NCLEX Test 74 Questions

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1. 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?

Explanation

Strategy: Answers are implementation. Determine the outcome of each answer. Is it desired?

(1) route used for pain medication to ensure absorption, but not primary purpose of IV

(2) correct—loss of fluid occurs from open burn surfaces; maintaining circulation is life-saving requirement

(3) threat of gastrointestinal upset not primary importance; IV’s primary purpose to maintain fluid and electrolyte balance

(4) peripheral IV not used for this purpose

Submit
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About This Quiz
NCLEX Quizzes & Trivia

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?

Explanation

Strategy:Set up a ratio.

(1) inaccurate

(2) correct– 100 mg/150 mg = x mL/15 mL = 10 mL

(3) inaccurate

(4) inaccurate

Submit
3. The nurse cares for a client with a tracheostomy. Which of the following is the priority nursing diagnosis for this client?

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 painful

Submit
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?

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 solution

Submit
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?

Explanation

Strategy: Remember the formula.

(1) incorrect

(2) correct—IV is to run in 12 hours, or 720 minutes

(3) incorrect

(4) incorrect

Submit
6. Which information should the nurse recognize as being the MOST pertinent to the diagnosis of cholecystitis?

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 problem

Submit
7. Prior to sending a client for a cardiac catheterization, it is MOST important for the nurse to report which of the following?

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 test

Submit
8. The nurse understands that the primary reason elderly adults have problems with constipation is because of which of the following?

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 constipation

Submit
9. Which of the following types of foods should the nurse encourage for a client diagnosed with hypoparathyroidism?

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 parathyroid

Submit
10. 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?

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 hernia

Submit
11. 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?

Explanation

(2) correct–6-month-old should sit with help

Submit
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?

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 medication

Submit
13. Which of the following would be MOST important for the rehabilitation nurse to assess during a new client's admission?

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 goals

Submit
14. 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?

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 repeated

Submit
15. If the nurse cares for a client with ataxia, which of the following actions is MOST important?

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 relevant

Submit
16. The physician orders hydromorphone hydrochloride (Dilaudid) 15 mg IM for a patient. The nurse should observe for which of the following side effects?

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 medication

Submit
17. 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?

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 monitoring

Submit
18. The nurse administers oral verapamil (Calan) to a client. Before administering the medication, the nurse should check which of the following?

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 administration

Submit
19. 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?

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 LPN

Submit
20. 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?

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 amniocentesis

Submit
21. 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?

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 ordered

Submit
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?

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.

Submit
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?

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 area

Submit
24. The nurse knows that according to Erikson's stages of psychosocial development, which of the following best represents a 50-year-old client?

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 adolescent

Submit
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?

Explanation

not-available-via-ai

Submit
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?

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 patient

Submit
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?

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 age

Submit
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?

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 effect

Submit
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?

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 stage

Submit
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?

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 vessels

Submit
31. Which of the following is the BEST way for a nurse to assess the fluid balance of an elderly client?

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 status

Submit
32. The nurse recognizes which of the following are early signs of lithium toxicity?

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 lithium

Submit
33. 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?

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 hallucinations

Submit
34. 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?

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 treated

Submit
35. 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?

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 substantiated

Submit
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?

Explanation

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 behavior

Submit
37. Which of the following instructions should the nurse give to an adult client to prepare for a plasma cholesterol screening?

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.

Submit
38. 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?

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 eclampsia

Submit
39. The nurse should caution the client with hypothyroidism to avoid which of the following?

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 constipation

Submit
40. 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?

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) inaccurate

Submit
41. 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?

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 intake

Submit
42. 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)?

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 properly

Submit
43. The nurse cares for a newborn infant diagnosed with fetal alcohol syndrome. The nurse expects to see which of the following physical characteristics?

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 epiglottis

Submit
44. 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?

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 poisoning

Submit
45. 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?

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 application

Submit
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?

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 intravenously

Submit
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?

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 day

Submit
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?

Explanation

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 coping

Submit
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?

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 answer

Submit
50. The nurse cares for a patient diagnosed with a pneumothorax resulting from a motor vehicle accident three days ago. The client has a chest tube connected to a three-chamber water-seal drainage system (Pleur-evac) with 20 cm suction. The nurse determines the lung has re-expanded if which of the following is observed?

Explanation

Strategy: Determine how each observation relates to a chest tube.

(1) doesn’t indicate re-expansion

(2) correct—indicates no more air leaking into pleural space

(3) indicates air leak; need to check for location of leak; clamp tubing close to chest and check for bubbling, and then clamp tubing close to container and check for bubbling

(4) normal finding

Submit
51. In preparing a teaching plan regarding colostomy irrigations, the nurse should include which of the following?

Explanation

Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?

(1) correct—colostomy irrigation should be done at same time each day to assist in establishing a normal pattern of elimination

(2) colostomy should be irrigated only once a day

(3) catheter should never be inserted more than 4 inches.

(4) solution should be at body temperature; increasing the temperature does not make irrigation more efficient

Submit
52. The outpatient clinic nurse cares for an elderly client diagnosed with type 1 diabetes. Because the client is unwilling to perform blood glucose monitoring, the client tests urine for sugar and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because of which of the following?

Explanation

Strategy: Think about each answer.

(1) correct—the level at which glucose starts to appear in the urine increases, leading to false-negative readings; results in elevated glucose levels

(2) more expensive procedure

(3) provides false-negative readings; may be negative from 0 to 180 mg/dL

(4) results are expressed as a percentage according to color change

Submit
53. The nurse cares for a 3-month-old infant scheduled for a barium swallow in the morning. Prior to the procedure, it is MOST appropriate for the nurse to take which of the following actions?

Explanation

Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?

(1) inappropriate

(2) correct—infant should be NPO 3 hours prior to the procedure

(3) inappropriate

(4) unnecessary for an infant to be NPO for 6 hours

Submit
54. The physician orders naproxen sodium (Naprosyn) for an elderly client. The nurse should assess the patient for which of the following?

Explanation

Strategy: Determine how each answer relates to Naprosyn.

(1) not side effects seen with this medication; may see headache, nausea

(2) not side effects seen with this medication; may see epigastric distress and rash

(3) correct—NSAID (nonsteroidal anti-inflammatory drug) used as analgesic; side effects include headache, dizziness, gastrointestinal distress, pruritus, and rash

(4) not side effects seen with this medication; may see nephrotoxicity and pruritus

Submit
55. The nurse cares for a postoperative client diagnosed with type 2 diabetes controlled with oral antihyperglycemic agents. The client asks why the physician ordered subcutaneous insulin injections after surgery. The nurse's response should be based on which of the following statements?

Explanation

Strategy: Think about each answer.

(1) inaccurate

(2) inaccurate

(3) correct—inability to control diabetes mellitus by diet and oral agents, coupled with surgically induced metabolic changes, being NPO both before and after surgery, and the infusion of intravenous fluids necessitates temporary control by insulin

(4) inaccurate

Submit
56. The nurse prepares an adult client diagnosed with mental retardation for discharge. The physician ordered warfarin sodium (Coumadin), 5 mg each day. To maintain client safety, which of the following actions should the nurse take FIRST?

Explanation

Strategy: Answers are a mix of assessment and implementation. Does this situation require assessment? Yes.

(1) implementation; might be done after assessment of the comprehension level

(2) correct—assessment; mentally retarded client should be carefully evaluated to ensure complete comprehension of the dosage regimen to prevent overdosage and underdosage

(3) implementation; might be done after assessment of the comprehension level

(4) implementation; might be done after evaluation of the comprehension level

Submit
57. The nurse cares for clients in the outpatient clinic. Which of the following messages should the nurse return FIRST?

Explanation

(2) correct—fontanelle should feel soft and flat; fullness or bulging indicates increased intracranial pressure

Submit
58. Which of the following should be charted by the nurse to reflect a client's emotional adjustment to being hospitalized in the intensive care unit?

Explanation

Strategy: Good charting is the objective.

(1) does not describe emotional adjustment

(2) draws conclusions without supporting data

(3) correct—gives an objective description of the client’s behavior and affect

(4) describes the client’s family, not the client

Submit
59. The nurse cares for a client receiving a blood transfusion for approximately 30 minutes. Which of these assessments, if made by the nurse, indicates an allergic reaction?

Explanation

Strategy: Think about each answer.

(1) indicative of a hemolytic transfusion reaction

(2) indicative of a hemolytic transfusion reaction

(3) correct—allergic reaction is characterized by wheezing, urticaria (hives), facial flushing, and epiglottal edema

(4) indicative of a hemolytic transfusion reaction

Submit
60. The nurse cares for clients in a drug rehabilitation facility. Which of the following complications of IV drug abuse is the nurse MOST likely to observe?

Explanation

Strategy: Determine how each answer relates to IV drug abuse.

(1) jaundice can develop because of hepatitis B and cirrhosis, which may occur in narcotic abusers who use intravenous drugs

(2) may occur because of the chemicals that are used in cutting the drugs by the client or the drug dealer

(3) may occur because of the chemicals that are used in cutting the drugs by the client or drug dealer

(4) correct—most narcotic addicts do not inject sterile purified material with aseptic techniques; cellulitis is a common complication because of skin popping or using an infected drug apparatus

Submit
61. The parents of a child diagnosed with hemophilia ask the nurse to explain the cause of the disease. Which of the following responses by the nurse is BEST?

Explanation

(3) correct—hemophilia is a sex-linked disorder

Submit
62. Which of the following observations suggests to the nurse that the client has developed an addisonian crisis?

Explanation

Strategy: Determine how each answer relates to Addison’s.

(1) signs and symptoms of Addison’s disease, but do not indicate a crisis

(2) correct—may be signs of shock related to an addisonian crisis

(3) signs and symptoms of Addison’s disease, but do not indicate a crisis

(4) signs and symptoms of Addison’s disease, but do not indicate a crisis

Submit
63. The nurse prepares an older client for an intravenous pyelogram (IVP). The client asks the nurse to explain the reason why the procedure is performed. The nurse's response should be based on which of the following?

Explanation

Strategy: Think about each answer.

(1) would involve invasive procedure, such as cystoscopy

(2) not primary purpose

(3) correct—x-rays of entire urinary tract taken, evaluates kidney function

(4) not primary purpose

Submit
64. An elderly client recently immobilized is ordered to begin passive range-of-motion (ROM) exercises. What should the nurse understand about ROM before initiating this order?

Explanation

Strategy: Think about each answer.

(1) inaccurate statement

(2) ROM may be limited

(3) should not be done to point of discomfort

(4) correct—full ROM may not be needed or accomplished without discomfort for an elderly client; emphasis should be on ROMs that support ADLs

Submit
65. A client comes to the outpatient psychiatric clinic for treatment of a fear of heights. The nurse knows that phobias involve which of the following?

Explanation

(1) correct—projection (attributing one’s thoughts or impulses to another) and displacement (shifting of emotion concerning person or object to another neutral or less dangerous person or object)

(2) sublimation (diversion of unacceptable drives into socially acceptable channels) and internalization (incorporation of someone else’s opinion as one’s own)

(3) rationalization (attempt to make behavior appear to be the result of logical thinking) and intellectualization (excessive reasoning or logic used to avoid experiencing disturbing feelings)

(4) reaction formation (development of conscious attitudes and behavior patterns into opposite of what one really wants to do) and symbolization (something represents something else); symbolization is involved in phobias

Submit
66. Which of the following might alert the nurse to consider an alcohol problem in a client hospitalized for a physical illness?

Explanation

Strategy: Remember the "comma, comma, and" rule.

(1) is more indicative of a dysphoric or depressed client

(2) could warrant a further exploration of alcohol use but is not the best indication

(3) correct—when a client is admitted for another physical problem to a general medical, surgical, or critical care unit, the nurse many times becomes the case finder and must be alert for subtle symptoms of an alcohol-related problem; client who has several complaints of pain that do not appear to be correlated to the admissions problem requires further investigation; tremors, elevated temperature, and pain symptoms are indicative of an alcohol-related problem

(4) is more indicative of withdrawal from narcotics or an infective problem such as tuberculosis

Submit
67. The physician inserts a temporary pacemaker in a client following a myocardial infarction. The nurse knows that the primary purpose of the pacemaker is which of the following?

Explanation

Strategy: Think about each answer.

(1) action of cardiac glycosides such as digoxin

(2) correct—acts to regulate cardiac rhythm

(3) action of antiarrhythmics such as quinidine

(4) action of diuretics such as Lasix

Submit
68. A client with an endotracheal tube requires suctioning. Which of the following statements is an accurate description of how the nurse should perform the procedure?

Explanation

(4) correct—insert suction catheter until resistance is met without applying suction, withdraw 0.4 to 0.8 inches (1 to 2 cm), and apply intermittent suction with twirling motion

Submit
69. The nurse knows that cortisol is responsible for which of the following?

Explanation

Strategy: Think about each answer.

(1) action of epinephrine

(2) action of parathyroid hormone parathormone

(3) correct—action of cortisol; is also an anti-inflammatory agent

(4) action of norepinephrine

Submit
70. The nurse on a psychiatric unit of the hospital refuses to agree to a patient's request to organize a party on the unit for the patient's friends. The patient becomes angry and uses abusive language toward the nurse. Which of the following statements indicates that the nurse has an understanding of the patient's behavior?

Explanation

Strategy: Think about each answer.

(1) inaccurate; doesn’t undermine authority of staff

(2) shows lack of understanding of cause for patient’s behavior

(3) correct—symptoms will respond to treatment

(4) suggests that using acceptable language will change patient’s behavior; shows lack of understanding of patient’s behavior

Submit
71. An 18-month-old is admitted to the unit with a diagnosis of laryngotracheobronchitis (LTB). During the initial assessment, the nurse expects to find which of the following early symptoms?

Explanation

Strategy: Determine how each answer relates to croup.

(1) Kussmaul respirations are associated with diabetic ketoacidosis; hypoxia and anxiety are associated with tachycardia

(2) respiratory rate would be increased

(3) more often noted with respiratory distress of the newborn

(4) correct—this condition is characterized by edema and inflammation of upper airways

Submit
72. A 7-year-old girl is seen in the clinic with a diagnosis of pituitary dwarfism. Which of the following clinical manifestations is the nurse MOST likely to observe?

Explanation

Strategy: Determine how each answer relates to dwarfism.

(1) see small size but normal body proportions

(2) usually have delayed sexual maturity

(3) correct—appear younger than chronological age

(4) usually see fine, smooth skin

Submit
73. A client develops a postoperative infection and receives ceftriaxone sodium (Rocephin) IV every day. It is MOST important for the nurse to monitor which of the following?

Explanation

Strategy: Answer choices indicates a complication.

(1) correct—cephalosporin, long-term use of Rocephin can cause overgrowth of organisms; monitoring of tongue and oral cavity is recommended

(2) does not reflect a problem with this medication

(3) does not reflect a problem with this medication

(4) does not reflect a problem with this medication

Submit
74. The nurse cares for a client admitted with a diagnosis of cerebrovascular accident (CVA) and facial paralysis. Nursing care should be planned to prevent which of the following complications?

Explanation

[Show/hide explanation]

Strategy: Think about each answer.

(1) may occur, but nursing care cannot prevent it

(2) may occur, but nursing care cannot prevent it

(3) may occur, but nursing care cannot prevent it

(4) correct—client will be unable to close eye voluntarily; when facial nerve (cranial nerve VII) is affected, the lacrimal gland will no longer supply secretions that protect eye

Submit
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