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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 361

A 24-year-old client presents to the emergency department protesting "I am God." The nurse identifies this as a:

Correct Answer: A
(A) Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion is the expression of intrapsychic conflict through sensory or motor manifestations.
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Question 362

A 52-year-old client's abdominal aortic aneurysm ruptured. She received rapid massive blood transfusions for bleeding. One potential complication of blood administration
for which she is especially at risk is:

Correct Answer: C
(A) Air embolism is a potential complication of blood administration, but it is fairly rare and can be prevented by using good IV technique. (B) Circulatory overload is a potential complication of blood administration, but because this client is actively bleeding, she is not at high risk for overload. (C) Hypocalcemia is a potential complication of blood administration that occurs in situations where massive transfusion has occurred over a short period of time. It occurs because the citrate in stored blood binds with the client's calcium. Another potential complication for which this client is especially at risk is hypothermia, which can be prevented by using a blood warmer to administer the blood. (D) Hypokalemia is not a complication of blood administration.
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Question 363

Which of the following menu choices would indicate that a client with pressure ulcers understands the role diet plays in restoring her albumin levels?

Correct Answer: A
Section: Questions Set B
Explanation:
(A) Broiled fish and rice are both excellent sources of protein. (B) Fresh fruits are not a good source of protein.
(C) Foods in the bread group are not high in protein. (D) Most vegetables are not high in protein; peas and beans are the major vegetables higher in protein.
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Question 364

At her monthly prenatal visit, a client reports experiencing heartburn. Which nursing measure should be included in her plan of care to help alleviate it?

Correct Answer: C
Section: Questions Set E
Explanation:
(A) At least eight glasses of fluid per day are encouraged to help dilute stomach contents, thereby decreasing irritation. (B) Alka Seltzer contains aspirin, which is irritating to gastric mucosa, and therefore should be avoided. (C) Small, frequent bland meals help to decrease gastric pressure and to prevent reflux. (D) Lying down after meals may cause gastric reflux and prevents optimal gastric emptying.
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Question 365

A client is dilated 8 cm and entering the transition phase of labor. Common behaviors of the laboring woman during transition are:

Correct Answer: A
(A) During the transition phase, the mother may become frustrated and unclear in her communication owing to severe pain and fear of loss of control. (B) These behaviors are common in the active phase of labor. (C) These behavioral clues are seen in the latent phase of labor. (D) These characteristics are observed in the latent phase of labor.
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