NCLEX-RN Practice 100 Questions
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For a client with a neurologic disorder, which of the following nursing assessments is MOST helpful in determining subtle changes in the client’s level of consciousness?
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Client posturing.
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Glasgow coma scale.
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Client thinking pattern.
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Occurrence of hallucinations.
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This NCLEX-RN Practice quiz features 100 questions designed to assess and enhance nursing knowledge and skills. It covers critical aspects such as patient nutrition post-surgery, neurological assessments, signs of bulimia, and medication administration, preparing learners for practical nursing challenges.
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- 2.
The nurse assists a nursing assistant in providing a bed bath to a comatose patient with incontinence. The nurse should intervene if which of the following actions is noted?
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The nursing assistant answers the phone while wearing gloves.
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The nursing assistant log rolls the patient to provide back care.
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The nursing assistant places an incontinent pad under the patient.
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The nursing assistant positions the patient on the left side, head elevated.
Correct Answer
A. The nursing assistant answers the phone while wearing gloves.Explanation
Strategy: "Nurse should intervene" indicates that you are looking for an incorrect action.
(1) correct—contaminated gloves should be removed before answering the phone
(2) correct way to roll a patient to maintain proper alignment
(3) appropriate to use incontinence pad for this patient
(4) appropriate position to prevent aspiration and protect the airwayRate this question:
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- 3.
The nurse cares for clients on a psychiatric unit and is suddenly faced with multiple issues. Which of the following situations require the nurse’s IMMEDIATE attention?
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A client with bipolar disorder walks into the day room in her underwear and begins dancing.
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A client with depression says to the nurse, "My plan is complete, and I’m ready to go for it."
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A client recovering from substance abuse complains that another client is harassing him.
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A client with schizophrenia tells the nurse that it’s "God’s will" that he destroy the "evil TV."
Correct Answer
A. A client with depression says to the nurse, "My plan is complete, and I’m ready to go for it."Explanation
Strategy: "Require IMMEDIATE intervention" indicates that you are looking for the least stable situation.
(1) should remove to quiet area, decrease environmental stimuli
(2) correct—could indicate impending suicide; requires immediate follow-up
(3) potential suicide is more immediate concern
(4) command hallucination; potential suicide takes priorityRate this question:
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- 4.
A client has a total laryngectomy with a permanent tracheostomy. The nurse plans nutritional intake for the next 3 days. Which of the following is necessary for the nurse to consider regarding the client’s nutrition?
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To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented.
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The client will be unable to maintain any oral intake as long as the tracheotomy is in place.
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Nutritional and/or gastric feedings will not be attempted for approximately 3 weeks to decrease the incidence of aspiration.
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Because the client is dependent on the ventilator, nutritional intake will be delayed.
Correct Answer
A. To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented.Explanation
Strategy: Think about each answer choice.
(1) correct—tube feedings frequently started as the initial nutritional intake; prevents trauma to suture area
(2) although client has permanent tracheotomy, will be able to eat normally after area has healed
(3) nutritional intake will begin when bowel sounds return and client can tolerate intake
(4) client is not dependent on ventilatorRate this question:
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- 5.
A child has a closed transverse fracture of the right ulna. Which of the following actions, if performed by the nurse before the application of a cast, is MOST important?
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Check the radial pulses bilaterally and compare.
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Evaluate the skin temperature and tissue turgor in the area.
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Assess sensation of each foot while the child closes her eyes.
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Apply baby powder to decrease skin irritation under the cast.
Correct Answer
A. Check the radial pulses bilaterally and compare.Explanation
Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes.
(1) correct—assess neurovascular status, check pain, pallor, paralysis, paresthesia, pulselessness
(2) assessment; temperature indicates decreased circulation but is subjective and not most important
(3) assessment; upper (not lower) extremity fracture
(4) implementation; should not be done because it would increase skin irritationRate this question:
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- 6.
A patient is admitted to the hospital for a hypoglossectomy with lymph node dissection. The patient’s preoperative care includes frequent oral hygiene with hydrogen peroxide. The nurse knows the purpose of this treatment includes which of the following?
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Minimizes the bacterial count in the mouth.
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Softens the mucous membranes of the tongue before surgery.
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Stimulates the microcirculation of the mouth.
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Hydrates the tissues of the gums.
Correct Answer
A. Minimizes the bacterial count in the mouth.Explanation
The purpose of frequent oral hygiene with hydrogen peroxide before a hypoglossectomy with lymph node dissection is to minimize the bacterial count in the mouth. This is important because reducing the bacterial count can help prevent infection during and after surgery.Rate this question:
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- 7.
The nurse checks for placement of a nasogastric (NG) tube prior to initiating a tube feeding for a client. Which of the following results indicates to the nurse that the tube feeding can begin?
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A small amount of white mucus is aspirated from the NG tube.
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The contents aspirated from the NG tube have a pH of 3.
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No bubbles are seen when the nurse inverts the NG tube in water.
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The client says he can feel the NG tube in the back of his throat.
Correct Answer
A. The contents aspirated from the NG tube have a pH of 3.Explanation
Strategy: Determine how the answers relate to a tube feeding.
(1) mucus may be from lungs
(2) correct—stomach contents are acidic
(3) not a safe way to check placement
(4) not a reliable indicationRate this question:
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- 8.
A male client is admitted with urinary tract problems. A prostate-specific antigen (PSA) and acid phosphatase test are to be done. The nurse knows that
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these tests are valuable screening tests for prostatic cancer.
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the level of PSA is decreased in clients with renal stones.
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the tests reflect the level of renal involvement in acid-base problems.
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the level of PSA is elevated in clients in early-stage renal failure.
Correct Answer
A. these tests are valuable screening tests for prostatic cancer.Explanation
Strategy: Think about each answer choice.
(1) correct—PSA test has replaced acid phosphatase test in screening for prostatic cancer; test must be drawn before digital rectal exam, as manipulation of the prostate will abnormally increase PSA value
(2) inaccurate information about a PSA
(3) inaccurate information about a PSA
(4) inaccurate information about a PSARate this question:
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- 9.
A client in a psychiatric facility describes seeing snakes on the walls of the room. Which of the following is an accurate nursing diagnosis?
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Sensory–perceptual alterations: visual.
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Altered thought processes.
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Ineffective individual coping.
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Impaired social interaction.
Correct Answer
A. Sensory–perceptual alterations: visual.Explanation
Strategy: Think about each answer choice.
(1) correct—reflects a pattern of impaired perception, which is supported by the data that client is having a hallucination, defined as a sensory perception for which no external stimuli exist
(2) not relevant to the data
(3) not relevant to the data
(4) not relevant to the dataRate this question:
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- 10.
The nurse teaches nutrition classes at the community center. Which of the following foods should the nurse encourage a low-income client to eat to satisfy essential protein needs?
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Legumes.
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Red meat.
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Seafood.
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Cheese.
Correct Answer
A. Legumes.Explanation
Strategy: Think about each answer choice.
(1) correct—legumes are an economical source rich in protein
(2) high in protein, but more expensive to purchase
(3) high in protein, but more expensive to purchase
(4) high in protein, but more expensive to purchaseRate this question:
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- 11.
The nurse conducts a physical examination of a client suspected to have bulimia. Which of the following observations by the nurse MOST likely indicates bulimia?
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The client has edema of the lower extremities.
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Physical exam of the client reveals the presence of lanugo.
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The client has ulcerated mucous membranes of the mouth.
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The client has dry, yellowish color of the skin.
Correct Answer
A. The client has ulcerated mucous membranes of the mouth.Explanation
Strategy: Determine the cause of each symptom. Does it relate to bulimia?
(1) common with anorexia
(2) seen with anorexia
(3) correct—due to frequent vomiting
(4) bulimics are normal in appearanceRate this question:
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- 12.
A client is admitted to the neurosurgery unit for the removal of a cerebellar tumor. The nurse expects the patient to make which of the following statements about symptoms?
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"I have been having difficulty with my hearing."
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"I lose my balance easily."
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"I can't tell the difference between a sweet and sour taste."
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"It is not easy for me to remember names and faces."
Correct Answer
A. "I lose my balance easily."Explanation
Strategy: Remember physiology.
(1) temporal lobe contains auditory center, loss of hearing would involve CN VIII acoustic
(2) correct—cerebellum maintains balance
(3) CN IX, glossopharyngeal responsible for differentiation of taste
(4) not specific symptom of cerebellum dysfunctionRate this question:
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- 13.
The nurse knows that which of these plans is MOST successful in caring for a client with dementia?
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Teach new skills for adjusting to the aging process.
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Adjust the environment to meet the client’s individual needs.
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Encourage competitive activities to keep the client physically strong.
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Provide unstructured activities with frequent changes to increase stimulation.
Correct Answer
A. Adjust the environment to meet the client’s individual needs.Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) unable to learn new skills
(2) correct—client with dementia does not have cognitive abilities to learn new skills or to adapt; environment must be adapted for client with attention to safety and predictability
(3) requires skills the client with dementia does not have
(4) requires skills the client with dementia does not haveRate this question:
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- 14.
A neonate weighing 7 lb 4 oz with Apgar scores of 7 and 8 at 1 and 5 minutes, respectively, is admitted to the nursery. Because the infant’s mother is diagnosed with a type 1 diabetes, the nurse knows the infant is at GREATEST risk for developing which of the following?
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Hypovolemia.
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Hypoglycemia.
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Hyperglycemia.
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Cold stress.
Correct Answer
A. Hypoglycemia.Explanation
Strategy: Determine the cause of each answer choice.
(1) no change in blood volume for infant of diabetic mother
(2) correct—fetus produces increased insulin to match mother’s increased glucose level during pregnancy; infant continues to have high insulin output after birth, resulting in hypoglycemia
(3) infant would be at risk of hypoglycemia due to increased insulin production
(4) thermal receptors in skin are stimulated due to cold environment; increases metabolic rate; infant needs to maintain normal body temperature while producing minimal amount of heat generated from metabolic processes; not expected with diabetic motherRate this question:
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- 15.
The MOST appropriate nursing action before administering captopril (Capoten) is to check the client’s
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apical pulse for 60 seconds.
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blood pressure.
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urine output.
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temperature.
Correct Answer
A. blood pressure.Explanation
Strategy: Think about each answer choice and how it relates to Capoten.
(1) important, but not a priority
(2) correct—Capoten is an antihypertensive that necessitates assessment of BP before administration
(3) important, but not priority
(4) unnecessary to assess prior to the administration of the medicationRate this question:
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- 16.
The nurse makes patient assignments on the obstetrics unit. Which of the following patients should the nurse assign to an RN who has been reassigned to the obstetrics unit from outpatient surgery?
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A patient at 16 weeks’ gestation admitted with hyperemesis and receiving IV fluids.
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A patient at 26 weeks’ gestation in premature labor and receiving terbutaline (Brethine).
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A patient at 32 weeks’ gestation with a placenta previa and ruptured membranes.
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A patient at 37 weeks’ gestation with pregnancy-induced hypertension and epigastric pain.
Correct Answer
A. A patient at 16 weeks’ gestation admitted with hyperemesis and receiving IV fluids.Explanation
Strategy: LPN/LVN and "pulled" RN receive stable patients with expected outcomes.
(1) correct—monitor IV therapy, administer antiemetics and nutritional supplements
(2) monitor patient’s response to medication and the status of the fetus
(3) prepare for delivery, closely monitor fetal response
(4) indicates impending seizures, prepare for deliveryRate this question:
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- 17.
The nurse teaches a health class at the local library to a group of senior citizens. Which of the following behaviors should the nurse emphasize to facilitate regular bowel elimination?
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Avoid strenuous activity.
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Eat more foods with increased bulk.
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Decrease fluid intake to decrease urinary losses.
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Use oral laxatives so that a bowel pattern emerges.
Correct Answer
A. Eat more foods with increased bulk.Explanation
Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) regular exercise program facilitates bowel elimination
(2) correct—contained in whole grains, legumes, vegetables, fruits, seeds, nuts, bulk promotes peristalsis
(3) normal fluid intake of 1,500 ml/day facilitates bowel elimination
(4) laxatives used as last resort because they become habit-formingRate this question:
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- 18.
The nurse cares for a client after right cataract surgery. The nurse should intervene if which of the following is observed?
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Client is in the supine position.
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The head of the bed is elevated 30 degrees.
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The client is lying on the right side.
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An eye shield is over the right eye.
Correct Answer
A. The client is lying on the right side.Explanation
Strategy: "Nurse should intervene" indicates an incorrect action.
(1) appropriate position
(2) decreases swelling and pain
(3) correct—client should not be positioned with operative side in a dependent position or against the bed
(4) shield is appropriateRate this question:
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- 19.
The nurse reviews client assignments on a medical/surgical unit. The nurse determines that the assignment is appropriate if the nursing assistant is caring for which of the following clients?
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A client with AIDS dementia complex who requires a urine specimen.
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A client complaining of postoperative pain after repair of a torn rotator cuff.
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A client with GI bleeding due to a duodenal ulcer who is receiving packed cells.
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A client with type 1 diabetes receiving prednisone for a herniated disk.
Correct Answer
A. A client with AIDS dementia complex who requires a urine specimen.Explanation
Strategy: Assign clients with standard, unchanging procedures.
(1) correct—standard, unchanging procedure
(2) assign to the RN
(3) assign to the RN
(4) assign to the RNRate this question:
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- 20.
A client has a three-way Foley catheter following a transurethral resection. The nurse should rapidly infuse the irrigating solutions if which of the following is observed?
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The urinary output is increased.
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Bright-red drainage or clots are present.
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Dark-brown drainage is present.
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The client complains of pain.
Correct Answer
A. Bright-red drainage or clots are present.Explanation
Strategy: Think about each answer choice.
(1) not a reason to infuse irrigating solution rapidly
(2) correct—three-way Foley catheter should be irrigated rapidly when bright-red drainage or clots are present; irrigation rate should be decreased to about 40 gtt/min when the drainage clears
(3) not an indication to infuse irrigating solution rapidly
(4) not an indication to infuse irrigating solution rapidlyRate this question:
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- 21.
The nurse caring for a client on suicide precautions makes the following observations: the client is verbalizing other options besides suicide, appears to be responding to antidepressant medication, is sleeping and eating better, and has indicated a willingness to interact more with family members. Based on these data, which of the following nursing actions is MOST appropriate?
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Recommend that the physician decrease the client’s medication dosage.
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Recommend that the treatment team reevaluate the client’s treatment plan.
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Give the client privileges to walk around the hospital by himself.
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Ask the family to begin planning for the client’s discharge.
Correct Answer
A. Recommend that the treatment team reevaluate the client’s treatment plan.Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) may reverse the client’s progress
(2) correct—data suggest that client is beginning to benefit from treatment; entire treatment team should share data and make a decision about the suicide precautions so that restrictions are changed gradually on the basis of a full-data picture
(3) may be the team’s decision, but not until a thorough review of the case is completed
(4) prematureRate this question:
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- 22.
An 11-year-old boy falls off his bicycle and sustains a minor head injury, which is treated at the outpatient clinic. The nurse instructs the boy’s mother about his care at home. The nurse determines that further teaching is necessary if the mother makes which of the following statements?
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"My son may have dizziness for 24 hours."
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"My son can drink carbonated beverages if he vomits."
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"My son may complain of nausea."
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"My son will probably have a headache."
Correct Answer
A. "My son can drink carbonated beverages if he vomits."Explanation
Strategy: Determine how each answer choice relates to a minor head injury.
(1) expected for at least 24 hours
(2) correct—vomiting unexpected; should be reported to physician immediately; also unexpected is blurred vision, drainage from ear or nose, weakness, slurred speech, worsening headache
(3) expected for at least 24 hours
(4) expected for at least 24 hours; should not get more intenseRate this question:
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- 23.
The mother of a 7-year-old child is dying. The nurse anticipates the child will have which of the following concepts of death?
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Death is punishment for his/her actions.
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Death is inevitable and irreversible.
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Death is temporary and gradual.
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Death as a concept based on past experience.
Correct Answer
A. Death is punishment for his/her actions.Explanation
Strategy: Remember growth and development.
(1) correct–7-year-olds see death as a punishment
(2) by age of 9, most children begin to develop an adult concept of death and begin to understand that death is irreversible
(3) is a preschool child’s concept of death
(4) is an adolescent’s concept of deathRate this question:
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- 24.
The nurse plans a diet for a child diagnosed with cystic fibrosis (CF). Which of the following dietary requirements should be considered by the nurse?
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High protein, high fat, and high calories.
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High protein, low fat, and high calories.
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Low protein, low fat, and low carbohydrate.
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High protein, high fat, and low carbohydrate.
Correct Answer
A. High protein, low fat, and high calories.Explanation
Strategy: Think about each answer choice.
(1) contains high fat
(2) correct—impaired intestinal absorption due to cystic fibrosis necessitates a diet higher in protein and calories; fat is decreased because it may interfere with absorption of other nutrients
(3) not adequate for this child
(4) contains high fatRate this question:
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- 25.
The nurse is aware that Rh immune globulin (RhoGAM) is administered to prevent complications in which of the following situations?
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The baby is Rh-negative, the mother is Rh-negative, and the father is Rh-positive.
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The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs.
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The mother is Rh-positive and previously sensitized, and the baby is Rh-negative.
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The mother is Rh-positive, the baby is Rh-negative, and there is a history of one incomplete pregnancy.
Correct Answer
A. The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs.Explanation
Strategy: Think about each answer choice.
(1) if both mother and baby are Rh-negative, there is no problem
(2) correct—RhoGAM is given to an Rh-negative mother who delivers an Rh-positive baby when the baby has a negative Coombs test
(3) medication is not given if the mother has been sensitized by a previous pregnancy
(4) there is no incompatibility here, but the mother needs to be evaluated regarding sensitization in the incomplete pregnancyRate this question:
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- 26.
A 6-month-old infant has had all of the required immunizations. The nurse knows that this would include which of the following?
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Two doses of diphtheria, tetanus, and pertussis vaccine.
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Measles, mumps, and rubella vaccines.
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A booster dose of the inactivated polio vaccine.
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Chickenpox and smallpox vaccines.
Correct Answer
A. Two doses of diphtheria, tetanus, and pertussis vaccine.Explanation
Strategy: Think about each answer choice.
(1) correct—first dose of the DPT may be given at 2 months of age, the second is given around 4 months
(2) MMR is given at 15 months
(3) polio is given at 2 and 4 months and again at 12 to 18 months
(4) recommended for first respondersRate this question:
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- 27.
A 25-year-old primigravida diagnosed with type 1 diabetes mellitus reviews the insulin regimen with the nurse. The nurse explains to the client that her insulin needs will change in which of the following ways?
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Increase during pregnancy and decrease after delivery.
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Decrease during pregnancy and increase after delivery.
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Increase during pregnancy and remain increased after delivery.
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Decrease during pregnancy and fluctuate after delivery.
Correct Answer
A. Increase during pregnancy and decrease after delivery.Explanation
Strategy: Think about each answer choice.
(1) correct—needs increase during pregnancy due to hormonal interference in glucose metabolism
(2) needs increase during pregnancy due to hormonal interference in glucose metabolism
(3) insulin needs will decrease after delivery
(4) needs increase during pregnancyRate this question:
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- 28.
The nurse cares for patients on the pediatric unit. The mother of a 2-year-old who is one day postoperative tells the nurse, "My child is so restless and overactive." The nurse should take which of the following actions?
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Direct the LPN/LVN to obtain the child’s vital signs.
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Ask the mother if the child’s sutures are still intact.
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Tell the nursing assistant to take the child for a walk.
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Check to see when the child last received pain medication.
Correct Answer
A. Check to see when the child last received pain medication.Explanation
Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? Yes. Determine the best assessment.
(1) no indication that there are any problems
(2) passing the buck
(3) implementation; should first assess
(4) correct—young children typically become restless and overactive if in pain; grimacing, clenching teeth, rocking, and aggressive behavior may also be observedRate this question:
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- 29.
The nurse prepares a dopamine (Intropin) infusion on a client. Before beginning the infusion the nurse should take which of the following actions?
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Evaluate the urine output.
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Obtain the client’s weight.
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Determine the patency of the IV line.
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Measure pulmonary artery pressures.
Correct Answer
A. Determine the patency of the IV line.Explanation
Strategy: Determine how each answer choice relates to dopamine.
(1) not a critical assessment at this time
(2) contains correct information, but is not a priority
(3) correct—if extravasation occurs, there is sloughing of the surrounding skin and tissue; patent IV line is essential to prevent serious side effects
(4) not a critical assessment at this timeRate this question:
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- 30.
A young adult immobilized for trauma to the spinal cord has periods of diaphoresis, a draining abdominal wound, and diarrhea. On the basis of the nursing assessment, which of the following is the MOST important nursing diagnosis?
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Risk for constipation related to immobilization.
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Risk for impaired skin integrity related to immobilization and secretions.
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Risk for wound infection related to involuntary bowel secretions.
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Risk for fluid volume excess related to secretions.
Correct Answer
A. Risk for impaired skin integrity related to immobilization and secretions.Explanation
Strategy: Think about each answer choice.
(1) constipation is not a problem because the client has diarrhea
(2) correct—skin is very susceptible to breakdown because of immobility and bodily secretions; needs numerous nursing interventions to prevent this
(3) not most important
(4) may be risk of fluid volume deficit due to diarrhea and secretionsRate this question:
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- 31.
A client with newly diagnosed type 1 diabetes says to the nurse, "I know that I have to take good care of my feet. When I buy new shoes, is there anything special I should do?" Which of the following responses by the nurse is BEST?
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"It is best to buy new shoes in the morning."
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"Have each foot measured every time you buy new shoes."
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"Buy shoes a half-size larger than your foot size so the fit is roomy."
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"Buy vinyl shoes because they won’t lose their shape easily."
Correct Answer
A. "Have each foot measured every time you buy new shoes."Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) should buy shoes in the afternoon when feet are larger than in the morning
(2) correct—feet enlarge with age, break in shoes gradually rather than all at one time, have measurements for shoes taken while standing (feet are larger)
(3) buy correct shoe size
(4) leather shoes recommended because they "breathe," vinyl could cause foot to perspire and aggravate fungal infectionsRate this question:
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- 32.
A client is scheduled for electromyography (EMG). What should the nurse tell the client about the procedure?
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"Your hair will be carefully washed prior to the procedure."
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"This is a noninvasive procedure that takes about 30 minutes."
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"A sedative will be given to you shortly before the procedure."
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"You will not be allowed to eat 4 to 6 hours before the procedure."
Correct Answer
A. "This is a noninvasive procedure that takes about 30 minutes."Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) usually performed on the legs
(2) correct—electrodes are attached to legs, length of time for impulse transmission is measured
(3) may impair test results
(4) procedure does not involve general anesthesia or GI systemRate this question:
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- 33.
An elderly man diagnosed with chronic schizophrenia is followed in a partial hospitalization program. The client has been on long-term antipsychotic medication and recently developed symptoms of tardive dyskinesia. The nurse’s documentation should include which of the following?
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Assessment of ADL (self-care) ability.
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Mini-Mental Status Examination (MMSE).
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Abnormal Involuntary Movement Scale (AIMS).
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Modified Overt Aggression Scale (MOAS).
Correct Answer
A. Abnormal Involuntary Movement Scale (AIMS).Explanation
Strategy: Think about each answer choice.
(1) assessment of client’s abilities to complete his activities of daily living (ADLs) needs to be completed and revised with a client who is aging and chronically mentally ill
(2) measures cognitive function
(3) correct is most widely accepted examination to test for the presence of tardive dyskinesia
(4) assessment tool for determining severity of aggression; usually utilized to determine nature, severity, and prevalence of aggression in an inpatient populationRate this question:
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- 34.
Which observation indicates to the nurse that the client needs further teaching before self-administering insulin?
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The client draws up the regular insulin first, then the NPH.
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The client gently rotates the insulin bottle before withdrawing the dose.
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The client rotates injection sites following the guide on the printed diagram.
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The client administers the insulin while it is still cold from the refrigerator.
Correct Answer
A. The client administers the insulin while it is still cold from the refrigerator.Explanation
Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) when mixing regular insulin with other types of insulin, the client should draw up the clear (regular) before the cloudy (NPH)
(2) bottle of insulin should never be vigorously shaken, but rather gently mixed
(3) imperative to rotate injection sites to avoid tissue irritation/infection and ensure proper absorption
(4) correct—insulin should be administered at room temperature; temperature extremes should be avoidedRate this question:
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- 35.
The nurse supervises care given to clients on a medical/surgical unit. The nurse should intervene if which of the following is observed?
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A nurse and client wear masks during a dressing change for the central catheter used for total parenteral nutrition.
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A nurse injects insulin through a single-lumen percutaneous central catheter for a client receiving total parenteral nutrition.
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A nurse applies lip balm to his/her lips immediately after performing a blood draw to obtain a specimen.
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A nurse wears a disposable particulate respirator when administering rifampin to a client with tuberculosis.
Correct Answer
A. A nurse applies lip balm to his/her lips immediately after performing a blood draw to obtain a specimen.Explanation
Strategy: "Nurse should intervene" indicates that you are looking for an incorrect action.
(1) appropriate procedure, prevents airborne contamination
(2) insulin is the only medication that can be given, compatible with TPN
(3) correct—applying lip balm or handling contact lenses is prohibited in work areas where exposure to bloodborne pathogens may occur
(4) use airborne precautions for TB, private room with negative air pressure, minimum of six exchanges per hourRate this question:
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- 36.
A client asks what the difference is between a gastric ulcer and a duodenal ulcer. The nurse’s response should be based on which of the following statements?
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"Gastric ulcers have an increased association with clients who experience increased psychological pressures."
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"The pain of a duodenal ulcer usually occurs 2 to 4 hours after meals."
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"Clients with gastric ulcers often gain weight, as food alleviates the pain."
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"Antacids such as Maalox are seldom prescribed for clients with duodenal ulcers."
Correct Answer
A. "The pain of a duodenal ulcer usually occurs 2 to 4 hours after meals."Explanation
Strategy: Think about each answer choice.
(1) refers to duodenal ulcers
(2) correct—clients with duodenal ulcers experience pain after meals, e.g., midmorning and midafternoon
(3) clients with gastric ulcer may be malnourished because food may cause nausea or vomiting
(4) antacids are given to duodenal ulcer clientsRate this question:
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- 37.
An older woman is hospitalized with a fractured left hip. While awaiting surgery, the client is placed in Buck’s traction with a 7-pound weight. Which of the following instructions about moving should be given by the nurse to encourage the patient to participate in her care?
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"Pull up on the overhead trapeze while you push down on your right foot to lift your body."
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"With your right arm, grasp the bedside rail on the opposite side and pull yourself over gently."
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"I’ll raise the head of the bed 45 degrees, and then you lean forward and rotate your hips to the left."
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"Swing your right leg over your left leg and turn from your waist down, keeping your legs straight."
Correct Answer
A. "Pull up on the overhead trapeze while you push down on your right foot to lift your body."Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) correct—body must move as single, straight unit
(2) turning or twisting from the waist down interferes with countertraction
(3) prevents proper pull of weights
(4) can’t turn from side to side; can only move up and downRate this question:
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- 38.
The nurse obtains a client’s temperature of 103°F(39.4°C). The nurse knows body compensatory mechanisms include which of the following?
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Decreased respiratory rate and bradycardia.
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Normal blood pressure and pulse.
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Increased respiratory rate and tachycardia.
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Diaphoresis with cool, clammy skin.
Correct Answer
A. Increased respiratory rate and tachycardia.Explanation
Strategy: Think about each answer choice.
(1) respirations and heart rate will increase with fever
(2) blood pressure and pulse usually increase with fever
(3) correct—hyperthermia increases the oxygen requirements, which results in faster breathing as well as an increase in the pulse rate
(4) diaphoresis may occur, but the skin will be warmRate this question:
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- 39.
The nurse assesses a client with severe bilateral peripheral edema. Which of the following is the BEST way for the nurse to determine the degree of edema in a limb?
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Measure both limbs with the tape measure and compare.
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Depress the skin and rank the degree of pitting.
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Describe the swelling in the affected area.
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Pinch the skin and note how quickly it returns to normal.
Correct Answer
A. Depress the skin and rank the degree of pitting.Explanation
Strategy: Think about each answer choice.
(1) is not the best way to evaluate for peripheral edema
(2) correct—severity of edema is characterized by grading it 1+ (2-mm pitting) to 4+ (8-mm pitting)
(3) not as objective
(4) is used for evaluating hydrationRate this question:
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- 40.
The nurse should include which of the following in a teaching plan for a client receiving tetracycline?
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Take the medication with milk or antacids to decrease GI problems.
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The medication should always be taken with meals.
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Use a maximum-protection sunscreen when outdoors.
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Crackers and juice will help decrease gastric irritation.
Correct Answer
A. Use a maximum-protection sunscreen when outdoors.Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) tetracycline should never be taken with milk or antacids because these inhibit the medication’s action
(2) should take with full glass of water at least 1 hour before or 2 hours after meals
(3) correct—because of problems related to photosensitivity, client should wear sunscreen, wide-brimmed hats, and long sleeves when at risk for sun exposure
(4) should take with full glass of water at least 1 hour before or 2 hours after mealsRate this question:
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- 41.
An elderly alcoholic client receives a long-acting benzodiazepine (Librium) for 2 days for symptom management and reduction. The client states, "Get those bugs off of me and clean them out of here." The nurse knows the client is exhibiting symptoms of which of the following?
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A reaction to the sedative medication.
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A worsening course of the withdrawal syndrome.
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An exacerbation of the schizophrenia process.
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The process of aging and the effects of delirium.
Correct Answer
A. A worsening course of the withdrawal syndrome.Explanation
Strategy: Think about each answer choice.
(1) client has been medicated with benzodiazepines and did not experience untoward reactions
(2) correct—client has most probably progressed to another level of abstinence withdrawal from polypharmacy chemical dependence; characteristic symptoms include tremors, increased heart rate, and fever, as well as psychological problems of confusion, delusions, and hallucinations
(3) schizophrenic client usually experiences an episode of auditory hallucinations, not visual or tactile hallucinations
(4) combination effect of the normal aging process and dementia could precipitate a similar reaction; however, the normal aging process does not produce delirium but rather dementiaRate this question:
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- 42.
An adult woman has missed her menstrual period. The client’s last menstrual period began May 8 and ended May 12. The nurse determines that the client’s EDC (estimated date of confinement) is which of the following?
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February 1.
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February 15.
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February 19.
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March 14.
Correct Answer
A. February 15.Explanation
Strategy: Remember Naegele rule.
(1) should add 7 days
(2) correct—when using the Naegele rule, add 7 days to first day of last menstrual period and subtract 3 months
(3) incorrectly started with the last day of the menstrual cycle
(4) incorrectRate this question:
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- 43.
The nurse anticipates which of the following when assessing a client with a diagnosis of a ruptured lumbar disc?
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Sensation loss in an upper extremity.
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Clonic jerks in the affected foot.
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Paresthesia in the affected leg.
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Chorea in the upper and lower extremities.
Correct Answer
A. Paresthesia in the affected leg.Explanation
Strategy: Think about each answer choice.
(1) results from cervical lesions
(2) can occur in a person who has been paralyzed from a spinal cord injury
(3) correct—lumbar lesions can cause paresthesia, pain, muscle weakness, and atrophy in the lower extremities
(4) is a sign of Huntington chorea, resulting from atrophy of parts of the brainRate this question:
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- 44.
The nurse cares for a child who is in Buck’s traction. During the neurovascular assessment, the nurse notes that the foot of the uninjured leg feels warmer to touch than that of the broken leg. The nurse should take which of the following actions?
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Record the observation.
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Encourage the child to move the foot.
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Cover the colder foot with a sock.
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Notify the physician.
Correct Answer
A. Notify the physician.Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) ignores possibility that Ace bandage is too tight
(2) does not relieve the circulation problem
(3) does not relieve the circulation problem
(4) correct—assessment indicates that Ace bandage is too tight and needs readjustingRate this question:
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- 45.
The nurse cares for a client who presents with confusion, mood lability, impaired communication, and lethargy. The nurse should question which of the following orders?
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Dexamethasone suppression test.
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Thyroid studies.
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Drug toxicology screen.
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Trendelenburg test.
Correct Answer
A. Trendelenburg test.Explanation
Strategy: Think about each test.
(1) may be ordered to determine the presence of major depression
(2) may be ordered to check for an endocrine cause for the symptoms before the diagnosis of dementia is made
(3) may be ordered to see if the client’s symptoms are caused by excessive use of medications or alcohol
(4) correct—test is used with a client who may have varicose veins, no relationship to the symptoms described in this situationRate this question:
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- 46.
A client is admitted with irritable bowel syndrome. The nurse anticipates that the client’s history will reflect which of the following?
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Pattern of alternating diarrhea and constipation.
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Chronic diarrhea stools occurring 10 to 12 times per day.
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Diarrhea and vomiting with severe abdominal distention.
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Bloody stools with increased cramping after eating.
Correct Answer
A. Pattern of alternating diarrhea and constipation.Explanation
Strategy: Think about each answer choice.
(1) correct—condition is often called spastic bowel disease; no inflammation is present
(2) refers to inflammatory bowel disease such as ulcerative colitis or Crohn’s disease
(3) refers to inflammatory bowel disease such as ulcerative colitis or Crohn’s disease
(4) bloody stools do not occur with irritable bowel syndromeRate this question:
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- 47.
The physician orders morphine sulfate 8 mg IM q 3 to 4 h for pain PRN. In which of the following situations should the nurse consider withholding the medication until further assessment is completed?
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The patient complains of acute pain from a partial-thickness burn affecting the lower left leg.
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The patient’s blood pressure is 140/90, pulse is 90, and respiration is 28.
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The patient’s level of consciousness fluctuates from alert to lethargic.
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The patient exhibits restlessness, anxiety, and cold, clammy skin.
Correct Answer
A. The patient’s level of consciousness fluctuates from alert to lethargic.Explanation
Strategy: Determine the significance of each answer choice and how it relates to morphine.
(1) morphine used for moderate to severe pain; medication should be given
(2) BP slightly elevated, respirations elevated, may be the result of pain; medication should be given
(3) correct—morphine depresses CNS, especially respiratory center in medulla
(4) may be the result of painRate this question:
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- 48.
A client has orders for cefoxitin (Mefoxin) 2 g IV piggyback in 100 ml 5% dextrose in water. The primary IV is 5% dextrose in lactated Ringer’s and is infusing by gravity. It is MOST important for the nurse to take which of the following actions?
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Administer the medication slowly, at 20 to 25 cc/h.
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Change the primary IV solution.
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Hang the piggyback infusion bag higher than the primary infusion bag.
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Obtain an infusion pump prior to administration.
Correct Answer
A. Hang the piggyback infusion bag higher than the primary infusion bag.Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) antibiotic should be administered within 1 hour
(2) unnecessary for safe infusion
(3) correct—when using a gravity drip, piggyback fluid level needs to be higher than primary infusion
(4) unnecessary for safe infusionRate this question:
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- 49.
The nurse knows that which of the following symptoms is supportive of a diagnosis of Guillain-Barré syndrome?
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Hemiplegia, hypertension, tachycardia.
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Respiratory failure, flaccid paralysis, urinary retention.
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Peripheral edema, hypertension, pulmonary congestion.
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Diminished reflexes, pain, paresthesia.
Correct Answer
A. Respiratory failure, flaccid paralysis, urinary retention.Explanation
Strategy: All parts of the answer choice must be correct in order for the answer to be correct.
(1) relates to a CVA
(2) correct—classic symptoms include respiratory failure and flaccidity due to paralysis of the muscles and urinary retention due to loss of sensation
(3) relates to pulmonary edema
(4) relates to peripheral nerve problemsRate this question:
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Current Version
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Aug 22, 2023Quiz Edited by
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Sep 18, 2012Quiz Created by
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