NCLEX RN Practice Questions 14 (Exam Mode) By RNpedia.Com

1. The nurse should visit which of the following clients first?

The client with diabetes with a blood glucose of 95mg/dL

The client with hypertension being maintained on Lisinopril

The client with chest pain and a history of angina

The client with Raynaud’s disease

The client with chest pain should be seen first because this could indicate a myocardial infarction. The client with diabetes with a blood glucose of 95mg/dL has a blood glucose within normal limits. The client with hypertension being maintained on Lisinopril is maintained on blood pressure medication. The client with Raynaud’s disease is in no distress.

Explanation

The client with chest pain should be seen first because this could indicate a myocardial infarction. The client with diabetes with a blood glucose of 95mg/dL has a blood glucose within normal limits. The client with hypertension being maintained on Lisinopril is maintained on blood pressure medication. The client with Raynaud’s disease is in no distress.

2. Which action by the nurse indicates understanding of herpes zoster?

The nurse covers the lesions with a sterile dressing.

The nurse wears gloves when providing care.

The nurse administers a prescribed antibiotic.

The nurse administers oxygen

Herpes zoster is shingles. Clients with shingles should be placed in contact precautions. Wearing gloves during care will prevent transmission of the virus. Covering the lesions with a sterile gauze is not necessary, antibiotics are not prescribed for herpes zoster, and oxygen is not necessary for shingles.

Explanation

Herpes zoster is shingles. Clients with shingles should be placed in contact precautions. Wearing gloves during care will prevent transmission of the virus. Covering the lesions with a sterile gauze is not necessary, antibiotics are not prescribed for herpes zoster, and oxygen is not necessary for shingles.

3. Which of the following diet instructions should be given to the client with recurring urinary tract infections?

Increase intake of meats.

Avoid citrus fruits.

Perform pericare with hydrogen peroxide.

Drink a glass of cranberry juice every day.

Cranberry juice is more alkaline and, when metabolized by the body, is excreted with acidic urine. Bacteria does not grow freely in acidic urine. Increasing intake of meats is not associated with urinary tract infections, so increasing intake of meats is incorrect. The client does not have to avoid citrus fruits and pericare should be done, but hydrogen peroxide is drying.

Explanation

Cranberry juice is more alkaline and, when metabolized by the body, is excreted with acidic urine. Bacteria does not grow freely in acidic urine. Increasing intake of meats is not associated with urinary tract infections, so increasing intake of meats is incorrect. The client does not have to avoid citrus fruits and pericare should be done, but hydrogen peroxide is drying.

4. A client is receiving Pyridium (phenazopyridine hydrochloride) for a urinary tract infection. The client should be taught that the medication may:

Cause diarrhea

Change the color of her urine

Cause mental confusion

Cause changes in taste

Clients taking Pyridium should be taught that the medication will turn the urine orange or red. It is not associated with diarrhea, mental confusion, or changes in taste. Pyridium can also cause a yellowish color to skin and sclera if taken in large doses.

Explanation

Clients taking Pyridium should be taught that the medication will turn the urine orange or red. It is not associated with diarrhea, mental confusion, or changes in taste. Pyridium can also cause a yellowish color to skin and sclera if taken in large doses.

5. The nurse is providing postpartum teaching for a mother planning to breastfeed her infant. Which of the client's statements indicates the need for additional teaching?

"I’m wearing a support bra."

"I’m expressing milk from my breast."

"I’m drinking four glasses of fluid during a 24-hour period."

"While I’m in the shower, I’ll allow the water to run over my breasts."

Mothers who plan to breastfeed should drink plenty of liquids, and four glasses is not enough in a 24-hour period. Wearing a support bra is a good practice for the mother who is breastfeeding as well as the mother who plans to bottle-feed. Expressing milk from the breast will stimulate milk production. Allowing the water to run over the breast will also facilitate "letdown," when the milk begins to be produced.

Explanation

Mothers who plan to breastfeed should drink plenty of liquids, and four glasses is not enough in a 24-hour period. Wearing a support bra is a good practice for the mother who is breastfeeding as well as the mother who plans to bottle-feed. Expressing milk from the breast will stimulate milk production. Allowing the water to run over the breast will also facilitate "letdown," when the milk begins to be produced.

6. Cataracts result in opacity of the crystalline lens. Which of the following best explains the functions of the lens?

The lens controls stimulation of the retina.

The lens orchestrates eye movement.

The lens focuses light rays on the retina.

The lens magnifies small objects.

The lens allows light to pass through the pupil and focus light on the retina. The lens does not stimulate the retina, assist with eye movement, or magnify small objects.

Explanation

The lens allows light to pass through the pupil and focus light on the retina. The lens does not stimulate the retina, assist with eye movement, or magnify small objects.

7. A client with a severe corneal ulcer has an order for Gentamycin gtt. q 4 hours and Neomycin 1 gtt q 4 hours. Which of the following schedules should be used when administering the drops?

Allow 5 minutes between the two medications.

The medications may be used together.

The medications should be separated by a cycloplegic drug

The medications should not be used in the same client.

When using eyedrops, allow 5 minutes between the two medications. These medications can be used by the same client but it is not necessary to use a cyclopegic with these medications.

Explanation

When using eyedrops, allow 5 minutes between the two medications. These medications can be used by the same client but it is not necessary to use a cyclopegic with these medications.

8. Damage to the VII cranial nerve results in:

Facial pain

Absence of ability to smell

Absence of eye movement

Tinnitus

The facial nerve is cranial nerve VII. If damage occurs, the client will experience facial pain. The auditory nerve is responsible for hearing loss and tinnitus, eye movement is controlled by the Trochear or C IV, and the olfactory nerve controls smell.

Explanation

The facial nerve is cranial nerve VII. If damage occurs, the client will experience facial pain. The auditory nerve is responsible for hearing loss and tinnitus, eye movement is controlled by the Trochear or C IV, and the olfactory nerve controls smell.

9. A client with cystic fibrosis is taking pancreatic enzymes. The nurse should administer this medication:

Once per day in the morning

Three times per day with meals

Once per day at bedtime

Four times per day

Pancreatic enzymes should be given with meals for optimal effects. These enzymes assist the body in digesting needed nutrients. Other answer choices are incorrect methods of administering pancreatic enzymes.

Explanation

Pancreatic enzymes should be given with meals for optimal effects. These enzymes assist the body in digesting needed nutrients. Other answer choices are incorrect methods of administering pancreatic enzymes.

10. A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir?

Limit the client’s activity

Encourage a high-carbohydrate diet

Utilize an incentive spirometer to improve respiratory function

Encourage fluids

Clients taking Acyclovir should be encouraged to drink plenty of fluids because renal impairment can occur. Limiting activity is not necessary, nor is eating a high-carbohydrate diet. Use of an incentive spirometer is not specific to clients taking Acyclovir.

Explanation

Clients taking Acyclovir should be encouraged to drink plenty of fluids because renal impairment can occur. Limiting activity is not necessary, nor is eating a high-carbohydrate diet. Use of an incentive spirometer is not specific to clients taking Acyclovir.

11. The client has an order for a trough to be drawn on the client receiving Vancomycin. The nurse is aware that the nurse should contact the lab for them to collect the blood:

15 minutes after the infusion

30 minutes before the infusion

1 hour after the infusion

2 hours after the infusion

A trough level should be drawn 30 minutes before the third or fourth dose. The times in other answer choices are incorrect times to draw blood levels.

Explanation

A trough level should be drawn 30 minutes before the third or fourth dose. The times in other answer choices are incorrect times to draw blood levels.

12. The client with enuresis is being taught regarding bladder retraining. The nurse should advise the client to refrain from drinking after:

1900

1200

1000

0700

Clients who are being retrained for bladder control should be taught to withhold fluids after about 7 p.m., or 1. The times in other answer choices are too early in the day.

Explanation

Clients who are being retrained for bladder control should be taught to withhold fluids after about 7 p.m., or 1. The times in other answer choices are too early in the day.

13. A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment, the nurse should:

Serve high-calorie foods she can carry with her

Encourage her appetite by sending out for her favorite foods

Serve her small, attractively arranged portions

Allow her in the unit kitchen for extra food whenever she pleases

The client with mania is seldom sitting long enough to eat and burns many calories for energy. Encouraging her appetite by sending out for her favorite foods is incorrect because the client should be treated the same as other clients. Small meals are not a correct option for this client. Allowing her into the kitchen gives her privileges that other clients do not have and should not be allowed.

Explanation

The client with mania is seldom sitting long enough to eat and burns many calories for energy. Encouraging her appetite by sending out for her favorite foods is incorrect because the client should be treated the same as other clients. Small meals are not a correct option for this client. Allowing her into the kitchen gives her privileges that other clients do not have and should not be allowed.

14. Which of the following tests should be performed before beginning a prescription of Accutane?

Check the calcium level

Perform a pregnancy test

Monitor apical pulse

Obtain a creatinine level

Accutane is contraindicated for use by pregnant clients because it causes teratogenic effects. Calcium levels, apical pulse, and creatinine levels are not necessary.

Explanation

Accutane is contraindicated for use by pregnant clients because it causes teratogenic effects. Calcium levels, apical pulse, and creatinine levels are not necessary.

15. To maintain Bryant's traction, the nurse must make certain that the child's:

Hips are resting on the bed, with the legs suspended at a right angle to the bed

Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed

Hips and legs are flat on the bed, with the traction positioned at the foot of the bed

Bryant’s traction is used for fractured femurs and dislocated hips. The hips should be elevated 15° off the bed. The hips should not be resting on the bed. The hips should not be above the level of the body. The hips and legs should not be flat on the bed.

Explanation

Bryant’s traction is used for fractured femurs and dislocated hips. The hips should be elevated 15° off the bed. The hips should not be resting on the bed. The hips should not be above the level of the body. The hips and legs should not be flat on the bed.

16. During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-right quadrant. The infant is most likely in which position?

Right breech presentation

Right occipital anterior presentation

Left sacral anterior presentation

Left occipital transverse presentation

If the fetal heart tones are heard in the right upper abdomen, the infant is in a breech presentation. If the infant is positioned in the right occipital anterior presentation, the FHTs will be located in the right lower quadrant. If the fetus is in the sacral position, the FHTs will be located in the center of the abdomen. If the FHTs are heard in the left lower abdomen, the infant is most likely in the left occipital transverse position.

Explanation

If the fetal heart tones are heard in the right upper abdomen, the infant is in a breech presentation. If the infant is positioned in the right occipital anterior presentation, the FHTs will be located in the right lower quadrant. If the fetus is in the sacral position, the FHTs will be located in the center of the abdomen. If the FHTs are heard in the left lower abdomen, the infant is most likely in the left occipital transverse position.

17. A client who has glaucoma is to have miotic eyedrops instilled in both eyes. The nurse knows that the purpose of the medication is to:

Anesthetize the cornea

Dilate the pupils

Constrict the pupils

Paralyze the muscles of accommodation

Miotic eyedrops constrict the pupil and allow aqueous humor to drain out of the Canal of Schlemm. They do not anesthetize the cornea, dilate the pupil, or paralyze the muscles of the eye.

Explanation

Miotic eyedrops constrict the pupil and allow aqueous humor to drain out of the Canal of Schlemm. They do not anesthetize the cornea, dilate the pupil, or paralyze the muscles of the eye.

18. The client with a pacemaker should be taught to:

Report ankle edema

Check his blood pressure daily

Refrain from using a microwave oven

Monitor his pulse rate

The client with a pacemaker should be taught to count and record his pulse rate. Other answer choices are incorrect. Ankle edema is a sign of right-sided congestive heart failure. Although this is not normal, it is often present in clients with heart disease. If the edema is present in the hands and face, it should be reported. Checking the blood pressure daily is not necessary for these clients. The client with a pacemaker can use a microwave oven, but he should stand about 5 feet from the oven while it is operating.

Explanation

The client with a pacemaker should be taught to count and record his pulse rate. Other answer choices are incorrect. Ankle edema is a sign of right-sided congestive heart failure. Although this is not normal, it is often present in clients with heart disease. If the edema is present in the hands and face, it should be reported. Checking the blood pressure daily is not necessary for these clients. The client with a pacemaker can use a microwave oven, but he should stand about 5 feet from the oven while it is operating.

19. The primary physiological alteration in the development of asthma is:

Bronchiolar inflammation and dyspnea

Hypersecretion of abnormally viscous mucus

Infectious processes causing mucosal edema

Spasm of bronchiolar smooth muscle

Asthma is the presence of bronchiolar spasms. This spasm can be brought on by allergies or anxiety. Answer choice bronchiolar inflammation and dyspnea is incorrect because the primary physiological alteration is not inflammation. Answer choice hypersecretion of abnormally viscous mucus is incorrect because there is the production of abnormally viscous mucus, not a primary alteration. Answer choice infectious processes causing mucosal edema is incorrect because infection is not primary to asthma.

Explanation

Asthma is the presence of bronchiolar spasms. This spasm can be brought on by allergies or anxiety. Answer choice bronchiolar inflammation and dyspnea is incorrect because the primary physiological alteration is not inflammation. Answer choice hypersecretion of abnormally viscous mucus is incorrect because there is the production of abnormally viscous mucus, not a primary alteration. Answer choice infectious processes causing mucosal edema is incorrect because infection is not primary to asthma.

20. A client is admitted for an MRI. The nurse should question the client regarding:

Pregnancy

A titanium hip replacement

Allergies to antibiotics

Inability to move his feet

Clients who are pregnant should not have an MRI because radioactive isotopes are used. However, clients with a titanium hip replacement can have an MRI. No antibiotics are used with this test and the client should remain still only when instructed.

Explanation

Clients who are pregnant should not have an MRI because radioactive isotopes are used. However, clients with a titanium hip replacement can have an MRI. No antibiotics are used with this test and the client should remain still only when instructed.

21. The client with color blindness will most likely have problems distinguishing which of the following colors?

Orange

Violet

Red

White

Clients with color blindness will most likely have problems distinguishing violets, blues, and green. The colors in other answer choices are less commonly affected.

Explanation

Clients with color blindness will most likely have problems distinguishing violets, blues, and green. The colors in other answer choices are less commonly affected.

22. The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?

"I will make sure I eat breakfast within 2 hours of taking my insulin."

"I will need to carry candy or some form of sugar with me all the time."

"I will eat a snack around three o’clock each afternoon."

"I can save my dessert from supper for a bedtime snack."

NPH insulin peaks in 8–12 hours, so a snack should be offered at that time. NPH insulin onsets in 90–120 minutes, so making sure I eat breakfast within 2 hours of taking my insulin is incorrect. Needing to carry candy or some form of sugar all the time is not necessary because NPH insulin is time released and does not usually cause sudden hypoglycemia. Saving dessert from supper for a bedtime snack is incorrect, but the client should eat a bedtime snack.

Explanation

NPH insulin peaks in 8–12 hours, so a snack should be offered at that time. NPH insulin onsets in 90–120 minutes, so making sure I eat breakfast within 2 hours of taking my insulin is incorrect. Needing to carry candy or some form of sugar all the time is not necessary because NPH insulin is time released and does not usually cause sudden hypoglycemia. Saving dessert from supper for a bedtime snack is incorrect, but the client should eat a bedtime snack.

23. The client using a diaphragm should be instructed to:

Refrain from keeping the diaphragm in longer than 4 hours

Keep the diaphragm in a cool location

Have the diaphragm resized if she gains 5 pounds

Have the diaphragm resized if she has any surgery

The client using a diaphragm should keep the diaphragm in a cool location. She should refrain from leaving the diaphragm in longer than 8 hours, not 4 hours. She should have the diaphragm resized when she gains or loses 10 pounds or has abdominal surgery.

Explanation

The client using a diaphragm should keep the diaphragm in a cool location. She should refrain from leaving the diaphragm in longer than 8 hours, not 4 hours. She should have the diaphragm resized when she gains or loses 10 pounds or has abdominal surgery.

24. The nurse is caring for the client receiving Amphotericin B. Which of the following indicates that the client has experienced toxicity to this drug?

Changes in vision

Nausea

Urinary frequency

Changes in skin color

Clients taking Amphotericin B should be monitored for liver, renal, and bone marrow function because this drug is toxic to the kidneys and liver, and causes bone marrow suppression. Jaundice is a sign of liver toxicity and is not specific to the use of Amphotericin B. Changes in vision are not related, and nausea is a side effect, not a sign of toxicity; nor is urinary frequency.

Explanation

Clients taking Amphotericin B should be monitored for liver, renal, and bone marrow function because this drug is toxic to the kidneys and liver, and causes bone marrow suppression. Jaundice is a sign of liver toxicity and is not specific to the use of Amphotericin B. Changes in vision are not related, and nausea is a side effect, not a sign of toxicity; nor is urinary frequency.

25. A client with a history of abusing barbiturates abruptly stops taking the medication. The nurse should give priority to assessing the client for:

Depression and suicidal ideation

Tachycardia and diarrhea

Muscle cramping and abdominal pain

Tachycardia and euphoric mood

Barbiturates create a sedative effect. When the client stops taking barbiturates, he will experience tachycardia, diarrhea, and tachpnea. Even though depression and suicidal ideation go along with barbiturate use; it is not the priority. Muscle cramps and abdominal pain are vague symptoms that could be associated with other problems. Tachycardia is associated with stopping barbiturates, but euphoria is not.

Explanation

Barbiturates create a sedative effect. When the client stops taking barbiturates, he will experience tachycardia, diarrhea, and tachpnea. Even though depression and suicidal ideation go along with barbiturate use; it is not the priority. Muscle cramps and abdominal pain are vague symptoms that could be associated with other problems. Tachycardia is associated with stopping barbiturates, but euphoria is not.