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  1. Home
  2. NCLEX Certification
  3. NCLEX-RN Exam
  4. NCLEX.NCLEX-RN.v2024-01-19.q623 Dumps
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Question 211

A pregnant client continues to visit the clinic regularly during her pregnancy. During one of her visits while lying supine on the examining table, she tells the RN that she is becoming light-headed. The RN notices that the client has pallor in her face and is perspiring profusely.
The first intervention the RN should initiate is to:

Correct Answer: D
Explanation
(A) This position would cause the gravid uterus to bear the increased pressure of the vena cava, which could lead to maternal hypotension, in turn causing the client to continue to have pallor and to feel light-headed. (B) This would not be the first intervention the RN should initiate. TheRN should understand the supine position and its effect on the gravid uterus and vena cava. (C) The RN's first intervention should be one that helps to alleviate the client's symptoms. Obtaining her vital signs will not alleviate her symptoms. (D) This would move the gravid uterus off of the client's vena cava, which would alleviate the maternal hypotension that is the cause of her symptoms.
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Question 212

Primary nursing diagnoses for the antisocial client are:

Correct Answer: B
Section: Questions Set D
Explanation:
(A) This answer is incorrect. Perception is not altered because the client is not psychotic. (B) This answer is correct. The antisocial client lacks responsibility, accountability, and social commitment; has impaired problem- solving ability; tends to overuse defense mechanisms; lies and steals; and is often grandiose concerning self.
(C) This answer is incorrect. Altered communication processes do not characterize this client. The antisocial person communicates well and tends to have a charming personality. (D) This answer is incorrect. Altered thought processes refer to delusional thinking, which is bizarre and fixed, and do not characterize this client.
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Question 213

A female client admitted to the labor and delivery unit thinks her bag of water "broke" approximately 2 hours ago. She is having mild contractions 5 minutes apart. The most immediate nursing intervention would be to:

Correct Answer: B
Explanation/Reference:
Explanation:
(A) Amniotic fluid is generally pale and straw colored. Meconium- stained amniotic fluid would indicate a previous hypoxic episode. This intervention, though appropriate, is not the immediate priority. (B) With rupture of the membranes, the umbilical cord may prolapse if the presenting part does not fill the pelvis.
Assessing FHR ascertains fetal well-being. (C) More information regarding fetal status and assessing for membrane rupture is needed prior to contacting the physician. (D) Nitrazine test paper differentiates amniotic fluid from urine. Amniotic fluid is normally alkaline in contrast to urine, which is acidic. This intervention, though appropriate, is not the immediate priority.
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Question 214

The physician of a client diagnosed with alcoholism orders neomycin 0.5 g q6h to prevent hepatic coma.
Neomycin decreases serum ammonia levels by:

Correct Answer: A
Explanation
(A) Neomycin interferes with protein synthesis in the bacterial cell, causing bacterial death. Neomycin reduces the growth of the ammonia-producing bacteria in the intestines and is used for the treatment of hepatic coma.
(B) This choice describes the action of lactulose, another drug commonly used to decrease systemic ammonia levels. (C) Neomycin's action doesnotdecrease uptake of vitamin D to reduce serum ammonia levels. (D) Bowel irritation with diarrhea is more likely to occur with administration of lactulose rather than of neomycin.
Besides, diarrhea is a side effect of a drug, not the action of the drug.
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Question 215

A burn victim's immunization history is assessed by the nurse. Which immunization is of priority concern?

Correct Answer: C
(A) Oral poliovirus vaccine is given to prevent polio. Polio is transmitted by direct contact with an infected person. (B) Inactivated poliovirus vaccine is given to adults and immunosuppressed individuals. Polio is transmitted by direct contact with an infected person. (C) Tetanus toxoid prevents tetanus. Tetanus is transmitted through contaminated wounds. (D) Hepatitis B vaccine prevents hepatitis B infection. Hepatitis B is transmitted through contact with infected blood or body fluids.
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