NCLEX RN Practice Questions 15 (Exam Mode) By RNpedia.Com

1. The nurse is preparing to suction the client with a tracheotomy. The nurse notes a previously used bottle of normal saline on the client’s bedside table. There is no label to indicate the date or time of initial use. The nurse should:

Lip the bottle and use a pack of sterile 4×4 for the dressing

Obtain a new bottle and label it with the date and time of first use

Ask the ward secretary when the solution was requested

Label the existing bottle with the current date and time

Because the nurse is unaware of when the bottle was opened or whether the saline is sterile, it is safest to obtain a new bottle. Answers A, C, and D are not safe practices.

Explanation

Because the nurse is unaware of when the bottle was opened or whether the saline is sterile, it is safest to obtain a new bottle. Answers A, C, and D are not safe practices.

2. The physician has ordered a thyroid scan to confirm the diagnosis. Before the procedure, the nurse should:

Assess the client for allergies

Bolus the client with IV fluid Tell the client he will be asleep

Tell the client he will be asleep

Insert a urinary catheter

A thyroid scan uses a dye, so the client should be assessed for allergies to iodine. The client will not have a bolus of fluid, will not be asleep, and will not have a urinary catheter inserted, so answers B, C, and D are incorrect.

Explanation

A thyroid scan uses a dye, so the client should be assessed for allergies to iodine. The client will not have a bolus of fluid, will not be asleep, and will not have a urinary catheter inserted, so answers B, C, and D are incorrect.

3. The physician has ordered an MRI for a client with an orthopedic ailment. An MRI should not be done if the client has:

The need for oxygen therapy

A history of claustrophobia

A permanent pacemaker

Sensory deafness

Clients with an internal defibrillator or a pacemaker should not have an MRI because it can cause dysrhythmias in the client with a pacemaker. If the client has a need for oxygen, is claustrophobic, or is deaf, he can have an MRI, but provisions such as extension tubes for the oxygen, sedatives, or a signal system should be made to accommodate these problems. Therefore, answers A, B, and D are incorrect.

Explanation

Clients with an internal defibrillator or a pacemaker should not have an MRI because it can cause dysrhythmias in the client with a pacemaker. If the client has a need for oxygen, is claustrophobic, or is deaf, he can have an MRI, but provisions such as extension tubes for the oxygen, sedatives, or a signal system should be made to accommodate these problems. Therefore, answers A, B, and D are incorrect.

4. Following a heart transplant, a client is started on medication to prevent organ rejection. Which category of medication prevents the formation of antibodies against the new organ?

Antivirals

Antibiotics

Immunosuppressants

Analgesics

Immunosuppressants are used to prevent antibody formation. Antivirals, antibiotics, and analgesics are not used to prevent antibody production, so answers A, B, and D are incorrect.

Explanation

Immunosuppressants are used to prevent antibody formation. Antivirals, antibiotics, and analgesics are not used to prevent antibody production, so answers A, B, and D are incorrect.

5. A client with Alzheimer’s disease is awaiting placement in a skilled nursing facility. Which long-term plans would be most therapeutic for the client?

Placing mirrors in several locations in the home

Placing a picture of herself in her bedroom

Placing simple signs to indicate the location of the bedroom, bathroom, and so on

Alternating healthcare workers to prevent boredom

Placing simple signs that indicate the location of rooms where the client sleeps, eats, and bathes will help the client be more independent. Providing mirrors and pictures is not recommended with the client who has Alzheimer’s disease because mirrors and pictures tend to cause agitation, and alternating healthcare workers confuses the client; therefore, answers A, B, and D are incorrect.

Explanation

Placing simple signs that indicate the location of rooms where the client sleeps, eats, and bathes will help the client be more independent. Providing mirrors and pictures is not recommended with the client who has Alzheimer’s disease because mirrors and pictures tend to cause agitation, and alternating healthcare workers confuses the client; therefore, answers A, B, and D are incorrect.

6. A client with an abdominal cholecystectomy returns from surgery with a Jackson-Pratt drain. The chief purpose of the Jackson-Pratt drain is to:

Prevent the need for dressing changes

Reduce edema at the incision

Provide for wound drainage

Keep the common bile duct open

A Jackson-Pratt drain is a serum-collection device commonly used in abdominal surgery. A Jackson-Pratt drain will not prevent the need for dressing changes, reduce edema of the incision, or keep the common bile duct open, so answers A, B, and D are incorrect. A t-tube is used to keep the common bile duct open.

Explanation

A Jackson-Pratt drain is a serum-collection device commonly used in abdominal surgery. A Jackson-Pratt drain will not prevent the need for dressing changes, reduce edema of the incision, or keep the common bile duct open, so answers A, B, and D are incorrect. A t-tube is used to keep the common bile duct open.

7. An adolescent primigravida who is 10 weeks pregnant attends the antepartal clinic for a first check-up. To develop a teaching plan, the nurse should initially assess:

The client’s knowledge of the signs of preterm labor

The client’s feelings about the pregnancy

Whether the client was using a method of birth control

The client’s thought about future children

The client who is 10 weeks pregnant should be assessed to determine how she feels about the pregnancy. It is too early to discuss preterm labor, too late to discuss whether she was using a method of birth control, and after the client delivers, a discussion of future children should be instituted. Thus, answers A, C, and D are incorrect.

Explanation

The client who is 10 weeks pregnant should be assessed to determine how she feels about the pregnancy. It is too early to discuss preterm labor, too late to discuss whether she was using a method of birth control, and after the client delivers, a discussion of future children should be instituted. Thus, answers A, C, and D are incorrect.

8. A client with pancreatic cancer has an infusion of TPN (Total Parenteral Nutrition). The doctor has ordered for sliding-scale insulin. The most likely explanation for this order is:

Total Parenteral Nutrition leads to negative nitrogen balance and elevated glucose levels.

Total Parenteral Nutrition cannot be managed with oral hypoglycemics.

Total Parenteral Nutrition is a high-glucose solution that often elevates the blood glucose levels.

Total Parenteral Nutrition leads to further pancreatic disease.

Total Parenteral Nutrition is a high-glucose solution. This therapy often causes the glucose levels to be elevated. Because this is a common complication, insulin might be ordered. Answers A, B, and D are incorrect. TPN is used to treat negative nitrogen balance; it will not lead to negative nitrogen balance. Total Parenteral Nutrition can be managed with oral hypoglycemic drugs, but it is difficult to do so. Total Parenteral Nutrition will not lead to further pancreatic disease.

Explanation

Total Parenteral Nutrition is a high-glucose solution. This therapy often causes the glucose levels to be elevated. Because this is a common complication, insulin might be ordered. Answers A, B, and D are incorrect. TPN is used to treat negative nitrogen balance; it will not lead to negative nitrogen balance. Total Parenteral Nutrition can be managed with oral hypoglycemic drugs, but it is difficult to do so. Total Parenteral Nutrition will not lead to further pancreatic disease.

9. A client tells the nurse that she is allergic to eggs, dogs, rabbits, and chicken feathers. Which order should the nurse question?

TB skin test

Rubella vaccine

ELISA test

Chest x-ray

The client who is allergic to dogs, eggs, rabbits, and chicken feathers is most likely allergic to the rubella vaccine. The client who is allergic to neomycin is also at risk. There is no danger to the client if he has an order for a TB skin test, ELISA test, or chest x-ray; thus, answers A, C, and D are incorrect.

Explanation

The client who is allergic to dogs, eggs, rabbits, and chicken feathers is most likely allergic to the rubella vaccine. The client who is allergic to neomycin is also at risk. There is no danger to the client if he has an order for a TB skin test, ELISA test, or chest x-ray; thus, answers A, C, and D are incorrect.

10. The nurse is caring for a client admitted with multiple trauma. Fractures include the pelvis, femur, and ulna. Which finding should be reported to the physician immediately?

Hematuria

Muscle spasms

Dizziness

Nausea

Hematuria in a client with a pelvic fracture can indicate trauma to the bladder or impending bleeding disorders. It is not unusual for the client to complain of muscles spasms with multiple fractures, so answer B is incorrect. Dizziness can be associated with blood loss and is nonspecific, making answer C incorrect. Nausea, as stated in answer D, is also common in the client with multiple traumas.

Explanation

Hematuria in a client with a pelvic fracture can indicate trauma to the bladder or impending bleeding disorders. It is not unusual for the client to complain of muscles spasms with multiple fractures, so answer B is incorrect. Dizziness can be associated with blood loss and is nonspecific, making answer C incorrect. Nausea, as stated in answer D, is also common in the client with multiple traumas.

11. While assessing the postpartal client, the nurse notes that the fundus is displaced to the right. Based on this finding, the nurse should:

Ask the client to void

Assess the blood pressure for hypotension

Administer oxytocin

Check for vaginal bleeding

If the nurse checks the fundus and finds it to be displaced to the right or left, this is an indication of a full bladder. This finding is not associated with hypotension or clots, as stated in answer B. Oxytoxic drugs (Pitocin) are drugs used to contract the uterus, so answer C is incorrect. It has nothing to do with displacement of the uterus. Answer D is incorrect because displacement is associated with a full bladder, not vaginal bleeding.

Explanation

If the nurse checks the fundus and finds it to be displaced to the right or left, this is an indication of a full bladder. This finding is not associated with hypotension or clots, as stated in answer B. Oxytoxic drugs (Pitocin) are drugs used to contract the uterus, so answer C is incorrect. It has nothing to do with displacement of the uterus. Answer D is incorrect because displacement is associated with a full bladder, not vaginal bleeding.

12. The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse understands that RhoGam is given to:

Provide immunity against Rh isoenzymes

Prevent the formation of Rh antibodies

Eliminate circulating Rh antibodies

Convert the Rh factor from negative to positive

RhoGam is used to prevent formation of Rh antibodies. It does not provide immunity to Rh isoenzymes, eliminate circulating Rh antibodies, or convert the Rh factor from negative to positive; thus, answers A, C, and D are incorrect.

Explanation

RhoGam is used to prevent formation of Rh antibodies. It does not provide immunity to Rh isoenzymes, eliminate circulating Rh antibodies, or convert the Rh factor from negative to positive; thus, answers A, C, and D are incorrect.

13. The nurse is caring for a client admitted to the emergency room after a fall. X-rays reveal that the client has several fractured bones in the foot. Which treatment should the nurse anticipate for the fractured foot?

Application of a short inclusive spica cast

Stabilization with a plaster-of-Paris cast

Surgery with Kirschner wire implantation

A gauze dressing only

A client with a fractured foot often has a short leg cast applied to stabilize the fracture. A spica cast is used to stabilize a fractured pelvis or vertebral fracture. Kirschner wires are used to stabilize small bones such as toes and the client will most likely have a cast or immobilizer, so answers A, C, and D are incorrect.

Explanation

A client with a fractured foot often has a short leg cast applied to stabilize the fracture. A spica cast is used to stabilize a fractured pelvis or vertebral fracture. Kirschner wires are used to stabilize small bones such as toes and the client will most likely have a cast or immobilizer, so answers A, C, and D are incorrect.

14. A client is brought to the emergency room by the police. He is combative and yells, "I have to get out of here. They are trying to kill me." Which assessment is most likely correct in relation to this statement?

The client is experiencing an auditory hallucination.

The client is having a delusion of grandeur.

The client is experiencing paranoid delusions.

The client is intoxicated.

The client’s statement "They are trying to kill me" indicates paranoid delusions. There is no data to indicate that the client is hearing voices or is intoxicated, so answers A and D are incorrect. Delusions of grandeur are fixed beliefs that the client is superior or perhaps a famous person, making answer B incorrect.

Explanation

The client’s statement "They are trying to kill me" indicates paranoid delusions. There is no data to indicate that the client is hearing voices or is intoxicated, so answers A and D are incorrect. Delusions of grandeur are fixed beliefs that the client is superior or perhaps a famous person, making answer B incorrect.

15. An infant’s Apgar score is 9 at 5 minutes. The nurse is aware that the most likely cause for the deduction of one point is:

The baby is cold.

The baby is experiencing bradycardia.

The baby’s hands and feet are blue.

The baby is lethargic.

Infants with an Apgar of 9 at 5 minutes most likely have acryocyanosis, a normal physiologic adaptation to birth. It is not related to the infant being cold, experiencing bradycardia, or being lethargic; thus, answers A, B, and D are incorrect.

Explanation

Infants with an Apgar of 9 at 5 minutes most likely have acryocyanosis, a normal physiologic adaptation to birth. It is not related to the infant being cold, experiencing bradycardia, or being lethargic; thus, answers A, B, and D are incorrect.

16. The nurse is preparing to discharge a client with a long history of polio. The nurse should tell the client that:

Taking a hot bath will decrease stiffness and spasticity.

A schedule of strenuous exercise will improve muscle strength.

Rest periods should be scheduled throughout the day

Visual disturbances can be corrected with prescription glasses.

The client with polio has muscle weakness. Periods of rest throughout the day will conserve the client’s energy. A hot bath can cause burns; however, a warm bath would be helpful, so answer A is incorrect. Strenuous exercises are not advisable, making answer B incorrect. Visual disturbances are directly associated with polio and cannot be corrected with glasses; therefore, answer D is incorrect.

Explanation

The client with polio has muscle weakness. Periods of rest throughout the day will conserve the client’s energy. A hot bath can cause burns; however, a warm bath would be helpful, so answer A is incorrect. Strenuous exercises are not advisable, making answer B incorrect. Visual disturbances are directly associated with polio and cannot be corrected with glasses; therefore, answer D is incorrect.

17. A client with pneumacystis carini pneumonia is receiving trimetrexate. The rationale for administering leucovorin calcium to a client receiving Methotrexate is to:

Treat anemia.

Create a synergistic effect.

Increase the number of white blood cells.

Reverse drug toxicity.

Methotrexate is a folic acid antagonist. Leucovorin is the drug given for toxicity to this drug. It is not used to treat iron-deficiency anemia, create a synergistic effects, or increase the number of circulating neutrophils. Therefore, answers A, B, and C are incorrect.

Explanation

Methotrexate is a folic acid antagonist. Leucovorin is the drug given for toxicity to this drug. It is not used to treat iron-deficiency anemia, create a synergistic effects, or increase the number of circulating neutrophils. Therefore, answers A, B, and C are incorrect.

18. The nurse is preparing a client for cataract surgery. The nurse is aware that the procedure will use:

Mydriatics to facilitate removal

Miotic medications such as Timoptic

A laser to smooth and reshape the lens

Silicone oil injections into the eyeball

Before cataract removal, the client will have Mydriatic drops instilled to dilate the pupil. This will facilitate removal of the lens. Miotics constrict the pupil and are not used in cataract clients. A laser is not used to smooth and reshape the lens; the diseased lens is removed. Silicone oil is not injected in this client; thus, answers B, C, and D are incorrect.

Explanation

Before cataract removal, the client will have Mydriatic drops instilled to dilate the pupil. This will facilitate removal of the lens. Miotics constrict the pupil and are not used in cataract clients. A laser is not used to smooth and reshape the lens; the diseased lens is removed. Silicone oil is not injected in this client; thus, answers B, C, and D are incorrect.

19. A client on the postpartum unit has a proctoepisiotomy. The nurse should anticipate administering which medication?

Dulcolax suppository

Docusate sodium (Colace)

Methyergonovine maleate (Methergine)

Bromocriptine sulfate (Parlodel)

The client with a protoepisiotomy will need stool softeners such as docusate sodium. Suppositories are given only with an order from the doctor, Methergine is a drug used to contract the uterus, and Parlodel is an anti-Parkinsonian drug; therefore, answers A, C, and D are incorrect.

Explanation

The client with a protoepisiotomy will need stool softeners such as docusate sodium. Suppositories are given only with an order from the doctor, Methergine is a drug used to contract the uterus, and Parlodel is an anti-Parkinsonian drug; therefore, answers A, C, and D are incorrect.

20. The physician has prescribed rantidine (Zantac) for a client with erosive gastritis. The nurse should administer the medication:

30 minutes before meals

With each meal

In a single dose at bedtime

60 minutes after meals

Zantac (rantidine) is a histamine blocker that should be given with meals for optimal effect, not before meals. However, Tagamet (cimetidine) is a histamine blocker that can be given in one dose at bedtime. Neither of these drugs should be given before or after meals, so answers A and D are incorrect.

Explanation

Zantac (rantidine) is a histamine blocker that should be given with meals for optimal effect, not before meals. However, Tagamet (cimetidine) is a histamine blocker that can be given in one dose at bedtime. Neither of these drugs should be given before or after meals, so answers A and D are incorrect.

21. An obstetric client is admitted with dehydration. Which IV fluid would be most appropriate for the client?

.45 normal saline

Dextrose 1% in water

Lactated Ringer’s

Dextrose 5% in .45 normal saline

The best IV fluid for correction of dehydration is normal saline because it is most like normal serum. Dextrose pulls fluid from the cell, lactated Ringer’s contains more electrolytes than the client’s serum, and dextrose with normal saline will also alter the intracellular fluid. Therefore, answers B, C, and D are incorrect.

Explanation

The best IV fluid for correction of dehydration is normal saline because it is most like normal serum. Dextrose pulls fluid from the cell, lactated Ringer’s contains more electrolytes than the client’s serum, and dextrose with normal saline will also alter the intracellular fluid. Therefore, answers B, C, and D are incorrect.

22. A temporary colostomy is performed on the client with colon cancer. The nurse is aware that the proximal end of a double barrel colostomy:

Is the opening on the client’s left side

Is the opening on the distal end on the client’s left side

Is the opening on the client’s right side

Is the opening on the distal right side

The proximal end of the double-barrel colostomy is the end toward the small intestines. This end is on the client’s right side. The distal end, as in answers A, B, and D, is on the client’s left side.

Explanation

The proximal end of the double-barrel colostomy is the end toward the small intestines. This end is on the client’s right side. The distal end, as in answers A, B, and D, is on the client’s left side.

23. A client with bladder cancer is being treated with iridium seed implants. The nurse’s discharge teaching should include telling the client to:

Strain his urine

Increase his fluid intake

Report urinary frequency

Avoid prolonged sitting

Iridium seeds can be expelled during urination, so the client should be taught to strain his urine and report to the doctor if any of the seeds are expelled. Increasing fluids, reporting urinary frequency, and avoiding prolonged sitting are not necessary; therefore, answers B, C, and D are incorrect.

Explanation

Iridium seeds can be expelled during urination, so the client should be taught to strain his urine and report to the doctor if any of the seeds are expelled. Increasing fluids, reporting urinary frequency, and avoiding prolonged sitting are not necessary; therefore, answers B, C, and D are incorrect.

24. A 6-month-old client is placed on strict bed rest following a hernia repair. Which toy is best suited to the client?

Colorful crib mobile

Hand-held electronic games

Cars in a plastic container

30-piece jigsaw puzzle

A 6-month-old is too old for the colorful mobile. He is too young to play with the electronic game or the 30-piece jigsaw puzzle. The best toy for this age is the cars in a plastic container, so answers A, B, and D are incorrect.

Explanation

A 6-month-old is too old for the colorful mobile. He is too young to play with the electronic game or the 30-piece jigsaw puzzle. The best toy for this age is the cars in a plastic container, so answers A, B, and D are incorrect.

25. The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect to find the presence of:

Mongolian spots

Scrotal rugae

Head lag

Vernix caseosa

The infant who is 32 weeks gestation will not be able to control his head, so head lag will be present. Mongolian spots are common in African American infants, not Caucasian infants; the client at 32 weeks will have scrotal rugae or redness but will not have vernix caseosa, the cheesy appearing covering found on most full-term infants. Therefore, answers A, B, and D are incorrect.

Explanation

The infant who is 32 weeks gestation will not be able to control his head, so head lag will be present. Mongolian spots are common in African American infants, not Caucasian infants; the client at 32 weeks will have scrotal rugae or redness but will not have vernix caseosa, the cheesy appearing covering found on most full-term infants. Therefore, answers A, B, and D are incorrect.