NCLEX Test 74 Questions
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An adolescent is brought to the hospital for treatment of deep partial thickness and full thickness burns sustained in a house fire. An intravenous infusion is started in the patient’s left forearm. The nurse identifies the primary purpose of the IV is which of the following?
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Provide a route for pain medications.
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Maintain fluid balance.
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Prevent gastrointestinal upset.
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Obtain blood specimens for analysis.
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NCLEX Test 74 Questions assesses nursing knowledge with scenarios on client care, genetic conditions, developmental milestones, medical procedures, psychiatric treatments, and prenatal health. It's designed for nursing professionals to enhance clinical decision-making skills.
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- 2.
The nurse cares for a client who is to receive docusate sodium (Colace) 100 mg through a gastric tube. The solution contains 150 mg/15 mL. The nurse should administer how much solution to the client?
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1.5 mL.
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10 mL.
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15 mL.
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20 mL.
Correct Answer
A. 10 mL.Explanation
Strategy:Set up a ratio.
(1) inaccurate
(2) correct– 100 mg/150 mg = x mL/15 mL = 10 mL
(3) inaccurate
(4) inaccurateRate this question:
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- 3.
The nurse cares for a client with a tracheostomy. Which of the following is the priority nursing diagnosis for this client?
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Impaired verbal communication related to absence of speaking ability.
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Ineffective airway clearance related to increased tracheobronchial secretions.
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Risk for impaired skin integrity related to tracheostomy incision.
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Alteration in comfort: pain related to tracheostomy.
Correct Answer
A. Ineffective airway clearance related to increased tracheobronchial secretions.Explanation
Strategy: Think about each answer.
(1) correct diagnosis; however, answer choice 2 is a priority
(2) correct—ineffective airway clearance is the top priority for clients with a tracheostomy because loss of the upper airway increases the amount and viscosity of secretions
(3) correct diagnosis; however, answer choice 2 is a priority
(4) tracheostomy is not usually painfulRate this question:
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- 4.
The nurse supervises an LPN/LVN administering an enema to a patient. The nurse determines the LPN/LVN’s actions are appropriate if which of the following is observed?
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The LPN/LVN places the solution 20 inches above the anus.
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The LPN/LVN adjusts the temperature of the solution.
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The LPN/LVN inserts the tube 6 inches.
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The LPN/LVN positions the patient left side-lying (Sim’s) with knee flexed.
Correct Answer
A. The LPN/LVN positions the patient left side-lying (Sim’s) with knee flexed.Explanation
Strategy: Answers are all implementation. Determine the outcome of each answer. Is it desired?
(1) could cause rapid infusion and possible painful distention of the colon
(2) is not feasible during the administrative phase
(3) tube should be inserted no more than 4 inches
(4) correct—allows solution to flow downward along the natural curve of the sigmoid colon and rectum, which improves retention of solutionRate this question:
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- 5.
The nurse cares for a client with an order for IV fluid of D5 0.45% normal saline 1,000 ml to run from 9 A.M. to 9 P.M. The drip factor on the delivery tubing is 15 gtt/ml. The nurse determines the IV is infusing correctly if the infusion is set at which of the following rates?
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12 gtt/min.
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21 gtt/min.
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25 gtt/min.
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31 gtt/min.
Correct Answer
A. 21 gtt/min.Explanation
Strategy: Remember the formula.
(1) incorrect
(2) correct—IV is to run in 12 hours, or 720 minutes
(3) incorrect
(4) incorrectRate this question:
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- 6.
Which information should the nurse recognize as being the MOST pertinent to the diagnosis of cholecystitis?
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Flatulence.
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Nausea and vomiting.
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Right upper abdominal pain.
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Dyspepsia.
Correct Answer
A. Right upper abdominal pain.Explanation
Strategy: Think about each answer.
(1) indicates other gastrointestinal problem
(2) indicate other gastrointestinal problem
(3) correct—will experience pain in the upper-right abdominal quadrant
(4) indicates other gastrointestinal problemRate this question:
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- 7.
Prior to sending a client for a cardiac catheterization, it is MOST important for the nurse to report which of the following?
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The client has an allergy to shellfish.
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The client has diminished palpable peripheral pulses.
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The client has cool lower extremities bilaterally.
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The client is anxious about the pending procedure.
Correct Answer
A. The client has an allergy to shellfish.Explanation
Strategy: Think about the significance of each answer and how it relates to a cardiac catheterization.
(1) correct—allergies to iodine and/or seafood must be reported immediately before a cardiac catheterization to avoid anaphylactic shock during the procedure
(2) may be normal finding before the test
(3) may be normal finding before the test
(4) may be normal finding before the testRate this question:
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- 8.
The nurse understands that the primary reason elderly adults have problems with constipation is because of which of the following?
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Elderly adults eat a small volume of food with decreased bulk.
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Elderly adults have less activity and decreased muscle tone.
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Elderly adults have neurological changes in the gastrointestinal tract.
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Elderly adults have decreased sensation in the gastrointestinal tract.
Correct Answer
A. Elderly adults have less activity and decreased muscle tone.Explanation
Strategy: Think about each answer.
(1) decreased intake of high-fiber foods due to chewing difficulties is seen but is not a major cause of constipation
(2) correct—reduced gastrointestinal motility due to decreased muscle tone, decreased exercise; other factors include prolonged use of laxatives, ignoring urge to defecate, side effect of medications, emotional problems, insufficient fluid intake, and excessive dietary fat
(3) decreased response to stretch receptors in rectum and anal canal occurs but is not a major cause of constipation
(4) decreased response to stretch receptors in rectum and anal canal occurs but is not a major cause of constipationRate this question:
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- 9.
Which of the following types of foods should the nurse encourage for a client diagnosed with hypoparathyroidism?
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Foods high in phosphorus.
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Foods high in calcium.
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Foods low in sodium.
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Foods low in potassium.
Correct Answer
A. Foods high in calcium.Explanation
Strategy: Think about each answer.
(1) diet should be low in phosphorus; hypoparathyroidism is decreased secretion of parathyroid hormone; indications include tetany, muscular irritability, carpopedal spasms, dysphagia, paresthesia, and laryngeal spasm
(2) correct—diet for the client should provide high calcium and low phosphorus because the parathyroid controls calcium balance
(3) not regulated by the parathyroid
(4) not regulated by the parathyroidRate this question:
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- 10.
A 6-month-old is brought to the clinic for a well-baby checkup. During the exam, the nurse expects to observe which of the following?
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A pincer grasp.
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Sitting with support.
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Tripling of the birth weight.
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Presence of the posterior fontanelle.
Correct Answer
A. Sitting with support.Explanation
(2) correct–6-month-old should sit with helpRate this question:
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- 11.
The nurse cares for a client diagnosed with reflux due to a hiatal hernia. The client asks the nurse why he has been instructed to withhold food and fluids just before going to bed. Which of the following responses by the nurse is MOST appropriate?
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“You are less likely to awaken during the night with heartburn if the stomach is empty.”
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“Early-morning vomiting will be less of a problem if the stomach is empty.”
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“Drinking or eating before lying down causes decreased respirations due to increased pressure on the lungs.”
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“You may develop fluid overload if fluids are taken just before going to bed.”
Correct Answer
A. “You are less likely to awaken during the night with heartburn if the stomach is empty.”Explanation
Strategy: Think about each answer.
(1) correct—full stomach is more likely to slide (reflux) through the hernia, causing regurgitation and heartburn
(2) vomiting, decreased respirations, and fluid overload are not related to hiatal hernia
(3) vomiting, decreased respirations, and fluid overload are not related to hiatal hernia
(4) vomiting, decreased respirations, and fluid overload are not related to hiatal herniaRate this question:
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- 12.
The physician orders mannitol (Osmitrol) for a client with a closed head injury. Which of the following should the nurse recognize as the desired response to this medication?
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The blood pressure increases to 150/90.
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Urinary output increases to 175 cc/hour.
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There is a decrease in the level of activity.
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There is an absence of fine tremors of the fingers.
Correct Answer
A. Urinary output increases to 175 cc/hour.Explanation
Strategy: Think about each answer.
(1) increase in blood pressure is not desired
(2) correct—mannitol (Osmitrol) is an osmotic diuretic; increases urinary output and decreases intracranial pressure
(3) does not indicate desired effect of medication
(4) does not indicate desired effect of medicationRate this question:
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- 13.
The physician orders hydromorphone hydrochloride (Dilaudid) 15 mg IM for a patient. The nurse should observe for which of the following side effects?
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Photosensitivity and constipation.
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Hypotension and respiratory depression.
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Tardive dyskinesia and diplopia.
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Dry mouth and tinnitus.
Correct Answer
A. Hypotension and respiratory depression.Explanation
Strategy: Recall the classification of the drug.
(1) these side effects are not seen with this medication
(2) correct—narcotic analgesic used for moderate to severe pain, monitor vital signs frequently
(3) these side effects are not seen with this medication
(4) these side effects are not seen with this medicationRate this question:
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- 14.
Which of the following would be MOST important for the rehabilitation nurse to assess during a new client’s admission?
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The client’s expectations of family members.
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The client’s understanding of available supportive services.
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The client’s personal goals for rehabilitation.
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The client’s past experiences in the hospital.
Correct Answer
A. The client’s personal goals for rehabilitation.Explanation
Strategy: Determine the outcome and how it relates to rehabilitation.
(1) important to assess but is not as crucial for future success as the client’s goals
(2) important to assess but is not as crucial for future success as the client’s goals
(3) correct—it is important for the nurse to understand what the client expects from the rehabilitation program for future success
(4) important to assess but is not as crucial for future success as the client’s goalsRate this question:
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- 15.
The physician writes an order for a stat dose of Demerol 50 mg IM for pain. Three hours later the client again complains of pain, and the nurse administers a second injection of Demerol. Which of the following describes the nurse’s liability?
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The nurse administered the medication appropriately; there is no liability.
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The nurse violated the narcotic law in not having an order to administer the Demerol a second time.
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The client was not injured; if injury did not occur, then the nurse is not liable.
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The nurse should have waited at least 4 hours; then there would be no liability.
Correct Answer
A. The nurse violated the narcotic law in not having an order to administer the Demerol a second time.Explanation
Strategy: Think about each answer.
(1) does not address the fact that there was no order for the Demerol to be repeated
(2) correct—order for a stat dose does not state PRN; nurse had an order for only the first injection, not the second one
(3) does not address the fact that there was no order for the Demerol to be repeated
(4) does not address the fact that there was no order for the Demerol to be repeatedRate this question:
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- 16.
If the nurse cares for a client with ataxia, which of the following actions is MOST important?
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Supervise ambulation.
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Measure the intake and output accurately.
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Consult the speech therapist.
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Elevate the foot of the bed.
Correct Answer
A. Supervise ambulation.Explanation
Strategy: Think about each answer.
(1) correct—client’s coordination is poor; the only relevant nursing action is to supervise ambulation
(2) unnecessary
(3) not relevant
(4) not relevantRate this question:
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- 17.
At 32 weeks’ gestation, a client has an order for an ultrasound. The nurse determines the client understands the procedure if the client states which of the following?
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"The results will inform us of the gestational age."
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"This test will evaluate the baby’s lungs."
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"The test will show us if there is any problem in the spinal cord."
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"Early problems with the baby’s blood can be identified with this test."
Correct Answer
A. "The results will inform us of the gestational age."Explanation
Strategy: Think about each answer.
(1) correct—ultrasound detects the gestational age
(2) determined with lecithin/sphingomyelin (L/S) ratio by an amniocentesis
(3) determined with an amniocentesis
(4) determined with an amniocentesisRate this question:
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- 18.
The nurse cares for a patient receiving chlorpromazine hydrochloride (Thorazine). The nurse notes the patient is restless, unable to sit still, and complains of insomnia and fine tremors of the hands. The nurse identifies which of the following as the BEST explanation about why these symptoms are occurring?
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A side effect of the medication that will disappear as time passes.
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The reason the patient is receiving this medication.
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Extrapyramidal side effects resulting from this medication.
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An indication that the dosage of the medication needs to be increased.
Correct Answer
A. Extrapyramidal side effects resulting from this medication.Explanation
Strategy: Determine how each answer relates to Thorazine.
(1) untrue statement; dosage may need to be decreased because of side effect of medication; antiparkinsonian drug such as Cogentin may be ordered
(2) not accurate; antipsychotic medication
(3) correct—side effects include akathisia (motor restlessness), dystonias (protrusion of tongue, abnormal posturing), pseudoparkinsonism (tremors, rigidity), and dyskinesia (stiff neck, difficulty swallowing)
(4) dosage may be decreased; antiparkinsonian drug such as Cogentin may be orderedRate this question:
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- 19.
A client arrives at the hospital in active labor, and the admitting nurse attaches an internal fetal monitor. The nurse knows which of the following is the MOST important reason for the fetal monitor?
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To evaluate the progress of the client’s labor.
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To assess the strength and duration of the client’s contractions.
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To monitor the oxygen status of the fetus during labor.
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To determine if an oxytocin drip is necessary.
Correct Answer
A. To monitor the oxygen status of the fetus during labor.Explanation
Strategy: Think about each answer.
(1) clinical assessments provide information about progress of labor (dilation and effacement)
(2) not most important reason for monitoring
(3) correct—goal is early detection of mild fetal hypoxia
(4) fetal well-being is most important reason for fetal monitoringRate this question:
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- 20.
The nurse administers oral verapamil (Calan) to a client. Before administering the medication, the nurse should check which of the following?
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The client’s electrolytes.
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The client’s urine output.
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The client’s weight.
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The client’s heart rate.
Correct Answer
A. The client’s heart rate.Explanation
Strategy: Think about the action of the drug.
(1) unnecessary action
(2) unnecessary action
(3) unnecessary action
(4) correct—verapamil is indicated for the treatment of supraventricular tachycardias, so the client’s heart rate should be checked prior to administrationRate this question:
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- 21.
The nursing team consists of an RN who has been practicing for 6 months, an LPN/LVN who has been practicing for 15 years, and a nursing assistant who has been caring for clients for 3 years. The RN should care for which of the following clients?
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A client 1 day postop after an internal fixation of a fractured left femur.
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A client receiving diltiazem (Cardizem) and phenytoin (Dilantin).
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A client ordered to receive two units of packed cells prior to an upper endoscopy procedure.
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A client admitted yesterday with exhaustion and a diagnosis of acute bipolar disorder.
Correct Answer
A. A client ordered to receive two units of packed cells prior to an upper endoscopy procedure.Explanation
Strategy: The RN cares for clients that require assessment, teaching, and nursing judgment.
(1) care can be assigned to the nursing assistant; standard, unchanging procedure
(2) medication can be given by the LPN
(3) correct—requires the assessment and teaching skills of the RN
(4) offer food and fluids; assign to the LPNRate this question:
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- 22.
The mother of a child with chickenpox asks the physician’s office nurse why her child will not come down with chickenpox again if exposed to the virus at school at a later date. The nurse’s response should be based on which of the following?
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Natural passive immunity occurs because the child receives antibodies from outside the body.
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Artificial active immunity occurs because the child receives specific antigens against the chickenpox virus.
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Natural active immunity occurs because the child’s body actively makes antibodies against the chickenpox virus.
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Artificial passive immunity occurs because of the inflammatory process of chickenpox.
Correct Answer
A. Natural active immunity occurs because the child’s body actively makes antibodies against the chickenpox virus.Explanation
The correct answer is natural active immunity occurs because the child's body actively makes antibodies against the chickenpox virus. This is because when a person is infected with a virus like chickenpox, their immune system responds by producing antibodies specific to that virus. These antibodies help to fight off the infection and also provide long-term protection against future exposure to the same virus. This is why the child will not come down with chickenpox again if exposed to the virus at a later date.Rate this question:
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- 23.
The nurse cares for an elderly client admitted with a possible fractured right hip. During the initial nursing assessment, which of the following observations of the right leg validates or supports this diagnosis?
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The leg appears to be shortened and is adducted and externally rotated.
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Plantar flexion is observed with sciatic pain radiating down the leg.
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From the hip, the leg appears to be longer and is externally rotated.
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There is evidence of paresis with decreased sensation and limited mobility.
Correct Answer
A. The leg appears to be shortened and is adducted and externally rotated.Explanation
Strategy: Think about each symptom and how it relates to hip fracture.
(1) correct—accurate assessments of the position of a fractured hip prior to repair
(2) plantar flexion occurs with foot drop
(3) leg would not appear to be longer
(4) occurs with injury to the lumbar disc areaRate this question:
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- 24.
The nurse knows that according to Erikson’s stages of psychosocial development, which of the following best represents a 50-year-old client?
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Integrity versus despair and disgust.
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Generativity versus stagnation.
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Intimacy versus isolation.
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Identity versus role diffusion.
Correct Answer
A. Generativity versus stagnation.Explanation
Strategy: Think about each answer.
(1) appropriate for ages 65 and older
(2) correct—stage of development is appropriate for 45 to 64 years of age
(3) appropriate for the young adult
(4) appropriate for the adolescentRate this question:
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- 25.
Several days after the delivery of a stillborn, the parents say, "We wish we could talk with other couples who have gone through this trauma." Which of the following responses by the nurse is BEST?
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"SIDS will provide you with this opportunity."
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"SHARE will provide you with this opportunity."
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"RESOLVE will provide you with this opportunity."
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"CANDLELIGHTERS will provide you with this opportunity."
Correct Answer
A. "SHARE will provide you with this opportunity." -
- 26.
A client had a kidney transplant yesterday, and the client’s son has come to visit. The nurse should instruct the son to do which of the following?
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No special isolation techniques are necessary.
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Wear a double mask and gloves.
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Perform good hand washing.
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Wear a gown and a mask.
Correct Answer
A. Perform good hand washing.Explanation
Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?
(1) inaccurate
(2) inaccurate; masks are unnecessary for this patient
(3) correct—good hand washing is the most effective method of reducing infection; very important with immunosuppressed clients
(4) inaccurate; masks are unnecessary for this patientRate this question:
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- 27.
The home care nurse visits a new mother and her 2-week-old infant. The client asks the nurse when she should start giving her child solid foods. The nurse’s response should be based on which of the following statements?
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Rice cereal is usually the first solid food and is started around 4 to 5 months.
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Strained fruits are well tolerated as the first solid food, and infants like them.
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Introduction of solid foods is not important at this time.
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Solid foods are usually not started until the infant is around 6 months old.
Correct Answer
A. Rice cereal is usually the first solid food and is started around 4 to 5 months.Explanation
Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?
(1) correct—infants are less likely to be allergic to rice cereal than to any other solid food; usually started between 4 and 5 months of age; breast-fed infants may be started on solids even later
(2) inaccurate
(3) does not answer the mother’s question
(4) usually started between 4 and 5 months of ageRate this question:
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- 28.
A woman is evaluated for infertility, and the physician prescribes clomiphene citrate (Clomid) 50 mg daily for 5 days. The client asks the nurse about how the medication works. Which of the following responses by the nurse is BEST?
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Clomiphene citrate (Clomid) induces ovulation by changing hormonal effects on the ovary.
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Clomiphene citrate (Clomid) changes the uterine lining to be more conducive to implantation.
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Clomiphene citrate (Clomid) alters the vaginal pH to increase sperm motility.
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Clomiphene citrate (Clomid) produces multiple pregnancy for those who desire twins.
Correct Answer
A. Clomiphene citrate (Clomid) induces ovulation by changing hormonal effects on the ovary.Explanation
Strategy: Think about each answer.
(1) correct—clomiphene citrate (Clomid) induces ovulation by altering estrogen and stimulating follicular growth to produce a mature ovum
(2) infertility problem, but Clomid does not affect it
(3) infertility problem, but Clomid does not affect it
(4) not a desired effectRate this question:
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- 29.
In the process of a normal adjustment to a terminal illness, the nurse knows that the client’s initial denial and isolation will give way to the second stage. The second stage is characterized by which of the following?
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Acceptance.
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Bargaining.
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Anger.
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Depression.
Correct Answer
A. Anger.Explanation
Strategy: Think about each answer.
(1) this is the fifth stage
(2) this is the third stage
(3) correct—second stage is characterized by anger
(4) this is the fourth stageRate this question:
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- 30.
The nurse cares for a client diagnosed with type 1 diabetes complaining of decreased vision. The client asks the nurse what caused the visual changes. The nurse’s response is based on which of the following?
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The client’s decreased vision is caused by bleeding into the inner ocular chamber of the eye.
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The client’s decreased vision is caused by gradual separation of the retina from the base of the eye.
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The client’s decreased vision is caused by an increase in the size of the vessels in the back of the eye.
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The client’s decreased vision is caused by gradual destruction and degeneration of the retina.
Correct Answer
A. The client’s decreased vision is caused by gradual destruction and degeneration of the retina.Explanation
Strategy: Think about each answer.
(1) complication of postoperative eye surgery or traumatic injury (hyphema)
(2) describes a retinal detachment
(3) destruction of the vessels, as well as edema, occurs
(4) correct—gradual destruction occurs because of deterioration of the retinal vesselsRate this question:
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- 31.
Which of the following is the BEST way for a nurse to assess the fluid balance of an elderly client?
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Assess the client’s blood pressure.
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Check the client’s tissue turgor.
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Ask the client if he/she is thirsty.
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Maintain an accurate intake and output.
Correct Answer
A. Maintain an accurate intake and output.Explanation
Strategy: Determine how each answer relates to hydration.
(1) may be elevated because of age-related hypertension
(2) not accurate because of changes in skin elasticity from the aging process
(3) not reliable indicator; may have diminished sensation of thirst
(4) correct—best indicator of fluid statusRate this question:
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- 32.
The nurse cares for prenatal client at 8 weeks’ gestation with a positive VDRL. When the nurse prepares the teaching plan, it is MOST important for the nurse to include which of the following?
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Advise the client to not take any over-the-counter medications.
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Instruct the client on the importance of taking the penicillin for the prescribed time.
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Inform the client to refrain from sexual activity.
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Maintain the confidentiality of sexual partners or contacts.
Correct Answer
A. Instruct the client on the importance of taking the penicillin for the prescribed time.Explanation
Strategy: Think "Maslow."
(1) physical, should not take medication over the counter unless prescribed by a doctor, but not highest priority
(2) correct—physical, vitally important to complete all the penicillin
(3) physical, more important to be treated for disease
(4) psychosocial, communicable diseases are reportable; partners or contacts need to be found and notified so that they may be treatedRate this question:
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- 33.
The nurse cares for an older patient scheduled for a colon resection this morning. The nurse notes the patient had polyethylene glycol-electrolyte solution (GoLYTELY) and a soapsuds enema the previous evening. This morning the patient passes a medium amount of soft brown stool. Which of the following conclusions by the nurse is MOST accurate?
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The bowel preparation is incomplete.
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The patient ate something after midnight.
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This is an expected finding before this type of surgery.
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The patient passed the last stool left in the colon.
Correct Answer
A. The bowel preparation is incomplete.Explanation
Strategy: Think about each answer.
(1) correct—colon should not have remaining soft stool
(2) anything eaten after midnight would not appear as stool by the next morning
(3) not expected; need to clean gastrointestinal tract for surgery
(4) assumption; not substantiatedRate this question:
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- 34.
The nurse recognizes which of the following are early signs of lithium toxicity?
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Restlessness, shuffling gait, involuntary muscle movements.
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Ataxia, confusion, seizures.
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Fine tremors, nausea, vomiting, diarrhea.
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Elevated white blood cell count, fever, orthostatic hypotension.
Correct Answer
A. Fine tremors, nausea, vomiting, diarrhea.Explanation
Strategy: Think about each answer.
(1) indicative of side effects associated with antipsychotic agents, not lithium
(2) indicative of severe lithium toxicity, which requires prompt medical management
(3) correct—nurse should be alert to early signs/symptoms of lithium toxicity; include fine tremors of fingers, wrists, and hands; and nausea, vomiting, and diarrhea
(4) indicative of side effects associated with antipsychotic agents, not lithiumRate this question:
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- 35.
A middle-aged client is admitted to an inpatient psychiatric unit. The client complains that a family member is trying to steal the client’s property. The client is diagnosed with paranoid disorder. The nurse knows that the client is demonstrating which of the following?
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Delusions of persecution.
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Command hallucinations.
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Delusions of reference.
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Persecution hallucinations.
Correct Answer
A. Delusions of persecution.Explanation
Strategy: Think about each answer.
(1) correct—client has delusions of persecution; delusion is a strongly held belief that is not validated by reality; the idea that his brother is trying to steal his property is a belief not validated by reality
(2) hallucinations are sensory perceptions that take place without external stimuli; most common are auditory, or hearing voices; other types of hallucinations are tactile, visual, gustatory, and olfactory; command hallucinations involve client experiencing auditory hallucinations that are telling him/her to do something; for example, to kill someone
(3) delusions of reference are a false belief that public events or people are directly related to the individual
(4) are not hallucinationsRate this question:
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- 36.
The nurse is discussing growth and development with the parents of a 4-year-old child. The nurse identifies which of the following as the type of play characteristic of this age group?
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Solitary play
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Parallel play
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Associative play
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Aggressive play
Correct Answer
A. Associative playExplanation
Strategy: Picture a 4-year-old.
(1) describes play for an infant
(2) describes play for a toddler
(3) correct—this is the play that characterizes 4-year-olds
(4) is not play but a behaviorRate this question:
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- 37.
Which of the following instructions should the nurse give to an adult client to prepare for a plasma cholesterol screening?
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Eat a vegetarian diet for 1 week before the test.
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Limit alcohol intake to two glasses of wine the day before the test.
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Abstain from dairy products for 48 hours before the test.
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Only sips of water should be taken for 12 hours before the test.
Correct Answer
A. Only sips of water should be taken for 12 hours before the test.Explanation
The nurse should instruct the adult client to only consume sips of water for 12 hours before the plasma cholesterol screening. This is because consuming any food or beverages, other than water, can affect the accuracy of the test results. By abstaining from food and other drinks, the client ensures that the cholesterol levels measured in the blood sample are not influenced by recent consumption.Rate this question:
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- 38.
The nurse cares for a newborn infant diagnosed with fetal alcohol syndrome. The nurse expects to see which of the following physical characteristics?
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An infant large for gestational age (LGA), craniofacial abnormalities, and hydrocephalus.
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An infant with a small head circumference, low birth weight, and undeveloped cheekbones.
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An infant with a large head circumference, low birth weight, and excessive rooting and sucking behaviors.
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An infant with a normal head circumference, low birth weight, and respiratory distress syndrome.
Correct Answer
A. An infant with a small head circumference, low birth weight, and undeveloped cheekbones.Explanation
Strategy: All answers are assessment. Determine how each assessment relates to fetal alcohol syndrome.
(1) usually small for gestational age
(2) correct—seen with fetal alcohol syndrome
(3) may have feeding difficulties and poor sucking ability
(4) head circumference usually small, respiratory distress related to preterm birth, neurologic damage, small trachea, floppy epiglottisRate this question:
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- 39.
A client, gravida 2 para 1, is admitted with hypertension and complains that her wedding band is tight. The nurse should assess which of the following indications of early pre-eclampsia?
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Blurred vision and proteinuria.
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Epigastric pain and headache.
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Facial swelling and proteinuria.
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Polyuria and hypertonic reflexes.
Correct Answer
A. Facial swelling and proteinuria.Explanation
Strategy: Determine how each answer relates to pre-eclampsia.
(1) only partially correct; blurred vision appears later, with eclampsia
(2) contains signs of eclampsia before a seizure
(3) correct—represents the complete triad seen with pre-eclampsia
(4) oliguria is seen later with eclampsiaRate this question:
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- 40.
The nurse should caution the client with hypothyroidism to avoid which of the following?
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Warm environmental temperatures.
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Narcotic sedatives.
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Increased physical exercise.
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A diet high in fiber.
Correct Answer
A. Narcotic sedatives.Explanation
Strategy: Think about each answer.
(1) client with hypothyroidism cannot tolerate cold temperatures
(2) correct—client is very sensitive to narcotics, barbiturates, and anesthetics
(3) should not be avoided
(4) requires high fiber, high cellulose foods to prevent constipationRate this question:
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- 41.
The nurse performs the Rinne tests on a 6-year-old girl. Which of the following is an accurate statement of how this test should be performed?
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The stem of a vibrating tuning fork is held against the auditory canal until the child indicates that she can no longer hear the sound. Then the tuning fork is moved away from the canal.
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The stem of a vibrating tuning fork is held against the mastoid bone until the child indicates that she can no longer hear the sound. Then the tuning fork is moved in front of the auditory canal.
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The stem of a vibrating tuning fork is held in the middle of the forehead, and the girl’s hearing is assessed in both ears.
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The stem of a vibrating tuning fork is positioned 2 in behind the girl’s head, and the length of time she hears the sound is documented.
Correct Answer
A. The stem of a vibrating tuning fork is held against the mastoid bone until the child indicates that she can no longer hear the sound. Then the tuning fork is moved in front of the auditory canal.Explanation
Strategy: Think about each answer.
(1) inaccurate
(2) correct—child should hear sound again when tuning fork is moved from mastoid bone to the front of the auditory canal because air conduction is better than bone conduction
(3) the Weber test
(4) inaccurateRate this question:
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- 42.
In planning diet teaching for a child in the early stages of nephrotic syndrome, the nurse should discuss with the parents which of the following dietary changes?
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Adequate protein, low sodium intake.
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Low protein, low potassium intake.
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Low potassium, low calorie intake.
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Limited protein, high carbohydrate intake.
Correct Answer
A. Adequate protein, low sodium intake.Explanation
Strategy: Think about each answer.
(1) correct—if child can tolerate the protein intake, then this diet is encouraged to speed healing; sodium is usually restricted
(2) low protein contraindicated in renal clients
(3) does not address protein need at all
(4) may be appropriate only if the child cannot tolerate protein intakeRate this question:
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- 43.
The nurse knows which of the following would have the greatest impact on an elderly client’s ability to complete activities of daily living (ADLs)?
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Perseveration.
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Aphasia.
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Mnemonic disturbance.
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Apraxia.
Correct Answer
A. Apraxia.Explanation
Strategy: Think about each answer.
(1) speech disturbance, which would have the greatest impact on communication ability
(2) speech disturbance, which would have the greatest impact on communication ability
(3) speech disturbance, which would have the greatest impact on communication ability
(4) correct—apraxia is loss of purposeful movement in the absence of motor or sensory impairment; when it affects an ADL, such as dressing, the client may not be able to put clothes on properlyRate this question:
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- 44.
The nurse cares for a child diagnosed with pediculosis capitis (head lice) and is being treated with 1% gamma benzene hexachloride (Kwell) shampoo. The nurse should include which of the following when instructing the child’s parents?
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Continue treatment every other day for 1 week.
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Wash the child’s clothing and personal belongings in soap and cool water.
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Repeat the application of the shampoo in 7 to 10 days.
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One treatment with Kwell kills both lice and nits.
Correct Answer
A. Repeat the application of the shampoo in 7 to 10 days.Explanation
Strategy: Answers are implementation. Determine the outcome of each answer. Is it desired?
(1) too frequent an application of the shampoo
(2) very hot water and a special detergent (RID) need to be used for cleansing clothing and personal belongings
(3) correct—Kwell is an organic solvent, can be toxic, absorbed through scalp; may be repeated 5 to 7 days after first application
(4) must be repeated after the eggs hatch; permethrin 1% crème rinse (Nix) kills both lice and nits after one applicationRate this question:
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- 45.
A toddler diagnosed with lead poisoning is admitted to the pediatric unit. The physician writes and order to encourage fluids. Which of the following fluids is BEST for the nurse to offer to the toddler?
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Milk.
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Water.
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Orange juice
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Fruit punch.
Correct Answer
A. Milk.Explanation
Strategy: Determine how each answer relates to lead poisoning.
(1) correct—milk provides a large amount of vitamin D; vitamin D optimizes deposition of lead in the long bones; purpose of the treatment is to remove lead from the blood and soft tissues
(2) good for fluid replacement; does not relate to the lead poisoning
(3) good for fluid replacement; does not relate to the lead poisoning
(4) good for fluid replacement; does not relate to the lead poisoningRate this question:
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- 46.
The nurse knows which of the following mood-altering drugs is most often associated with an increased risk for HIV infection related to intravenous drug use?
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Benzodiazepines.
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Marijuana.
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Barbiturates.
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Narcotics.
Correct Answer
A. Narcotics.Explanation
Strategy: Think about how each drug is administered.
(1) not commonly used intravenously
(2) not commonly used intravenously
(3) not commonly used intravenously
(4) correct—narcotics are most often used intravenouslyRate this question:
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- 47.
The nurse leads a parenting class for a group of expectant mothers. The nurse should advise that the breast-feeding mother should increase her daily caloric intake by how many calories?
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200.
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300.
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400.
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500.
Correct Answer
A. 500.Explanation
Strategy: Think about each answer.
(1) inadequate amount
(2) inadequate amount
(3) inadequate amount
(4) correct—milk production requires an increase of 500 calories per dayRate this question:
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- 48.
The nurse collects the following data: anger directed by client toward staff in the form of frequent sarcastic or crude comments, increased wringing of hands, and purposeless pacing, particularly after the client has used the telephone. Based on these data, the nurse should make which nursing diagnosis?
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Impaired social interaction related to conversion reaction.
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Risk for potential activity intolerance as evidenced by purposeless pacing
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Powerlessness in hospital situation.
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Ineffective individual coping related to recent anger and anxiety
Correct Answer
A. Ineffective individual coping related to recent anger and anxietyExplanation
Strategy: Think about each answer.
(1) not warranted with the data indicated
(2) not warranted with the data indicated
(3) not warranted with the data indicated
(4) correct—client is displaying evidence of anger and anxiety and an inability to directly deal with concerns, which is ineffective copingRate this question:
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- 49.
A postoperative cataract client is cautioned about not making sudden movements or bending over. The nurse understands that the rationale for this recommendation is to prevent which of the following complications?
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Impairment of cerebral blood flow and headaches.
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Increased intracranial pressure.
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Pressure on the ocular suture line.
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Displacement of the lens implant.
Correct Answer
A. Pressure on the ocular suture line.Explanation
Strategy: Think about each answer.
(1) not relevant to this situation
(2) not relevant to this situation
(3) correct—sudden changes in position, constipation, vomiting, stooping, or bending over increase the intraocular pressure and put pressure on the suture line
(4) occurs because of pressure on suture area; not all clients have lens implants; answer choice 3 is a more comprehensive answerRate this question:
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Current Version
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Mar 22, 2023Quiz Edited by
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Sep 14, 2012Quiz Created by
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