acute and chronic respiratory acidosis. (B) Hypoxia does not determine acid-base status. (C) Elevation of HCO3 is a compensatory mechanism in acidosis that occurs almost immediately, but it takes hours to show any effect and days to reach maximum compensation. Renal disease and diuretic therapy may impair the ability of the kidneys to compensate. (D) Base excess is a nonrespiratory contributor to acid-base balance. It would increase to compensate for acidosis.

NEW QUESTION 468
Provide the 1-minute Apgar score for an infant born with the following findings: Heart rate: Above 100 Respiratory effort: Slow, irregular Muscle tone: Some flexion of extremities Reflex irritability: Vigorous cry Color: Body pink, blue extremities

Explanation
(A) Seven out of a possible perfect score of 10 is correct. Two points are given for heart rate above 100; 1 point is given for slow, irregular respiratory effort; 1 point is given for some flex- ion of extremities in assessing muscle tone; 2 points are given for vigorous cry in assessing reflex irritability; 1 point is assessed for color when the body is pink with blue extremities (acrocyanosis). (B) For a perfect Apgar score of 10, the infant would have a heart rate over 100 but would also have a good cry, active motion, and be completely pink. (C) For an Apgar score of 8 the respiratory rate, muscle tone, or color would need to fall into the 2-point rather than the 1-point category. (D) For this infant to receive an Apgar score of 9, four of the areas evaluated would need ratings of 2 points and one area, a rating of 1 point.

NEW QUESTION 469
The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take?

Place a tongue blade in the child’s mouth.

Restrain the child so he will not injure himself.

Go to the nurses station and call the physician.

Move furniture out of the way and place a blanket under his head.

Explanation/Reference:
Explanation:
(A) The nurse should not put anything in the child’s mouth during a seizure; this action could obstruct the airway. (B) Restraining the child’s movements could cause constrictive injury. (C) Staying with the child during a seizure provides protection and allows the nurse to observe the seizure activity. (D) The nurse should provide safety for the child by moving objects and protecting the head.

NEW QUESTION 470
As a nurse in the emergency room, you receive an outside call from an elderly woman who states she has just been raped. She states, “I know I must come to the hospital, but what do I do next?” You advise her to call the police, then come to the hospital emergency room. What action by the nurse would indicate an understanding of the examination process once the victim enters the emergency room?

Inform the victim not to wash, change clothes, douche, brush teeth, or eat or drink anything.

Inform the victim to bring insurance information with her to the hospital so she can be properly cared for.

Phone a rape counselor to begin working with the victim as soon as she enters the hospital.

Do not leave the victim alone to collect her thoughts.

Section: Questions Set E
Explanation:
(A) Providing the victim with these instructions will aid in the determination of physical evidence of rape. Victims frequently feel “dirty” after rape, and their first instinct is to take care of personal hygiene before facing anyone.
(B) This action is of lesser importance at this time. (C) Although this is a nursing measure appropriate in this situation, contacting a counselor can be done once the victim enters the hospital. Frequently victims call but do not follow up with the visit. (D) Once the victim enters the emergency room, it is important not to leave her alone.

NEW QUESTION 471
A client is experiencing mucosal cell damage secondary to chemotherapy. Because of mucosal ulcers, eating has become increasingly uncomfortable for her. Which of the following interventions would be most effective in getting her to eat?

Local anesthetics or mouth washes applied to ulcers 30 minutes prior to meals

A bland, moist, soft diet

Staying with the client and providing distraction during meals

Cleaning the mouth carefully with lemon glycerin swabs and milk of magnesia before meals

Explanation/Reference:
Explanation:
(A) Local anesthetics do temporarily relieve the pain but leave an unpleasant taste and numb feeling that are not conductive to eating. (B) Such a diet is less irritating to the damaged mucosa and is easier for the child to tolerate. (C) This intervention is helpful if the child has only anorexia. It does not work if the type and texture of the food increase oral discomfort. (D) Lemon glycerin swabs and milk of magnesia dry the oral mucosa and should be avoided.

NEW QUESTION 472
Iron dextran (Imferon) is a parenteral iron preparation.
The nurse should know that it:

Is also called intrinsic factor

Must be given in the abdomen

Requires use of the Z-track method

Should be given SC

Explanation
(A) Intrinsic factor is needed to absorb vitamin B12.(B) Iron dextran is given parenterally, but Z-track in a large muscle. (C) A Ztrack method of injection is required to prevent staining and irritation of the tissue. (D) An SC injection is not deep enough and may cause subcutaneous fat abscess formation.

NEW QUESTION 473
A 5-year-old child was recently diagnosed as having acute lymphoid leukemia. She is hospitalized for additional tests and to begin a course of chemotherapy designed to induce a remission. She is scheduled to have a bone marrow aspiration tomorrow. She has had a bone marrow test previously and is apprehensive about having another. Which of the following interventions will be most effective in relieving her anxiety?

Explain what will take place and what she will see, feel, and hear.

Remind her that she has had this procedure before and that it is nothing to be afraid of.

Tell her not to worry about it, that it will be over soon and she can join her friends in the playroom.

Give her a big hug and tell her that she is a big girl now and that she will do just fine.

Section: Questions Set D
Explanation
Explanation:
(A) Even though the child has had the procedure before, she will probably need additional explanations and emotional support. (B) The fact that the child has had the procedure before and possibly found it painful or uncomfortable may increase, not relieve, her stress. (C) This intervention does nothing to reassure the child and may well prevent her from expressing her feelings. (D) This does not prepare the child for the test and burdens her with the expectation that she act bigger and braver than she is.

NEW QUESTION 474
During a client’s first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus.
This may be due to:

Endometritis

Fibroid tumor on the uterus

Displacement due to bowel distention

Urine retention or a distended bladder

Explanation/Reference:
Explanation:
(A, B) Endometritis, urine retention, or bladder distention provide good distractors because they may delay involution but do not usually cause the uterus to be lateral. (C) Bowel distention and constipation are common in the postpartum period but do not displace the uterus laterally. (D) Urine retention or bladder distention commonly displaces the uterus to the right and may delay involution.

NEW QUESTION 475
A primigravida with a blood type A negative is at 28 weeks’ gestation. Today her physician has ordered a RhoGAM injection. Which statement by the client demonstrates that more teaching is needed related to this therapy?

“I’m getting this shot so that my baby won’t develop antibodies against my blood, right?”

“I understand that if my baby is Rh positive I’ll be getting another one of these injections.”

“This shot should help to protect me in future pregnancies if this baby is Rh positive, like my husband.”

“This shot will prevent me from becoming sensitized to Rh-positive blood.”

Explanation
(A) RhoGAM is given to Rh-negative mothers to prevent the maternal Rh immune response to fetal Rh-positive antigens. (B) If the infant is Rh positive, the mother will receive another dose postdelivery to prevent maternal sensitization. (C) Prevention of maternal sensitization will protect future pregnancies because the mother’s blood will be free of antibodies against her fetus. (D) RhoGAM prevents maternal sensitization to Rh-positive blood.

NEW QUESTION 476
A client tells the nurse that he has been hearing voices that tell him to kill his girlfriend because she is a spy.
He further states that he is having difficulty not obeying the voices because, if he does not, his house will be burned down. The highest priority nursing diagnosis for him at this time is:

Sensory-perceptual alteration: auditory command hallucinations

Alteration in thought processes: paranoid delusions

Potential for violence directed at others

Impaired verbal communication: loose associations

Explanation
(A) Although the client is having command hallucinations, this is second in priority to real or potential violence, which can be a threat to life itself. (B) Although the client is experiencing delusions, this is also a lower priority than his potential or actual loss of control. (C) Whether real or potential, violence directed at self or others is always high priority. (D) There is no evidence of loosening of associations.

NEW QUESTION 477
An 8-year-old child is admitted to the hospital for surgery. She has had no previous hospitalizations, and both she and her family appear anxious and fearful. It will be most helpful for the nurse to:

Take the child to her room and calmly and matter-offactly begin to get her ready to go to the operating room

Take time to orient the child and her family to the hospital and the forthcoming events

Explain that as soon as the child goes to the operating room she will have time to answer any questions the family has

Tell the child and her family that there is nothing to worry about, that the operation will not take long, and she will soon be as “good as new”

Explanation
(A) This action does nothing to prepare the child and her family for what will happen or to relieve their anxiety and fear. (B) This action provides security by preparing the child and the family for what will happen and will help to relieve fear and anxiety. (C) This action does nothing to help prepare the child for what will happen and does not give the parents permission to ask questions until later. (D) This action provides possibly false reassurance and may prevent the child and/or the family from asking pressing questions.

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