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NUR 2960 – NCLEX-RN EXAM REVIEW LATEST 2024.2025 100% GUARANTEED
PASS (VERIFIED EXAM) FSCJ
On the third postpartum day, the nurse would expect the lochia to be: A. Rubra B. Serosa C. Alba D. Scant Answer: A Explanation: (A) This discharge occurs from delivery through the 3rd day. There is dark red blood, placental debris, and clots. (B) This discharge occurs from days 4 - 10. The lochia is brownish, serous, and thin. (C) This discharge occurs from day 10 through the 6thweek. The lochia is yellowish white. (D) This is not a classification of lochia but relates to the amount of discharge.
Question: 2
A pregnant client is having a nonstress test (NST). It is noted that the fetal heart beat rises 20 bpm, lasting 20 seconds, every time the fetus moves. The nurse explains that: A. The test is inconclusive and should be repeated B. Further testing is needed C. The test is normal and the fetus is reacting appropriately D. The fetus is distressed Answer: C Explanation: (A) The test results were normal, so there would be no need to repeat to determine results. (B) There are no data toindicate further tests are needed, because the result of the NST was normal. (C) An NST is reported as reactive if there are two to three increases in the fetal heart rate of 15 bpm, lasting at least 15 seconds during a 15-minute period. (D) The NST results were normal, so there was no fetal distress.
Question: 3
Which stage of labor lasts from delivery of the baby to delivery of the placenta? A. Second B. Third C. Fourth D. Fifth Answer: B Explanation: (A) This stage is from complete dilatation of the cervix to delivery of the fetus. (B) This is the correct stage for the definition. (C) This stage lasts for about 2 hours after the delivery of the placenta. (D)
There is no fifth stage of labor.
Question: 4
A client develops complications following a hysterectomy. Blood cultures reveal Pseudomonas aeruginosa. The nurse expects that the physician would order an appropriate antibiotic to treat P. aeruginosa such as: A. Cefoperazone (Cefobid) B. Clindamycin (Cleocin) C. Dicloxacillin (Dycill) D. Erythromycin (Erythrocin)
statement when a baby has died. There
are also no guarantees that the couple will be able to have another child.
Question: 8
A 29 - year-old client is admitted for a hysterectomy. She has repeatedly told the nurses that she is worried about having this surgery, has not slept well lately, and is afraid that her husband will not find her desirable after the surgery. Shortly into the preoperative teaching, she complains of a tightness in her chest, a feeling of suffocation, lightheadedness, and tingling in her hands. Her respirations are rapid and deep. Assessment reveals that the clientis: A. Having a heart attack B. Wanting attention from the nurses C. Suffering from complete upper airway obstruction D. Hyperventilating Answer: D Explanation: (A) Classic symptoms of a heart attack include heaviness or squeezing pain in the chest, pain spreading to the jaw, neck, and arm. Nausea and vomiting, sweating, and shortness of breath may be present. The client does not exhibit these symptoms. (B) Clients suffering from anxiety or fear prior to surgical procedures may develop hyperventilation. This client is not seeking attention. (C) Symptoms of complete airway obstruction include not being able to speak, and no airflow between the nose and mouth. Breath sounds are absent. (D) Tightness in the chest; a feeling of suffocation; lightheadedness; tingling in the hands; and rapid, deep respirations are signs and symptoms of hyperventilation. This is almost always a manifestation of anxiety.
Question: 9
A 44 - year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains of severe abdominal pain. Assessment reveals abdominal rigidity and distention, increased temperature, and tachycardia. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has developed: A. Gastritis B. Evisceration C. Peritonitis D. Pulmonary embolism Answer: C Explanation: (A) Assessment findings for gastritis would reveal anorexia, nausea and vomiting, epigastric fullness and tenderness, and discomfort. (B) Evisceration is the extrusion of abdominal viscera as a result of trauma or sutures failing in a surgical incision. (C) Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and fluid into the abdominal cavity. This causes infection and irritation. (D) Assessment findings of pulmonary embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath, anxiety or panic, and wheezing and coughing often accompanied by blood-tinged sputum.
Question: 10
A 35 - year-old client is admitted to the hospital for elective tubal ligation. While the nurse is doing preoperative teaching, the client says, "The anesthesiologist said she was going to give me balanced anesthesia. What exactly is that?" The best explanation for the nurse to give the client would be that balanced anesthesia: A. Is a type of regional anesthesia B. Uses equal amounts of inhalation agents and liquid agents C. Does not depress the central nervous system D. Is a combination of several anesthetic agents or drugs producing a smooth induction and
Answer: D Explanation: (A) Regional anesthesia does not produce loss of consciousness and is indicated for excision of moles, cysts, and endoscopic surgeries. (B) Varying amounts of anesthetic agents are used when employing balanced anesthesia. Amounts depend on age, weight, condition of the client, and surgical procedure. (C) General anesthesia is a drug- induced depression of the central nervous system that produces loss of consciousness and decreased muscle activity. (D) Balanced anesthesia is a combination of a number of anesthetic agents that produce a smooth induction, appropriate depth of anesthesia, and
appropriate muscle relaxation with minimal complications. Question: 11
Following a gastric resection, a 70 - year-old client is admitted to the postanesthesia care unit. He was extubated prior to leaving the suite. On arrival at the postanesthesia care unit, the nurse should: A. Check airway, feeling for amount of air exchange noting rate, depth, and quality of respirations B. Obtain pulse and blood pressure readings noting rate and quality of pulse C. Reassure the client that his surgery is over and that he is in the recovery room D. Review physician’s orders, administering medications as ordered Answer: A Explanation: (A) Adequate air exchange and tissue oxygenation depend on competent respiratory function. Checking the airwayis the nurse’s priority action. (B) Obtaining the vital signs is an important action, but it is secondary to airway management. (C) Reorienting a client to time, place, and person after surgery is important, but it is secondary to airway and vital signs. (D) Airway management takes precedence over physician’s orders unless they specifically relate to airway management.
Question: 12
A 25 - year-old client is admitted for a tonsillectomy. She tells the nurse that she has had episodes of muscle cramps, weakness, and unexplained temperature elevation. Many years ago her father died shortly after surgery after developing a high fever. She further tells the nurse that her surgeon is having her take dantrolene sodium (Dantrium) prophylactically prior to her tonsillectomy. Dantrolene sodium is ordered preoperatively to reduce the risk or prevent: A. Infection postoperatively B. Malignant hyperthermia C. Neuroleptic malignant syndrome D. Fever postoperatively Answer: B Explanation: (A, D) Dantrolene sodium is a peripheral skeletal muscle relaxant and would have no effect on a postoperative infection. (B) Dantrolene sodium is indicated prophylactically for clients with malignant hyperthermia or with afamily history of the disorder. The mortality rate for malignant hyperthermia is high. (C) Neuroleptic malignant syndrome is an exercise-induced muscle pain and spasm and is unrelated to malignant hyperthermia.
Question: 13
The family member of a child scheduled for heart surgery states, "I just don’t understand this open-heart or closed- heart business. I’m so confused! Can you help me understand it?" The nurse explains that patent ductus arteriosus repair is: A. Open-heart surgery. The child will be placed on a heart-lung machine while the surgery is being performed. B. Closed-heart surgery. It does not require that the child be placed on the heart-lung machine
while the surgery is being performed. C. A pediatric version of the coronary artery bypass graft surgery performed on adults. It is an open- heart
which causes temperature elevation, but would not directly affect such an elevation.
Question: 16
A 19 - month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is being
given digoxin. Prior to administering the medication, the nurse should: A. Not give the digoxin if the pulse is_ B. Not give the digoxin if the pulse is_ C. Take the apical pulse for a full minute D. Monitor for visual disturbances, a side effect of digoxin Answer: C Explanation: (A) Digoxin should not be given to adults with an apical pulse < 60 bpm. (B) Digoxin should be given to children with an apical pulse > 100 bpm. With a pulse < 100 bpm, the medication should be withheld and the physician notified. (C) Prior to digoxin administration in both children and adults, an apical pulse should be taken for 1 full minute. Aside from the rate per minute, the nurse should note any sudden increase or decrease in heart rate, irregular rhythm, or regularization of a chronic irregular heart rhythm. (D) Early indications of digoxin toxicity, such as visual disturbances, occur rarely as initial signs in children.
Question: 17
A 35 - year-old client has returned to her room following surgery on her right femur. She has an IV of D5 in onehalf normal saline infusing at 125 mL/hr and is receiving morphine sulfate 1015 mg IM q4h prn for pain. She last voided 51/2 hours ago when she was given her preoperative medication. In monitoring and promoting return of urinary function after surgery, the nurse would: A. Provide food and fluids at the client’s request B. Maintain IV, increasing the rate hourly until the client voids C. Report to the surgeon if the client is unable to void within 8 hours of surgery D. Hold morphine sulfate injections for pain until the client voids, explaining to her that morphine sulfate can cause urinary retention Answer: C Explanation: (A) Provision of food and fluid promotes bowel elimination. Nutritional needs postoperatively are determined by the physician, not the client. (B) Increasing IV fluids postoperatively will not cause a client to void. Any change in rate of administration of IV fluids should be determined by the physician. (C) The postoperative client with normal kidney function who cannot void 8 hours after surgery is retaining urine. The client may need catheterization or medication. The physician must provide orders for both as necessary. (D) Although morphine sulfate can cause urinary retention, withholding pain medication will not ensure that the client will void. The client with uncontrolled pain will probably not be able to void.
Question: 18
A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low, intermittent suction with orders to "Irrigate NG tube with sterile saline q1h and prn." The rationale for using sterile saline, asopposed to using sterile water to irrigate the NG tube is: A. Water will deplete electrolytes resulting in metabolic acidosis. B. Saline will reduce the risk of severe, colicky abdominal pain during NG irrigation. C. Water is not isotonic and will increase restlessness and insomnia in the immediate postoperative period. D. Saline will increase peristalsis in the bowel. Answer: A Explanation: (A) Water is a hypotonic solution and will deplete electrolytes and cause metabolic acidosis when used
placed in the stomach is used to decompress the bowel. Irrigating with saline ensures a patent, well- functioning tube. Irrigating with saline will not increase peristalsis.
Question: 19
The nurse writes the following nursing diagnosis for a client in acute renal failure–Impaired gas exchange related to: A. Decreased red blood cell production B. Increased levels of vitamin D C. Increased red blood cell production D. Decreased production of renin Answer: A Explanation: (A) Red blood cell production is impaired in renal failure owing to impaired erythropoietin production. This causes a decrease in the delivery of oxygen to the tissue and impairs gas exchange. (B) The conversion of vitamin D to its physiologically active form is impaired in renal failure. (C) In renal failure, a decrease in red blood cell production occurs owing to an impaired production of erythropoietin, leading to impaired gas exchange at the cellular level. (D) The decreased production of renin in renal failure causes an increased production of aldosterone causing sodium and water retention.
Question: 20
A 6 - year-old child returned to the surgical floor 20 hours ago after an appendectomy for a gangrenous appendix. His mother tells the nurse that he is becoming more restless and is anxious. Assessment findings indicate that the child has atelectasis. Appropriate nursing actions would include: A. Allowing the child to remain in the position of comfort, preferably semi-or high-Fowler position B. Administering analgesics as ordered C. Having the child turn, cough, and deep breathe every 12 hours D. Remaining with the child and keeping as calm and quiet as possible Answer: C Explanation: (A) Allowing the client to remain in the position of comfort will not resolve the atelectasis. This position, if left unchanged, over time may actually increase the atelectasis. (B) Analgesics will not resolve the atelectasis and maycontribute to it if proper nursing actions are not taken to help resolve the atelectasis. (C) Having the client turn, cough, and deep breathe every 12 hours will aid in resolving the atelectasis. Surgery clients are at risk for postoperative respiratory complications because pulmonary function is reduced as a result of anesthesia and surgery. (D) Remaining with the client and keeping him calm and quiet will not affect the client’s anxiety, restlessness, or help to resolve the atelectasis. The cause (atelectasis) needs to be treated, not the symptoms (anxiety and restlessness).
Question: 21
A 52 - year-old female client is admitted to the hospital in acute renal failure. She has been on hemodialysis for the past 2 years. Stat arterial blood gases are drawn on the client yielding the following results: pH 7.30, PCO2 51 mm Hg, HCO3, 18 mEq/L, PaO2, 84 mm Hg. The nurse would interpret these results as: A. Compensated metabolic alkalosis B. Respiratory acidosis C. Partially compensated metabolic alkalosis D. Combined respiratory and metabolic acidosis
Answer: D Explanation:
increases the
susceptibility to infections. (B) The faulty processing of bilirubin produces bilesalts, which are irritating to the skin. (C) The detoxification of drugs is impaired with cirrhosis of the liver. (D)Collateral circulation develops due to portal hypertension. This is manifest through the development of esophageal varices, hemorrhoids, and caput medusae.
Question: 25
Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack? A. Fresh fruit B. A milkshake C. Saltine crackers and peanut butter D. A ham and cheese sandwich Answer: A Explanation: (A) High levels of ammonia, a by-product of protein metabolism, can precipitate metabolic encephalopathy. Theseclients need a diet high in carbohydrates and bulk. (B) Metabolic encephalopathy of the brain associated with liver failure is precipitated by elevated ammonia levels. Ammonia is a by- product of protein metabolism. (C, D) Metabolic encephalopathy in liver failure is precipitated by elevated ammonia levels. Ammonia is a byproduct of protein metabolism.
Question: 26
Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack? A. Fresh fruit B. A milkshake C. Saltine crackers and peanut butter D. A ham and cheese sandwich Answer: B Explanation: (A) Albumin, a blood volume expander, increases the circulating blood volume by exerting an osmotic pull on tissue fluids, pulling them into the vascular system. This fluid shift causes an increase in the heart rate and blood pressure. (B) Albumin, a blood volume expander, exerts an osmotic pull on fluids in the interstitial spaces, pulling the fluid back into the circulatory system. This fluid shift causes an increase in the urinary output. (C) Adventitious breath sounds and dyspnea can occur due to circulatory overload if the albumin is infused too rapidly. (D) Chills, fever, itching, and rashes are signs of a hypersensitivity reaction to albumin.
Question: 27
A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube. The rationale for this therapy is to: A. Prevent systemic infection B. Promote diuresis C. Decrease ammonia formation D. Acidify the small bowel Answer: C Explanation:
Diuretics and salt-free albumin are used to promote diuresis in clients with cirrhosis of the liver. (C) Neomycin destroys the bacteria in the intestines. It is the bacteria in the bowel that break down protein into ammonia. (D) Lactulose is administered to create an acid environment in the bowel. Ammonia leaves the blood and migrates tothis acidic environment where it is trapped and excreted.
Question: 28
The nurse notes multiple bruises on the arms and legs of a newly admitted client with lupus. The client states, "I get them whenever I bump into anything." The nurse would expect to note a decrease in which of the following laboratory tests? A. Number of platelets B. WBC count C. Hemoglobin level D. Number of lymphocytes Answer: A Explanation: (A) Thrombocytopenia, a decrease in platelets, occurs in lupus and causes a decrease in blood coagulation and thrombus formation. (B) Clients with lupus will have a decrease in the WBC count decreasing their resistance to infection. (C) Clients with lupus may have a decrease in the hemoglobin level causing anemia. (D) Leukopenia, adecrease in white blood cells, is seen in lupus and decreases resistance to infection.
Question: 29
A client is started on prednisone 2.5 mg po bid. Which of the following instructions should be included in her discharge teaching specific to this medication? A. Increase your oral intake of fluids to at least 4000 mL every day. B. Avoid contact with people who have contagious illnesses. C. Brush your teeth at least 4 times a day with a firm toothbrush. D. Immediately stop taking the prednisone if you feel depressed. Answer: B Explanation: (A) Fluid retention is a side effect of prednisone. The nurse should teach clients to weigh themselves daily and to observe for signs of edema. If these signs of fluid retention occur, they should notify the physician. (B) Prednisone, a glucocorticoid, suppresses the normal immune response making the client more susceptible to infections. (C) An increase in bleeding tendencies is a side effect of prednisone therapy. The nurse should teach clients to use preventive measures (i.e., electric razors and soft toothbrushes). (D) Depression and personality changes are side effects of prednisone therapy. Prednisone should never be discontinued abruptly.
Question: 30
When assessing a client, the nurse notes the typical skin rash seen with systemic lupus erythematosus. Which of thefollowing descriptions correctly describes this rash? A. Small round or oval reddish brown macules scattered over the entire body B. Scattered clusters of macules, papules, and vesicles over the body C. Bright red appearance of the palmar surface of the hands D. Reddened butterfly shaped rash over the cheeks and nose Answer: D Explanation: (A) The appearance of small, round or oval reddish brown macules scattered over the entire body is
characteristic of rubeola. (B) The appearance of scattered clusters of macules, papules, and vesicles throughout the body is characteristic of chickenpox. (C) Palmar redness is seen in clients with cirrhosis of the liver. (D) The characteristic
