NCLEX Practice Exam 29 (10 Questions)

1. The client presents to the clinic with a serum cholesterol of 275 mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client?

Report muscle weakness to the physician.

Allow six months for the drug to take effect.

Take the medication with fruit juice.

Ask the doctor to perform a complete blood count before starting the medication.

The client taking antilipidemics should be encouraged to report muscle weakness because this is a sign of rhabdomyolysis. The medication takes effect within 1 month of beginning therapy. so answer B is incorrect. The medication should be taken with water because fruit juice. particularly grapefruit. can decrease the effectiveness. making answer C incorrect. Liver function studies should be checked before beginning the medication. not after the fact. making answer D incorrect.

Explanation

The client taking antilipidemics should be encouraged to report muscle weakness because this is a sign of rhabdomyolysis. The medication takes effect within 1 month of beginning therapy. so answer B is incorrect. The medication should be taken with water because fruit juice. particularly grapefruit. can decrease the effectiveness. making answer C incorrect. Liver function studies should be checked before beginning the medication. not after the fact. making answer D incorrect.

2. The 6-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?

Blood pressure of 126/80

Blood glucose of 110 mg/dL

Heart rate of 60 bpm

Respiratory rate of 30 per minute

A heart rate of 60 in the baby should be reported immediately. The dose should be held if the heart rate is below 100 bpm. The blood glucose. blood pressure. and respirations are within normal limits; thus answers A. B. and D are incorrect.

Explanation

A heart rate of 60 in the baby should be reported immediately. The dose should be held if the heart rate is below 100 bpm. The blood glucose. blood pressure. and respirations are within normal limits; thus answers A. B. and D are incorrect.

3. A client with vaginal cancer is being treated with a radioactive vaginal implant. The client's husband asks the nurse if he can spend the night with his wife. The nurse should explain that:

Overnight stays by family members is against hospital policy.

There is no need for him to stay because staffing is adequate.

His wife will rest much better knowing that he is at home.

Visitation is limited to 30 minutes when the implant is in place.

Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time spent exposed to radium. putting distance between people and the radium source. and using lead to shield against the radium. Teaching the family member these principles is extremely important. Answers A. B. and C are not empathetic and do not address the question; therefore. they are incorrect.

Explanation

Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time spent exposed to radium. putting distance between people and the radium source. and using lead to shield against the radium. Teaching the family member these principles is extremely important. Answers A. B. and C are not empathetic and do not address the question; therefore. they are incorrect.

4. The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?

Macaroni and cheese

Shrimp with rice

Turkey breast

Spaghetti

Turkey contains the least amount of fats and cholesterol. Liver. eggs. beef. cream sauces. shrimp. cheese. and chocolate should be avoided by the client; thus. answers A. B. and D are incorrect. The client should bake meat rather than frying to avoid adding fat to the meat during cooking.

Explanation

Turkey contains the least amount of fats and cholesterol. Liver. eggs. beef. cream sauces. shrimp. cheese. and chocolate should be avoided by the client; thus. answers A. B. and D are incorrect. The client should bake meat rather than frying to avoid adding fat to the meat during cooking.

5. The client admitted with angina is given a prescription for nitroglycerin. The client should be instructed to:

Replenish his supply every 3 months

Take one every 15 minutes if pain occurs

Leave the medication in the brown bottle

Crush the medication and take with water

Nitroglycerine should be kept in a brown bottle (or even a special air- and water-tight. solid or plated silver or gold container) because of its instability and tendency to become less potent when exposed to air. light. or water. The supply should be replenished every 6 months. not 3 months. and one tablet should be taken every 5 minutes until pain subsides. so answers A and B are incorrect. If the pain does not subside. the client should report to the emergency room. The medication should be taken sublingually and should not be crushed. as stated in answer D.

Explanation

Nitroglycerine should be kept in a brown bottle (or even a special air- and water-tight. solid or plated silver or gold container) because of its instability and tendency to become less potent when exposed to air. light. or water. The supply should be replenished every 6 months. not 3 months. and one tablet should be taken every 5 minutes until pain subsides. so answers A and B are incorrect. If the pain does not subside. the client should report to the emergency room. The medication should be taken sublingually and should not be crushed. as stated in answer D.

6. The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the:

Phlebostatic axis

PMI

Erb’s point

Tail of Spence

The phlebostatic axis is located at the fifth intercostals space midaxillary line and is the correct placement of the manometer. The PMI or point of maximal impulse is located at the fifth intercostals space midclavicular line. so answer B is incorrect. Erb’s point is the point at which you can hear the valves close simultaneously. making answer C incorrect. The Tail of Spence (the upper outer quadrant) is the area where most breast cancers are located and has nothing to do with placement of a manometer; thus. answer D is incorrect.

Explanation

The phlebostatic axis is located at the fifth intercostals space midaxillary line and is the correct placement of the manometer. The PMI or point of maximal impulse is located at the fifth intercostals space midclavicular line. so answer B is incorrect. Erb’s point is the point at which you can hear the valves close simultaneously. making answer C incorrect. The Tail of Spence (the upper outer quadrant) is the area where most breast cancers are located and has nothing to do with placement of a manometer; thus. answer D is incorrect.

7. The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration. the nurse should:

Utilize an infusion pump

Check the blood glucose level

Place the client in Trendelenburg position

Cover the solution with foil

Hyperstat is given IV push for hypertensive crises. but it often causes hyperglycemia. The glucose level will drop rapidly when stopped. Answer A is incorrect because the hyperstat is given by IV push. The client should be placed in dorsal recumbent position. not a Trendelenburg position. as stated in answer C. Answer D is incorrect because the medication does not have to be covered with foil.

Explanation

Hyperstat is given IV push for hypertensive crises. but it often causes hyperglycemia. The glucose level will drop rapidly when stopped. Answer A is incorrect because the hyperstat is given by IV push. The client should be placed in dorsal recumbent position. not a Trendelenburg position. as stated in answer C. Answer D is incorrect because the medication does not have to be covered with foil.

8. The client is admitted with left-sided congestive heart failure. In assessing the client for edema. the nurse should check the:

Feet

Neck

Hands

Sacrum

The jugular veins in the neck should be assessed for distension. The other parts of the body will be edematous in right-sided congestive heart failure. not left-sided; thus. answers A. C. and D are incorrect.

Explanation

The jugular veins in the neck should be assessed for distension. The other parts of the body will be edematous in right-sided congestive heart failure. not left-sided; thus. answers A. C. and D are incorrect.

9. The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:

Question the order

Administer the medications

Administer separately

Contact the pharmacy

Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix for hypertension. Answers A. C. and D are incorrect because the order is accurate. There is no need to question the order. administer the medication separately. or contact the pharmacy.

Explanation

Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix for hypertension. Answers A. C. and D are incorrect because the order is accurate. There is no need to question the order. administer the medication separately. or contact the pharmacy.

10. The best method of evaluating the amount of peripheral edema is:

Weighing the client daily

Measuring the extremity

Measuring the intake and output

Checking for pitting

The best indicator of peripheral edema is measuring the extremity. A paper tape measure should be used rather than one of plastic or cloth. and the area should be marked with a pen. providing the most objective assessment. Answer A is incorrect because weighing the client will not indicate peripheral edema. Answer C is incorrect because checking the intake and output will not indicate peripheral edema. Answer D is incorrect because checking for pitting edema is less reliable than measuring with a paper tape measure.

Explanation

The best indicator of peripheral edema is measuring the extremity. A paper tape measure should be used rather than one of plastic or cloth. and the area should be marked with a pen. providing the most objective assessment. Answer A is incorrect because weighing the client will not indicate peripheral edema. Answer C is incorrect because checking the intake and output will not indicate peripheral edema. Answer D is incorrect because checking for pitting edema is less reliable than measuring with a paper tape measure.