NCLEX-PN - National Council Licensure Examination(NCLEX-PN) Real Exam Questions by


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Question: 1441
Which of the following is most likely to impact the body image of an infant newly diagnosed with Hemophilia?
A. immobility
B. altered growth and development
C. hemarthrosis
D. altered family processes
Answer: D
Altered Family Processes is a potential nursing diagnosis for the family and client with a new diagnosis of
Hemophilia. Infants are aware of how their caregivers respond to their needs. Stresses can have an immediate
impact on the infant�s development of trust and how others relate to them because of their diagnosis. The longterm
effects of hemophilia can include problems related to immobility. Altered growth and development could not have
developed in a newly diagnosed client. Hemarthrosis is acute bleeding into a joint space that is characteristic of
hemophilia. It does not have an immediate effect on the body image of a newly diagnosed hemophiliac.Health
Promotion and Maintenance
Question: 1442
Teaching about the need to avoid foods high in potassium is most important for which client?
A. a client receiving diuretic therapy
B. a client with an ileostomy
C. a client with metabolic alkalosis
D. a client with renal disease
Answer: D
Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. Choices 1, 2,
and 3 are incorrect because clients receiving diuretics with ileostomy or with metabolic alkalosis are at risk for
hypokalemia and should be encouraged to eat foods high in potassium.Physiological Adaptation
Question: 1443
What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36mmHg, and HCO3 24 mEq/L?
A. metabolic alkalosis
B. homeostasis
C. respiratory acidosis
D. respiratory alkalosis
Answer: B
These ABG values are within normal limits. Choices 1, 3, and 4 are incorrect because the ABG values indicate
none of these acid-base disturbances.Physiological Adaptation
Question: 1444
When administering intravenous electrolyte solution, the nurse should take which of the following precautions?
A. Infuse hypertonic solutions rapidly.
B. Mix no more than 80 mEq of potassium per liter of fluid.
C. Prevent infiltration of calcium, which causes tissue necrosis and sloughing.
D. As appropriate, reevaluate the client�s digitalis dosage. He might need an increased dosage because IV
calcium diminishes digitalis�s action.
Answer: C
Preventing tissue infiltration is important to avoid tissue necrosis. Choice 1 is incorrect because hypertonic
solutions should be infused cautiously and checked with the RN if there is a concern. Choice 2 is incorrect because
potassium, mixed in the pharmacy per physician order, is mixed at a concentration no higher than 60 mEq/L.
Physiological Adaptation
Question: 1445
Which of the following physical findings indicates that an 1112-month-old child is at risk for developmental
dysplasia of the hip?
A. refusal to walk
B. not pulling to a standing position
C. negative Trendelenburg sign
D. negative Ortolani sign
Answer: B
The nurse might be concerned about developmental dysplasia of the hip if an 1112-month-old child doesn�t pull to
a standing position. An infant who does not walk by 15 months of age should be evaluated. Children should start
walking between 1115 months of age. Trendelenberg sign is related to weakness of the gluteus medius muscle, not
hip dysplasia. Ortolani sign is used to identify congenital subluxation or dislocation of the hip in infants.Health
Promotion and Maintenance
Question: 1446
When obtaining a health history on a menopausal woman, which information should a nurse recognize as a
contraindication for hormone replacement therapy?
A. family history of stroke
B. ovaries removed before age 45
C. frequent hot flashes and/or night sweats
D. unexplained vaginal bleeding
Answer: D
Unexplained vaginal bleeding is a contraindication for hormone replacement therapy. Family history of stroke is
not a contraindication for hormone replacement therapy. If the woman herself had a history of stroke or other
blood-clotting events, hormone therapy could be contraindicated. Frequent hot flashes and/or night sweats can be
relieved by hormone replacement therapy.Health Promotion and Maintenance
Question: 1447
Which of the following statements, if made by the parents of a newborn, does not indicate a need for further
teaching about cord care?
A. "I should put alcohol on my baby�s cord 34 times a day."
B. "I should put the baby�s diaper on so that it covers the cord."
C. "I should call the physician if the cord becomes dark."
D. "I should wash my hands before and after I take care of the cord."
Answer: D
Parents should be taught to wash their hands before and after providing cord care. This prevents transferring
pathogens to and from the cord. Folding the diaper below the cord exposes the cord to air and allows for drying. It
also prevents wet or soiled diapers from coming into contact with the cord. Current recommendations include
cleaning the area around the cord 34 times a day with a cotton swab but do not include putting alcohol or other
antimicrobials on the cord. It is normal for the cord to turn dark as it dries.Health Promotion and Maintenance
Question: 1448
The nurse is teaching parents of a newborn about feeding their infant. Which of the following instructions should
the nurse include?
A. Use the defrost setting on microwave ovensto warm bottles.
B. When refrigerating formula, don�t feed the baby partially used bottles after 24 hours.
C. When using formula concentrate, mix two parts water and one part concentrate.
D. If a portion of one bottle is left for the next feeding, go ahead and add new formula to fill it.
Answer: A
Parents must be careful when warming bottles in a microwave oven because the milk can become superheated.
When a microwave oven is used, the defrost setting should be chosen, and the temperature of the formula should be
checked before giving it to the baby. Refrigerated, partially used bottles should be discarded after 4 hours because
the baby might have introduced some pathogens into the formula. Returning the bottle to the refrigerator does not
destroy pathogens. Formula concentrate and water are usually mixed in a 1:1 ratio of one part concentrate and
one part water. Infants should be offered fresh formula at each feeding. Partially used bottles should not have fresh
formula added to them. Pathogens can grow in partially used bottles of formula and be transferred to the new
formula.Health Promotion and Maintenance
Question: 1449
The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to
A. 6
B. 8
C. 12
D. 16
Answer: C
In general, children begin dentition around 6 months of age. During the first 2 years of life, a quick guide to the
number of teeth a child should have is as follows: Subtract the number 6 from the number of months in the age of
the child. In this example, the child is 18 months old, so the formula is 18 6 = 12. An 18-month-old child should
have approximately 12 teeth.Health Promotion and Maintenance
Question: 1450
A middle-aged woman tells the nurse that she has been experiencing irregular menses for the past six months. The
nurse should assess the woman for other symptoms of:
A. climacteric.
B. menopause.
C. perimenopause.
D. postmenopause.
Answer: C
Perimenopause refers to a period of time in which hormonal changes occur gradually, ovarian function diminishes,
and menses become irregular. Perimenopause lasts approximately five years.
Climacteric is a term applied to the period of life in which physiologic changes occur and result in cessation of a
woman�s reproductive ability and lessened sexual activity in males. The term applies to both genders. Climacteric
and menopause are interchangeable terms when used for females. Menopause is the period when permanent
cessation of menses has occurred. Postmenopause refers to the period after the changes accompanying menopause
are complete.Health Promotion and Maintenance

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