NCLEX-RN Practice 75 Questions Part 2
NCLEX-RN Practice 75 Questions Part 2
- 1.
The nurse supervises care given to a group of patients on the unit. The nurse observes a staff member entering a patient's room wearing gown and gloves. The nurse knows that the staff member is caring for which of the following patients?
- A.
An 18-month-old with respiratory syncytial virus.
- B.
A 4-year-old with Kawasaki disease.
- C.
A 10-year-old with Lyme disease.
- D.
A 16-year-old with infectious mononucleosis.
Correct Answer
A. An 18-month-old with respiratory syncytial virus.Explanation
Strategy: Think about each answer.
(1) correct—acute viral infection; requires contact precautions; assign to private room or with other RSV-infected children
(2) acute systemic vasculitis in children under 5; standard precautions
(3) connective tissue disease; standard precautions
(4) standard precautionsRate this question:
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- 2.
The nurse assesses a client diagnosed with a spinal cord injury. Which of the following assessment findings by the nurse suggests the complication of autonomic dysreflexia? Select all that apply.
- A.
Urinary bladder spasm pain.
- B.
Severe pounding headache.
- C.
Profuse sweating.
- D.
Tachycardia.
- E.
Severe hypotension.
- F.
Nasal congestion.
Correct Answer(s)
B. Severe pounding headache.
C. Profuse sweating.
F. Nasal congestion.Explanation
Strategy: Think about each answer.
(1) may be the cause of autonomic dysreflexia due to overfilling of the bladder, but pain is not perceived
(2) correct—severe headache results from rapid onset of hypertension
(3) correct—especially of forehead
(4) pulse will slow
(5) BP will increase
(6) correct—also causes piloerection (goose flesh)Rate this question:
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- 3.
An adolescent is scheduled for a below-knee (BK) amputation following a motorcycle accident. The nurse knows preoperative teaching for this client should include which of the following?
- A.
Explain that the client will walk with a prosthesis soon after surgery.
- B.
Encourage the client to share feelings and fears about the surgery.
- C.
Take the informed consent form to the client and ask the client to sign it.
- D.
Evaluate how the client plans to complete schoolwork during hospitalization.
Correct Answer
B. Encourage the client to share feelings and fears about the surgery.Explanation
Strategy: Remember therapeutic communication.
(1) fails to recognize his immediate concerns
(2) correct—discussing his feelings and fears is important in dealing with his anxiety due to a change in body image and functioning
(3) client is underage; parents will need to sign the permit
(4) is more appropriate for the postoperative period of time than for the preoperative periodRate this question:
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- 4.
A client at 16 weeks’ gestation undergoes an amniocentesis. The client asks the nurse what the physician will learn from this procedure. The nurse's response should be based on an understanding that which of the following conditions can be detected by an amniocentesis?
- A.
Tetralogy of Fallot.
- B.
Talipes equinovarus.
- C.
Hemolytic disease of the newborn.
- D.
Cleft lip and palate.
Correct Answer
C. Hemolytic disease of the newborn.Explanation
Strategy: Think about each answer.
(1) cardiac abnormality detected at birth; pulmonary stenosis, ventricular septal defect, overriding aorta, hypertrophy of right ventricle
(2) congenital deformity detected at birth; foot twisted out of normal position, clubfoot
(3) correct—maternal antibodies destroy fetal RBCs; bilirubin secreted because of hemolysis
(4) congenital deformity detected at birth, midline fissure or opening into lip or palateRate this question:
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- 5.
The nurse evaluates the nutritional intake of an adolescent girl attending camp. The adolescent eats all of the food provided to her at the camp cafeteria. Each of the day's three meals contains foods from all areas of the food pyramid, and each meal averages about 900 calories and 3 mg of iron. The girl has been menstruating monthly for about two years. Which of the following descriptions, if made by the nurse, BEST describes the girl's intake if her weight is appropriate for her height?
- A.
Her diet is low in calories and high in iron.
- B.
Her diet is low in calories and low in iron.
- C.
Her diet is high in calories and low in iron.
- D.
Her diet is high in calories and high in iron.
Correct Answer
C. Her diet is high in calories and low in iron.Explanation
Strategy: Think about each answer.
(1) only 1,200 to 1,500 kcal/day required, and 15 mg/day of iron
(2) only 1,200 to 1,500 kcal/day required
(3) correct–900 × 3 = 2,700 calories/day and women need 1,200 to 1,500 kcal/day (men need 1,500 to 1,800 kcal/day); 3 mg × 3 = 9 mg/day of iron and women need 15 mg/day of iron (men need 10 mg/day); with pregnancy 30 mg/day required
(4) 18 mg/day of iron requiredRate this question:
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- 6.
A client returns from surgery with a fine, reddened rash noted around the area where Betadine prep had been applied prior to surgery. Nursing documentation in the client’s chart should include which of the following?
- A.
Time and circumstances under which the rash was noted.
- B.
Explanation given to the client and family of the reason for the rash.
- C.
Notation on an allergy list and notification of the doctor.
- D.
The need for application of corticosteroid cream to decrease inflammation.
Correct Answer
C. Notation on an allergy list and notification of the doctor.Explanation
Strategy: Answers are implementation. Determine the outcome of each answer. Is it desired?
(1) would be noted, but is not as high a priority
(2) inappropriate
(3) correct—suspected reaction to drugs should be reported to the doctor and noted on list of possible allergies
(4) inappropriateRate this question:
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- 7.
A client receives a blood transfusion and experiences a hemolytic reaction. The nurse anticipates which of the following assessment findings?
- A.
Hypotension, backache, low back pain, fever.
- B.
Wet breath sounds, severe shortness of breath.
- C.
Chills and fever occurring about an hour after the infusion started.
- D.
Urticaria, itching, respiratory distress.
Correct Answer
A. Hypotension, backache, low back pain, fever.Explanation
Strategy: Think about each answer.
(1) correct—signs and symptoms of a hemolytic reaction include chills, headache, backache, dyspnea
(2) describes symptoms of circulatory overload
(3) describes a febrile or pyrogenic reaction
(4) describes an allergic reactionRate this question:
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- 8.
The nurse develops a comprehensive care plan for a young woman diagnosed with anorexia nervosa. The nurse refers the client to assertiveness skills classes. The nurse knows that this is an appropriate intervention because this client may have problems with which of the following?
- A.
Aggressive behaviors and angry feelings.
- B.
Self-identity and self-esteem.
- C.
Focusing on reality.
- D.
Family boundary intrusions.
Correct Answer
B. Self-identity and self-esteem.Explanation
Strategy: Think about each answer.
(1) these clients do have problems with feelings of anger; family therapy sessions can be helpful in identifying some of these feelings and difficulties with family boundaries
(2) correct—clients with eating disorders experience difficulty with self-identity and self-esteem, which inhibits their abilities to act assertively; some assertiveness techniques that are taught include giving and receiving criticism, giving and accepting compliments, accepting apologies, being able to say no, and setting limits on what they can realistically do rather than just doing what others want them to do
(3) do not have problems with reality
(4) these clients do have problems with family boundary intrusion; family therapy sessions can be helpful in identifying some of these feelings and difficulties with family boundariesRate this question:
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- 9.
Under the supervision of the registered nurse, a student nurse changes the dressing of a client with a newly inserted peritoneal dialysis catheter. Which of the following activities, if performed by the student nurse after removal of the old dressing, requires an intervention by the registered nurse?
- A.
The student nurse cleans the catheter insertion site using a sterile cotton swab soaked in povidone-iodine.
- B.
The student nurse applies two sterile precut 4 × 4s to the catheter insertion site.
- C.
The student nurse cleans the insertion site using a circular motion from the outer abdomen toward the insertion site.
- D.
The student nurse securely tapes the edges of the sterile dressing with paper tape.
Correct Answer
C. The student nurse cleans the insertion site using a circular motion from the outer abdomen toward the insertion site.Explanation
Strategy: "Requires an intervention" indicates incorrect behavior. All answers are implementations. Determine outcome of each answer. Is it desired?
(1) appropriate procedure
(2) appropriate procedure
(3) correct—should clean from insertion site outward toward outer abdomen
(4) appropriate procedureRate this question:
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- 10.
The home care nurse performs an assessment of a client diagnosed with pneumonia secondary to chronic pulmonary disease. Which of the following nursing goals is MOST appropriate?
- A.
Maintain and improve the quality of oxygenation.
- B.
Improve the status of ventilation.
- C.
Increase oxygenation of peripheral circulation.
- D.
Correct the bicarbonate deficit.
Correct Answer
B. Improve the status of ventilation.Explanation
Strategy: Determine the outcome of each answer.
(1) primary problem is not level of oxygenation, but the level of carbon dioxide contributing to an acidotic state
(2) correct—to improve the quality of ventilation refers to levels of carbon dioxide and oxygen
(3) not appropriate for the situation
(4) not appropriate for the situationRate this question:
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- 11.
A client comes to the clinic for the results of a glycosylated hemoglobin (HbA1c). Which statement, if made by the client to the nurse, indicates an understanding of the procedure?
- A.
"This test is performed by sticking my finger and measuring the results."
- B.
"This test needs to be performed in the morning before I eat breakfast."
- C.
"This test indicates how well my blood sugar has been controlled the past 6 to 8 weeks."
- D.
"I must follow my diet carefully for several days before the test."
Correct Answer
C. "This test indicates how well my blood sugar has been controlled the past 6 to 8 weeks."Explanation
Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?
(1) 3 to 5 ml of blood is needed
(2) timing of test is not important
(3) correct—when RBCs are being formed, sugar is attached (glycosylated) and remains attached throughout the life of the RBC; normal 2.5 to 6%
(4) current blood sugar doesn't affect testRate this question:
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- 12.
The nurse recognizes which of these symptoms as characteristic of a panic attack?
- A.
Palpitations, decreased perceptual field, diaphoresis, fear of going crazy.
- B.
Decreased blood pressure, chest pain, choking feeling.
- C.
Increased blood pressure, bradycardia, shortness of breath.
- D.
Increased respiratory rate, increased perceptual field, increased concentration ability.
Correct Answer
A. Palpitations, decreased perceptual field, diaphoresis, fear of going crazy.Explanation
Strategy: Think about each answer.
(1) correct—panic disorders are characterized by recurrent, unpredictable attacks of intense apprehension or terror that can render a client unable to control a situation or to perform simple tasks; client can experience palpitations, chest pain, shortness of breath, a decrease in perceptual field, and a fear of "losing it" or going crazy
(2) not accurate because typically the client has increased blood pressure related to stimulation of the sympathetic nervous system
(3) heart rate would be increased due to stimulation of the sympathetic nervous system
(4) client's perceptual field is decreased during a panic attack; client becomes less aware of his/her surroundings, and his/her performance is inhibitedRate this question:
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- 13.
The clinic physician diagnoses Graves’ disease for a client. The nurse expects the client to exhibit which of the following symptoms?
- A.
Lethargy in the early morning.
- B.
Sensitivity to cold.
- C.
Weight loss of 10 lb in 3 weeks.
- D.
Reduced deep tendon reflexes.
Correct Answer
C. Weight loss of 10 lb in 3 weeks.Explanation
Strategy: Think about the indications of an increased metabolic rate.
(1) will be restless
(2) will have heat intolerance due to increased metabolic rate
(3) correct—increased metabolic rate causes weight loss even with increased appetite
(4) reflexes will be hyperactiveRate this question:
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- 14.
During an initial interview at an outpatient clinic, a 34-year-old single mother tells the nurse that she has always had difficulty forming relationships and is worried that her 7-year-old daughter will have the same problem. Which of the following statements, if made by the nurse, is BEST?
- A.
"Children develop trust from birth to 18 months of age."
- B.
"Children develop trust from 18 months to three years of age."
- C.
"Children develop trust from three to six years of age."
- D.
"Children develop trust from six to twelve years of age."
Correct Answer
A. "Children develop trust from birth to 18 months of age."Explanation
Strategy: "BEST" indicates discrimination is required. Topic of question is unstated. Read answer choices to determine topic.
(1) correct—Erikson states that trust results from interaction with dependable, predictable primary caretaker
(2) toddler stage concerns autonomy verses shame and doubt
(3) preschool state concerns initiative versus guilt
(4) latency or school age stage concerns industry versus inferiorityRate this question:
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- 15.
The nurse recognizes which of the following nursing interventions is MOST important when caring for a client just placed in physical restraints?
- A.
Prepare PRN dose of psychotropic medication.
- B.
Check that the restraints have been applied correctly.
- C.
Review hospital policy regarding duration of restraints.
- D.
Monitor the client's needs for hydration and nutrition while restrained.
Correct Answer
B. Check that the restraints have been applied correctly.Explanation
Strategy: Answers are a mix of assessment and implementation. Is this a situation that requires assessment? Yes. Is there an appropriate assessment? Yes.
(1) implementation; inappropriate for the client in restraints
(2) correct—assessment; while a client is restrained, physiological integrity is important; monitoring positioning, tightness, and peripheral circulation is essential; nurse documents the client's response and clinical status after being restrained
(3) implementation; all staff members involved in a restraint event must be aware of hospital policy before using restraints
(4) assessment; important to attend to client's nutrition and hydration after the client is safely restrainedRate this question:
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- 16.
The geriatric residents of a long-term care facility participate in a reminiscing group. The nurse identifies which of the following as the primary goal of this type of group activity?
- A.
Provides psychosocial educational opportunities for stress and coping.
- B.
Provides an avenue for physical exercise.
- C.
Provides an environment for social interaction and companionship.
- D.
Reorients and provides a reality test for confused clients.
Correct Answer
C. Provides an environment for social interaction and companionship.Explanation
Strategy: Think about each answer.
(1) is not primary goal of a reminiscing group
(2) is not primary goal of a reminiscing group
(3) correct—primary goal of a reminiscing group for geriatric clients is to review and share their life experiences with the group members
(4) groups that facilitate orientation to time, person, place, and current events are called reality orientation groupsRate this question:
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- 17.
The nurse is aware that which of the following assessments indicates hypocalcemia?
- A.
Constipation.
- B.
Depressed reflexes.
- C.
Decreased muscle strength.
- D.
Positive Trousseau's sign.
Correct Answer
D. Positive Trousseau's sign.Explanation
Strategy: Think about the cause of each answer.
(1) symptom associated with hypercalcemia
(2) symptom associated with hypercalcemia
(3) symptom associated with hypercalcemia
(4) correct—positive Trousseau's sign is indicative of neuromuscular hyperreflexia associated with hypocalcemiaRate this question:
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- 18.
When obtaining a specimen from a client for sputum culture and sensitivity (C and S), the nurse identifies which of the following instructions is BEST?
- A.
After pursed lip breathing, cough into a container.
- B.
Upon awakening, cough deeply and expectorate into a container.
- C.
Save all sputum for three days in a covered container.
- D.
After respiratory treatment, expectorate into a container.
Correct Answer
B. Upon awakening, cough deeply and expectorate into a container.Explanation
Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?
(1) coughing into a container is indicated, but not pursed-lip breathing
(2) correct—specimens should be obtained in the early morning because secretions develop during the night
(3) appropriate for acid-fast stain for TB
(4) earliest specimen is most desirableRate this question:
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- 19.
A patient has a Levin tube connected to intermittent low suction. At 7 A.M., the nurse charts that there is 235 ml of greenish drainage in the suction container. At 3 P.M., the nurse notes that there is 445 ml of greenish drainage in the suction container. Twice during the shift, the nurse irrigates the Levin tube with 30 ml of normal saline, as ordered by the physician. What is the actual amount of drainage from the nasogastric tube for the 7 to 3 shift?
- A.
150 ml.
- B.
210 ml.
- C.
295 ml.
- D.
385 ml.
Correct Answer
A. 150 ml.Explanation
Strategy: Think about each answer.
(1) correct–445 − 235 = 210 − 60 = 150
(2) does not subtract 60 ml of fluid used to irrigate Levin tube
(3) does not take into account solution added to container during day shift; does not subtract for fluids used to irrigate Levin tube
(4) does not subtract 235 ml that was in container from night shiftRate this question:
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- 20.
The nurse cares for a patient during a radium implant. During the removal of the implant, it is MOST important for the nurse to take which of the following actions?
- A.
Clean the radium implant carefully with a disinfectant (alcohol or bleach) using long forceps.
- B.
Handle the radium carefully using forceps and rubber latex gloves.
- C.
Chart the date and time of removal together with the total time of implant treatment.
- D.
Double-bag the radium implant before the person from radiology removes it from the room.
Correct Answer
C. Chart the date and time of removal together with the total time of implant treatment.Explanation
Strategy: Answers are all implementation. Determine the outcome of each answer. Is it desired?
(1) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant
(2) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant
(3) correct—important that accurate documentation be maintained on the internal radium implant
(4) at no time should the nurse or client handle the radium; radiology department is responsible for handling implantRate this question:
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- 21.
The physician prescribes lithium carbonate (Lithobid) 300 mg PO QID for an adult client. The nurse in the outpatient clinic instructs the client about the medication. The nurse should encourage the client to maintain an adequate intake of which of the following?
- A.
Sodium.
- B.
Protein.
- C.
Potassium.
- D.
Iron.
Correct Answer
A. Sodium.Explanation
Strategy: Think about each answer.
(1) correct—alkali metal salt acts like sodium ions in the body; excretion of lithium depends on normal sodium levels; sodium reduction causes marked lithium retention, leading to toxicity
(2) doesn't interact with lithium
(3) doesn't interact with lithium
(4) doesn't interact with lithiumRate this question:
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- 22.
A college student comes to the college health services complaining of a severe headache, nausea, and photophobia. The physician orders a complete blood count (CBC) and a lumber puncture (LP). Which of the following lab results would the nurse expect if a diagnosis of bacterial meningitis is made?
- A.
Cerebrospinal fluid (CSF) cloudy, Hgb 13 g/dL, HCT 38%, WBC 18,000/mm3.
- B.
CSF with RBCs present, Hgb 10 g/dL, HCT 37%, WBC 8,000/mm3.
- C.
CSF cloudy, Hgb 12 g/dL, HCT 37%, WBC 7,000/mm3.
- D.
CSF clear, Hgb 15 g/dL, HCT 40%, WBC 11,000/mm3.
Correct Answer
A. Cerebrospinal fluid (CSF) cloudy, Hgb 13 g/dL, HCT 38%, WBC 18,000/mm3.Explanation
(1) correct—CSF normally clear, colorless; normal WBC 5,000 to 10,000 per mm3, normal Hgb (male 13.5 to 17.5 g/dL, female 12 to 16 g/dL), normal HCT (male 41 to 53%, female 36 to 46%)
(2) indicates trauma or hemorrhage
(3) WBC too low, not typical of bacterial meningitis
(4) indicates viral meningitisRate this question:
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- 23.
A Miller-Abbott tube is ordered for a client. The nurse knows that the main reason this tube is inserted is because of which of the following?
- A.
Provides an avenue for nutrients to flow past an obstructed area.
- B.
Prevents fluid and gas accumulation in the stomach.
- C.
Administers drugs that can be absorbed directly from the intestinal mucosa.
- D.
Removes fluid and gas from the small intestine.
Correct Answer
D. Removes fluid and gas from the small intestine.Explanation
Strategy: Think about each answer.
(1) tube would be placed in an area of reduced peristalsis and would slowly work past an obstruction
(2) describes a tube such as a Levin or Salem Sump, which decompresses the stomach
(3) tube provides for decompression instead of instillation of medications
(4) correct—Miller-Abbott tube provides for intestinal decompression; intestinal tube is often used for treatment of paralytic ileusRate this question:
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- 24.
The nurse prepares discharge teaching for the parents of a newborn. Which of the following information should the nurse provide to the parents regarding the accuracy of a PKU (phenylketonuria) test?
- A.
The initial specimen should be collected as close to discharge as possible but not after 7 days.
- B.
The infant can have water but should not have formula for 6 hours before the test.
- C.
The test will need to be repeated at 6 weeks and at the 3-month check-up.
- D.
Blood will be drawn at three 1-hour intervals; there is no specific preparation.
Correct Answer
A. The initial specimen should be collected as close to discharge as possible but not after 7 days.Explanation
Strategy: Think about each answer.
(1) correct—if initial specimen is collected before newborn is 24 hours old, a repeat test should be performed by 2 weeks of age
(2) no restriction on formula intake
(3) test may be repeated within 2 weeks to ensure accuracy
(4) only one blood sample is neededRate this question:
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- 25.
Promethazine hydrochloride (Phenergan) 25 mg IV push is ordered for a patient. Prior to administering this medication to the patient, the nurse should check which of the following?
- A.
The color of the medication solution.
- B.
The patient’s pulse and temperature.
- C.
The time of the last analgesic dose the patient received.
- D.
The patency of the patient’s vein.
Correct Answer
D. The patency of the patient’s vein.Explanation
Strategy: Determine how each assessment relates to the medication.
(1) is true, but not as high a priority as answer choice (4)
(2) no relevance to the question asked
(3) Phenergan is used as an adjunct to analgesics but has no analgesic activity itself
(4) correct—is very important to determine absolute patency of the vein; extravasation will cause necrosisRate this question:
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- 26.
The nurse reviews procedures with the health care team. The nurse should intervene if an RN staff member makes which of the following statements?
- A.
"It is my responsibility to ensure that the consent form has been signed and is attached to the patient’s chart."
- B.
"It is my responsibility to witness the signature of the patient before surgery is performed."
- C.
"It is my responsibility to explain the surgery and ask the patient to sign the consent form."
- D.
"It is my responsibility to answer questions that the patient may have before surgery."
Correct Answer
C. "It is my responsibility to explain the surgery and ask the patient to sign the consent form."Explanation
Strategy: "Nurse should intervene" indicates that you should look for an incorrect statement. Question is unstated. Read answer choices for clues.
(1) describes the nurse's responsibility in obtaining consent
(2) signature indicates that the nurse saw the patient sign the form
(3) correct—physician should provide explanation and obtain patient's signature
(4) the nurse should answer questions after the physician has obtained consentRate this question:
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- 27.
A middle-aged woman is brought to the emergency department after being raped in her home. The client asks the nurse to call her husband to come to the emergency department. The nurse knows that the most common reaction of significant others to a rape victim is reflected in which of the following statements?
- A.
Supportive and helpful to the victim.
- B.
Disconnected from and apathetic toward the victim.
- C.
Frustrated and feeling vulnerable, but denying need for help.
- D.
Emotionally distressed and needing assistance.
Correct Answer
D. Emotionally distressed and needing assistance.Explanation
Strategy: Think about each answer.
(1) significant others may want to be helpful; however, they generally do not have the immediate coping strategies to do so
(2) rarely feel disconnected
(3) usually family members will need and respond well to psychological intervention
(4) correct—sexual assault by rape is a crisis situation for victim and family members and friendsRate this question:
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- 28.
A clinic nurse obtains a health history from a client newly diagnosed with Buerger’s disease. The nurse expects the client’s complaints to include which of the following?
- A.
Heart palpitations.
- B.
Dizziness when walking.
- C.
Blurred vision.
- D.
Digital sensitivity to cold.
Correct Answer
D. Digital sensitivity to cold.Explanation
Strategy: Determine the cause of each sympton and how it relates to Buerger's disease.
(1) no cardiac involvement
(2) dizziness not seen; intermittent claudication (pain with exercise) seen
(3) optic nerve not affected
(4) correct—vasculitis of blood vessels in upper and lower extremitiesRate this question:
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- 29.
Which of the following is the BEST method for the nurse to use when evaluating the effectiveness of tracheal suctioning?
- A.
Notes subjective data, such as "My breathing is much improved now."
- B.
Notes objective findings, such as decreased respiratory rate and pulse.
- C.
Consults with the respiratory therapist to determine effectiveness.
- D.
Auscultates the chest for change or clearing of adventitious breath sounds.
Correct Answer
D. Auscultates the chest for change or clearing of adventitious breath sounds.Explanation
Strategy: Determine how each answer relates to suctioning.
(1) subjective data and not as conclusive
(2) correct but not as effective
(3) not appropriate
(4) correct—to assess the effectiveness of suctioning, auscultate the client's chest to determine if adventitious sounds are cleared and to ensure that the airway is clear of secretionsRate this question:
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- 30.
The nurse knows which of the following is an important consideration in the care of a newborn with fetal alcohol syndrome?
- A.
Prevent iron deficiency anemia.
- B.
Decrease touch to prevent overstimulation.
- C.
Provide feedings via gavage to decrease energy expenditure.
- D.
Replace vitamins depleted as a result of poor maternal diet.
Correct Answer
D. Replace vitamins depleted as a result of poor maternal diet.Explanation
Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?
(1) not highest priority
(2) infant needs to be held and cuddled due to a poorly developed CNS
(3) usually unnecessary
(4) correct—frequently, maternal diet is poor and infant is malnourished; adequate intake of B complex vitamins is necessary for normal CNS functionRate this question:
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- 31.
A client returns from surgery after a right mastectomy with an IV of 0.9% NaCl infusing at 100 ml/h into her left forearm. Several hours later, the IV infiltrates. The nurse supervises a student nurse preparing to insert a new peripheral intravenous catheter. The nurse should intervene in which of the following situations?
- A.
The student nurse selects a site where the veins are soft and elastic.
- B.
The student nurse selects a site on the distal portion of the left arm.
- C.
The student nurse selects a site close to the joint to provide for stability.
- D.
The student nurse holds the skin taut to stabilize the vein.
Correct Answer
C. The student nurse selects a site close to the joint to provide for stability.Explanation
Strategy: "Nurse should intervene" indicates an incorrect action.
(1) acceptable site selection
(2) acceptable site selection
(3) correct inappropriate; movement in area could cause displacement
(4) acceptable procedureRate this question:
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- 32.
A client diagnosed with Addison’s disease comes to the health clinic. When assessing the client’s skin, the nurse expects to observe which of the following?
- A.
Darker skin that is more pigmented.
- B.
Skin that is ruddy and oily.
- C.
Skin that is puffy and scaly.
- D.
Skin that is pale and dry.
Correct Answer
A. Darker skin that is more pigmented.Explanation
Strategy: Determine how each answer relates to Addison's disease.
(1) correct—increase in melanocyte-stimulating hormone results in "eternal tan"
(2) not seen with Addison's disease
(3) not seen with Addison's disease
(4) not seen with Addison's diseaseRate this question:
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- 33.
Which of the following statements is both a correctly stated nursing diagnosis and a high priority for an older client immediately following a modified radical mastectomy and axillary dissection?
- A.
Anxiety related to the mastectomy.
- B.
Impaired skin integrity related to the mastectomy.
- C.
Pain related to surgical incision.
- D.
Self-care deficit related to dressing changes.
Correct Answer
C. Pain related to surgical incision.Explanation
Strategy: Think about each answer.
(1) is stated incorrectly with "related to the mastectomy"
(2) is stated incorrectly with "related to the mastectomy"
(3) correct—immediately after surgery the priority is optimizing the client's comfort
(4) is not an immediate priorityRate this question:
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- 34.
An older client with a history of hypertension and closed-angle glaucoma visits the clinic for a routine check-up. Which of the following medications, if ordered by the physician, should the nurse question?
- A.
Propranolol (Inderal), 80 mg PO QID.
- B.
Verapamil (Nifedipine), 40 mg PO TID.
- C.
Tetrahydrozoline (Visine), 2 gtt both eyes TID.
- D.
Timolol (Timoptic solution), 1 gtt both eyes daily.
Correct Answer
C. Tetrahydrozoline (Visine), 2 gtt both eyes TID.Explanation
Strategy: "Medication should the nurse question" indicates a contraindication.
(1) antihypertensive, beta-blocker used as an antianginal, reduces cardiac oxygen demand, no effect on glaucoma
(2) calcium channel blocker used as antianginal; not contraindicated
(3) correct—contraindicated; ophthalmic vasoconstrictor, contraindicated with closed angle glaucoma; use cautiously with hypertension
(4) reduces aqueous formation and increases outflow, used for glaucomaRate this question:
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- 35.
The nurse cares for a client diagnosed with a recurrent urinary tract infection. The physician orders methenamine mandelate (Mandelamine). The nurse should instruct the client to limit intake of which of the following fluids?
- A.
Milk.
- B.
Cranberry juice.
- C.
Water.
- D.
Tea.
Correct Answer
A. Milk.Explanation
(1) correct—should limit intake of alkaline foods and fluids
(2) should be increased to acidify urine
(3) does not need to be restricted
(4) does not need to be restrictedRate this question:
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- 36.
The physician prescribes estrogen (Premarin) 0.625 mg daily for a 43-year-old woman. The nurse identifies which of the following symptoms is a common initial side effect of this medication?
- A.
Nausea.
- B.
Visual disturbances.
- C.
Tinnitus.
- D.
Ataxia.
Correct Answer
A. Nausea.Explanation
Strategy: Think about what causes each symptom and determine its relationship to Premarin.
(1) correct—common at breakfast time; will subside after weeks of medication use; take after eating to reduce incidence
(2) seen with long-term use
(3) ringing in the ears is seen with long-term use
(4) unsteady gait rarely seenRate this question:
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- 37.
The nurse assesses a client immediately after an exploratory laparotomy. Which of the following nursing observations indicates the complication of intestinal obstruction?
- A.
Protruding soft abdomen with frequent diarrhea.
- B.
Distended abdomen with ascites.
- C.
Minimal bowel sounds in all four quadrants.
- D.
Distended abdomen with complaints of pain.
Correct Answer
D. Distended abdomen with complaints of pain.Explanation
Strategy: Determine how each answer relates to an intestinal obstruction.
(1) does not support intestinal obstruction
(2) does not support intestinal obstruction
(3) immediately after postoperative abdominal surgery, bowel sounds are absent or decreased; would be no passage of stool; ascites not often seen
(4) correct—if an obstruction is present, the abdomen will become distended and painfulRate this question:
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- 38.
The school nurse conducts a class on childcare at the local high school. During the class, one of the participants asks the nurse what age is best to start toilet training a child. Which of the following is the BEST response by the nurse?
- A.
11 months of age.
- B.
14 months of age.
- C.
17 months of age.
- D.
20 months of age.
Correct Answer
D. 20 months of age.Explanation
Strategy: Think about growth and development.
(1) not able to physiologically control sphincters until 18 months of age
(2) not able to physiologically control sphincters until 18 months of age
(3) not able to physiologically control sphincters until 18 months of age
(4) correct—by 24 months may be able to achieve daytime bladder controlRate this question:
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- 39.
The nurse determines which of the following actions has HIGHEST priority when caring for the client diagnosed with hypoparathyroidism?
- A.
Develop a teaching plan.
- B.
Plan measures to deal with cardiac dysrhythmias.
- C.
Take measures to prevent a respiratory infection.
- D.
Assess laboratory results.
Correct Answer
B. Plan measures to deal with cardiac dysrhythmias.Explanation
Strategy: ABCs.
(1) not highest priority action related to the diagnosis
(2) correct—cardiac dysrhythmias related to low serum calcium would be the highest priority
(3) potential for respiratory infection is not a major threat
(4) not highest priority action related to the diagnosisRate this question:
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- 40.
A nurse discusses changes due to aging with a group at the senior citizen center. The nurse knows that which of the following changes in the pattern of urinary elimination normally occurs with aging?
- A.
Decreased frequency.
- B.
Nocturia.
- C.
Incontinence.
- D.
Hematuria.
Correct Answer
B. Nocturia.Explanation
Strategy: Think about each answer.
(1) frequency increases because bladder capacity decreases
(2) correct—decreased ability to concentrate urine increases urine formation and increased nocturnal urine production lead to need to awaken to void
(3) ureters, bladder, and urethra lose muscle tone; results in stress and urge incontinence
(4) blood in urine- sign of cancer, infection, or trauma of urinary tract, glomerular disease, renal calculi, bleeding disordersRate this question:
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- 41.
The nurse cares for a patient the first day postoperative after a transurethral prostatectomy (TURP). The patient has a continuous bladder irrigation (CBI). The patient’s wife asks why the client has the CBI. Which of the following responses by the nurse is BEST?
- A.
"The CBI prevents urinary stasis and infection."
- B.
"The CBI dilutes the urine to prevent infection."
- C.
"The CBI enables urine to keep flowing."
- D.
"The CBI delivers medication to the bladder."
Correct Answer
C. "The CBI enables urine to keep flowing."Explanation
Strategy: Think about each answer.
(1) refers to a possible preoperative complication of infection due to the enlarged prostate
(2) not the reason for the CBI
(3) correct—continuous bladder irrigation prevents formation of clots that can lead to obstruction and spasm in the postoperative TURP client
(4) medication is not routinely administered via a CBI in a first-day postop TURPRate this question:
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- 42.
A client diagnosed with an adjustment disorder with depressed mood has the greatest chance of success in activities that require psychic and physical energy if the nurse schedules activities at which of the following times?
- A.
During the morning hours.
- B.
During the middle of the day.
- C.
During the afternoon hours.
- D.
During the evening hours.
Correct Answer
A. During the morning hours.Explanation
Strategy: Think about each answer.
(1) correct—client with reactive depression has the highest level of physical and psychic energy in the morning
(2) as the day progresses, energy level declines
(3) as the day progresses, energy level declines
(4) as the day progresses, energy level declinesRate this question:
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- 43.
The nurse identifies which psychosocial stage should be a priority to consider while planning care for a 20-year-old client?
- A.
Identity versus identity diffusion.
- B.
Intimacy versus isolation.
- C.
Integrity versus despair and disgust.
- D.
Industry versus inferiority.
Correct Answer
B. Intimacy versus isolation.Explanation
Strategy: Think about each answer.
(1) appropriate for adolescents
(2) correct—is the stage for 19- to 35-year-olds
(3) for 65 years and older
(4) for 6 to 12 years of ageRate this question:
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- 44.
The nurse cares for a homebound client with a urinary catheter. The client’s spouse states the catheter is obstructed. Which of the following observations by the nurse confirms this suspicion?
- A.
The nurse notes that the bladder is distended.
- B.
The client complains of a constant urge to void.
- C.
The nurse notes that the urine is concentrated.
- D.
The client complains of a burning sensation.
Correct Answer
A. The nurse notes that the bladder is distended.Explanation
Strategy: Determine how each answer relates to a urinary catheter.
(1) correct—bladder distention is one of the earliest signs of obstructed drainage tubing
(2) seen with a urinary tract infection
(3) seen with dehydration
(4) seen with a urinary tract infectionRate this question:
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- 45.
An older client receives total parenteral nutrition (TPN) for several weeks. If the TPN were abruptly discontinued, the nurse expects the patient to exhibit which of the following?
- A.
Tinnitus, vertigo, blurred vision.
- B.
Fever, malaise, anorexia.
- C.
Diaphoresis, confusion, tachycardia.
- D.
Hyperpnea, flushed face, diarrhea.
Correct Answer
C. Diaphoresis, confusion, tachycardia.Explanation
Strategy: Think about the cause of each symptom. Determine how it relates to TPN. Remember the "comma, comma, and" rule.
(1) not seen
(2) suggestive of infection
(3) correct—insulin levels remain high while glucose levels decline; results in hypoglycemia; will also see restlessness, headache, weakness, irritability, apprehension, lack of muscle coordination
(4) not seenRate this question:
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- 46.
The nurse anticipates a client diagnosed with a gastric ulcer to experience pain at which of the following times?
- A.
Two to three hours after a meal.
- B.
During the night.
- C.
Prior to the ingestion of food.
- D.
One-half to 1 hour after a meal.
Correct Answer
D. One-half to 1 hour after a meal.Explanation
Strategy: Think about each answer.
(1) feature of a duodenal ulcer
(2) feature of a duodenal ulcer
(3) feature of a duodenal ulcer
(4) correct—pain related to a gastric ulcer occurs about 0.5 to 1 hour after a meal and rarely at night; is not helped by ingestion of foodRate this question:
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- 47.
During a prenatal visit, the client states, "I have been very nauseated during my first trimester, and I don’t understand the reason." Which of the following responses by the nurse is BEST?
- A.
"You are nauseated because of the fatigue you are feeling."
- B.
"The nausea is due to an increase in the basal metabolic rate."
- C.
"The nausea is caused by an elevation in the hormones."
- D.
"If you eat different kinds of foods, you won’t be nauseated."
Correct Answer
C. "The nausea is caused by an elevation in the hormones."Explanation
The correct answer is "The nausea is caused by an elevation in the hormones." During the first trimester of pregnancy, there is a significant increase in hormone levels, particularly human chorionic gonadotropin (hCG) and estrogen. These hormonal changes can lead to nausea and vomiting, commonly known as morning sickness. Therefore, it is important for the nurse to provide an accurate explanation to the client about the cause of her nausea.Rate this question:
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- 48.
A nursing assistant reports to the RN that a patient with anemia complains of weakness. Which of the following responses by the nurse to the nursing assistant is BEST?
- A.
"Listen to the patient’s breath sounds and report back to me."
- B.
"Set up the patient’s lunch tray."
- C.
"Obtain a diet history from the patient."
- D.
"Instruct the patient to balance rest and activity."
Correct Answer
B. "Set up the patient’s lunch tray."Explanation
Strategy: Topic of question not clearly stated.
(1) requires assessment; should be performed by the RN
(2) correct—standard, unchanging procedure; decreases cardiac workload
(3) involves assessment; should be performed by the RN
(4) assessment and teaching required; performed by the RNRate this question:
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- 49.
A 4-year-old child is admitted with drooling and an inflamed epiglottis. During the assessment, the nurse identifies which of the following symptoms as indicative of an increase in respiratory distress?
- A.
Bradycardia.
- B.
Tachypnea.
- C.
General pallor.
- D.
Irritability.
Correct Answer
B. Tachypnea.Explanation
Strategy: Determine how each answer relates to respiratory distress.
(1) tachycardia occurs early in hypoxia
(2) correct—increase in the respiratory rate is an early sign of hypoxia, also for tachycardia
(3) pallor is not specific for hypoxia
(4) client may be anxious and restless, but is generally not described as irritableRate this question:
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- 50.
The nurse observes a student nurse auscultate the lungs of a client. The nurse knows that the student nurse is correctly auscultating the right middle lobe (RML) if the stethoscope is placed in which of the following positions?
- A.
Posterior and anterior base of right side.
- B.
Right anterior chest between the fourth and sixth intercostals.
- C.
Left of the sternum, midclavicular, at right fifth intercostal.
- D.
Posterior chest wall, midaxillary, right side.
Correct Answer
B. Right anterior chest between the fourth and sixth intercostals.Explanation
Strategy: Think about the anatomy of the lung.
(1) cannot auscultate the RML from the posterior
(2) correct—RML is found in the right anterior chest between the fourth and sixth intercostal spaces
(3) point of maximum impulse or apical pulse
(4) cannot auscultate the RML from the posteriorRate this question:
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Current Version
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Mar 22, 2023Quiz Edited by
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Sep 15, 2012Quiz Created by
Kvmtoolsdotcom
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