NCLEX-RN Exam Dumps - National Council Licensure Examination(NCLEX-RN)

(A) Consistent weight gain, even if it is slow, is an indication that the child is eating and digesting sufficient calories. (B) Recording how much the child eats is useful, but it is not an indicator of how well his body is using the foods consumed. (C) Counting calories will indicate how much he is eating, but it will not reflect whether or not the foods are properly digested. (D) Keeping track of the enzyme intake will indicate compliance with medication but not whether the child is getting sufficient calories.

(A) Dyspnea is a common complaint during the third trimester owing to the increasing size of the uterus and the resulting pressure against the diaphragm. (B) Edema of the face, hands, or pitting edema after 12 hours of bed rest may be indicative of preeclampsia and would be of great concern to the healthcare provider. (C) An increase in heart rate of 10–15 bpm is a normal physiological change in pregnancy due to the multiple hemodynamic changes. (D) A hematocrit value of 39% is within the normal range. A value <35% would indicate anemia.

(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 and plasma PCO2 increase; plasma HCO3 may decrease and then increase to compensate.

(A) The level of consciousness is not affected by elevated potassium levels. (B) An electrocardiogram (EKG) can tell the nurse whether this client is experiencing any cardiac dysfunction or arrhythmias related to the elevated potassium level. (C) Measurement of the urine output is not a priority nursing action at this time. (D) The client’s serum potassium values for the past several days may provide information about his renal function, but they are not a priority at this time.

(A) The nurse must assess the labor status to determine if birth is imminent. The nurse may note perineal bulging, crowning, or birth of the head to ascertain labor status. (B) Assessing uterine contractions is one intervention to ascertain labor status. Based on the client’s cry, it is not the intervention of choice. (C) If delivery of the infant is imminent, preparing a clean or sterile area for delivery is appropriate, but labor status must be established, whether delivery is imminent, by perineal assessment. (D) Assessing FHR is one intervention to ascertain fetal well-being. Based on the client’s cry, this is not the intervention of choice.

(A) Aspirin should never be given to children with influenza because of the possibility of causing Reye’s syndrome. Pepto- Bismol is also classified as a salicylate and should be avoided. (B) Depending on the severity of symptoms, the child may be receiving IV therapy or clear liquids. (C) The disease has a 1–3 day incubation period and affected children are most infectious 24 hours before and after the onset of symptoms. (D) Although viral pneumonia can be a complication of influenza, this would not be an initial priority.

(A) One will always hear what the most vocal person has to say. It is best to start with the quietest family member to encourage that person to express emotions. (B) All family members are encouraged to speak for themselves. (C) In the initial family assessment, only data collection occurs; interpretations are made later. (D) Allowing family members to choose their own seats will assist the nurse in assessing the family system and in determining who feels closer to whom.

(A) The mother and the father require support; the nurse should not minimize their grief in this situation. (B) Attachment to this infant occurs during the pregnancy for both the mother and father. Another child cannot replace this child. (C) Attachment to this infant occurs during the pregnancy for both the mother and father. Siblings will not replace their feelings or minimize their loss of this infant. (D) Holding and viewing the infant decreases denial and may facilitate the grief process. The nurse should prepare family members for how the infant appears (“she is bruised”) and provide support.