NCLEX RN Practice Questions 16 (Exam Mode) By RNpedia.Com

1. A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse's response is based on the knowledge that hemodialysis works by:

Eliminating plasma proteins from the blood

Lowering the pH by removing nonvolatile acids

Filtering waste through a dialyzing membrane

Passing water through a dialyzing membrane

Hemodialysis works by using a dialyzing membrane to filter waste that has accumulated in the blood. It does not pass water through a dialyzing membrane nor does it eliminate plasma proteins or lower the pH.

Explanation

Hemodialysis works by using a dialyzing membrane to filter waste that has accumulated in the blood. It does not pass water through a dialyzing membrane nor does it eliminate plasma proteins or lower the pH.

2. A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact?

The client should be placed in a room with negative pressure.

Infection requires close contact; therefore, the door may remain open.

Transmission is highly likely, so the client should wear a mask at all times.

Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown.

The client with MRSA should be placed in isolation. Gloves, a gown, and a mask should be used when caring for the client and hand washing is very important. The door should remain closed, but a negative-pressure room is not necessary. MRSA is spread by contact with blood or body fluid or by touching the skin of the client. It is cultured from the nasal passages of the client, so the client should be instructed to cover his nose and mouth when he sneezes or coughs. It is not necessary for the client to wear the mask at all times; the nurse should wear the mask.

Explanation

The client with MRSA should be placed in isolation. Gloves, a gown, and a mask should be used when caring for the client and hand washing is very important. The door should remain closed, but a negative-pressure room is not necessary. MRSA is spread by contact with blood or body fluid or by touching the skin of the client. It is cultured from the nasal passages of the client, so the client should be instructed to cover his nose and mouth when he sneezes or coughs. It is not necessary for the client to wear the mask at all times; the nurse should wear the mask.

3. The nurse is educating the lady's club in self-breast exam. The nurse is aware that most malignant breast masses occur in the Tail of Spence. On the diagram, the X mark is the Tail of Spence.

True

False

The explanation for the given correct answer is that the nurse is aware that most malignant breast masses occur in the Tail of Spence. This implies that it is important for women to be educated about self-breast exams and to pay special attention to the Tail of Spence during these exams. The diagram with the X mark indicates the location of the Tail of Spence, further emphasizing its significance in detecting breast abnormalities. Therefore, the statement "True" is correct.

Explanation

The explanation for the given correct answer is that the nurse is aware that most malignant breast masses occur in the Tail of Spence. This implies that it is important for women to be educated about self-breast exams and to pay special attention to the Tail of Spence during these exams. The diagram with the X mark indicates the location of the Tail of Spence, further emphasizing its significance in detecting breast abnormalities. Therefore, the statement "True" is correct.

4. A client with cancer of the pancreas has undergone a Whipple procedure. The nurse is aware that during the Whipple procedure, the doctor will remove the:

Head of the pancreas

Proximal third section of the small intestines

Stomach and duodenum

Esophagus and jejunum

During a Whipple procedure the head of the pancreas, which is a part of the stomach, the jejunum, and a portion of the stomach are removed and reanastomosed.The proximal third of the small intestine is not removed. The entire stomach is not removed, the esophagus is not removed.

Explanation

During a Whipple procedure the head of the pancreas, which is a part of the stomach, the jejunum, and a portion of the stomach are removed and reanastomosed.The proximal third of the small intestine is not removed. The entire stomach is not removed, the esophagus is not removed.

5. A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to:

Have a Protime done monthly

Eat more fruits and vegetables

Drink more liquids

Avoid crowds

Coumadin is an anticoagulant. One of the tests for bleeding time is a Protime. This test should be done monthly. Eating more fruits and vegetables is not necessary, and dark-green vegetables contain vitamin K, which increases clotting. Drinking more liquids and avoiding crowds is not necessary.

Explanation

Coumadin is an anticoagulant. One of the tests for bleeding time is a Protime. This test should be done monthly. Eating more fruits and vegetables is not necessary, and dark-green vegetables contain vitamin K, which increases clotting. Drinking more liquids and avoiding crowds is not necessary.

6. The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside?

A tracheotomy set

A padded tongue blade

An endotracheal tube

An airway

The client who has recently had a thyroidectomy is at risk for tracheal edema. A padded tongue blade is used for seizures and not for the client with tracheal edema. If the client experiences tracheal edema, the endotracheal tube or airway will not correct the problem.

Explanation

The client who has recently had a thyroidectomy is at risk for tracheal edema. A padded tongue blade is used for seizures and not for the client with tracheal edema. If the client experiences tracheal edema, the endotracheal tube or airway will not correct the problem.

7. The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:

Tire easily

Grow normally

Need more calories

Be more susceptible to viral infections

The toddler with a ventricular septal defect will tire easily. He will not grow normally but will not need more calories. He will be susceptible to bacterial infection, but he will be no more susceptible to viral infections than other children.

Explanation

The toddler with a ventricular septal defect will tire easily. He will not grow normally but will not need more calories. He will be susceptible to bacterial infection, but he will be no more susceptible to viral infections than other children.

8. The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:

Using oil- or cream-based soaps

Flossing between the teeth

The intake of salt

Using an electric razor

The client who is immune-suppressed and has bone marrow suppression should be taught not to floss his teeth because platelets are decreased. Using oils and cream-based soaps is allowed, as is eating salt and using an electric razor.

Explanation

The client who is immune-suppressed and has bone marrow suppression should be taught not to floss his teeth because platelets are decreased. Using oils and cream-based soaps is allowed, as is eating salt and using an electric razor.

9. The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to:

Turning the client to the left side

Milking the tube to ensure patency

Slowing the intravenous infusion

Notifying the physician

The output of 300mL is indicative of hemorrhage and should be reported immediately. Turning the client to the left side does nothing to help the client. Milking the tube is done only with an order and will not help in this situation, and slowing the intravenous infusion is not correct; thus, milking the tube to ensure patency and slowing the intravenous infusion are incorrect.

Explanation

The output of 300mL is indicative of hemorrhage and should be reported immediately. Turning the client to the left side does nothing to help the client. Milking the tube is done only with an order and will not help in this situation, and slowing the intravenous infusion is not correct; thus, milking the tube to ensure patency and slowing the intravenous infusion are incorrect.

10. The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:

Determine lung maturity

Measure the fetal activity

Show the effect of contractions on fetal heart rate

Measure the well-being of the fetus

A nonstress test determines periodic movement of the fetus. It does not determine lung maturity, show contractions, or measure neurological well-being, making other answer choices incorrect.

Explanation

A nonstress test determines periodic movement of the fetus. It does not determine lung maturity, show contractions, or measure neurological well-being, making other answer choices incorrect.

11. The primary reason for rapid continuous rewarming of the area affected by frostbite is to:

Lessen the amount of cellular damage

Prevent the formation of blisters

Promote movement

Prevent pain and discomfort

Rapid continuous rewarming of a frostbite primarily lessens cellular damage. It does not prevent formation of blisters. It does promote movement, but this is not the primary reason for rapid rewarming. It might increase pain for a short period of time as the feeling comes back into the extremity; therefore, other answer choices are incorrect.

Explanation

Rapid continuous rewarming of a frostbite primarily lessens cellular damage. It does not prevent formation of blisters. It does promote movement, but this is not the primary reason for rapid rewarming. It might increase pain for a short period of time as the feeling comes back into the extremity; therefore, other answer choices are incorrect.

12. The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to:

Apply the new tie before removing the old one.

Have a helper present.

Hold the tracheotomy with the nondominant hand while removing the old tie.

Ask the doctor to suture the tracheostomy in place.

The best method and safest way to change the ties of a tracheotomy is to apply the new ones before removing the old ones. Having a helper is good, but the helper might not prevent the client from coughing out the tracheotomy. Holding the tracheotomy with the nondominant hand while removing the old tie is not the best way to prevent the client from coughing out the tracheotomy. Asking the doctor to suture the tracheotomy in place is not appropriate.

Explanation

The best method and safest way to change the ties of a tracheotomy is to apply the new ones before removing the old ones. Having a helper is good, but the helper might not prevent the client from coughing out the tracheotomy. Holding the tracheotomy with the nondominant hand while removing the old tie is not the best way to prevent the client from coughing out the tracheotomy. Asking the doctor to suture the tracheotomy in place is not appropriate.

13. A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain?

"The pain will go away in a few days."

"The pain is due to peripheral nervous system interruptions. I will get you some pain medication."

"The pain is psychological because your foot is no longer there."

"The pain and itching are due to the infection you had before the surgery."

Pain related to phantom limb syndrome is due to peripheral nervous system interruption. Phantom limb pain can last several months or indefinitely. Phantom limb pain is not psychological. It is also not due to infections.

Explanation

Pain related to phantom limb syndrome is due to peripheral nervous system interruption. Phantom limb pain can last several months or indefinitely. Phantom limb pain is not psychological. It is also not due to infections.

14. The infant is admitted to the unit with tetrology of falot. The nurse would anticipate an order for which medication?

Digoxin

Epinephrine

Aminophyline

Atropine

The infant with tetrology of falot has five heart defects. He will be treated with digoxin to slow and strengthen the heart. Epinephrine, aminophyline, and atropine will speed the heart rate and are not used in this client.

Explanation

The infant with tetrology of falot has five heart defects. He will be treated with digoxin to slow and strengthen the heart. Epinephrine, aminophyline, and atropine will speed the heart rate and are not used in this client.

15. A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should:

Be injected into the deltoid muscle

Be injected into the abdomen

Aspirate after the injection

Clear the air from the syringe before injections

Lovenox injections should be given in the abdomen, not in the deltoid muscle. The client should not aspirate after the injection or clear the air from the syringe before injection.

Explanation

Lovenox injections should be given in the abdomen, not in the deltoid muscle. The client should not aspirate after the injection or clear the air from the syringe before injection.

16. A client with frequent urinary tract infections asks the nurse how she can prevent the reoccurrence. The nurse should teach the client to:

Douche after intercourse

Void every 3 hours

Obtain a urinalysis monthly

Wipe from back to front after voiding

Voiding every 3 hours prevents stagnant urine from collecting in the bladder, where bacteria can grow. Douching is not recommended and obtaining a urinalysis monthly is not necessary. The client should practice wiping from front to back after voiding and bowel movements.

Explanation

Voiding every 3 hours prevents stagnant urine from collecting in the bladder, where bacteria can grow. Douching is not recommended and obtaining a urinalysis monthly is not necessary. The client should practice wiping from front to back after voiding and bowel movements.

17. Which task should be assigned to the nursing assistant?

Placing the client in seclusion

Emptying the Foley catheter of the preeclamptic client

Feeding the client with dementia

Ambulating the client with a fractured hip

Of these clients, the one who should be assigned to the care of the nursing assistant is the client with dementia. Only an RN or the physician can place the client in seclusion. The nurse should empty the Foley catheter of the preeclamptic client because the client is unstable. A nurse or physical therapist should ambulate the client with a fractured hip.

Explanation

Of these clients, the one who should be assigned to the care of the nursing assistant is the client with dementia. Only an RN or the physician can place the client in seclusion. The nurse should empty the Foley catheter of the preeclamptic client because the client is unstable. A nurse or physical therapist should ambulate the client with a fractured hip.

18. During a home visit, a client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is most appropriate?

Administer an antibiotic

Contact the physician for an order for immune globulin

Administer an antiviral

Tell the client that he should remain in isolation for 2 weeks

The client who is immune-suppressed and is exposed to measles should be treated with medications to boost his immunity to the virus. An antibiotic or antiviral will not protect the client and it is too late to place the client in isolation.

Explanation

The client who is immune-suppressed and is exposed to measles should be treated with medications to boost his immunity to the virus. An antibiotic or antiviral will not protect the client and it is too late to place the client in isolation.

19. The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as:

Atrial flutter

A sinus rhythm

Ventricular tachycardia

Atrial fibrillation

The graph indicates ventricular tachycardia. Other answer choices are not noted on the ECG strip.

Explanation

The graph indicates ventricular tachycardia. Other answer choices are not noted on the ECG strip.

20. He physician has ordered a histoplasmosis test for the elderly client. The nurse is aware that histoplasmosis is transmitted to humans by:

Cats

Dogs

Turtles

Birds

Histoplasmosis is a fungus carried by birds. It is not transmitted to humans by cats, dogs, or turtles.

Explanation

Histoplasmosis is a fungus carried by birds. It is not transmitted to humans by cats, dogs, or turtles.

21. The nurse is evaluating the client who was admitted 8 hours ago for induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse?

Instruct the client to push

Perform a vaginal exam

Turn off the Pitocin infusion

Place the client in a semi-Fowler’s position

The monitor indicates variable decelerations caused by cord compression. If Pitocin is infusing, the nurse should turn off the Pitocin. Instructing the client to push is incorrect because pushing could increase the decelerations and because the client is 8cm dilated. Performing a vaginal exam should be done after turning off the Pitocin, and placing the client in a semi-Fowler’s position is not appropriate for this situation.

Explanation

The monitor indicates variable decelerations caused by cord compression. If Pitocin is infusing, the nurse should turn off the Pitocin. Instructing the client to push is incorrect because pushing could increase the decelerations and because the client is 8cm dilated. Performing a vaginal exam should be done after turning off the Pitocin, and placing the client in a semi-Fowler’s position is not appropriate for this situation.

22. The nurse has a preop order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The correct method of administering these medications is to:

Administer the medications together in one syringe

Administer the medication separately

Administer the Valium, wait 5 minutes, and then inject the Phenergan

Question the order because they cannot be given at the same time

Valium is not given in the same syringe with other medications. These medications can be given to the same client. Administering the Valium, wait 5 minutes, and then inject the Phenergan it is not necessary to wait to inject the second medication. Valium is an antianxiety medication, and Phenergan is used as an antiemetic.

Explanation

Valium is not given in the same syringe with other medications. These medications can be given to the same client. Administering the Valium, wait 5 minutes, and then inject the Phenergan it is not necessary to wait to inject the second medication. Valium is an antianxiety medication, and Phenergan is used as an antiemetic.

23. A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for:

Allergies to pineapples and bananas

A history of streptococcal infections

Prior therapy with phenytoin

A history of alcohol abuse

Clients with a history of streptococcal infections could have antibodies that render the streptokinase ineffective. There is no reason to assess the client for allergies to pineapples or bananas, there is no correlation to the use of phenytoin and streptokinase, and a history of alcohol abuse is also not a factor in the order for streptokinase; therefore, other answer choices are incorrect.

Explanation

Clients with a history of streptococcal infections could have antibodies that render the streptokinase ineffective. There is no reason to assess the client for allergies to pineapples or bananas, there is no correlation to the use of phenytoin and streptokinase, and a history of alcohol abuse is also not a factor in the order for streptokinase; therefore, other answer choices are incorrect.

24. The nurse is assisting the physician with removal of a central venous catheter. To facilitate removal, the nurse should instruct the client to:

Perform the Valsalva maneuver as the catheter is advanced

Turn his head to the left side and hyperextend the neck

Take slow, deep breaths as the catheter is removed

Turn his head to the right while maintaining a sniffing position

The client who is having a central venous catheter removed should be told to hold his breath and bear down. This prevents air from entering the line. Other answer choices will not facilitate removal.

Explanation

The client who is having a central venous catheter removed should be told to hold his breath and bear down. This prevents air from entering the line. Other answer choices will not facilitate removal.

25. The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to avoid eating:

Fruits

Salt

Pepper

Ketchup

Pepper is not processed and contains bacteria. Other answer choices are incorrect because fruits should be cooked or washed and peeled, and salt and ketchup are allowed.

Explanation

Pepper is not processed and contains bacteria. Other answer choices are incorrect because fruits should be cooked or washed and peeled, and salt and ketchup are allowed.