NCLEX Review Practice Questions! Quiz

1. A client receiving Lopressor 50mg IV should most importantly have which vital signs checked prior to administration?

Temperature

Respirations

Blood pressure, and heart rate

Pain

Prior to administration of Lopressor 50mg IV, it is most important to check the client's blood pressure and heart rate. Lopressor is a medication used to treat high blood pressure and certain heart conditions. It works by slowing down the heart rate and reducing the force of the heart's contractions. Therefore, it is crucial to assess the client's blood pressure and heart rate before administering Lopressor to ensure that the medication is appropriate and safe for the client. Checking the temperature, respirations, and pain are also important assessments, but they are not as directly related to the administration of Lopressor as blood pressure and heart rate.

Explanation

Prior to administration of Lopressor 50mg IV, it is most important to check the client's blood pressure and heart rate. Lopressor is a medication used to treat high blood pressure and certain heart conditions. It works by slowing down the heart rate and reducing the force of the heart's contractions. Therefore, it is crucial to assess the client's blood pressure and heart rate before administering Lopressor to ensure that the medication is appropriate and safe for the client. Checking the temperature, respirations, and pain are also important assessments, but they are not as directly related to the administration of Lopressor as blood pressure and heart rate.

2. The doctor has ordered a urinalysis with C & S (culture and sensitivity) on a in your care. She has an indwelling Foley catheter to bedside drainage. The way to obtain the specimen is to:

Separate the catheter from the drainage bag tubing and drain only from catheter.

Open the port on the holding bag and obtain approximately 100 cc to both tests.

Use a sterile needle and withdraw urine through the rubber port on the drainage tubing.

Empty the collecting bag and collect the next 100 cc that drains into the bag

The correct answer is to use a sterile needle and withdraw urine through the rubber port on the drainage tubing. This method ensures that the urine sample is collected directly from the catheter, without any contamination from the drainage bag or tubing. Using a sterile needle helps maintain the sterility of the sample and reduces the risk of introducing any bacteria or other microorganisms. This method is commonly used for obtaining urine specimens in patients with indwelling Foley catheters.

Explanation

The correct answer is to use a sterile needle and withdraw urine through the rubber port on the drainage tubing. This method ensures that the urine sample is collected directly from the catheter, without any contamination from the drainage bag or tubing. Using a sterile needle helps maintain the sterility of the sample and reduces the risk of introducing any bacteria or other microorganisms. This method is commonly used for obtaining urine specimens in patients with indwelling Foley catheters.

3. A client has an order to begin short-term therapy with enoxaparin(Lovenox). The nurse explains to the client that this medication isbeing ordered to:

Dissolve urinary calculi

Reduce the risk of deep vein thrombosis

Relieve migraine headaches

Stop progression of multiple sclerosis

Enoxaparin is an anticoagulant that is administered to prevent deep veinthrombosis and thromboembolism in selected clients at risk. It is not used totreat urinary calculi, migraine headaches, or multiple sclerosis

Explanation

Enoxaparin is an anticoagulant that is administered to prevent deep veinthrombosis and thromboembolism in selected clients at risk. It is not used totreat urinary calculi, migraine headaches, or multiple sclerosis

4. A client has been taking fosinopril (Monopril) for 2 months. The nursedetermines that the client is having the intended effects of therapy if the nurse notes which of the following?

Lowered BP

Lowered pulse rate

Increased WBC

Increased monocyte count

Monopril is an angiotensin-converting enzyme (ACE) inhibitor that lowersblood pressure. It can cause tachycardia as a side effect of therapy, making option b incorrect. Other side effects of the medication are neutropenia and agranulocytopenia, making options c and d incorrect

Explanation

Monopril is an angiotensin-converting enzyme (ACE) inhibitor that lowersblood pressure. It can cause tachycardia as a side effect of therapy, making option b incorrect. Other side effects of the medication are neutropenia and agranulocytopenia, making options c and d incorrect

5. You are caring for a patient who is newly diagnosed with Congestive Heart Failure CHF. Which statement by the patient would indicate that your patient teaching has been a success?

I will just smoke one half pack of cigarettes per day, as this is healthier than one pack

The correct answer indicates that the patient understands the importance of monitoring their weight and reporting any significant weight gain to their doctor. This is crucial in managing congestive heart failure as weight gain can be a sign of fluid retention, which can worsen the condition. By conducting daily weight checks and keeping a log, the patient can track any changes and seek medical attention promptly if necessary. This shows that the patient has grasped the importance of self-monitoring and taking proactive measures to manage their condition.

Explanation

The correct answer indicates that the patient understands the importance of monitoring their weight and reporting any significant weight gain to their doctor. This is crucial in managing congestive heart failure as weight gain can be a sign of fluid retention, which can worsen the condition. By conducting daily weight checks and keeping a log, the patient can track any changes and seek medical attention promptly if necessary. This shows that the patient has grasped the importance of self-monitoring and taking proactive measures to manage their condition.

6. Identify the ACE inhibitor.

Enalapril

Aspirin

Labetolol

Paracetamol

Enalapril is the ACE inhibitor in the given options. ACE inhibitors are a class of medications commonly used to treat high blood pressure and heart failure. Enalapril works by blocking the action of an enzyme called angiotensin-converting enzyme (ACE), which helps to relax blood vessels and lower blood pressure. Aspirin is not an ACE inhibitor but a nonsteroidal anti-inflammatory drug (NSAID) used for pain relief and reducing inflammation. Labetolol is a beta-blocker used to treat high blood pressure, while Paracetamol is a pain reliever and fever reducer.

Explanation

Enalapril is the ACE inhibitor in the given options. ACE inhibitors are a class of medications commonly used to treat high blood pressure and heart failure. Enalapril works by blocking the action of an enzyme called angiotensin-converting enzyme (ACE), which helps to relax blood vessels and lower blood pressure. Aspirin is not an ACE inhibitor but a nonsteroidal anti-inflammatory drug (NSAID) used for pain relief and reducing inflammation. Labetolol is a beta-blocker used to treat high blood pressure, while Paracetamol is a pain reliever and fever reducer.

7. The diabetic patient who had undergone abdominal surgery experiences wound evisceration. Which of the following is the most appropriate immediate nursing action?

Cover the wound with sterile gauze moistened with sterile normal saline

Cover the wound with sterile dry gauze

Cover the wound with water-soaked gauze

Leave the wound uncovered and pull the skin edges together

Wound evisceration should be covered with sterile dressings moistened with normal saline to prevent drying and necrosis of protruding abdominal organs

Explanation

Wound evisceration should be covered with sterile dressings moistened with normal saline to prevent drying and necrosis of protruding abdominal organs

8. The client has a bull eye's rash. what quesitons would you ask:

Have you been out of the country in 6 months

Have you found any ticks on your body recently

What have you ate or drank recently

Have you had a fever in the last few days

The presence of a bull's eye rash is commonly associated with Lyme disease, which is transmitted through tick bites. Asking if the client has found any ticks on their body recently helps to determine if they may have been exposed to Lyme disease. This information is crucial for making an accurate diagnosis and providing appropriate treatment.

Explanation

The presence of a bull's eye rash is commonly associated with Lyme disease, which is transmitted through tick bites. Asking if the client has found any ticks on their body recently helps to determine if they may have been exposed to Lyme disease. This information is crucial for making an accurate diagnosis and providing appropriate treatment.

9. Your client's daughter states, "I'm so glad my mother is taking Namenda (memantine). She will be cured of Alzheimer's disease." As the nurse, what do you say next?

Yes, this will cure her disease

Namenda is for Parkinson’s disease, not Alzheimer’s disease.

Namenda is used for treating diabetes, not Alzheimer’s disease.

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Explanation

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10. The nurse cares for a client taking isoniazid (INH) for the past 5 weeks. The client tells the nurse she has been experiencing tingling in her extremities and symmetrical numbness. The nurse knows that the patient is experiencing which common side effect of INH?

Peripheral neuropathy

Optic neuritis

Decreased circulation

Hypersensitivity

The client's symptoms of tingling and numbness in the extremities are consistent with peripheral neuropathy, which is a common side effect of isoniazid (INH) therapy. INH can cause damage to the peripheral nerves, leading to these symptoms. Optic neuritis is inflammation of the optic nerve and would present with visual disturbances, not tingling and numbness in the extremities. Decreased circulation would manifest as reduced blood flow to the extremities, causing coldness and pallor, not tingling and numbness. Hypersensitivity reactions would typically involve rash, itching, and swelling, not neurological symptoms like tingling and numbness.

Explanation

The client's symptoms of tingling and numbness in the extremities are consistent with peripheral neuropathy, which is a common side effect of isoniazid (INH) therapy. INH can cause damage to the peripheral nerves, leading to these symptoms. Optic neuritis is inflammation of the optic nerve and would present with visual disturbances, not tingling and numbness in the extremities. Decreased circulation would manifest as reduced blood flow to the extremities, causing coldness and pallor, not tingling and numbness. Hypersensitivity reactions would typically involve rash, itching, and swelling, not neurological symptoms like tingling and numbness.

11. This type of tort includes assult and battary, deframamtion of character, fraud, invasion of privacy, and false imprisonment-any willing act against a person that nterferes with their rights.

Intentional tort

Unintentional tort

The given correct answer is intentional tort. This type of tort refers to any willing act against a person that interferes with their rights. It includes assault and battery, defamation of character, fraud, invasion of privacy, and false imprisonment. In intentional torts, the person committing the act does so with the intention to cause harm or injury to another person.

Explanation

The given correct answer is intentional tort. This type of tort refers to any willing act against a person that interferes with their rights. It includes assault and battery, defamation of character, fraud, invasion of privacy, and false imprisonment. In intentional torts, the person committing the act does so with the intention to cause harm or injury to another person.

12. A nurse in a physician's office is reviewing the results of a client'sphenytoin (Dilantin) level drawn that morning. The nurse determinesthat the client has a therapeutic drug level if the client's result was:

3 mcg/ml

8 mcg/ml

15 mcg/ml

24 mcg/ml

The therapeutic range for serum phenytoin levels is 10 to 20 mcg/mL inclients with normal serum albumin levels and renal function. A level belowthis range indicates that the client is not receiving sufficient medication, andis at risk for seizure activity. In this case, the medication dose should beadjusted upward. A level above this range indicates that the client is enteringthe toxic range and is at risk for toxic side effects of the medication. In thiscase, the dose should be adjusted downward.

Explanation

The therapeutic range for serum phenytoin levels is 10 to 20 mcg/mL inclients with normal serum albumin levels and renal function. A level belowthis range indicates that the client is not receiving sufficient medication, andis at risk for seizure activity. In this case, the medication dose should beadjusted upward. A level above this range indicates that the client is enteringthe toxic range and is at risk for toxic side effects of the medication. In thiscase, the dose should be adjusted downward.

13. The nurse is conducting a group therapy session, and a client with a manic disorder is monopolizing the group. The appropriate nursing action is which of the following?

Ask the client to leave.

Refer the client to another group.

Tell the client to stop monopolizing

Thank the client for the contribution and tell him or her to allow others a chance to contribute

f a client is monopolizing the group, the nurse must be direct and decisive. The best action is to thank the client and suggest that the client stop talking and try listening to others. Although
option 3 may be a direct response, option 4 is a more specific and direct statement. Options 1 and 2 are inappropriate.
Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are comparative or alike. Use therapeutic communication techniques to assist in directing you to option 4. If you had difficulty with this question, review therapeutic communication techniques for the client with a manic disorder.

Explanation

f a client is monopolizing the group, the nurse must be direct and decisive. The best action is to thank the client and suggest that the client stop talking and try listening to others. Although
option 3 may be a direct response, option 4 is a more specific and direct statement. Options 1 and 2 are inappropriate.
Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are comparative or alike. Use therapeutic communication techniques to assist in directing you to option 4. If you had difficulty with this question, review therapeutic communication techniques for the client with a manic disorder.

14. The nurse will provide preoperative teaching on deep breathing, coughing and turning exercises. When is the best time to provide the preoperative teachings?

Before administration of preoperative medications

The afternoon or evening prior to surgery

Several days prior to surgery

Upon admission of the client in the recovery room

The best time to provide preoperative teaching is the afternoon or evening prior to surgery. This time, the patient had finished undergoing different laboratory and diagnostic procedures. Therefore, he/she can now concentrate on the teachings. Teachings given days before surgery may tend to be forgotten. Teachings given before administration of preoperative medications may not be understood anymore because the anxiety level more likely is high during this time

Explanation

The best time to provide preoperative teaching is the afternoon or evening prior to surgery. This time, the patient had finished undergoing different laboratory and diagnostic procedures. Therefore, he/she can now concentrate on the teachings. Teachings given days before surgery may tend to be forgotten. Teachings given before administration of preoperative medications may not be understood anymore because the anxiety level more likely is high during this time

15. To prevent complications of immobility, which activities would the nurse plan for the first postoperative day after a colon resection?

Turn, cough, and deep breathe every 30 minutes around the clock

Get the client out of bed and ambulate to a bedside chair

Provide passive range of motion three times a day

It is not necessary to worry about complications of immobility on the first postoperative day

Weight bearing increases the vascular tone and decreases venous stasis, thereby preventing thrombi from developing; the increase in activity increases respiratory expansion and quality of breathing

Explanation

Weight bearing increases the vascular tone and decreases venous stasis, thereby preventing thrombi from developing; the increase in activity increases respiratory expansion and quality of breathing

16. The nurse is caring for a client who is taking furosemide (Lasix), 40 mg daily. The client displays muscle weakness and electrocardiogram changes. Which of the following is essential for the nurse to assess at this time?

Intake and output

Daily weight

Potassium level

Skin turgor

The client's muscle weakness and electrocardiogram changes could be indicative of hypokalemia, a common side effect of furosemide. Furosemide is a loop diuretic that promotes the excretion of potassium in the urine. Therefore, it is essential for the nurse to assess the client's potassium level to determine if it is low and take appropriate actions to prevent complications associated with hypokalemia.

Explanation

The client's muscle weakness and electrocardiogram changes could be indicative of hypokalemia, a common side effect of furosemide. Furosemide is a loop diuretic that promotes the excretion of potassium in the urine. Therefore, it is essential for the nurse to assess the client's potassium level to determine if it is low and take appropriate actions to prevent complications associated with hypokalemia.

17. Which chamber of the heart pumps oxygenated blood back into the circulatory system?

Right atrium

Right ventricle

Tricuspid valve

Left ventricle

The left ventricle pumps blood into the systemic circulation. The right atrium pumps blood to the right ventricle. The tricuspid valve is not a heart chamber. The right ventricle pumps blood to the lungs.

Explanation

The left ventricle pumps blood into the systemic circulation. The right atrium pumps blood to the right ventricle. The tricuspid valve is not a heart chamber. The right ventricle pumps blood to the lungs.

18. The name for the volume of blood in the ventricle immediately before it is ejected is:

Preload

Afterload

Contractility

Automaticity

The correct answer is preload.Afterload is the resistance that the LV must pump against. Contractility is the squeezing ability of the LV.Automaticity is what allows the SA node to initiate an impulse.

Explanation

The correct answer is preload.Afterload is the resistance that the LV must pump against. Contractility is the squeezing ability of the LV.Automaticity is what allows the SA node to initiate an impulse.

19. The Nurse Practice act and American disablity act is what kind of law?

Common law

Statutory law

Common law

The Nurse Practice Act and the American Disability Act are both examples of statutory law. Statutory law refers to laws that are enacted by a legislative body, such as a state or federal government, and are written down in statutes or codes. These laws are created to regulate specific areas or industries, in this case, nursing practice and disability rights. The Nurse Practice Act establishes the legal framework for nursing practice, while the American Disability Act protects the rights of individuals with disabilities. Both acts were passed by legislative bodies and are considered statutory laws.

Explanation

The Nurse Practice Act and the American Disability Act are both examples of statutory law. Statutory law refers to laws that are enacted by a legislative body, such as a state or federal government, and are written down in statutes or codes. These laws are created to regulate specific areas or industries, in this case, nursing practice and disability rights. The Nurse Practice Act establishes the legal framework for nursing practice, while the American Disability Act protects the rights of individuals with disabilities. Both acts were passed by legislative bodies and are considered statutory laws.

20. The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal. Which of the following would alert the nurse to the potential for withdrawal delirium?

Hypotension, ataxia, hunger

Stupor, agitation, muscular rigidity

Hypotension, coarse hand tremors, agitation

Hypertension, changes in level of consciousness, hallucinations

Some of the symptoms associated with withdrawal delirium typically are anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions.
Test-Taking Strategy: Use the process of elimination. Review each option carefully to ensure that all the symptoms in the option are correct. Eliminate options 1 and 3 first, knowing that hypertension rather than hypotension occurs. From the remaining options, recalling that the client who is stuporous is not likely to exhibit withdrawal delirium will direct you to option 4. Review these symptoms if you had difficulty with this question.

Explanation

Some of the symptoms associated with withdrawal delirium typically are anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions.
Test-Taking Strategy: Use the process of elimination. Review each option carefully to ensure that all the symptoms in the option are correct. Eliminate options 1 and 3 first, knowing that hypertension rather than hypotension occurs. From the remaining options, recalling that the client who is stuporous is not likely to exhibit withdrawal delirium will direct you to option 4. Review these symptoms if you had difficulty with this question.

21. A client with a history of coronary artery disease begins to experience chest pain. After putting the client on bedrest and administering a nitroglycerin tablet sublingually, which intervention should the nurse implement first?

A. Calling the health care provider

Checking the heart's creatine kinase MB (CK-MB) level

Getting a 12-lead electrocardiogram (ECG)

Preparing the client for angioplasty

For the client experiencing chest pain, obtaining a 12-lead ECG is a priority to reveal possible changes occurring during an acute anginal attack that will be helpful in treatment. Before calling the health care provider, the nurse should obtain the results of the 12-lead ECG so that these results can be communicated to him. A CK-MB level may be ordered later and the client may need angioplasty in the near future, but getting the 12-lead ECG during the chest pain is the most important priority.

Explanation

For the client experiencing chest pain, obtaining a 12-lead ECG is a priority to reveal possible changes occurring during an acute anginal attack that will be helpful in treatment. Before calling the health care provider, the nurse should obtain the results of the 12-lead ECG so that these results can be communicated to him. A CK-MB level may be ordered later and the client may need angioplasty in the near future, but getting the 12-lead ECG during the chest pain is the most important priority.

22. Assessment that focuses on past medical history, family history, reason for admission, medications currently taking, previous hospitalization, surgeries, psyhosocial assessment, nutrition, complete physical assessment

Initial assessment

Focus assessment

Emergency assessment

The correct answer is initial assessment. The given list of information and assessments, such as past medical history, family history, reason for admission, etc., are all components of an initial assessment. This type of assessment is typically conducted when a patient is first admitted to a healthcare facility to gather comprehensive information about their medical background and current condition. It helps healthcare professionals establish a baseline for the patient's care and develop an appropriate treatment plan.

Explanation

The correct answer is initial assessment. The given list of information and assessments, such as past medical history, family history, reason for admission, etc., are all components of an initial assessment. This type of assessment is typically conducted when a patient is first admitted to a healthcare facility to gather comprehensive information about their medical background and current condition. It helps healthcare professionals establish a baseline for the patient's care and develop an appropriate treatment plan.

23. Oxybutynin (ditropan) may be prescribed for which of the following postoperative complications

Nausea

Pain

Bladder spasm

Bleeding

Oxybutynin (ditropan) may be prescribed for postoperative bladder spasms. Bladder spasms are involuntary contractions of the bladder muscles, which can cause discomfort and urgency. Oxybutynin is an anticholinergic medication that helps relax the bladder muscles and reduce spasms. It is commonly used to treat overactive bladder and urinary incontinence, but it can also be prescribed postoperatively to relieve bladder spasms that may occur as a complication of surgery.

Explanation

Oxybutynin (ditropan) may be prescribed for postoperative bladder spasms. Bladder spasms are involuntary contractions of the bladder muscles, which can cause discomfort and urgency. Oxybutynin is an anticholinergic medication that helps relax the bladder muscles and reduce spasms. It is commonly used to treat overactive bladder and urinary incontinence, but it can also be prescribed postoperatively to relieve bladder spasms that may occur as a complication of surgery.

24. A client is to receive conscious sedation for a minor surgical procedure. Which drug administration should the nurse expect?

Benztropine (Cogentin)

Nitroprusside (Nipride)

Clonidine (Catapres)

Propofol (Diprivan)

The nurse should expect to administer Propofol (Diprivan) for conscious sedation during the minor surgical procedure. Propofol is a short-acting sedative-hypnotic medication that provides sedation and anesthesia. It is commonly used for procedures that require conscious sedation due to its rapid onset and short duration of action. Benztropine is an anticholinergic medication used to treat side effects of antipsychotic medications, nitroprusside is a vasodilator used to lower blood pressure, and clonidine is an alpha-2 adrenergic agonist used to treat hypertension. These medications are not typically used for conscious sedation during surgical procedures.

Explanation

The nurse should expect to administer Propofol (Diprivan) for conscious sedation during the minor surgical procedure. Propofol is a short-acting sedative-hypnotic medication that provides sedation and anesthesia. It is commonly used for procedures that require conscious sedation due to its rapid onset and short duration of action. Benztropine is an anticholinergic medication used to treat side effects of antipsychotic medications, nitroprusside is a vasodilator used to lower blood pressure, and clonidine is an alpha-2 adrenergic agonist used to treat hypertension. These medications are not typically used for conscious sedation during surgical procedures.

25. Oral hypoglycemic drugs do not work for type 1 DM

True

False

People with type II diabetes mellitus should have a preprandial blood sugar below 110 mg/dl

Explanation

People with type II diabetes mellitus should have a preprandial blood sugar below 110 mg/dl

26. The nurse has been doing medication education for the client receiving atenolol (Tenormin), a beta-blocker. The nurse determines that learning has occurred when the client makes which statement?

“I need to take my pulse every day.”

"I cannot take this drug if I develop glaucoma.”

“If I have any side effects, I will stop the medication.”

“I cannot continue to have my morning cup of coffee.”

The correct answer is "I need to take my pulse every day." This statement indicates that the client has understood the importance of monitoring their pulse while taking atenolol, as beta-blockers can lower heart rate. Monitoring the pulse can help assess the effectiveness and safety of the medication. The other statements are incorrect because the client can still take atenolol if they develop glaucoma, they should not stop the medication if they experience side effects without consulting their healthcare provider, and they can continue to have their morning cup of coffee, although they may need to be cautious about the potential interaction between caffeine and atenolol.

Explanation

The correct answer is "I need to take my pulse every day." This statement indicates that the client has understood the importance of monitoring their pulse while taking atenolol, as beta-blockers can lower heart rate. Monitoring the pulse can help assess the effectiveness and safety of the medication. The other statements are incorrect because the client can still take atenolol if they develop glaucoma, they should not stop the medication if they experience side effects without consulting their healthcare provider, and they can continue to have their morning cup of coffee, although they may need to be cautious about the potential interaction between caffeine and atenolol.

27. This step of the nursing process includes the systematic collection of all subjective and objective data about the client in which the nurse focuses holistically on the client- physical, psychological, emotional, sociocultural, and spirtual.

Assessment

Planning

Implementation

Diagnosis

Assessment is the correct answer because it involves the systematic collection of subjective and objective data about the client. During this step of the nursing process, the nurse gathers information about the client's physical, psychological, emotional, sociocultural, and spiritual aspects. This comprehensive approach allows the nurse to have a holistic understanding of the client's health status and needs, which is essential for developing an effective care plan.

Explanation

Assessment is the correct answer because it involves the systematic collection of subjective and objective data about the client. During this step of the nursing process, the nurse gathers information about the client's physical, psychological, emotional, sociocultural, and spiritual aspects. This comprehensive approach allows the nurse to have a holistic understanding of the client's health status and needs, which is essential for developing an effective care plan.

28. The manic client announces to everyone in the dayroom that a stripper is coming to perform this evening. When the nurse firmly states that this will not happen, the manic client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, the nurse determines that the appropriate action would be to:

Orient the client to time, person, and place.

Tell the client that the behavior is not appropriate.

Escort the manic client to her room, with assistance.

Tell the client that smoking privileges are revoked for 24 hours.

The client is at risk for injury to self and others and therefore should be escorted out of the dayroom. Antipsychotic medications are useful to manage the manic client. Hyperactive and agitated behavior usually responds to haloperidol (Haldol). Option 4 may increase the agitation that already exists in this client. Orientation will not halt the behavior. Telling the client that the behavior is not appropriate already has been attempted by the nurse. Test-Taking Strategy: Use the process of elimination and Maslow's Hierarchy of Needs theory to answer the question. Look for the option that promotes safety of the client, other clients, and staff. If you had difficulty with this question, review the appropriate interventions when dealing with a manic client.

Explanation

The client is at risk for injury to self and others and therefore should be escorted out of the dayroom. Antipsychotic medications are useful to manage the manic client. Hyperactive and agitated behavior usually responds to haloperidol (Haldol). Option 4 may increase the agitation that already exists in this client. Orientation will not halt the behavior. Telling the client that the behavior is not appropriate already has been attempted by the nurse. Test-Taking Strategy: Use the process of elimination and Maslow's Hierarchy of Needs theory to answer the question. Look for the option that promotes safety of the client, other clients, and staff. If you had difficulty with this question, review the appropriate interventions when dealing with a manic client.

29. The client is admitted to the mental health unit with a diagnosis of schizophrenia. A nursing diagnosis formulated for the client is thought processes, disturbed related to paranoia. In formulating nursing interventions with the members of the health care team, the nurse provides instructions to:

Increase socialization of the client with peers.

Avoid laughing or whispering in front of the client.

Begin to educate the client about social supports in the community.

Disturbed thought process related to paranoia is the client's problem, and the plan of care must address this problem. The client is experiencing paranoia and is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Therefore, laughing or whispering in front of the client would be counterproductive. Options 1, 3, and 4 ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client who is paranoid. Test-Taking Strategy: Use the process of elimination and knowledge regarding this disorder to answer the question. Noting that the client has paranoia will direct you to option 2. Review this disorder if you had difficulty with this question.

Explanation

Disturbed thought process related to paranoia is the client's problem, and the plan of care must address this problem. The client is experiencing paranoia and is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Therefore, laughing or whispering in front of the client would be counterproductive. Options 1, 3, and 4 ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client who is paranoid. Test-Taking Strategy: Use the process of elimination and knowledge regarding this disorder to answer the question. Noting that the client has paranoia will direct you to option 2. Review this disorder if you had difficulty with this question.

30. The client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." The therapeutic response by the nurse is:

“Have you shared your feelings with your family?”

“I think we should talk more about your anger with your family.”

“You're feeling angry that your family continues to hope for you to be cured?”

“Well, it sounds like you're being pretty pessimistic. After all, years ago, people died of pneumonia.”

Restating is the therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review what was said. Option 3 uses the therapeutic technique of restating. In option 1, the nurse is attempting to assess the client's ability to discuss feelings openly with family members.
In option 2, the nurse attempts to use focusing, but the attempt to discuss central issues is premature. In option 4, the nurse makes a judgment and is nontherapeutic in the one-to-one relationship. Test-Taking Strategy: Use therapeutic communication techniques to answer the question. Option 3 is the only option that identifies the use of a therapeutic technique and focuses on the client's feelings. Review these techniques if you had difficulty with this question.

Explanation

Restating is the therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review what was said. Option 3 uses the therapeutic technique of restating. In option 1, the nurse is attempting to assess the client's ability to discuss feelings openly with family members.
In option 2, the nurse attempts to use focusing, but the attempt to discuss central issues is premature. In option 4, the nurse makes a judgment and is nontherapeutic in the one-to-one relationship. Test-Taking Strategy: Use therapeutic communication techniques to answer the question. Option 3 is the only option that identifies the use of a therapeutic technique and focuses on the client's feelings. Review these techniques if you had difficulty with this question.

31. Nadolol (Corgard) is prescribed for a patient with coronary artery disease. In evaluating the effectiveness of the drug, the nurse would expect to find

Increased urinary output and increased peripheral pulses.

Decreased heart rate, decreased blood pressure, and relief of chest pain.

Decreased respirations, increased diastolic pressure, and relief of chest pain

Decreased blood pressure, increased heart rate, and reduced coronary vasospasm.

Nadolol is a beta-blocker medication that is commonly prescribed for patients with coronary artery disease. It works by blocking the effects of adrenaline, which helps to slow down the heart rate and reduce blood pressure. By doing so, it can relieve chest pain that is caused by reduced blood flow to the heart. Therefore, the nurse would expect to find a decreased heart rate, decreased blood pressure, and relief of chest pain as indicators of the drug's effectiveness in treating coronary artery disease.

Explanation

Nadolol is a beta-blocker medication that is commonly prescribed for patients with coronary artery disease. It works by blocking the effects of adrenaline, which helps to slow down the heart rate and reduce blood pressure. By doing so, it can relieve chest pain that is caused by reduced blood flow to the heart. Therefore, the nurse would expect to find a decreased heart rate, decreased blood pressure, and relief of chest pain as indicators of the drug's effectiveness in treating coronary artery disease.

32. A patient is admitted with DT's to a private room. What is the nursing intervention priority?

Administer thiamine and zinc

Seizure precautions in place

Make sure the room is quiet and dark

Administer Valium

The nursing intervention priority in this scenario is to implement seizure precautions. DT's (delirium tremens) is a severe alcohol withdrawal symptom that can lead to seizures. Implementing seizure precautions, such as padding the bed and removing any potential hazards from the room, is crucial to ensure the safety of the patient. Administering thiamine and zinc, making the room quiet and dark, and administering Valium may also be necessary interventions, but they are not the priority in this case.

Explanation

The nursing intervention priority in this scenario is to implement seizure precautions. DT's (delirium tremens) is a severe alcohol withdrawal symptom that can lead to seizures. Implementing seizure precautions, such as padding the bed and removing any potential hazards from the room, is crucial to ensure the safety of the patient. Administering thiamine and zinc, making the room quiet and dark, and administering Valium may also be necessary interventions, but they are not the priority in this case.

33. The nurse is caring for a client with congestive heart failure. Furosemide (Lasix) is ordered for this patient by the health-care provider. The nurse understands this medication is given to produce which of the following outcomes?

To reduce oxygen requirements by the cardiac tissue

To improve cardiac output to the tissues

To increase sodium retention in the plasma

To reduce circulating fluid volume

Answer D is correct because furosemide will cause diuresis, reducing circulating blood volume by reducing blood plasma.

Explanation

Answer D is correct because furosemide will cause diuresis, reducing circulating blood volume by reducing blood plasma.

34. The nurse instructs a client receiving oral acyclovir (Zovirax). The nurse determines teaching is effective if the client states which of the following?

“If I miss a dose of medication, I can double up the next dose.”

“I should avoid sexual contact while I have lesions.”

“I’m glad this medication will cure me.”

“I must take this medication with food.”

The correct answer is "I should avoid sexual contact while I have lesions." This is the correct statement because acyclovir is used to treat viral infections, including herpes. Herpes is a sexually transmitted infection, and the medication helps to reduce the severity and duration of outbreaks. Avoiding sexual contact while having lesions is important to prevent transmission of the virus to others. The other statements are incorrect because doubling up on a missed dose can lead to overdose, acyclovir does not cure herpes but helps manage symptoms, and taking the medication with food is not necessary.

Explanation

The correct answer is "I should avoid sexual contact while I have lesions." This is the correct statement because acyclovir is used to treat viral infections, including herpes. Herpes is a sexually transmitted infection, and the medication helps to reduce the severity and duration of outbreaks. Avoiding sexual contact while having lesions is important to prevent transmission of the virus to others. The other statements are incorrect because doubling up on a missed dose can lead to overdose, acyclovir does not cure herpes but helps manage symptoms, and taking the medication with food is not necessary.

35. Which cholinergic agent would be used to treat non-obstructive urinary retention?

Labetolol

Atropine

Bethanachol

Dopamine

BETHANECHOL. INDICATIONS: acute postoperative or postpartum non-obstructive urinary retention; neurogenic atony of the bladder with retention. ACTION: Acts directly on cholinergic receptors tomimic the effects of acetylcholine; increases tone of detrusor muscles and causes emptying of the bladder. Is given ORALLY. ADVERSE EFFECTS: Abdominal discomfort, salivation, nausea, vomiting, sweating, and flushing. ASSESSMENT would include bradycardia, vasomotor instability, peptic ulcer, obstructive urinary or GI diseases, asthma, parkinsonism or epilepsy. BASELINE ASSESSMENT includes skin colour, lesions, temperature; pulse, blood pressure, ECG; respirations, adventitious sounds; and urine output and bladder tone

Explanation

BETHANECHOL. INDICATIONS: acute postoperative or postpartum non-obstructive urinary retention; neurogenic atony of the bladder with retention. ACTION: Acts directly on cholinergic receptors tomimic the effects of acetylcholine; increases tone of detrusor muscles and causes emptying of the bladder. Is given ORALLY. ADVERSE EFFECTS: Abdominal discomfort, salivation, nausea, vomiting, sweating, and flushing. ASSESSMENT would include bradycardia, vasomotor instability, peptic ulcer, obstructive urinary or GI diseases, asthma, parkinsonism or epilepsy. BASELINE ASSESSMENT includes skin colour, lesions, temperature; pulse, blood pressure, ECG; respirations, adventitious sounds; and urine output and bladder tone

36. Gingival hyperplasia is an oral condition possible in up to 50% of children using

Phentobarbital

Phenytoin (Dilantin)

Pentobarbital

Valproic acid (Depakote)

Gingival hyperplasia is a condition characterized by an overgrowth of gum tissue. It is a potential side effect of certain medications, including phenytoin (Dilantin). This medication is commonly used to treat seizures and epilepsy in children. It is estimated that up to 50% of children using phenytoin may develop gingival hyperplasia. The exact mechanism by which phenytoin causes this condition is not fully understood, but it is thought to involve an increase in the production of collagen, a protein that forms connective tissue. Other medications listed, such as phentobarbital, pentobarbital, and valproic acid, do not have a known association with gingival hyperplasia.

Explanation

Gingival hyperplasia is a condition characterized by an overgrowth of gum tissue. It is a potential side effect of certain medications, including phenytoin (Dilantin). This medication is commonly used to treat seizures and epilepsy in children. It is estimated that up to 50% of children using phenytoin may develop gingival hyperplasia. The exact mechanism by which phenytoin causes this condition is not fully understood, but it is thought to involve an increase in the production of collagen, a protein that forms connective tissue. Other medications listed, such as phentobarbital, pentobarbital, and valproic acid, do not have a known association with gingival hyperplasia.

37. The nurse is caring for a client who is taking atorvastatin (Lipitor), a "statin" for high-cholesterol level. The nurse must teach the client to report any muscle weakness or pain immediately because this could be a sign of this rare, but serious, adverse effect.

Multiple sclerosis

Myasthenia gravis

Rhabdomyolitis

The nurse must teach the client to report any muscle weakness or pain immediately because this could be a sign of rhabdomyolitis, a rare but serious adverse effect of taking atorvastatin (Lipitor). Rhabdomyolitis is a condition characterized by the breakdown of muscle tissue, leading to muscle weakness, pain, and potentially kidney damage. It is important for the client to report these symptoms promptly so that appropriate medical intervention can be provided to prevent further complications. Multiple sclerosis and myasthenia gravis are not associated with the use of statins and would not explain the muscle weakness or pain in this scenario.

Explanation

The nurse must teach the client to report any muscle weakness or pain immediately because this could be a sign of rhabdomyolitis, a rare but serious adverse effect of taking atorvastatin (Lipitor). Rhabdomyolitis is a condition characterized by the breakdown of muscle tissue, leading to muscle weakness, pain, and potentially kidney damage. It is important for the client to report these symptoms promptly so that appropriate medical intervention can be provided to prevent further complications. Multiple sclerosis and myasthenia gravis are not associated with the use of statins and would not explain the muscle weakness or pain in this scenario.

38. A post burn injury client should have what type of diet:

High protein,high sodium,high carbs

High protein,low sodium,low carbs

Low fat,high calories,high sodium

Low calorie,low fat, low protein

A post burn injury client should have a high protein diet to promote wound healing and tissue repair. Protein is essential for the production of collagen, which is necessary for skin regeneration. Additionally, a high sodium diet may be recommended to replace the electrolytes lost through sweating and to maintain fluid balance. Lastly, a high carbohydrate diet is important to provide the necessary energy for the body to heal and recover.

Explanation

A post burn injury client should have a high protein diet to promote wound healing and tissue repair. Protein is essential for the production of collagen, which is necessary for skin regeneration. Additionally, a high sodium diet may be recommended to replace the electrolytes lost through sweating and to maintain fluid balance. Lastly, a high carbohydrate diet is important to provide the necessary energy for the body to heal and recover.

39. The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to:

Remove the electrodes to shower or bathe.

Exercise as much as possible while his monitor is in place

Attach the recorder and call the assigned number if an episode of irregular heart beats occurs.

Keep a diary of his activities as long as he wears the monitor.

The nurse teaches the patient to keep a diary of his activities as long as he wears the monitor. This is because the Holter monitor is used to continuously record the patient's heart rhythm for a period of time, usually 24 to 48 hours. Keeping a diary of activities helps to correlate any symptoms or irregular heart beats with specific activities or events. This information is important for the healthcare provider to analyze the recorded data and make an accurate diagnosis or determine appropriate treatment.

Explanation

The nurse teaches the patient to keep a diary of his activities as long as he wears the monitor. This is because the Holter monitor is used to continuously record the patient's heart rhythm for a period of time, usually 24 to 48 hours. Keeping a diary of activities helps to correlate any symptoms or irregular heart beats with specific activities or events. This information is important for the healthcare provider to analyze the recorded data and make an accurate diagnosis or determine appropriate treatment.

40. Another name for ventricular contraction is:

Systole

Diastole

Repolarization

Sternum

Systole is ventricular contraction.Diastole is ventricular filling. Repolarization occurs when cells return to their negative resting state.The sternum is the breast bone.

Explanation

Systole is ventricular contraction.Diastole is ventricular filling. Repolarization occurs when cells return to their negative resting state.The sternum is the breast bone.

41. Please place a check mark next to the rhythm or rhythms that would require defibrillation.

Asystole

Atrial fibrillation

Supraventricular tachycardia

Ventricular fibrillation

Pulseless ventricular tachycardia

Asystole requires CPR, SVT requires cardioversion and/or meds. A fib requires meds and/or cardioversion.Ventricular fibrillation and pulseless ventricular tachycardia require defibrillation.

Explanation

Asystole requires CPR, SVT requires cardioversion and/or meds. A fib requires meds and/or cardioversion.Ventricular fibrillation and pulseless ventricular tachycardia require defibrillation.

Submit

42. The client has epilepsy and receives phenytoin (Dilantin). The client has been seizure-free, and asks the nurse why he still needs blood tests when he is not having seizures. What is the best response by the nurse?

“Because phenytoin (Dilantin) can deplete your system of potassium.”

“Because phenytoin (Dilantin) can cause blood-thinning in some clients.”

“Because phenytoin (Dilantin) has a very narrow range between a therapeutic dose and a toxic dose.”

“Because phenytoin (Dilantin) can cause Stevens-Johnson syndrome, which will show up in the blood tests.”

The best response by the nurse is "Because phenytoin (Dilantin) has a very narrow range between a therapeutic dose and a toxic dose." This response is appropriate because it explains the need for blood tests even if the client is seizure-free. Phenytoin is a medication with a narrow therapeutic index, meaning that the difference between a dose that is effective and a dose that is toxic is small. Regular blood tests are necessary to monitor the client's blood levels of phenytoin and ensure that they are within the therapeutic range to prevent toxicity.

Explanation

The best response by the nurse is "Because phenytoin (Dilantin) has a very narrow range between a therapeutic dose and a toxic dose." This response is appropriate because it explains the need for blood tests even if the client is seizure-free. Phenytoin is a medication with a narrow therapeutic index, meaning that the difference between a dose that is effective and a dose that is toxic is small. Regular blood tests are necessary to monitor the client's blood levels of phenytoin and ensure that they are within the therapeutic range to prevent toxicity.

43. Bupivacaine (Marcaine) is indicated for

Use as an antiepileptic, as it is a calcium channel blocker devised to target neurons

The palliative treatment of mild to moderate Alzheimer's disease

The treatment of certain inflammatory diesease and some types of cancer.

Local anesthesia including infiltration , nerve block, epidural and intrathecal anesthesia.

Bupivacaine (Marcaine) is indicated for local anesthesia including infiltration, nerve block, epidural, and intrathecal anesthesia. It is commonly used in medical procedures to numb a specific area of the body, block nerve signals, or provide pain relief during surgery or childbirth. Bupivacaine works by blocking sodium channels in nerve cells, preventing the transmission of pain signals to the brain. It is not used as an antiepileptic or for the treatment of Alzheimer's disease, inflammatory diseases, or cancer.

Explanation

Bupivacaine (Marcaine) is indicated for local anesthesia including infiltration, nerve block, epidural, and intrathecal anesthesia. It is commonly used in medical procedures to numb a specific area of the body, block nerve signals, or provide pain relief during surgery or childbirth. Bupivacaine works by blocking sodium channels in nerve cells, preventing the transmission of pain signals to the brain. It is not used as an antiepileptic or for the treatment of Alzheimer's disease, inflammatory diseases, or cancer.

44. The drug derived from cannabis (delta 9 THC) and considered a controlled substance and is used to treat chemotherapy induced nausea is

Dolasetron (Anzemet)

Lorazepam (Ativan

Dronabinol (Marinol)

Metoclopramide (Reglan)

Dronabinol (Marinol) is the correct answer because it is a drug derived from cannabis (delta 9 THC), which is a controlled substance. It is used to treat chemotherapy-induced nausea. Dolasetron (Anzemet), lorazepam (Ativan), and metoclopramide (Reglan) are not derived from cannabis and do not have the same properties as dronabinol in treating nausea induced by chemotherapy.

Explanation

Dronabinol (Marinol) is the correct answer because it is a drug derived from cannabis (delta 9 THC), which is a controlled substance. It is used to treat chemotherapy-induced nausea. Dolasetron (Anzemet), lorazepam (Ativan), and metoclopramide (Reglan) are not derived from cannabis and do not have the same properties as dronabinol in treating nausea induced by chemotherapy.

45. Where are the nursing standards of care outlined as well as the scope of practice by the nurse that will be used in a malpractice lawsuit

Nurse practice act

Nurses code of ethics

Nursing standards act

State board of nusing

The nursing practice act outlines the standards of care and scope of practice for nurses. It is a legal document that defines the responsibilities and limitations of nurses in a particular state or jurisdiction. In a malpractice lawsuit, the nurse practice act is often referenced to determine if the nurse adhered to the required standards of care and if their actions fell within their authorized scope of practice. The nurse practice act is specific to each state and provides guidelines for nursing practice, licensure, and disciplinary actions.

Explanation

The nursing practice act outlines the standards of care and scope of practice for nurses. It is a legal document that defines the responsibilities and limitations of nurses in a particular state or jurisdiction. In a malpractice lawsuit, the nurse practice act is often referenced to determine if the nurse adhered to the required standards of care and if their actions fell within their authorized scope of practice. The nurse practice act is specific to each state and provides guidelines for nursing practice, licensure, and disciplinary actions.

46. A client has just been given a prescription for diphenoxylate withatropine (Lomotil). The nurse teaches the client which of the followingabout the use of this medication?

Drooling may occur while taking this medication

Irritability may occur while taking this medication

This medication contains a habit-forming ingredient

Take the medication with a laxative of choice

Diphenoxylate with atropine (Lomotil) is an antidiarrheal. The client shouldnot exceed the recommended dose of this medication because it may behabit-forming. Since this medication is an antidiarrheal, it should not betaken with a laxative. Side effects of the medication include dry mouth anddrowsiness.

Explanation

Diphenoxylate with atropine (Lomotil) is an antidiarrheal. The client shouldnot exceed the recommended dose of this medication because it may behabit-forming. Since this medication is an antidiarrheal, it should not betaken with a laxative. Side effects of the medication include dry mouth anddrowsiness.

47. What are the clinical manifestations of hyperthyroidism:

Fatique,weight gain,decreased libido

Insomnia,tachycardia,shortness of breath

Hypokalemia,diuresis,fatique

Restlessness,weight loss,fatique

Restlessness, weight loss, and fatigue are the clinical manifestations of hyperthyroidism. Restlessness is commonly observed in hyperthyroidism due to increased metabolism and overactivity of the body. Weight loss occurs as a result of increased metabolic rate and decreased appetite. Fatigue is a common symptom due to increased energy expenditure and disruption of normal sleep patterns. These manifestations are indicative of an overactive thyroid gland and can help in the diagnosis of hyperthyroidism.

Explanation

Restlessness, weight loss, and fatigue are the clinical manifestations of hyperthyroidism. Restlessness is commonly observed in hyperthyroidism due to increased metabolism and overactivity of the body. Weight loss occurs as a result of increased metabolic rate and decreased appetite. Fatigue is a common symptom due to increased energy expenditure and disruption of normal sleep patterns. These manifestations are indicative of an overactive thyroid gland and can help in the diagnosis of hyperthyroidism.

48. A patient with a myocardial infarction has inferior wall disfunction. The nurse recognizes that the coronary artery most likely occluded is the?

Left circumflex coronary artery.

Right coronary artery.

Left descending coronary artery.

Right ascending coronary artery

The nurse recognizes that the coronary artery most likely occluded is the right coronary artery because it supplies blood to the inferior wall of the heart. The right coronary artery is responsible for supplying blood to the right atrium, right ventricle, and the inferior part of the left ventricle. Therefore, if there is dysfunction in the inferior wall of the heart, it suggests that the right coronary artery is occluded.

Explanation

The nurse recognizes that the coronary artery most likely occluded is the right coronary artery because it supplies blood to the inferior wall of the heart. The right coronary artery is responsible for supplying blood to the right atrium, right ventricle, and the inferior part of the left ventricle. Therefore, if there is dysfunction in the inferior wall of the heart, it suggests that the right coronary artery is occluded.

49. A client with lung cancer has had a pneumonectomy. What prescription would be ordered:

Supplement oxygen

Closed chest tube

Head of the bead elevated

Coughing and deeping breathing exercises

After a pneumonectomy, a closed chest tube would be ordered. This is because a pneumonectomy involves the removal of a lung, and a closed chest tube is typically used to drain any excess fluid or air that may accumulate in the chest cavity after surgery. The closed chest tube helps to prevent complications such as pneumothorax or hemothorax and allows for proper healing and lung expansion.

Explanation

After a pneumonectomy, a closed chest tube would be ordered. This is because a pneumonectomy involves the removal of a lung, and a closed chest tube is typically used to drain any excess fluid or air that may accumulate in the chest cavity after surgery. The closed chest tube helps to prevent complications such as pneumothorax or hemothorax and allows for proper healing and lung expansion.

50. The patient had undergone thyroidectomy. Which of the following are the earliest signs of poor tissue perfusion and poor respiratory function?

Cyanosis, lethargy

Fast, thready pulse, bradypnea

Apprehension and restlessness

Faintness, pallor

The earliest signs of poor tissue perfusion and poor respiratory function are apprehension and restlessness. The brain is the first organ affected by poor tissue perfusion and oxygenation. This also results from stimulation of the sympathetic nervous system

Explanation

The earliest signs of poor tissue perfusion and poor respiratory function are apprehension and restlessness. The brain is the first organ affected by poor tissue perfusion and oxygenation. This also results from stimulation of the sympathetic nervous system

51. The client has been taking lorazepam (Ativan) for two years. The client stopped this medication after a neighbor said the drug manufacturer's plant was contaminated with rat droppings. What best describes the nurse's assessment of the client when seen three days after stopping his medication?

A sense of calmness and lack of anxiety.

Increased heart rate, fever, and muscle cramps.

Pinpoint pupils, constipation, and urinary retention.

Nothing different; it is safe to abruptly stop lorazepam (Ativan).

The client is experiencing withdrawal symptoms after abruptly stopping lorazepam (Ativan) due to the neighbor's comment about the drug manufacturer's plant. Increased heart rate, fever, and muscle cramps are common symptoms of lorazepam withdrawal. This suggests that the client may have developed a physical dependence on the medication and should have gradually tapered off under medical supervision.

Explanation

The client is experiencing withdrawal symptoms after abruptly stopping lorazepam (Ativan) due to the neighbor's comment about the drug manufacturer's plant. Increased heart rate, fever, and muscle cramps are common symptoms of lorazepam withdrawal. This suggests that the client may have developed a physical dependence on the medication and should have gradually tapered off under medical supervision.

52. A 17 year old patient diagnosed with OCD (Obsessive Compulsive Disorder) and is taking Paxil (paroxetine). The following are instructions to give to patient and family. Please select all that apply to Paxil.

Do not stop Paxil abruptly as withdrawal can occur.

Paxil may cause unusual bleeding or bruising.

Paxil may increase risk of suicidal thinking or behavior in young adults.

Do not take this medicine with calcium as it may decrease the effects of the drug.

Paxil can cause sexual dysfunction in both men and women.

The instructions to give to the patient and family regarding Paxil are as follows: Do not stop Paxil abruptly as withdrawal can occur, Paxil may increase the risk of suicidal thinking or behavior in young adults, and Paxil can cause sexual dysfunction in both men and women. These instructions are important to ensure the safe and effective use of the medication and to inform the patient and family about potential side effects and risks associated with Paxil.

Explanation

The instructions to give to the patient and family regarding Paxil are as follows: Do not stop Paxil abruptly as withdrawal can occur, Paxil may increase the risk of suicidal thinking or behavior in young adults, and Paxil can cause sexual dysfunction in both men and women. These instructions are important to ensure the safe and effective use of the medication and to inform the patient and family about potential side effects and risks associated with Paxil.

Submit

53. Using the 6 second method or the rule of 10's, which of the following is the atrial rate if the number of P waves on a 6-second strip is 5?

30

50

55

150

10x5=50

Explanation

10x5=50

54. A client begins to experience extrapyramidal side effects from an antipsychotic medication. The nurse anticipates that the physician will prescribe which of the following to treat this condition?

Haloperidol (Haldol)

Benztropine (Cogentin)

Prochlorperazine (Compazine)

Chlorpromazine (Thorazine)

Benztropine (Cogentin) is an anticholinergic medication used to treat drug-induced extrapyramidal reactions, except tardive dyskinesia. Options 1, 3, and 4 are antipsychotic medications. Antipsychotic medications can cause extrapyramidal reactions Test-Taking Strategy: Focus on the medications in the options. Recalling the classifications of each will direct you to option 2. Remember that benztropine (Cogentin) is an anticholinergic medication. Review the side effects and extrapyramidal reactions of antipsychotic medications if you had difficulty with this question.

Explanation

Benztropine (Cogentin) is an anticholinergic medication used to treat drug-induced extrapyramidal reactions, except tardive dyskinesia. Options 1, 3, and 4 are antipsychotic medications. Antipsychotic medications can cause extrapyramidal reactions Test-Taking Strategy: Focus on the medications in the options. Recalling the classifications of each will direct you to option 2. Remember that benztropine (Cogentin) is an anticholinergic medication. Review the side effects and extrapyramidal reactions of antipsychotic medications if you had difficulty with this question.

55. When determining heart rate in a normal heart, you should always remember that the atrial rate is:

Always slower than the ventricular rate.

The most accurate rate to measure.

Always faster than the ventricular rate.

Always equal to the ventricular rate.

In the normal heart,the atrial and ventricular rate are always equal.

Explanation

In the normal heart,the atrial and ventricular rate are always equal.

56. The nurse is caring for a client who has been prescribed a beta-adrenergic blocker metoprolol (Lopressor) for hypertension. Which of the following best describes the mechanism of action of beta-adrenergic blockers?

This class of medication blocks converson of angiotensin I to angiotensin II.

This class of medication blocks sympathetic nervous system receptors.

This class of medication directly vasodilates the coronary arteries.

This class of medication allows the body to rid itself of sodium and water

Answer B is correct because beta-adrenergic blockers block beta1 sympathetic nervous system receptors in the heart at the sinoatrial and atrio-ventricular nodes.

Explanation

Answer B is correct because beta-adrenergic blockers block beta1 sympathetic nervous system receptors in the heart at the sinoatrial and atrio-ventricular nodes.

NCLEX Review Practice Questions! Quiz

1. A client receiving Lopressor 50mg IV should most importantly have which vital signs checked prior to administration?

2.

What first name or nickname would you like us to use?

2. The doctor has ordered a urinalysis with C & S (culture and sensitivity) on a in your care. She has an indwelling Foley catheter to bedside drainage. The way to obtain the specimen is to:

3. A client has an order to begin short-term therapy with enoxaparin(Lovenox). The nurse explains to the client that this medication isbeing ordered to:

4. A client has been taking fosinopril (Monopril) for 2 months. The nursedetermines that the client is having the intended effects of therapy if the nurse notes which of the following?

5. You are caring for a patient who is newly diagnosed with Congestive Heart Failure CHF. Which statement by the patient would indicate that your patient teaching has been a success?

6. Identify the ACE inhibitor.

7. The diabetic patient who had undergone abdominal surgery experiences wound evisceration. Which of the following is the most appropriate immediate nursing action?

8. The client has a bull eye's rash. what quesitons would you ask:

9. Your client's daughter states, "I'm so glad my mother is taking Namenda (memantine). She will be cured of Alzheimer's disease." As the nurse, what do you say next?

10. The nurse cares for a client taking isoniazid (INH) for the past 5 weeks. The client tells the nurse she has been experiencing tingling in her extremities and symmetrical numbness. The nurse knows that the patient is experiencing which common side effect of INH?

11. This type of tort includes assult and battary, deframamtion of character, fraud, invasion of privacy, and false imprisonment-any willing act against a person that nterferes with their rights.

12. A nurse in a physician's office is reviewing the results of a client'sphenytoin (Dilantin) level drawn that morning. The nurse determinesthat the client has a therapeutic drug level if the client's result was:

13. The nurse is conducting a group therapy session, and a client with a manic disorder is monopolizing the group. The appropriate nursing action is which of the following?

14. The nurse will provide preoperative teaching on deep breathing, coughing and turning exercises. When is the best time to provide the preoperative teachings?

15. To prevent complications of immobility, which activities would the nurse plan for the first postoperative day after a colon resection?

16. The nurse is caring for a client who is taking furosemide (Lasix), 40 mg daily. The client displays muscle weakness and electrocardiogram changes. Which of the following is essential for the nurse to assess at this time?

17. Which chamber of the heart pumps oxygenated blood back into the circulatory system?

18. The name for the volume of blood in the ventricle immediately before it is ejected is:

19. The Nurse Practice act and American disablity act is what kind of law?

20. The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal. Which of the following would alert the nurse to the potential for withdrawal delirium?

21. A client with a history of coronary artery disease begins to experience chest pain. After putting the client on bedrest and administering a nitroglycerin tablet sublingually, which intervention should the nurse implement first?

22. Assessment that focuses on past medical history, family history, reason for admission, medications currently taking, previous hospitalization, surgeries, psyhosocial assessment, nutrition, complete physical assessment

23. Oxybutynin (ditropan) may be prescribed for which of the following postoperative complications

24. A client is to receive conscious sedation for a minor surgical procedure. Which drug administration should the nurse expect?

25. Oral hypoglycemic drugs do not work for type 1 DM

26. The nurse has been doing medication education for the client receiving atenolol (Tenormin), a beta-blocker. The nurse determines that learning has occurred when the client makes which statement?

27. This step of the nursing process includes the systematic collection of all subjective and objective data about the client in which the nurse focuses holistically on the client- physical, psychological, emotional, sociocultural, and spirtual.

30. The client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." The therapeutic response by the nurse is:

31. Nadolol (Corgard) is prescribed for a patient with coronary artery disease. In evaluating the effectiveness of the drug, the nurse would expect to find

32. A patient is admitted with DT's to a private room. What is the nursing intervention priority?

33. The nurse is caring for a client with congestive heart failure. Furosemide (Lasix) is ordered for this patient by the health-care provider. The nurse understands this medication is given to produce which of the following outcomes?

34. The nurse instructs a client receiving oral acyclovir (Zovirax). The nurse determines teaching is effective if the client states which of the following?

35. Which cholinergic agent would be used to treat non-obstructive urinary retention?

36. Gingival hyperplasia is an oral condition possible in up to 50% of children using

37. The nurse is caring for a client who is taking atorvastatin (Lipitor), a "statin" for high-cholesterol level. The nurse must teach the client to report any muscle weakness or pain immediately because this could be a sign of this rare, but serious, adverse effect.

38. A post burn injury client should have what type of diet:

39. The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to:

40. Another name for ventricular contraction is:

41. Please place a check mark next to the rhythm or rhythms that would require defibrillation.

42. The client has epilepsy and receives phenytoin (Dilantin). The client has been seizure-free, and asks the nurse why he still needs blood tests when he is not having seizures. What is the best response by the nurse?

43. Bupivacaine (Marcaine) is indicated for

44. The drug derived from cannabis (delta 9 THC) and considered a controlled substance and is used to treat chemotherapy induced nausea is

45. Where are the nursing standards of care outlined as well as the scope of practice by the nurse that will be used in a malpractice lawsuit

46. A client has just been given a prescription for diphenoxylate withatropine (Lomotil). The nurse teaches the client which of the followingabout the use of this medication?

47. What are the clinical manifestations of hyperthyroidism:

48. A patient with a myocardial infarction has inferior wall disfunction. The nurse recognizes that the coronary artery most likely occluded is the?

49. A client with lung cancer has had a pneumonectomy. What prescription would be ordered:

50. The patient had undergone thyroidectomy. Which of the following are the earliest signs of poor tissue perfusion and poor respiratory function?

51. The client has been taking lorazepam (Ativan) for two years. The client stopped this medication after a neighbor said the drug manufacturer's plant was contaminated with rat droppings. What best describes the nurse's assessment of the client when seen three days after stopping his medication?

52. A 17 year old patient diagnosed with OCD (Obsessive Compulsive Disorder) and is taking Paxil (paroxetine). The following are instructions to give to patient and family. Please select all that apply to Paxil.

53. Using the 6 second method or the rule of 10's, which of the following is the atrial rate if the number of P waves on a 6-second strip is 5?

54. A client begins to experience extrapyramidal side effects from an antipsychotic medication. The nurse anticipates that the physician will prescribe which of the following to treat this condition?

55. When determining heart rate in a normal heart, you should always remember that the atrial rate is:

56. The nurse is caring for a client who has been prescribed a beta-adrenergic blocker metoprolol (Lopressor) for hypertension. Which of the following best describes the mechanism of action of beta-adrenergic blockers?