Practice Questions part 11 Answer and Rationales



NCLEX PRACTICE QUESTIONS PART 11 Answer and Rationales



[Questions No.101 to 150 ]



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📓Answer and Rationales For Practice Questions part 11 are Given Below read now 





101. Answer B is correct. 

Solid foods should be added to the diet one at a time, with intervals of 4–7 days between new foods. The extrusion reflex fades at 3–4 months of age; therefore, answer A is incorrect. Answer C is incorrect because solids should not be added to the bottle and the use of infant feeders is discouraged. Answer D is incorrect because the first food added to the infant’s diet is rice cereal. 

102. Answer D is correct. 
At 32 weeks gestation the fetus can be expected to be active. Answers A, B, and C are not typical findings during the Leopold maneuver of a client who is 32 weeks gestation; therefore, they are incorrect.





103. Answer A is correct. 

The client needs to avoid using sweeteners containing aspartame. Answers B, C, and D indicate that the client understands the nurse’s teaching; therefore, they are incorrect.

104. Answer A is correct. 
The treatment of galactosemia consists of eliminating all milk and lactose-containing foods, including breast milk. Answers B and D contain inaccurate information; therefore, they are incorrect. Galactosemia is inherited as an autosomal recessive disorder. There is a one-in-four chance that future children will be affected; therefore, answer C is incorrect.

105. Answer B is correct. 
The child with Tay Sachs disease has cherry-red spots on the macula of the eye. Answer A is incorrect because it is associated with anemia. Answer C is incorrect because it is associated with osteogenesis imperfecta. Answer D is incorrect because it is associated with Down syndrome. 



106. Answer C is correct.
 The client’s symptoms suggest an adverse reaction to the medication known as neuroleptic malignant syndrome. Answers A, B, and D are not appropriate interventions for the client; therefore, they are incorrect. 



107. Answer D is correct. 
The client with HIV should adhere to a low-bacteria diet by avoiding raw fruits and vegetables. Answers A, B, and C are incorrect because they are permitted in the client’s diets 



108. Answer C is correct. 
The child with leukemia has low platelet counts, which contribute to spontaneous bleeding. Answers A, B, and D, common in the child with leukemia, are not life-threatening. 
109. Answer A is correct. 
The nurse should prevent the infant with atopic dermatitis (eczema) from scratching, which can lead to skin infections. Answer B is incorrect because fever is not associated with atopic dermatitis. Answers C and D are incorrect because they increase dryness of the skin, which worsens the symptoms of atopic dermatitis. 



110. Answer B is correct. Pavulon is a neuromuscular blocking agent that paralyzes skeletal muscles, making it impossible for the client to fight the ventilator. Sublimaze is an analgesic used to control operative pain; therefore, answer A is incorrect. Versed is a benzodiazepine used to produce conscious sedation; therefore, answer C is incorrect. Answer D is wrong because Atarax is used to treat post-operative nausea. 


111. Answer D is correct. Symptoms associated with diverticulitis are usually reported after eating foods like popcorn, celery, raw vegetables, whole grains, and nuts. Answers A, B, and C are incorrect because they are allowed in the diet of the client with diverticulitis. 


112. Answer A is correct. 
The client with Paget’s disease has problems with mobility. Keeping the environment free of clutter will help prevent falls. Answers B, C, and D will improve the client’s overall health but are not specific to Paget’s disease; therefore, they are incorrect. 


113. Answer B is correct. 
The Whipple procedure is performed for cancer located in the head of the pancreas. Answers A, C, and D are not correct because of the location of the cancer. 


114. Answer C is correct. 
Side effects of Pulmozyme include sore throat, hoarseness, and laryngitis. Answers A, B, and D are not associated with Pulmozyme; therefore, they are incorrect. 


115. Answer B is correct. Retained placental fragments are the major cause of late postpartal hemorrhage. Uterine atony is the major cause of early postpartal hemorrhage; therefore, answer A is incorrect. Answers C and D result in slow, steady bleeding; therefore, they are incorrect. 



116. Answer A is correct. 
The nurse has a legal responsibility to report suspected abuse and neglect. The nurse does not have the authority to remove the children from the home; therefore, answers B and C are incorrect. Answer D is incorrect because it is unrealistic. 
117. Answer A is correct. Providing a caring attitude and supportive environment will make the client feel safe. Answer B is incorrect because the client needs to feel free to express anger. Answer C is incorrect because it will increase the client’s anxiety. Answer D is incorrect because it is not the most important aspect of care for the client with PTSD. 



118. Answer B is correct. 
The nurse should be concerned with alleviating the client’s pain. Answers A, C, and D are not primary objectives in the care of the client receiving an opiate analgesic; therefore, they are incorrect.



119. Answer D is correct. 
The therapeutic range for aminophylline is 10–20 micrograms/mL. Levels greater than 20 micrograms/mL can produce signs of toxicity. Answer A is incorrect because it is too low to be therapeutic. Answers B and C are within the therapeutic range; therefore, they are incorrect. 



120. Answer C is correct. Changes in breath sounds are the best indication of the need for suctioning in the client with ineffective airway clearance. Answers A, B, and D are incorrect because they can be altered by other conditions. 








121. Answer D is correct.
An adverse reaction to Myambutol is changes in visual acuity or color vision. Answer A is incorrect because it does not relate to the medication. Answer B is incorrect because it is an adverse reaction to Streptomycin. Answer C is incorrect because it is a side effect of Rifampin.


122. Answer D is correct. Insufficient erythropoietin production is the primary cause of anemia in the client with chronic renal failure. Answers A, B, and C do not relate to the anemia seen in clients with chronic renal failure; therefore, they are incorrect. 


123. Answer B is correct. 
The nurse’s highest priority should be asking the client about allergies to shellfish and iodine. The contrast media used during an intravenous pyelogram contains iodine, which can result in an anaphylactic reaction. Answers A, C, and D do not relate specifically to the test; therefore, they are incorrect. 




124. Answer A is correct. 
Ataxia affects the client’s mobility, making falls more likely. Answers B, C, and D are incorrect because they do not relate to the problem of ataxia. 





125. Answer D is correct. Aspirin decreases platelet aggregation or clumping, thereby preventing clots. Answer A is incorrect because the low-dose aspirin will not prevent headaches. Answers B and C are untrue statements; therefore, they are incorrect. 




126. Answer B is correct. Insulin molecules adhere to glass and plastic; therefore, the IV set and entire tubing should be flushed and 50mL discarded before administering the infusion to the client. Answers A and D are incorrect because insulin is mixed using 0.9% or 0.45% normal saline. Answer C is incorrect because the infusion is given using a pump or controller. 





127. Answer A is correct. 
A serologic marker of HB8 AG that is present 6 months after acute infection with hepatitis B indicates that the client is a carrier or has chronic hepatitis. Answer B is incorrect because the HB8 AG would normally decline and disappear. Answer C is incorrect because the client can still be infected with hepatitis C. Answer D is incorrect because the client is a carrier. 





128. Answer C is correct. 
The usual course of treatment using combined therapy with isoniazid and rifampin is 6 months. Answers A and D are incorrect because the treatment time is too brief. Answer B is incorrect because the medication is not needed for life. 




129. Answer D is correct. 
At 4 months of age, the infant can roll over, which makes it vulnerable to falls from dressing tables or beds without rails. Answer A is incorrect because it does not prove a threat to safety. Answers B and C are incorrect choices because the 4-month-old is not capable of crawling or standing.







130. Answer B is correct. Rhinitis, maculopapular rash, and hepatosplenomegaly are associated with congenital syphilis. Answer A is incorrect because it describes symptoms of scarlet fever. Answer C is incorrect because it describes symptoms of Fifth’s disease. Answer D is incorrect because it describes the symptoms of Down syndrome. 




132. Answer B is correct. 
The client with irritable bowel syndrome has bouts of constipation and diarrhea. Answer A is incorrect because it describes changes associated with diverticulosis. Answer C is incorrect because it describes changes associated with Crohn’s disease. Answer D is incorrect because it describes findings associated with ulcerative colitis. 



131. Answer C is correct. 
It is recommended that infants up to 20 pounds be restrained in a car seat in a semireclining position facing the rear of the car. Answers A and B are incorrect because the child is young enough to require the rear-facing position. Answer D is incorrect because the child can be placed in an upright position in an approved safety seat facing forward. 








133. Answer C is correct. Adverse side effects of Dilantin include agranulocytosis and aplastic anemia; therefore, the client will need regularly scheduled blood work. Answer A is incorrect because the medication does not cause dental staining. Answer B is incorrect because the medication does not interfere with the metabolism of carbohydrates. Answer D is incorrect because the medication does not cause drowsiness. 



134. Answer A is correct. The infant with hypospadias should not be circumcised because the foreskin is used in reconstruction. Answers B and C are incorrect because surgical correction is done when the infant is 16 to 18 months of age. Answer D is incorrect because the infant with hypospadias should not be circumcised. 






135. Answer C is correct. Coconut oil is high in saturated fat and is not appropriate for the client on a low-cholesterol diet. Answers A, B, and D are incorrect because they are suggested for the client with elevated cholesterol levels. 







136. Answer D is correct. Increased blood pressure following a renal transplant is an early sign of transplant failure. Answers A, B, and C are expected with successful renal transplant; therefore, they are incorrect. 







137. Answer D is correct. The time it takes for alcohol to be fully metabolized is calculated by dividing the blood alcohol level on admission by 20mg/dL (amount metabolized in an hour). Answers A, B, and C are incorrect because there has not been sufficient time for the alcohol to be fully metabolized. 







138. Answer B is correct. 
In stage III of Alzheimer’s disease, the client develops agnosia, or failure to recognize familiar objects. Answer A is incorrect because it appears in stage I. Answer C is incorrect because it appears in stage II. Answer D is incorrect because it appears in stage IV. 






139. Answer D is correct. The client taking steroid medication should receive an annual influenza vaccine. Answer A is incorrect because the medication should be taken with food. Answer B is incorrect because increased appetite and weight gain are expected side effects of the medication. Answer C is incorrect because wearing sunglasses will not prevent the development of cataracts in the client taking steroids.






140. Answer A is correct. The client with an above-the-knee amputation should be placed in a prone position 15–30 minutes twice a day to prevent contractures. Answers B and D are incorrect choices because elevation of the extremity one day post amputation promotes the development of contractures. Use of a trochanter roll will prevent rotation of the extremity but will not prevent contracture; therefore, answer C is incorrect. 







141. Answer D is correct. All 20 primary, or deciduous, teeth should be present by age 30 months. Answers A, B, and C are incorrect because the ages are wrong. 




142. Answer B is correct. Displacement of the esophageal balloon is the most likely cause of respiratory distress in the client with an esophageal tamponade. The nurse should deflate both the gastric and esophageal balloons before removing the tube. Answers A and C are incorrect because applying nasal oxygen and elevating the head will not relieve airway obstruction. Answer D is incorrect because it would cause further obstruction of the airway. 




143. Answer D is correct. The mitral valve is heard loudest at the fourth intercostal space midclavicular line, which is the apex of the heart. Answer A is incorrect because it is the location for the aortic valve. Answer B is incorrect because it is the location for the pulmonic valve. Answer C is wrong because it is the location for the tricuspid valve. 



144. Answer C is correct. The radioactive implant should be picked up with tongs and returned to the lead-lined container. Answer A is incorrect because radioactive materials are placed in lead-lined containers, not plastic ones, and they are returned to the radiation department, not the lab. Answer B is incorrect because the client should not touch the implant or try to reinsert it. Answer D is incorrect because the implant should not be placed in the commode for disposal. 



145. Answer A is correct. Following a laparoscopic cholecystectomy, the client should avoid a tub bath for 48 hours. Answer B is incorrect because the stools should not be clay colored. Answer C is incorrect because pain is usually located in the shoulders. Answer D is incorrect because pain in the back and shoulders is expected following laparoscopic surgery. 




146. Answer B is correct. The client recovering from mononeucleosis should avoid contact sports and other activities that could result in injury or rupture of the spleen. Answer A is incorrect because the client does not need additional fluids. Hypoglycemia is not associated with mononucleosis; therefore, answer C is incorrect. Answer D is incorrect because antibiotics are not usually indicated in the treatment of mononeucleosis. 



147. Answer B is correct. Pancreatic enzyme replacement is given with meals and snacks. Answers A, C, and D do not specify a relationship to meals; therefore, they are incorrect. 



148. Answer A is correct. Meat, eggs, and dairy products are good sources of vitamin B12. Answer B is incorrect because peanut butter, raisins, and molasses are good sources of iron. Answer C is incorrect because broccoli, cauliflower, and cabbage are good sources of vitamin K. Answer D is incorrect because shrimp, legumes, and bran cereals are good sources of magnesium.



149. Answer A is correct. The client’s aerobic workout should be 20–30 minutes long three times a week. Answers B, C, and D exceed the recommended time for the client beginning an aerobic program; therefore, they are incorrect. 



150. Answer B is correct. Demadex is a loop diuretic that depletes potassium. Answers A, C, and D are incorrect because they are potassium-sparing diuretic



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