NGN NCLEX RN ACTUAL EXAM LATEST 2023 TEST BANK
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES |AGRADE
After a liver biopsy, the best position for the client is:
High Fowler
• Prone
• Supine
• Right lateral
Answer: D Explanation:
(A) This position does not help to prevent bleeding. (B) This position does not help to
prevent bleeding. (C) This position does not help to prevent bleeding. (D) The right lateral
position would allow pressure on the liverto prevent bleeding.
In assisting preconceptual clients, the nurse should teach that the corpus luteum secretes
progesterone, whichthickens the endometrial lining in which of the phases of the
menstrual cycle?
• Menstrual phase
• Proliferative phase
• Secretory phase
• Ischemic phase
Answer: C Explanation:
(A) Menses occurs during the menstrual phase, during which levels of both estrogen and
progesterone are decreased. (B) The ovarian hormone responsible for the proliferative phase,
during which the uterine endometrium enlarges, is estrogen. (C) The ovarian hormone
responsible for the secretory phase is progesterone, which is secreted by the corpus luteum and
causes marked swelling in the uterine endometrium. (D) The corpus luteum begins to
degenerate in the ischemic phase, causing a fall in both estrogen and progesterone.
A 4-year-old child is being discharged from the hospital after being treated for severe croup.
Which one of the following instructions should the nurse give to the child’s mother for the
home treatment of croup?
• Take him in the bathroom, turn on the hot water, and close the door.
• Give him a dose of antihistamine.
• Give large amounts of clear liquids if drooling occurs.
• Place him near a cool mist vaporizer and encourage crying.
Answer: A
Explanation:
,(A) Initial home treatment of croup includes placing the child in an environment of high
humidity to liquefy and mobilize secretions. (B) Antihistamines should be avoided because they
can cause thickening of secretions. (C) Drooling is a characteristic sign of airway obstruction
and the child should be taken directly to the emergency room. (D) Crying increases respiratory
distress and hypoxia in the child with croup. The nurse should promote methods that will calm
the child.
A male client is started on IV anticoagulant therapy with heparin. Which of the following
laboratory studies willbe ordered to monitor the therapeutic effects of heparin?
• Partial thromboplastin time
• Hemoglobin
• Red blood cell (RBC) count
• Prothrombin time
Answer: A Explanation:
(A) Partial thromboplastin time is used to monitor the effects of heparin, and dosage is
adjusted depending on test results. It is a screening test used to detect deficiencies in all
plasma clotting factors except factors VII andXIII and platelets. (B) Hemoglobin is the
main component of RBCs. Its main function is to carry O2from the lungs to the body
tissues and to transport CO2back to the lungs. (C) RBC count is the determination of the
number of RBCs found in each cubic millimeter of whole blood. (D) PT is used to monitor
the effects of oral anticoagulants, e.g., coumarintype anticoagulants.
A 16-year-old student has a long history of bronchial asthma and has experienced
several severe asthmaticattacks during the school year. The school nurse is required to
administer 0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How
does the school nurse evaluate the effectiveness of this intervention?
• Increased pulse rate
• Increased expectorate of secretions
• Decreased inspiratory difficulty
• Increased respiratory rate
Answer: C Explanation:
(A) A side effect of epinephrine is fatal ventricular fibrillation owing to its effects on cardiac
stimulation. (B) Medications used to treat asthma are designed to decrease bronchospasm, not
to increase expectorate of secretions. (C) Epinephrine decreased inspiratory difficulty by
stimulating -, 1, and 2-receptors causing sympathomimetic stimulation (e.g., bronchodilation).
(D) The person with asthma fights to inspire sufficient airthus increasing respiratory rate.
Nursing interventions designed to decrease the risk of infection in a client with an indwelling
catheter include:
, • Cleanse area around the meatus twice a day
• Empty the catheter drainage bag at least daily
• Change the catheter tubing and bag every 48 hours
• Maintain fluid intake of 1200–1500 mL every day
Answer: A Explanation:
• Catheter site care is to be done at least twice daily to prevent pathogen growth at the
catheter insertion site.
• 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.
A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an
impulsive act of self- mutilation. A few hours after admission, she requests special
privileges, and when these are not granted, she stands up and angrily shouts that the people
on the unit do not care, and she storms across the room. The nurse should respond to this
behavior by:
• Placing her in seclusion until the behavior is under control
• Walking up to the client and touching her on the arm to get her attention
• Communicating a desire to assist the client to regain control, offering a one-to-one session in
a quiet area
• Confronting the client, letting her know the consequences for getting angry and disrupting
the unit
Answer: C Explanation:
• Threatening a client with punitive action is violating a client’s rights and could escalate the
client’s anger.
• Angry clients need respect for personal space, and physical contact may be perceived
as a threatening gesture escalating anger. (C) Client lacks sufficient self-control to limit
own maladaptive behavior; she mayneed assistance from staff. (D) Confronting an angry
client may escalate her anger to further acting out, andconsequences are for acting out
anger aggressively, not for getting angry or feeling angry.
A client is being discharged with albuterol (Proventil) and beclomethasone dipropionate
(Vanceril) to be administered via inhalation three times a day and at bedtime. Client
teaching regarding the sequential order inwhich the drugs should be administered includes:
• Glucocorticoid followed by the bronchodilator
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES |AGRADE
After a liver biopsy, the best position for the client is:
High Fowler
• Prone
• Supine
• Right lateral
Answer: D Explanation:
(A) This position does not help to prevent bleeding. (B) This position does not help to
prevent bleeding. (C) This position does not help to prevent bleeding. (D) The right lateral
position would allow pressure on the liverto prevent bleeding.
In assisting preconceptual clients, the nurse should teach that the corpus luteum secretes
progesterone, whichthickens the endometrial lining in which of the phases of the
menstrual cycle?
• Menstrual phase
• Proliferative phase
• Secretory phase
• Ischemic phase
Answer: C Explanation:
(A) Menses occurs during the menstrual phase, during which levels of both estrogen and
progesterone are decreased. (B) The ovarian hormone responsible for the proliferative phase,
during which the uterine endometrium enlarges, is estrogen. (C) The ovarian hormone
responsible for the secretory phase is progesterone, which is secreted by the corpus luteum and
causes marked swelling in the uterine endometrium. (D) The corpus luteum begins to
degenerate in the ischemic phase, causing a fall in both estrogen and progesterone.
A 4-year-old child is being discharged from the hospital after being treated for severe croup.
Which one of the following instructions should the nurse give to the child’s mother for the
home treatment of croup?
• Take him in the bathroom, turn on the hot water, and close the door.
• Give him a dose of antihistamine.
• Give large amounts of clear liquids if drooling occurs.
• Place him near a cool mist vaporizer and encourage crying.
Answer: A
Explanation:
,(A) Initial home treatment of croup includes placing the child in an environment of high
humidity to liquefy and mobilize secretions. (B) Antihistamines should be avoided because they
can cause thickening of secretions. (C) Drooling is a characteristic sign of airway obstruction
and the child should be taken directly to the emergency room. (D) Crying increases respiratory
distress and hypoxia in the child with croup. The nurse should promote methods that will calm
the child.
A male client is started on IV anticoagulant therapy with heparin. Which of the following
laboratory studies willbe ordered to monitor the therapeutic effects of heparin?
• Partial thromboplastin time
• Hemoglobin
• Red blood cell (RBC) count
• Prothrombin time
Answer: A Explanation:
(A) Partial thromboplastin time is used to monitor the effects of heparin, and dosage is
adjusted depending on test results. It is a screening test used to detect deficiencies in all
plasma clotting factors except factors VII andXIII and platelets. (B) Hemoglobin is the
main component of RBCs. Its main function is to carry O2from the lungs to the body
tissues and to transport CO2back to the lungs. (C) RBC count is the determination of the
number of RBCs found in each cubic millimeter of whole blood. (D) PT is used to monitor
the effects of oral anticoagulants, e.g., coumarintype anticoagulants.
A 16-year-old student has a long history of bronchial asthma and has experienced
several severe asthmaticattacks during the school year. The school nurse is required to
administer 0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How
does the school nurse evaluate the effectiveness of this intervention?
• Increased pulse rate
• Increased expectorate of secretions
• Decreased inspiratory difficulty
• Increased respiratory rate
Answer: C Explanation:
(A) A side effect of epinephrine is fatal ventricular fibrillation owing to its effects on cardiac
stimulation. (B) Medications used to treat asthma are designed to decrease bronchospasm, not
to increase expectorate of secretions. (C) Epinephrine decreased inspiratory difficulty by
stimulating -, 1, and 2-receptors causing sympathomimetic stimulation (e.g., bronchodilation).
(D) The person with asthma fights to inspire sufficient airthus increasing respiratory rate.
Nursing interventions designed to decrease the risk of infection in a client with an indwelling
catheter include:
, • Cleanse area around the meatus twice a day
• Empty the catheter drainage bag at least daily
• Change the catheter tubing and bag every 48 hours
• Maintain fluid intake of 1200–1500 mL every day
Answer: A Explanation:
• Catheter site care is to be done at least twice daily to prevent pathogen growth at the
catheter insertion site.
• 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.
A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an
impulsive act of self- mutilation. A few hours after admission, she requests special
privileges, and when these are not granted, she stands up and angrily shouts that the people
on the unit do not care, and she storms across the room. The nurse should respond to this
behavior by:
• Placing her in seclusion until the behavior is under control
• Walking up to the client and touching her on the arm to get her attention
• Communicating a desire to assist the client to regain control, offering a one-to-one session in
a quiet area
• Confronting the client, letting her know the consequences for getting angry and disrupting
the unit
Answer: C Explanation:
• Threatening a client with punitive action is violating a client’s rights and could escalate the
client’s anger.
• Angry clients need respect for personal space, and physical contact may be perceived
as a threatening gesture escalating anger. (C) Client lacks sufficient self-control to limit
own maladaptive behavior; she mayneed assistance from staff. (D) Confronting an angry
client may escalate her anger to further acting out, andconsequences are for acting out
anger aggressively, not for getting angry or feeling angry.
A client is being discharged with albuterol (Proventil) and beclomethasone dipropionate
(Vanceril) to be administered via inhalation three times a day and at bedtime. Client
teaching regarding the sequential order inwhich the drugs should be administered includes:
• Glucocorticoid followed by the bronchodilator
