NCLEX Pn Practice Questions 4 (Exam Mode) By Rnpedia

1. The doctor has ordered Percocet (oxycodone) for a client following abdominal surgery. The primary objective of nursing care for the client receiving an opiate analgesic is to:

Prevent addiction

Alleviate pain

Facilitate mobility

Prevent nausea

The nurse should be concerned with alleviating the client’s pain.Other answer choices are not primary objectives in the care of the client receiving an opiate analgesic; therefore, they are incorrect.

Explanation

The nurse should be concerned with alleviating the client’s pain.Other answer choices are not primary objectives in the care of the client receiving an opiate analgesic; therefore, they are incorrect.

2. Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:

Record the pulse rate and administer the medication

Administer the medication and monitor the heart rate

Withhold the medication and notify the doctor

Withhold the medication until the heart rate increases

The medication should be withheld and the doctor should be notified. Other answer choices are incorrect because they do not provide for the client’s safety.

Explanation

The medication should be withheld and the doctor should be notified. Other answer choices are incorrect because they do not provide for the client’s safety.

3. A client is being treated for cancer with linear acceleration radiation. The physician has marked the radiation site with a blue marking pen. The nurse should:

Remove the unsightly markings with acetone or alcohol

Cover the radiation site with loose gauze dressing

Sprinkle baby powder over the radiated area

Refrain from using soap or lotion on the marked area

The nurse should not use water, soap, or lotion on the area marked for radiation therapy. Removing the unsightly markings with acetone or alcohol is incorrect because it would remove the marking. Covering the radiation site with loose gauze dressing and Sprinkling baby powder over the radiated area are not necessary for the client receiving radiation; therefore, they are incorrect.

Explanation

The nurse should not use water, soap, or lotion on the area marked for radiation therapy. Removing the unsightly markings with acetone or alcohol is incorrect because it would remove the marking. Covering the radiation site with loose gauze dressing and Sprinkling baby powder over the radiated area are not necessary for the client receiving radiation; therefore, they are incorrect.

4. The chart indicates that a client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with:

Speaking and writing

Comprehending spoken words

Carrying out purposeful motor activity

Recognizing and using an object correctly

The client with expressive aphasia has trouble forming words that are understandable. Comprehending spoken words is incorrect because it describes receptive aphasia. Carrying out purposeful motor activity refers to apraxia; therefore, it is incorrect. Recognizing and using an object correctly is incorrect because it refers to agnosia.

Explanation

The client with expressive aphasia has trouble forming words that are understandable. Comprehending spoken words is incorrect because it describes receptive aphasia. Carrying out purposeful motor activity refers to apraxia; therefore, it is incorrect. Recognizing and using an object correctly is incorrect because it refers to agnosia.

5. What information should the nurse give a new mother regarding the introduction of solid foods for her infant?

Solid foods should not be given until the extrusion reflex disappears, at 8–10 months of age.

Solid foods should be introduced one at a time, with 4- to 7-day intervals.

Solid foods can be mixed in a bottle or infant feeder to make feeding easier.

Solid foods should begin with fruits and vegetables.

Solid foods should be added to the diet one at a time, with 4- to 7-day intervals between new foods. The extrusion reflex fades at 3–4 months of age. Solids should not be added to the bottle and the use of infant feeders is discouraged. The first food added to the infant’s diet is rice cereal.

Explanation

Solid foods should be added to the diet one at a time, with 4- to 7-day intervals between new foods. The extrusion reflex fades at 3–4 months of age. Solids should not be added to the bottle and the use of infant feeders is discouraged. The first food added to the infant’s diet is rice cereal.

6. The nurse is caring for a client with a history of diverticulitis. The client complains of abdominal pain, fever, and diarrhea. Which food was responsible for the client's symptoms?

Mashed potatoes

Steamed carrots

Baked fish

Whole-grain cereal

Symptoms associated with diverticulitis are usually reported after eating popcorn, celery, raw vegetables, whole grains, and nuts. Other answer choices are incorrect because they are allowed in the diet of the client with diverticulitis.

Explanation

Symptoms associated with diverticulitis are usually reported after eating popcorn, celery, raw vegetables, whole grains, and nuts. Other answer choices are incorrect because they are allowed in the diet of the client with diverticulitis.

7. A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is:

Weight gain

Hair loss

Sore throat

Brittle nails

Side effects of Pulmozyme include sore throat, hoarseness, and laryngitis. Other answer choices are not associated with Pulmozyme; therefore, they are incorrect.

Explanation

Side effects of Pulmozyme include sore throat, hoarseness, and laryngitis. Other answer choices are not associated with Pulmozyme; therefore, they are incorrect.

8. A client with human immunodeficiency syndrome has gastrointestinal symptoms, including diarrhea. The nurse should teach the client to avoid:

Calcium-rich foods

Canned or frozen vegetables

Processed meat

Raw fruits and vegetables

The client with HIV should adhere to a low-bacteria diet by avoiding raw fruits and vegetables. Other answer choices are incorrect because they are permitted in the client’s diet.

Explanation

The client with HIV should adhere to a low-bacteria diet by avoiding raw fruits and vegetables. Other answer choices are incorrect because they are permitted in the client’s diet.

9. A 5-month-old is diagnosed with atopic dermatitis. Nursing interventions will focus on:

Preventing infection

Administering antipyretics

Keeping the skin free of moisture

Limiting oral fluid intake

The nurse should prevent the infant with atopic dermatitis (eczema) from scratching, which can lead to skin infections. Administering antipyretics is incorrect because fever is not associated with atopic dermatitis. Keeping the skin free of moisture and limiting oral fluid intake are incorrect because they increase dryness of the skin, which worsens the symptoms of atopic dermatitis.

Explanation

The nurse should prevent the infant with atopic dermatitis (eczema) from scratching, which can lead to skin infections. Administering antipyretics is incorrect because fever is not associated with atopic dermatitis. Keeping the skin free of moisture and limiting oral fluid intake are incorrect because they increase dryness of the skin, which worsens the symptoms of atopic dermatitis.

10. The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?

Reluctance to swallow

Drooling of blood-tinged saliva

An axillary temperature of 99°F

Respiratory stridor

Respiratory stridor is a symptom of partial airway obstruction. Other answer choices are expected with a tonsillectomy; therefore, they are incorrect.

Explanation

Respiratory stridor is a symptom of partial airway obstruction. Other answer choices are expected with a tonsillectomy; therefore, they are incorrect.

11. The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort lessens when he:

Skips a meal

Rests in recumbent position

Eats a meal

Sits upright after eating

Pain associated with duodenal ulcers is lessened if the client eats a meal or snack. Skipping a meal is incorrect because it makes the pain worse. Resting in recumbent position refers to dumping syndrome; therefore, it is incorrect. Siting upright after eating refers to gastroesophageal reflux; therefore, it is incorrect.

Explanation

Pain associated with duodenal ulcers is lessened if the client eats a meal or snack. Skipping a meal is incorrect because it makes the pain worse. Resting in recumbent position refers to dumping syndrome; therefore, it is incorrect. Siting upright after eating refers to gastroesophageal reflux; therefore, it is incorrect.

12. A post-operative client has an order for Demerol (meperidine) 75mg and Phenergan (promethazine) 25mg IM every 3–4 hours as needed for pain. The combination of the two medications produces a/an:

Agonist effect

Synergistic effect

Antagonist effect

Excitatory effect

The combination of the two medications produces an effect greater than that of either drug used alone. Agonist effects are similar to those produced by chemicals normally present in the body; therefore incorrect. Antagonist effects are those in which the actions of the drugs oppose one another; therefore incorrect. Excitatory effect is incorrect because the drugs would have a combined depressing, not excitatory, effect.

Explanation

The combination of the two medications produces an effect greater than that of either drug used alone. Agonist effects are similar to those produced by chemicals normally present in the body; therefore incorrect. Antagonist effects are those in which the actions of the drugs oppose one another; therefore incorrect. Excitatory effect is incorrect because the drugs would have a combined depressing, not excitatory, effect.

13. A 2-month-old infant has just received her first Tetramune injection. The nurse should tell the mother that the immunization:

Will need to be repeated when the child is 4 years of age

Is given to determine whether the child is susceptible to pertussis

Is one of a series of injections that protects against dpt and Hib

Is a one-time injection that protects against MMR and varicella

The immunization protects the child against diphtheria, pertussis, tetanus, and H. influenza b. A second injection is given before 4 years of age. Is given to determine whether the child is susceptible to pertussis is incorrect statement. It is not a one-time injection, nor does it protect against measles, mumps, rubella, or varicella.

Explanation

The immunization protects the child against diphtheria, pertussis, tetanus, and H. influenza b. A second injection is given before 4 years of age. Is given to determine whether the child is susceptible to pertussis is incorrect statement. It is not a one-time injection, nor does it protect against measles, mumps, rubella, or varicella.

14. A 4-year-old is admitted with acute leukemia. It will be most important to monitor the child for:

Abdominal pain and anorexia

Fatigue and bruising

Bleeding and pallor

Petechiae and mucosal ulcers

The child with leukemia has low platelet counts, which contribute to spontaneous bleeding. Other answer choices are common in the child with leukemia, are not life-threatening.

Explanation

The child with leukemia has low platelet counts, which contribute to spontaneous bleeding. Other answer choices are common in the child with leukemia, are not life-threatening.

15. A camp nurse is applying sunscreen to a group of children enrolled in swim classes. Chemical sunscreens are most effective when applied:

Just before sun exposure

5 minutes before sun exposure

15 minutes before sun exposure

30 minutes before sun exposure

Sunscreens of at least an SPF of 15 should be applied 20–30 minutes before going into the sun. Other answer choices are incorrect because they do not allow sufficient time for sun protection.

Explanation

Sunscreens of at least an SPF of 15 should be applied 20–30 minutes before going into the sun. Other answer choices are incorrect because they do not allow sufficient time for sun protection.

16. The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client's cancer is located in:

The tail of the pancreas

The head of the pancreas

The body of the pancreas

The entire pancreas

The Whipple procedure is performed for cancer located in the head of the pancreas. Other answer choices are not correct because of the location of the cancer.

Explanation

The Whipple procedure is performed for cancer located in the head of the pancreas. Other answer choices are not correct because of the location of the cancer.

17. A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should:

Apply a lanolin-based lotion to the skin

Wash the skin with water and pat dry

Cover the area with a petroleum gauze

Apply an occlusive dressing to the site

The client going for therapy in the hyperbaric oxygen chamber requires no special skin care; therefore, washing the skin with water and patting it dry are suitable. Lotions, petroleum products, perfumes, and occlusive dressings interfere with oxygenation of the skin; therefore they are incorrect.

Explanation

The client going for therapy in the hyperbaric oxygen chamber requires no special skin care; therefore, washing the skin with water and patting it dry are suitable. Lotions, petroleum products, perfumes, and occlusive dressings interfere with oxygenation of the skin; therefore they are incorrect.

18. A 2-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?

"Currant jelly" stools

Projectile vomiting

"Ribbonlike" stools

Palpable mass over the flank

The child with intussusception has stools that contain blood and mucus, which are described as "currant jelly" stools. Projectile vomiting is a symptom of pyloric stenosis; therefore, it is incorrect. "Ribbonlike" stools is a symptom of Hirschsprung’s; therefore, it is incorrect. Palpable mass over the flank is a symptom of Wilms tumor; therefore, it is incorrect.

Explanation

The child with intussusception has stools that contain blood and mucus, which are described as "currant jelly" stools. Projectile vomiting is a symptom of pyloric stenosis; therefore, it is incorrect. "Ribbonlike" stools is a symptom of Hirschsprung’s; therefore, it is incorrect. Palpable mass over the flank is a symptom of Wilms tumor; therefore, it is incorrect.

19. Which of the following meal selections is appropriate for the client with celiac disease?

Toast, jam, and apple juice

Peanut butter cookies and milk

Rice Krispies bar and milk

Cheese pizza and Kool-Aid

Foods containing rice or millet are permitted on the diet of the client with celiac disease. Other answer choices are not permitted because they contain flour made from wheat, which exacerbates the symptoms of celiac disease; therefore, they are incorrect.

Explanation

Foods containing rice or millet are permitted on the diet of the client with celiac disease. Other answer choices are not permitted because they contain flour made from wheat, which exacerbates the symptoms of celiac disease; therefore, they are incorrect.

20. The nurse is caring for a client hospitalized with bipolar disorder, manic phase. Which of the following snacks would be best for the client with mania?

Potato chips

Diet cola

Apple

Milkshake

The milkshake will provide needed calories and nutrients for the client with mania. Potato chips and diet cola are incorrect because they are high in sodium, which causes the client to excrete the lithium. Apple has some nutrient value, but not as much as the milkshake.

Explanation

The milkshake will provide needed calories and nutrients for the client with mania. Potato chips and diet cola are incorrect because they are high in sodium, which causes the client to excrete the lithium. Apple has some nutrient value, but not as much as the milkshake.

21. The nurse is caring for a client with acromegaly. Following a transphenoidal hypophysectomy, the nurse should:

Monitor the client’s blood sugar

Suction the mouth and pharynx every hour

Place the client in low Trendelenburg position

Encourage the client to cough

Growth hormone levels generally fall rapidly after a hypophysectomy, allowing insulin levels to rise. The result is hypoglycemia. Suctioning the mouth and pharynx every hour is incorrect because it traumatizes the oral mucosa. Placing the client in low Trendelenburg position is incorrect because the client’s head should be elevated to reduce pressure on the operative site. Encouraging the client to cough is incorrect because it increases pressure on the operative site that can lead to a leak of cerebral spinal fluid.

Explanation

Growth hormone levels generally fall rapidly after a hypophysectomy, allowing insulin levels to rise. The result is hypoglycemia. Suctioning the mouth and pharynx every hour is incorrect because it traumatizes the oral mucosa. Placing the client in low Trendelenburg position is incorrect because the client’s head should be elevated to reduce pressure on the operative site. Encouraging the client to cough is incorrect because it increases pressure on the operative site that can lead to a leak of cerebral spinal fluid.

22. A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:

Withholding all morning medications

Ordering a CBC and CPK

Administering prescribed anti-Parkinsonian medication

Transferring the client to a medical unit

The client’s symptoms suggest an adverse reaction to the medication known as neuroleptic malignant syndrome. Other answer choices are not appropriate.

Explanation

The client’s symptoms suggest an adverse reaction to the medication known as neuroleptic malignant syndrome. Other answer choices are not appropriate.

23. A client newly diagnosed with diabetes is started on Precose (acarbose). The nurse should tell the client that the medication should be taken:

1 hour before meals

30 minutes after meals

With the first bite of a meal

Daily at bedtime

Precose (acarbose) is to be taken with the first bite of a meal. Other answer choices are incorrect because they specify the wrong schedule for medication administration.

Explanation

Precose (acarbose) is to be taken with the first bite of a meal. Other answer choices are incorrect because they specify the wrong schedule for medication administration.

24. A client with hyperthyroidism is taking lithium carbonate to inhibit thyroid hormone release. Which complaint by the client should alert the nurse to a problem with the client's medication?

The client complains of blurred vision.

The client complains of increased thirst and increased urination.

The client complains of increased weight gain over the past year.

The client complains of ringing in the ears.

Increased thirst and increased urination are signs of lithium toxicity. Blurring of vision and ringing in the ears do not relate to the medication; therefore, they are incorrect. Increased weight gain is an expected side effect of the medication; therefore, it is incorrect.

Explanation

Increased thirst and increased urination are signs of lithium toxicity. Blurring of vision and ringing in the ears do not relate to the medication; therefore, they are incorrect. Increased weight gain is an expected side effect of the medication; therefore, it is incorrect.

25. A client with a laryngectomy returns from surgery with a nasogastric tube in place. The primary reason for placement of the nasogastric tube is to:

Prevent swelling and dysphagia

Decompress the stomach via suction

Prevent contamination of the suture line

Promote healing of the oral mucosa

The primary reason for the NG to is to allow for nourishment without contamination of the suture line. Preventing swelling and dysphagia is not a true statement; therefore, it is incorrect. Decompressing the stomach via suction is incorrect because there is no mention of suction. Promoting healing of the oral mucosa is incorrect because the oral mucosa was not involved in the laryngectomy.

Explanation

The primary reason for the NG to is to allow for nourishment without contamination of the suture line. Preventing swelling and dysphagia is not a true statement; therefore, it is incorrect. Decompressing the stomach via suction is incorrect because there is no mention of suction. Promoting healing of the oral mucosa is incorrect because the oral mucosa was not involved in the laryngectomy.