NGN NCLEX RN ACTUAL EXAM LATEST 2023 TEST BANK
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES |AGRADE
QUESTION
On admission to the inpatient unit, a 34-year-old client is able to follow simple directions,
but with great difficulty.
He is worried about how he can keep clean in such a public place and repeatedly dusts his
bureau, straightenshis bed, and adjusts the clothes in his closet. The client is experiencing
a severe level of anxiety. Which response by the nurse would be most therapeutic in
initially attempting to reduce his anxiety?
• “You will not be allowed to remain in your room if you continue to bother things.”
• “I can see how uncomfortable you are, but I would like you to walk with me so I can show
you around the
unit.”
• “Tell me why your room needs to be so clean.”
• “I’ve inspected this room and it is perfectly clean.”
Answer: B Explanation:
(A) This statement is punitive. (B) Acknowledging the anxiety and channeling it into some
positive activity istherapeutic. (C) The client cannot say “why”; this statement puts the
client on the defensive. (D) A rational approach, especially a judgmental one, is
nontherapeutic.
QUESTION
A baby who was diagnosed with pyloric stenosis has continued to have projectile vomiting.
With prolonged
vomiting, the infant is prone to:
• Respiratory acidosis
• Respiratory alkalosis
• Metabolic acidosis
• Metabolic alkalosis
Answer: DExplanation:
(A) Respiratory acidosis is the result of problematic ventilation. Plasma pH decreases, while
plasma PCO2 and plasma HCO3 increase. (B) Respiratory alkalosis results from increased
respiratory rate and depth. Plasma pH increases, while plasma PCO2 and plasma HCO3
decrease. (C) Metabolic acidosis occurs when there is strong acid gain in the body. Plasma
pH, PCO2, and HCO3 decrease. (D) Increased risk for metabolic alkalosis is due to a loss of
hydrogen ions; depletion of potassium, sodium, and chloride when vomiting occurs. Plasma
pH andplasma PCO2 increase; plasma HCO3 may decrease and then increase to compensate.
QUESTION
,The nurse is caring for a client with pancreatitis. Which of the following IV medications
would the nurse expect the physician to prescribe for control of pain in this client?
• Morphine sulfate
• Kerolac tromethamine (Toradol)
• Promethazine (Phenergan)
• Meperidine (Demerol)
Answer: D Explanation:
(A) Morphine sulfate is contraindicated in clients with pancreatitis because it may cause
spasms of the sphincterof Oddi and increase pancreatic pain. (B) Ketorolac tromethamine is
currently not approved by the Food and Drug Administration for IV use. (C) Promethazine is
a medication that has no analgesic properties. (D) Meperidine is the drug of choice for clients
with pancreatitis. It will not cause spasms at the sphincter of Oddi, which can lead to
increased pancreatic pain.
QUESTION
At her first prenatal visit, a 21-year-old woman who is gravida 2, para 0, ab 1, is
currently at 32 weeks’ gestation and has a history of drug abuse, smoking, and
occasional ethyl alcohol use. Fetal ultrasound testsindicate poor fetal growth. The most
likely reason for the infant’s intrauterine growth retardation is:
• The client’s young age
• The client’s previous abortion
• The client’s history of drug, ethyl alcohol, and tobacco use
• The client’s late prenatal care
Answer: C Explanation:
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ld).A
(B
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subsequent pregnancies. (C) Compounds in cigarettes and some illicit drugs cause maternal
vasoconstrictionand a subsequent reduction in O2 availability for the fetus owing to the
resulting reduction in uteroplacentalblood flow. As few as one or two drinks of alcohol per
day will decrease birth weight. (D) Although early prenatal care has been shown to improve
pregnancy outcomes, not seeking care until the second week of gestation does not, in and of
itself, cause intrauterine growth retardation.
QUESTION
A 25-year-old lawyer who is married with three young children works long hours in an
effort to become apartner
in the law firm. Following a recent hospitalization for a bleeding ulcer, he was referred for
therapy to treat this psychophysiological disorder. On meeting with the therapist, he informed
him or her that he was a busy man and did not have much time for this “psych stuff.” When
guiding the client to ventilate his feelings, the therapist can expect him to express feelings of:
, • Guilt
• Shame
• Despair
• Anger
Answer: D Explanation:
(A) Guilt relates to depression. (B) Shame is not associated with psychophysiological
disorders. (C) Despair relates to depression. (D) Repressed anger is associated with
psychophysiologicaldisorders.
QUESTION
A client on the infectious disease unit is discussing transmission of human
immunodeficiency virus (HIV).The nurse would need to provide more client education
based on which client statement?
• “HIV is a virus transmitted by sexual contact.”
• “Condoms reduce the transmission of HIV.”
• “HIV is a virus that is easily transmitted by casual contact.”
• “HIV can be transmitted to an unborn infant.”
Answer: C Explanation:
(A) HIV is transmitted through unprotected sexual contact. (B) Condoms are an effective
barrier to prevent HIVtransmission. (C) HIV is not easily transmitted by casual contact. (D)
HIV can be transmitted intrauterinely at the time of delivery, and by breast-feeding.
QUESTION
A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis
of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change
in position. She is unable to speak or cough. In planning her nursing care for the first 24
hours following a CVA, which nursing diagnosis should receive the highest priority?
• Ineffective airway clearance related to immobility, ineffective cough, and decreased level of
consciousness
• Altered cerebral tissue perfusion related to pathophysiological changes that decrease blood
flow
• Potential for injury related to impaired mobility and seizures
• Impaired verbal communication related to aphasia
Answer: A Explanation:
(A) An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. (B)
Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is
secondary to maintenance of an effective airway. (C) While prevention of injury is
important, it is secondary to maintaining an effective airwayand cerebral tissue perfusion.
(D) Impaired verbal communication is not life threatening in the acute phase of recovery. It
is the lowest priority of the nursing diagnoses listed.
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES |AGRADE
QUESTION
On admission to the inpatient unit, a 34-year-old client is able to follow simple directions,
but with great difficulty.
He is worried about how he can keep clean in such a public place and repeatedly dusts his
bureau, straightenshis bed, and adjusts the clothes in his closet. The client is experiencing
a severe level of anxiety. Which response by the nurse would be most therapeutic in
initially attempting to reduce his anxiety?
• “You will not be allowed to remain in your room if you continue to bother things.”
• “I can see how uncomfortable you are, but I would like you to walk with me so I can show
you around the
unit.”
• “Tell me why your room needs to be so clean.”
• “I’ve inspected this room and it is perfectly clean.”
Answer: B Explanation:
(A) This statement is punitive. (B) Acknowledging the anxiety and channeling it into some
positive activity istherapeutic. (C) The client cannot say “why”; this statement puts the
client on the defensive. (D) A rational approach, especially a judgmental one, is
nontherapeutic.
QUESTION
A baby who was diagnosed with pyloric stenosis has continued to have projectile vomiting.
With prolonged
vomiting, the infant is prone to:
• Respiratory acidosis
• Respiratory alkalosis
• Metabolic acidosis
• Metabolic alkalosis
Answer: DExplanation:
(A) Respiratory acidosis is the result of problematic ventilation. Plasma pH decreases, while
plasma PCO2 and plasma HCO3 increase. (B) Respiratory alkalosis results from increased
respiratory rate and depth. Plasma pH increases, while plasma PCO2 and plasma HCO3
decrease. (C) Metabolic acidosis occurs when there is strong acid gain in the body. Plasma
pH, PCO2, and HCO3 decrease. (D) Increased risk for metabolic alkalosis is due to a loss of
hydrogen ions; depletion of potassium, sodium, and chloride when vomiting occurs. Plasma
pH andplasma PCO2 increase; plasma HCO3 may decrease and then increase to compensate.
QUESTION
,The nurse is caring for a client with pancreatitis. Which of the following IV medications
would the nurse expect the physician to prescribe for control of pain in this client?
• Morphine sulfate
• Kerolac tromethamine (Toradol)
• Promethazine (Phenergan)
• Meperidine (Demerol)
Answer: D Explanation:
(A) Morphine sulfate is contraindicated in clients with pancreatitis because it may cause
spasms of the sphincterof Oddi and increase pancreatic pain. (B) Ketorolac tromethamine is
currently not approved by the Food and Drug Administration for IV use. (C) Promethazine is
a medication that has no analgesic properties. (D) Meperidine is the drug of choice for clients
with pancreatitis. It will not cause spasms at the sphincter of Oddi, which can lead to
increased pancreatic pain.
QUESTION
At her first prenatal visit, a 21-year-old woman who is gravida 2, para 0, ab 1, is
currently at 32 weeks’ gestation and has a history of drug abuse, smoking, and
occasional ethyl alcohol use. Fetal ultrasound testsindicate poor fetal growth. The most
likely reason for the infant’s intrauterine growth retardation is:
• The client’s young age
• The client’s previous abortion
• The client’s history of drug, ethyl alcohol, and tobacco use
• The client’s late prenatal care
Answer: C Explanation:
(oA
ld).A
(B
lt)hoUungchom
adpolliecsactedntisnfdruecqeudenatblyorhtiaovnes ahahvigehneortinbceiednepnrcoevoefdlotowi-nbfilrutehn-
w
ceeitghhetgirnofw
antths,otfhiinsfcalnietsntofis 21 years
subsequent pregnancies. (C) Compounds in cigarettes and some illicit drugs cause maternal
vasoconstrictionand a subsequent reduction in O2 availability for the fetus owing to the
resulting reduction in uteroplacentalblood flow. As few as one or two drinks of alcohol per
day will decrease birth weight. (D) Although early prenatal care has been shown to improve
pregnancy outcomes, not seeking care until the second week of gestation does not, in and of
itself, cause intrauterine growth retardation.
QUESTION
A 25-year-old lawyer who is married with three young children works long hours in an
effort to become apartner
in the law firm. Following a recent hospitalization for a bleeding ulcer, he was referred for
therapy to treat this psychophysiological disorder. On meeting with the therapist, he informed
him or her that he was a busy man and did not have much time for this “psych stuff.” When
guiding the client to ventilate his feelings, the therapist can expect him to express feelings of:
, • Guilt
• Shame
• Despair
• Anger
Answer: D Explanation:
(A) Guilt relates to depression. (B) Shame is not associated with psychophysiological
disorders. (C) Despair relates to depression. (D) Repressed anger is associated with
psychophysiologicaldisorders.
QUESTION
A client on the infectious disease unit is discussing transmission of human
immunodeficiency virus (HIV).The nurse would need to provide more client education
based on which client statement?
• “HIV is a virus transmitted by sexual contact.”
• “Condoms reduce the transmission of HIV.”
• “HIV is a virus that is easily transmitted by casual contact.”
• “HIV can be transmitted to an unborn infant.”
Answer: C Explanation:
(A) HIV is transmitted through unprotected sexual contact. (B) Condoms are an effective
barrier to prevent HIVtransmission. (C) HIV is not easily transmitted by casual contact. (D)
HIV can be transmitted intrauterinely at the time of delivery, and by breast-feeding.
QUESTION
A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis
of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change
in position. She is unable to speak or cough. In planning her nursing care for the first 24
hours following a CVA, which nursing diagnosis should receive the highest priority?
• Ineffective airway clearance related to immobility, ineffective cough, and decreased level of
consciousness
• Altered cerebral tissue perfusion related to pathophysiological changes that decrease blood
flow
• Potential for injury related to impaired mobility and seizures
• Impaired verbal communication related to aphasia
Answer: A Explanation:
(A) An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. (B)
Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is
secondary to maintenance of an effective airway. (C) While prevention of injury is
important, it is secondary to maintaining an effective airwayand cerebral tissue perfusion.
(D) Impaired verbal communication is not life threatening in the acute phase of recovery. It
is the lowest priority of the nursing diagnoses listed.
