NCLEX 100 Practice Questions
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For a client with a neurologic disorder, which of the following nursing assessments is MOST helpful in determining subtle changes in the client’s level of consciousness?
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Client posturing.
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Glasgow coma scale.
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Client thinking pattern.
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Occurrence of hallucinations.
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This NCLEX practice quiz includes questions on client nutrition post-laryngectomy, nursing assessments, and care practices for various medical conditions, helping prepare for the NCLEX exam.
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- 2.
The nurse makes patient assignments on the obstetrics unit. Which of the following patients should the nurse assign to an RN who has been reassigned to the obstetrics unit from outpatient surgery?
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A patient at 16 weeks’ gestation admitted with hyperemesis and receiving IV fluids.
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A patient at 26 weeks’ gestation in premature labor and receiving terbutaline (Brethine).
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A patient at 32 weeks’ gestation with a placenta previa and ruptured membranes.
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A patient at 37 weeks’ gestation with pregnancy-induced hypertension and epigastric pain.
Correct Answer
A. A patient at 16 weeks’ gestation admitted with hyperemesis and receiving IV fluids.Explanation
Strategy: LPN/LVN and "pulled" RN receive stable patients with expected outcomes.
(1) correct—monitor IV therapy, administer antiemetics and nutritional supplements
(2) monitor patient’s response to medication and the status of the fetus
(3) prepare for delivery, closely monitor fetal response
(4) indicates impending seizures, prepare for deliveryRate this question:
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- 3.
The nurse teaches nutrition classes at the community center. Which of the following foods should the nurse encourage a low-income client to eat to satisfy essential protein needs?
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Legumes.
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Red meat.
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Seafood.
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Cheese.
Correct Answer
A. Legumes.Explanation
Strategy: Think about each answer choice.
(1) correct—legumes are an economical source rich in protein
(2) high in protein, but more expensive to purchase
(3) high in protein, but more expensive to purchase
(4) high in protein, but more expensive to purchaseRate this question:
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- 4.
The MOST appropriate nursing action before administering captopril (Capoten) is to check the client’s
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apical pulse for 60 seconds.
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blood pressure.
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urine output.
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temperature.
Correct Answer
A. blood pressure.Explanation
Strategy: Think about each answer choice and how it relates to Capoten.
(1) important, but not a priority
(2) correct—Capoten is an antihypertensive that necessitates assessment of BP before administration
(3) important, but not priority
(4) unnecessary to assess prior to the administration of the medicationRate this question:
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- 5.
The nurse cares for a client after right cataract surgery. The nurse should intervene if which of the following is observed?
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Client is in the supine position.
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The head of the bed is elevated 30 degrees.
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The client is lying on the right side.
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An eye shield is over the right eye.
Correct Answer
A. The client is lying on the right side.Explanation
Strategy: "Nurse should intervene" indicates an incorrect action.
(1) appropriate position
(2) decreases swelling and pain
(3) correct—client should not be positioned with operative side in a dependent position or against the bed
(4) shield is appropriateRate this question:
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- 6.
A 2-day-old infant in the newborn nursery does not appear interested in taking formula from the mother or the nurse. An appropriate nursing diagnosis is high risk for
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impaired swallowing.
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failure to thrive.
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fluid volume deficit.
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altered health maintenance.
Correct Answer
A. fluid volume deficit.Explanation
Strategy: Think about each answer choice.
(1) no information about swallowing provided with question
(2) this is a medical diagnosis, not a nursing diagnosis
(3) correct—may become dehydrated
(4) not specific for problem describedRate this question:
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- 7.
An adult woman has missed her menstrual period. The client’s last menstrual period began May 8 and ended May 12. The nurse determines that the client’s EDC (estimated date of confinement) is which of the following?
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February 1.
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February 15.
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February 19.
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March 14.
Correct Answer
A. February 15.Explanation
Strategy: Remember Naegele rule.
(1) should add 7 days
(2) correct—when using the Naegele rule, add 7 days to first day of last menstrual period and subtract 3 months
(3) incorrectly started with the last day of the menstrual cycle
(4) incorrectRate this question:
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- 8.
The nurse teaches a health class at the local library to a group of senior citizens. Which of the following behaviors should the nurse emphasize to facilitate regular bowel elimination?
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Avoid strenuous activity.
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Eat more foods with increased bulk.
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Decrease fluid intake to decrease urinary losses.
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Use oral laxatives so that a bowel pattern emerges.
Correct Answer
A. Eat more foods with increased bulk.Explanation
Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) regular exercise program facilitates bowel elimination
(2) correct—contained in whole grains, legumes, vegetables, fruits, seeds, nuts, bulk promotes peristalsis
(3) normal fluid intake of 1,500 ml/day facilitates bowel elimination
(4) laxatives used as last resort because they become habit-formingRate this question:
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- 9.
A young adult immobilized for trauma to the spinal cord has periods of diaphoresis, a draining abdominal wound, and diarrhea. On the basis of the nursing assessment, which of the following is the MOST important nursing diagnosis?
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Risk for constipation related to immobilization.
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Risk for impaired skin integrity related to immobilization and secretions.
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Risk for wound infection related to involuntary bowel secretions.
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Risk for fluid volume excess related to secretions.
Correct Answer
A. Risk for impaired skin integrity related to immobilization and secretions.Explanation
Strategy: Think about each answer choice.
(1) constipation is not a problem because the client has diarrhea
(2) correct—skin is very susceptible to breakdown because of immobility and bodily secretions; needs numerous nursing interventions to prevent this
(3) not most important
(4) may be risk of fluid volume deficit due to diarrhea and secretionsRate this question:
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- 10.
A client has been taking propranolol (Inderal) 40 mg BID and furosemide (Lasix) 40 mg daily for several months. Two weeks ago, the physician added verapamil (Calan) 80 mg TID to the client’s medication regimen. The client returns to the outpatient clinic for evaluation. It is MOST important for the nurse to assess for which of the following?
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Tachycardia.
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Diarrhea.
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Peripheral edema.
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Impotence.
Correct Answer
A. Peripheral edema.Explanation
Strategy: Determine how each answer choice relates to the medication.
(1) will cause bradycardia
(2) usually causes constipation
(3) correct—Calan is a calcium channel blocker, depresses myocardial contractility, decreases work of ventricles and O2 demand, dilates coronary arteries; when used with other antihypertensives can cause hypotension and heart failure
(4) not most important or frequent side effectRate this question:
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- 11.
A patient is treated in the telemetry unit for cardiac disease. The patient receives propranolol hydrochloride (Inderal) 20 mg PO at 9 A.M. When the nurse enters the room to give the medication to the patient, the nurse finds the patient wheezing with a nonproductive cough and shortness of breath. INITIALLY, the nurse should take which of the following actions?
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Hold the medication and count the respirations.
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Hold the medication and call the physician.
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Take an apical pulse and then give the medication.
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Give the mediation as ordered.
Correct Answer
A. Hold the medication and count the respirations.Explanation
Strategy: Determine the outcome of each answer choice.
(1) correct—side effects include increased airway resistance; patient is experiencing bronchospasm; should assess and then call the physician
(2) should assess the patient’s condition first
(3) patient is experiencing a side effect; medication should not be given
(4) medication should be held; patient is experiencing a side effectRate this question:
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- 12.
The nurse checks for placement of a nasogastric (NG) tube prior to initiating a tube feeding for a client. Which of the following results indicates to the nurse that the tube feeding can begin?
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A small amount of white mucus is aspirated from the NG tube.
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The contents aspirated from the NG tube have a pH of 3.
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No bubbles are seen when the nurse inverts the NG tube in water.
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The client says he can feel the NG tube in the back of his throat.
Correct Answer
A. The contents aspirated from the NG tube have a pH of 3.Explanation
Strategy: Determine how the answers relate to a tube feeding.
(1) mucus may be from lungs
(2) correct—stomach contents are acidic
(3) not a safe way to check placement
(4) not a reliable indicationRate this question:
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- 13.
The nurse cares for a client one day after a thoracotomy. Nursing actions listed on the care plan include turn, cough, and deep breathe q 2 h. The nurse understands that the purpose of this nursing action includes which of the following?
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Promote ventilation and prevent respiratory acidosis.
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Increase oxygenation and removal of secretions.
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Increase pH and facilitate balance of bicarbonate.
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Prevent respiratory alkalosis by increasing oxygenation.
Correct Answer
A. Promote ventilation and prevent respiratory acidosis.Explanation
Strategy: Think about each answer choice.
(1) correct—primary purpose of this nursing measure is to improve and/or maintain good gas exchange, especially removal of carbon dioxide in order to prevent respiratory acidosis
(2) answer choice #1 is better in that it refers to ventilation rather than oxygenation
(3) increasing the pH is not desirable
(4) respiratory alkalosis is not prevented by this nursing measureRate this question:
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- 14.
A client diagnosed with bipolar disorder is in a manic phase with combative behavior. Which of the following is the INITIAL priority nursing action?
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Provide adequate hygiene and nutrition.
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Decrease environmental stimuli.
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Slowly involve the client in unit activities.
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Administer and monitor sedative and mood-stabilizing medications.
Correct Answer
A. Administer and monitor sedative and mood-stabilizing medications.Explanation
Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) is very important to ensure adequate hygiene and nutrition, but behavioral control and client/milieu safety are an initial priority
(2) decreasing environmental stimulation is an additional strategy that, when utilized in conjunction with psychopharmacologic intervention, can reduce hyperactivity and aggressive acts; just decreasing environmental stimulation will not diminish client’s internal sense of agitation and aggression
(3) this action is inappropriate at this time
(4) correct—is most important to gain control with a physically aggressive client in manic phase; client has significant sympathetic nervous system stimulation and will require psychopharmacologic intervention with both sedative medications and mood-stabilizing agentsRate this question:
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- 15.
A client is admitted with irritable bowel syndrome. The nurse anticipates that the client’s history will reflect which of the following?
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Pattern of alternating diarrhea and constipation.
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Chronic diarrhea stools occurring 10 to 12 times per day.
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Diarrhea and vomiting with severe abdominal distention.
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Bloody stools with increased cramping after eating.
Correct Answer
A. Pattern of alternating diarrhea and constipation.Explanation
Strategy: Think about each answer choice.
(1) correct—condition is often called spastic bowel disease; no inflammation is present
(2) refers to inflammatory bowel disease such as ulcerative colitis or Crohn’s disease
(3) refers to inflammatory bowel disease such as ulcerative colitis or Crohn’s disease
(4) bloody stools do not occur with irritable bowel syndromeRate this question:
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- 16.
A patient is admitted to the hospital for a hypoglossectomy with lymph node dissection. The patient’s preoperative care includes frequent oral hygiene with hydrogen peroxide. The nurse knows the purpose of this treatment includes which of the following?
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Minimizes the bacterial count in the mouth.
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Softens the mucous membranes of the tongue before surgery.
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Stimulates the microcirculation of the mouth.
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Hydrates the tissues of the gums.
Correct Answer
A. Minimizes the bacterial count in the mouth.Explanation
Frequent oral hygiene with hydrogen peroxide before surgery is done to minimize the bacterial count in the mouth. Hydrogen peroxide has antimicrobial properties and can help reduce the number of bacteria present in the oral cavity, which can help prevent postoperative infections. This is particularly important for a patient undergoing a hypoglossectomy with lymph node dissection, as these procedures can increase the risk of infection. By minimizing the bacterial count in the mouth, the patient's risk of developing an infection after surgery is reduced.Rate this question:
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- 17.
A 6-month-old infant has had all of the required immunizations. The nurse knows that this would include which of the following?
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Two doses of diphtheria, tetanus, and pertussis vaccine.
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Measles, mumps, and rubella vaccines.
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A booster dose of the inactivated polio vaccine.
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Chickenpox and smallpox vaccines.
Correct Answer
A. Two doses of diphtheria, tetanus, and pertussis vaccine.Explanation
Strategy: Think about each answer choice.
(1) correct—first dose of the DPT may be given at 2 months of age, the second is given around 4 months
(2) MMR is given at 15 months
(3) polio is given at 2 and 4 months and again at 12 to 18 months
(4) recommended for first respondersRate this question:
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- 18.
An elderly alcoholic client receives a long-acting benzodiazepine (Librium) for 2 days for symptom management and reduction. The client states, "Get those bugs off of me and clean them out of here." The nurse knows the client is exhibiting symptoms of which of the following?
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A reaction to the sedative medication.
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A worsening course of the withdrawal syndrome.
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An exacerbation of the schizophrenia process.
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The process of aging and the effects of delirium.
Correct Answer
A. A worsening course of the withdrawal syndrome.Explanation
Strategy: Think about each answer choice.
(1) client has been medicated with benzodiazepines and did not experience untoward reactions
(2) correct—client has most probably progressed to another level of abstinence withdrawal from polypharmacy chemical dependence; characteristic symptoms include tremors, increased heart rate, and fever, as well as psychological problems of confusion, delusions, and hallucinations
(3) schizophrenic client usually experiences an episode of auditory hallucinations, not visual or tactile hallucinations
(4) combination effect of the normal aging process and dementia could precipitate a similar reaction; however, the normal aging process does not produce delirium but rather dementiaRate this question:
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- 19.
The nurse cares for a patient several days after an above-knee amputation (AKA). Which of the following symptoms are characteristic of an infected residual limb wound?
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The patient is anxious and restless.
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There is a small amount of dark drainage on the dressing.
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The patient complains of persistent pain at the operative site.
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The skin is cool above the operative site.
Correct Answer
A. The patient complains of persistent pain at the operative site.Explanation
Strategy: Determine how each answer choice relates to an infected wound.
(1) may be due to changes in body image or pain
(2) expected, not indicative of an infection
(3) correct—pain is characteristic of inflammation and infection
(4) warm skin above operative site would indicate infectionRate this question:
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- 20.
The nurse assists a nursing assistant in providing a bed bath to a comatose patient with incontinence. The nurse should intervene if which of the following actions is noted?
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The nursing assistant answers the phone while wearing gloves.
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The nursing assistant log rolls the patient to provide back care.
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The nursing assistant places an incontinent pad under the patient.
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The nursing assistant positions the patient on the left side, head elevated.
Correct Answer
A. The nursing assistant answers the phone while wearing gloves.Explanation
Strategy: "Nurse should intervene" indicates that you are looking for an incorrect action.
(1) correct—contaminated gloves should be removed before answering the phone
(2) correct way to roll a patient to maintain proper alignment
(3) appropriate to use incontinence pad for this patient
(4) appropriate position to prevent aspiration and protect the airwayRate this question:
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- 21.
A mother brings her 9-month-old infant to the pediatrician’s office with complaints of a fever of 102.2°F (39°C) and frequent vomiting. The nurse expects which of the following reflexes to still be present?
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Babinski’s reflex.
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Moro’s reflex.
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Tonic neck reflex.
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Grasp reflex.
Correct Answer
A. Babinski’s reflex.Explanation
Strategy: Think about growth and development.
(1) correct—stroking outer sole of foot upward causes toes to hyperextend and fan and great toe to dorsiflex; disappears after 1 year of age
(2) sudden jarring causes extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape; disappears after 3 to 4 months
(3) when head is turned to side, arm and leg extend on that side, and opposite arm and leg flex; disappears by age 3 to 4 months
(4) touching palms of hands or soles of feet causes flexion of hands and toes; palmar grasp disappears after 3 months of age, plantar grasp lessened by 8 months of ageRate this question:
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- 22.
The nurse cares for a child who is in Buck’s traction. During the neurovascular assessment, the nurse notes that the foot of the uninjured leg feels warmer to touch than that of the broken leg. The nurse should take which of the following actions?
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Record the observation.
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Encourage the child to move the foot.
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Cover the colder foot with a sock.
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Notify the physician.
Correct Answer
A. Notify the physician.Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) ignores possibility that Ace bandage is too tight
(2) does not relieve the circulation problem
(3) does not relieve the circulation problem
(4) correct—assessment indicates that Ace bandage is too tight and needs readjustingRate this question:
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- 23.
An older woman is hospitalized with a fractured left hip. While awaiting surgery, the client is placed in Buck’s traction with a 7-pound weight. Which of the following instructions about moving should be given by the nurse to encourage the patient to participate in her care?
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"Pull up on the overhead trapeze while you push down on your right foot to lift your body."
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"With your right arm, grasp the bedside rail on the opposite side and pull yourself over gently."
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"I’ll raise the head of the bed 45 degrees, and then you lean forward and rotate your hips to the left."
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"Swing your right leg over your left leg and turn from your waist down, keeping your legs straight."
Correct Answer
A. "Pull up on the overhead trapeze while you push down on your right foot to lift your body."Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) correct—body must move as single, straight unit
(2) turning or twisting from the waist down interferes with countertraction
(3) prevents proper pull of weights
(4) can’t turn from side to side; can only move up and downRate this question:
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- 24.
Which one do you like?
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Option 1
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Option 2
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Option 3
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Option 4
Correct Answer
A. Option 1 -
- 25.
A child has a closed transverse fracture of the right ulna. Which of the following actions, if performed by the nurse before the application of a cast, is MOST important?
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Check the radial pulses bilaterally and compare.
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Evaluate the skin temperature and tissue turgor in the area.
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Assess sensation of each foot while the child closes her eyes.
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Apply baby powder to decrease skin irritation under the cast.
Correct Answer
A. Check the radial pulses bilaterally and compare.Explanation
Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes.
(1) correct—assess neurovascular status, check pain, pallor, paralysis, paresthesia, pulselessness
(2) assessment; temperature indicates decreased circulation but is subjective and not most important
(3) assessment; upper (not lower) extremity fracture
(4) implementation; should not be done because it would increase skin irritationRate this question:
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- 26.
The nurse cares for an elderly client who is receiving IV fluids of 0.9% NaCl at 125 mL/h into the left arm. During a routine assessment, the nurse finds that the client has distended neck veins, shortness of breath, and crackles in both lung bases. Which of the following actions should the nurse take FIRST?
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Decrease the IV rate to 20 mL/h and notify the physician.
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Decrease the IV rate to 100 mL/h and continue to monitor the client.
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Discontinue the IV and start oxygen at 6 L/min.
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Assess for infiltration of the IV solution.
Correct Answer
A. Decrease the IV rate to 20 mL/h and notify the physician.Explanation
Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation.
(1) correct—KVO (20 cc/h) will keep access open
(2) need to notify physician; rate still too much since patient is in fluid overload
(3) IV line may be necessary; diuretics may be ordered
(4) description indicates circulatory overload, not infiltrationRate this question:
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- 27.
A client in a psychiatric facility describes seeing snakes on the walls of the room. Which of the following is an accurate nursing diagnosis?
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Sensory–perceptual alterations: visual.
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Altered thought processes.
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Ineffective individual coping.
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Impaired social interaction.
Correct Answer
A. Sensory–perceptual alterations: visual.Explanation
Strategy: Think about each answer choice.
(1) correct—reflects a pattern of impaired perception, which is supported by the data that client is having a hallucination, defined as a sensory perception for which no external stimuli exist
(2) not relevant to the data
(3) not relevant to the data
(4) not relevant to the dataRate this question:
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- 28.
The nurse reviews client assignments on a medical/surgical unit. The nurse determines that the assignment is appropriate if the nursing assistant is caring for which of the following clients?
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A client with AIDS dementia complex who requires a urine specimen.
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A client complaining of postoperative pain after repair of a torn rotator cuff.
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A client with GI bleeding due to a duodenal ulcer who is receiving packed cells.
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A client with type 1 diabetes receiving prednisone for a herniated disk.
Correct Answer
A. A client with AIDS dementia complex who requires a urine specimen.Explanation
Strategy: Assign clients with standard, unchanging procedures.
(1) correct—standard, unchanging procedure
(2) assign to the RN
(3) assign to the RN
(4) assign to the RNRate this question:
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- 29.
The nurse conducts a physical examination of a client suspected to have bulimia. Which of the following observations by the nurse MOST likely indicates bulimia?
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The client has edema of the lower extremities.
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Physical exam of the client reveals the presence of lanugo.
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The client has ulcerated mucous membranes of the mouth.
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The client has dry, yellowish color of the skin.
Correct Answer
A. The client has ulcerated mucous membranes of the mouth.Explanation
Strategy: Determine the cause of each symptom. Does it relate to bulimia?
(1) common with anorexia
(2) seen with anorexia
(3) correct—due to frequent vomiting
(4) bulimics are normal in appearanceRate this question:
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- 30.
A neonate weighing 7 lb 4 oz with Apgar scores of 7 and 8 at 1 and 5 minutes, respectively, is admitted to the nursery. Because the infant’s mother is diagnosed with a type 1 diabetes, the nurse knows the infant is at GREATEST risk for developing which of the following?
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Hypovolemia.
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Hypoglycemia.
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Hyperglycemia.
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Cold stress.
Correct Answer
A. Hypoglycemia.Explanation
Strategy: Determine the cause of each answer choice.
(1) no change in blood volume for infant of diabetic mother
(2) correct—fetus produces increased insulin to match mother’s increased glucose level during pregnancy; infant continues to have high insulin output after birth, resulting in hypoglycemia
(3) infant would be at risk of hypoglycemia due to increased insulin production
(4) thermal receptors in skin are stimulated due to cold environment; increases metabolic rate; infant needs to maintain normal body temperature while producing minimal amount of heat generated from metabolic processes; not expected with diabetic motherRate this question:
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- 31.
The nurse plans a diet for a child diagnosed with cystic fibrosis (CF). Which of the following dietary requirements should be considered by the nurse?
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High protein, high fat, and high calories.
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High protein, low fat, and high calories.
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Low protein, low fat, and low carbohydrate.
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High protein, high fat, and low carbohydrate.
Correct Answer
A. High protein, low fat, and high calories.Explanation
Strategy: Think about each answer choice.
(1) contains high fat
(2) correct—impaired intestinal absorption due to cystic fibrosis necessitates a diet higher in protein and calories; fat is decreased because it may interfere with absorption of other nutrients
(3) not adequate for this child
(4) contains high fatRate this question:
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- 32.
A male client is admitted with urinary tract problems. A prostate-specific antigen (PSA) and acid phosphatase test are to be done. The nurse knows that
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these tests are valuable screening tests for prostatic cancer.
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the level of PSA is decreased in clients with renal stones.
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the tests reflect the level of renal involvement in acid-base problems.
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the level of PSA is elevated in clients in early-stage renal failure.
Correct Answer
A. these tests are valuable screening tests for prostatic cancer.Explanation
Strategy: Think about each answer choice.
(1) correct—PSA test has replaced acid phosphatase test in screening for prostatic cancer; test must be drawn before digital rectal exam, as manipulation of the prostate will abnormally increase PSA value
(2) inaccurate information about a PSA
(3) inaccurate information about a PSA
(4) inaccurate information about a PSARate this question:
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- 33.
A client is admitted to the neurosurgery unit for the removal of a cerebellar tumor. The nurse expects the patient to make which of the following statements about symptoms?
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"I have been having difficulty with my hearing."
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"I lose my balance easily."
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"I can't tell the difference between a sweet and sour taste."
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"It is not easy for me to remember names and faces."
Correct Answer
A. "I lose my balance easily."Explanation
Strategy: Remember physiology.
(1) temporal lobe contains auditory center, loss of hearing would involve CN VIII acoustic
(2) correct—cerebellum maintains balance
(3) CN IX, glossopharyngeal responsible for differentiation of taste
(4) not specific symptom of cerebellum dysfunctionRate this question:
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- 34.
A client is admitted to the trauma intensive care unit (ICU) with a gunshot wound of the neck. The client, diagnosed with a spinal cord injury at the level of C4, is tearful, constantly complains of discomfort, and requests to be suctioned. The nurse understands that the client’s attention-seeking behaviors may be due to which of the following?
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Anger and frustration.
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Awareness of vulnerability.
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Increased social isolation.
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Increased sensory stimulation.
Correct Answer
A. Awareness of vulnerability.Explanation
Strategy: Think about each answer choice.
(1) is not accurate for situation
(2) correct—is experiencing an increased awareness of his physical vulnerability due to his spinal cord injury; fosters increased dependency needs that are real due to his injury; is trying to determine who is consistent and trustworthy for meeting his significant physical needs
(3) is not accurate for situation
(4) is not accurate for situationRate this question:
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- 35.
A client is scheduled for electromyography (EMG). What should the nurse tell the client about the procedure?
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"Your hair will be carefully washed prior to the procedure."
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"This is a noninvasive procedure that takes about 30 minutes."
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"A sedative will be given to you shortly before the procedure."
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"You will not be allowed to eat 4 to 6 hours before the procedure."
Correct Answer
A. "This is a noninvasive procedure that takes about 30 minutes."Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) usually performed on the legs
(2) correct—electrodes are attached to legs, length of time for impulse transmission is measured
(3) may impair test results
(4) procedure does not involve general anesthesia or GI systemRate this question:
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- 36.
The nurse is aware that Rh immune globulin (RhoGAM) is administered to prevent complications in which of the following situations?
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The baby is Rh-negative, the mother is Rh-negative, and the father is Rh-positive.
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The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs.
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The mother is Rh-positive and previously sensitized, and the baby is Rh-negative.
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The mother is Rh-positive, the baby is Rh-negative, and there is a history of one incomplete pregnancy.
Correct Answer
A. The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs.Explanation
Strategy: Think about each answer choice.
(1) if both mother and baby are Rh-negative, there is no problem
(2) correct—RhoGAM is given to an Rh-negative mother who delivers an Rh-positive baby when the baby has a negative Coombs test
(3) medication is not given if the mother has been sensitized by a previous pregnancy
(4) there is no incompatibility here, but the mother needs to be evaluated regarding sensitization in the incomplete pregnancyRate this question:
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- 37.
An older client diagnosed with pneumonia is admitted to the medical/surgical unit. The nurse should place the patient in a room with which of the following patients?
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A 20-year-old in traction for multiple fractures of the left lower leg.
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A 35-year-old with recurrent fever of unknown origin.
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A 50-year-old recovering alcoholic with cellulitis of the right foot.
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An 89-year-old with Alzheimer’s disease awaiting nursing home placement.
Correct Answer
A. A 50-year-old recovering alcoholic with cellulitis of the right foot.Explanation
Strategy: Determine the transmission of organisms.
(1) patients with fractures are considered "clean"; don’t place with an infectious patient
(2) don’t know the cause of the fever
(3) correct—generalized nonfollicular infection that involves deeper connective tissue, both patients have infections
(4) elderly are high risk for developing pneumoniaRate this question:
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- 38.
The nurse supervises care given to clients on a medical/surgical unit. The nurse should intervene if which of the following is observed?
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A nurse and client wear masks during a dressing change for the central catheter used for total parenteral nutrition.
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A nurse injects insulin through a single-lumen percutaneous central catheter for a client receiving total parenteral nutrition.
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A nurse applies lip balm to his/her lips immediately after performing a blood draw to obtain a specimen.
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A nurse wears a disposable particulate respirator when administering rifampin to a client with tuberculosis.
Correct Answer
A. A nurse applies lip balm to his/her lips immediately after performing a blood draw to obtain a specimen.Explanation
Strategy: "Nurse should intervene" indicates that you are looking for an incorrect action.
(1) appropriate procedure, prevents airborne contamination
(2) insulin is the only medication that can be given, compatible with TPN
(3) correct—applying lip balm or handling contact lenses is prohibited in work areas where exposure to bloodborne pathogens may occur
(4) use airborne precautions for TB, private room with negative air pressure, minimum of six exchanges per hourRate this question:
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- 39.
The nurse instructs a client who is receiving imipramine (Tofranil). It is MOST important for the nurse to instruct the client to immediately report which of the following?
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Sore throat, fever, increased fatigue, vomiting, diarrhea.
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Dry mouth, nasal stuffiness, weight gain.
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Rapid heartbeat, frequent headaches, yellowing of eyes or skin.
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Weakness, staggering gait, tremor, feeling of drunkenness.
Correct Answer
A. Sore throat, fever, increased fatigue, vomiting, diarrhea.Explanation
Strategy: Think about each answer choice.
(1) correct—possible side effects of Tofranil, a tricyclic antidepressant medication, which can be resolved by altering the dosage or changing the medication
(2) describes side effects of antidepressants, which client can learn to manage at home without changing the medication
(3) not side effects of Tofranil
(4) not side effects of TofranilRate this question:
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- 40.
The nurse cares for a multipara client who delivered a female infant 1 hour ago. The nurse observes that the client’s breasts are soft; the uterus is boggy to the right of the midline and 2 cm below the umbilicus; moderate lochia rubra. It is MOST important for the nurse to take which of the following actions?
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Perform a straight catheterization.
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Offer the client the bedpan.
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Put the baby to breast.
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Massage the uterine fundus.
Correct Answer
A. Offer the client the bedpan.Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) encourage the client to void before catheterizing
(2) correct—boggy uterus deviated to right indicates full bladder, encourage client to void
(3) will increase uterine tone, but the problem is a full bladder
(4) findings indicate a full bladderRate this question:
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- 41.
A patient is returned to the unit after surgery with a cuffed tracheostomy tube in place. The nurse knows that the purpose of the cuff on the tracheostomy tube includes which of the following?
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Guarantees secure placement of the tracheostomy tube in the airway.
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Prevents ischemia of the tracheal wall by distributing the pressure applied to it.
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Decreases the chance of aspiration into the trachea.
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Protects the trachea from ischemia and edema.
Correct Answer
A. Decreases the chance of aspiration into the trachea.Explanation
Strategy: Think about each answer choice.
(1) inaccurate, not the purpose of the cuff on a tracheostomy tube
(2) complication of using a cuffed tracheostomy tube
(3) correct—seals trachea, helps to prevent aspiration
(4) trauma from overinflated tube may cause edemaRate this question:
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- 42.
The nurse knows that which of these plans is MOST successful in caring for a client with dementia?
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Teach new skills for adjusting to the aging process.
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Adjust the environment to meet the client’s individual needs.
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Encourage competitive activities to keep the client physically strong.
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Provide unstructured activities with frequent changes to increase stimulation.
Correct Answer
A. Adjust the environment to meet the client’s individual needs.Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) unable to learn new skills
(2) correct—client with dementia does not have cognitive abilities to learn new skills or to adapt; environment must be adapted for client with attention to safety and predictability
(3) requires skills the client with dementia does not have
(4) requires skills the client with dementia does not haveRate this question:
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- 43.
A client has partial-thickness and full-thickness burns over 75% of his body. The nurse is MOST concerned if which of the following is observed?
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Epigastric pain.
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Restlessness.
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Tachypnea.
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Lethargy.
Correct Answer
A. Tachypnea.Explanation
Strategy: Determine how each answer relates to burns.
(1) insignificant for burn client
(2) may be due to pain
(3) correct—body responds to early hypovolemic shock by adrenergic stimulation; vasoconstriction compensates for the loss of fluid, resulting in cool, clammy skin, tachycardia, tachypnea, and pale color
(4) may be due to painRate this question:
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- 44.
The nurse cares for patients on the psychiatric unit. An extremely angry patient with bipolar illness tells the nurse he just learned his wife has filed for divorce and he needs to use the phone. Which of the following responses by the nurse is MOST appropriate?
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Allow the patient to use the phone.
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Confront the patient about his anger and inappropriate plan of action.
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Do not allow the patient to use the phone because he is an involuntary patient.
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Set limits on the patient’s phone use because he has been unable to control his behavior.
Correct Answer
A. Allow the patient to use the phone.Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) correct—patient is able to use phone unless otherwise indicated by court order or physician’s order
(2) has not lost civil right to use phone
(3) denies patient his civil rights
(4) inappropriateRate this question:
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- 45.
A client is admitted for regulation of insulin dosage. The client takes 15 units of Humulin N insulin at 8 A.M. every day. At 4 P.M., which of the following nursing observations indicates a complication from the insulin?
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Acetone odor to the breath, polyuria, and flushed skin.
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Irritability, tachycardia, and diaphoresis.
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Headache, nervousness, and polydipsia.
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Tenseness, tachycardia, and anorexia.
Correct Answer
A. Irritability, tachycardia, and diaphoresis.Explanation
Strategy: Determine the cause of each symptom and how it relates to hypoglycemia.
(1) signs of hyperglycemia
(2) correct—Humulin N insulin is an intermediate-acting insulin that peaks from 8 to 12 hours after administration; this is when signs and symptoms of hypoglycemia will occur
(3) signs of hyperglycemia
(4) signs of hyperglycemiaRate this question:
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- 46.
The nurse in the pediatrician’s office observes a child in the waiting room. The nurse notes that the child can walk up and down steps, has a steady gait, can stand on one foot momentarily, and jumps with both feet. The nurse identifies the child’s chronological age to be which of the following?
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1 year old.
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2 years old.
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3 years old.
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5 years old.
Correct Answer
A. 3 years old.Explanation
Strategy: Picture the child at each age.
(1) unable to walk up and down stairs with hand held until 18 months
(2) unable to jump until 30 months
(3) correct—able to jump with both feet and stand on one foot momentarily at 30 months
(4) behaviors are seen in younger childRate this question:
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- 47.
The nurse should include which of the following in a teaching plan for a client receiving tetracycline?
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Take the medication with milk or antacids to decrease GI problems.
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The medication should always be taken with meals.
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Use a maximum-protection sunscreen when outdoors.
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Crackers and juice will help decrease gastric irritation.
Correct Answer
A. Use a maximum-protection sunscreen when outdoors.Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) tetracycline should never be taken with milk or antacids because these inhibit the medication’s action
(2) should take with full glass of water at least 1 hour before or 2 hours after meals
(3) correct—because of problems related to photosensitivity, client should wear sunscreen, wide-brimmed hats, and long sleeves when at risk for sun exposure
(4) should take with full glass of water at least 1 hour before or 2 hours after mealsRate this question:
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- 48.
The nurse anticipates which of the following when assessing a client with a diagnosis of a ruptured lumbar disc?
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Sensation loss in an upper extremity.
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Clonic jerks in the affected foot.
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Paresthesia in the affected leg.
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Chorea in the upper and lower extremities.
Correct Answer
A. Paresthesia in the affected leg.Explanation
Strategy: Think about each answer choice.
(1) results from cervical lesions
(2) can occur in a person who has been paralyzed from a spinal cord injury
(3) correct—lumbar lesions can cause paresthesia, pain, muscle weakness, and atrophy in the lower extremities
(4) is a sign of Huntington chorea, resulting from atrophy of parts of the brainRate this question:
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- 49.
The nurse cares for clients on a psychiatric unit and is suddenly faced with multiple issues. Which of the following situations require the nurse’s IMMEDIATE attention?
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A client with bipolar disorder walks into the day room in her underwear and begins dancing.
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A client with depression says to the nurse, "My plan is complete, and I’m ready to go for it."
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A client recovering from substance abuse complains that another client is harassing him.
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A client with schizophrenia tells the nurse that it’s "God’s will" that he destroy the "evil TV."
Correct Answer
A. A client with depression says to the nurse, "My plan is complete, and I’m ready to go for it."Explanation
Strategy: "Require IMMEDIATE intervention" indicates that you are looking for the least stable situation.
(1) should remove to quiet area, decrease environmental stimuli
(2) correct—could indicate impending suicide; requires immediate follow-up
(3) potential suicide is more immediate concern
(4) command hallucination; potential suicide takes priorityRate this question:
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Quiz Review Timeline (Updated): Jan 3, 2024 +
Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.
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Current Version
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Jan 03, 2024Quiz Edited by
ProProfs Editorial Team -
Jan 14, 2020Quiz Created by
Arlin
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