NCLEX-RN 100 Practice Questions
- 1.
A client has a total laryngectomy with a permanent tracheostomy. The nurse plans nutritional intake for the next 3 days. Which of the following is necessary for the nurse to consider regarding the client’s nutrition?
- A.
To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented.
- B.
The client will be unable to maintain any oral intake as long as the tracheotomy is in place.
- C.
Nutritional and/or gastric feedings will not be attempted for approximately 3 weeks to decrease the incidence of aspiration.
- D.
Because the client is dependent on the ventilator, nutritional intake will be delayed.
Correct Answer
A. To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented.Explanation
Strategy: Think about each answer choice.
(1) correct—tube feedings frequently started as the initial nutritional intake; prevents trauma to suture area
(2) although client has permanent tracheotomy, will be able to eat normally after area has healed
(3) nutritional intake will begin when bowel sounds return and client can tolerate intake
(4) client is not dependent on ventilatorRate this question:
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- 2.
The nurse cares for a client who presents with confusion, mood lability, impaired communication, and lethargy. The nurse should question which of the following orders?
- A.
Dexamethasone suppression test.
- B.
Thyroid studies.
- C.
Drug toxicology screen.
- D.
Trendelenburg test.
Correct Answer
D. Trendelenburg test.Explanation
Strategy: Think about each test.
(1) may be ordered to determine the presence of major depression
(2) may be ordered to check for an endocrine cause for the symptoms before the diagnosis of dementia is made
(3) may be ordered to see if the client’s symptoms are caused by excessive use of medications or alcohol
(4) correct—test is used with a client who may have varicose veins, no relationship to the symptoms described in this situationRate this question:
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- 3.
For a client with a neurologic disorder, which of the following nursing assessments is MOST helpful in determining subtle changes in the client’s level of consciousness?
- A.
Client posturing.
- B.
Glasgow coma scale.
- C.
Client thinking pattern.
- D.
Occurrence of hallucinations.
Correct Answer
B. Glasgow coma scale.Explanation
Strategy: Think about each answer choice.
(1) indicates increased intracranial pressure
(2) correct—Glasgow coma scale score best evaluates changes in a client’s level of consciousness by evaluating eye-opening, motor, and verbal responses
(3) more appropriate for the psychiatric client
(4) more appropriate for the psychiatric clientRate this question:
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- 4.
The nurse conducts a physical examination of a client suspected to have bulimia. Which of the following observations by the nurse MOST likely indicates bulimia?
- A.
The client has edema of the lower extremities.
- B.
Physical exam of the client reveals the presence of lanugo.
- C.
The client has ulcerated mucous membranes of the mouth.
- D.
The client has dry, yellowish color of the skin.
Correct Answer
C. The client has ulcerated mucous membranes of the mouth.Explanation
Strategy: Determine the cause of each symptom. Does it relate to bulimia?
(1) common with anorexia
(2) seen with anorexia
(3) correct—due to frequent vomiting
(4) bulimics are normal in appearanceRate this question:
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- 5.
The nurse prepares a dopamine (Intropin) infusion on a client. Before beginning the infusion the nurse should take which of the following actions?
- A.
Evaluate the urine output.
- B.
Obtain the client’s weight.
- C.
Determine the patency of the IV line.
- D.
Measure pulmonary artery pressures.
Correct Answer
C. Determine the patency of the IV line.Explanation
Strategy: Determine how each answer choice relates to dopamine.
(1) not a critical assessment at this time
(2) contains correct information, but is not a priority
(3) correct—if extravasation occurs, there is sloughing of the surrounding skin and tissue; patent IV line is essential to prevent serious side effects
(4) not a critical assessment at this timeRate this question:
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- 6.
The nurse assists a nursing assistant in providing a bed bath to a comatose patient with incontinence. The nurse should intervene if which of the following actions is noted?
- A.
The nursing assistant answers the phone while wearing gloves.
- B.
The nursing assistant log rolls the patient to provide back care.
- C.
The nursing assistant places an incontinent pad under the patient.
- D.
The nursing assistant positions the patient on the left side, head elevated.
Correct Answer
A. The nursing assistant answers the phone while wearing gloves.Explanation
Strategy: "Nurse should intervene" indicates that you are looking for an incorrect action.
(1) correct—contaminated gloves should be removed before answering the phone
(2) correct way to roll a patient to maintain proper alignment
(3) appropriate to use incontinence pad for this patient
(4) appropriate position to prevent aspiration and protect the airwayRate this question:
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- 7.
The nurse instructs a client who is receiving imipramine (Tofranil). It is MOST important for the nurse to instruct the client to immediately report which of the following?
- A.
Sore throat, fever, increased fatigue, vomiting, diarrhea.
- B.
Dry mouth, nasal stuffiness, weight gain.
- C.
Rapid heartbeat, frequent headaches, yellowing of eyes or skin.
- D.
Weakness, staggering gait, tremor, feeling of drunkenness.
Correct Answer
A. Sore throat, fever, increased fatigue, vomiting, diarrhea.Explanation
Strategy: Think about each answer choice.
(1) correct—possible side effects of Tofranil, a tricyclic antidepressant medication, which can be resolved by altering the dosage or changing the medication
(2) describes side effects of antidepressants, which client can learn to manage at home without changing the medication
(3) not side effects of Tofranil
(4) not side effects of TofranilRate this question:
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- 8.
The nurse receives report from the previous shift. Which of the following patients should the nurse see FIRST?
- A.
A patient post coronary artery bypass graft (CABG) having the atrioventricular (AV) wires removed later in the day.
- B.
A patient with type 1 diabetes scheduled for a cardiac catheterization later today.
- C.
A patient 1 day postoperative with an epidural catheter in place.
- D.
A patient diagnosed with cardiomyopathy being evaluated for a heart transplant.
Correct Answer
C. A patient 1 day postoperative with an epidural catheter in place.Explanation
Strategy: Determine which patient is the least stable.
(1) although the patient requires a high level of nursing care, no indication that the patient is unstable
(2) patient requires preoperative assessment and teaching, no indication that the patient is unstable
(3) correct —epidural used for pain relief, monitor for urinary incontinence, hypotension, respiratory depression, and nausea and vomiting
(4) requires monitoring but patient with epidural takes priorityRate this question:
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- 9.
A child has a closed transverse fracture of the right ulna. Which of the following actions, if performed by the nurse before the application of a cast, is MOST important?
- A.
Check the radial pulses bilaterally and compare.
- B.
Evaluate the skin temperature and tissue turgor in the area.
- C.
Assess sensation of each foot while the child closes her eyes.
- D.
Apply baby powder to decrease skin irritation under the cast.
Correct Answer
A. Check the radial pulses bilaterally and compare.Explanation
Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes.
(1) correct—assess neurovascular status, check pain, pallor, paralysis, paresthesia, pulselessness
(2) assessment; temperature indicates decreased circulation but is subjective and not most important
(3) assessment; upper (not lower) extremity fracture
(4) implementation; should not be done because it would increase skin irritationRate this question:
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- 10.
The nurse cares for a multipara client who delivered a female infant 1 hour ago. The nurse observes that the client’s breasts are soft; the uterus is boggy to the right of the midline and 2 cm below the umbilicus; moderate lochia rubra. It is MOST important for the nurse to take which of the following actions?
- A.
Perform a straight catheterization.
- B.
Offer the client the bedpan.
- C.
Put the baby to breast.
- D.
Massage the uterine fundus.
Correct Answer
B. Offer the client the bedpan.Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) encourage the client to void before catheterizing
(2) correct—boggy uterus deviated to right indicates full bladder, encourage client to void
(3) will increase uterine tone, but the problem is a full bladder
(4) findings indicate a full bladderRate this question:
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- 11.
The nurse checks for placement of a nasogastric (NG) tube prior to initiating a tube feeding for a client. Which of the following results indicates to the nurse that the tube feeding can begin?
- A.
A small amount of white mucus is aspirated from the NG tube.
- B.
The contents aspirated from the NG tube have a pH of 3.
- C.
No bubbles are seen when the nurse inverts the NG tube in water.
- D.
The client says he can feel the NG tube in the back of his throat.
Correct Answer
B. The contents aspirated from the NG tube have a pH of 3.Explanation
Strategy: Determine how the answers relate to a tube feeding.
(1) mucus may be from lungs
(2) correct—stomach contents are acidic
(3) not a safe way to check placement
(4) not a reliable indicationRate this question:
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- 12.
The nurse cares for a client after right cataract surgery. The nurse should intervene if which of the following is observed?
- A.
Client is in the supine position.
- B.
The head of the bed is elevated 30 degrees.
- C.
The client is lying on the right side.
- D.
An eye shield is over the right eye.
Correct Answer
C. The client is lying on the right side.Explanation
Strategy: "Nurse should intervene" indicates an incorrect action.
(1) appropriate position
(2) decreases swelling and pain
(3) correct—client should not be positioned with operative side in a dependent position or against the bed
(4) shield is appropriateRate this question:
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- 13.
A young adult immobilized for trauma to the spinal cord has periods of diaphoresis, a draining abdominal wound, and diarrhea. On the basis of the nursing assessment, which of the following is the MOST important nursing diagnosis?
- A.
Risk for constipation related to immobilization.
- B.
Risk for impaired skin integrity related to immobilization and secretions.
- C.
Risk for wound infection related to involuntary bowel secretions.
- D.
Risk for fluid volume excess related to secretions.
Correct Answer
B. Risk for impaired skin integrity related to immobilization and secretions.Explanation
Strategy: Think about each answer choice.
(1) constipation is not a problem because the client has diarrhea
(2) correct—skin is very susceptible to breakdown because of immobility and bodily secretions; needs numerous nursing interventions to prevent this
(3) not most important
(4) may be risk of fluid volume deficit due to diarrhea and secretionsRate this question:
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- 14.
The nurse cares for a client one day after a thoracotomy. Nursing actions listed on the care plan include turn, cough, and deep breathe q 2 h. The nurse understands that the purpose of this nursing action includes which of the following?
- A.
Promote ventilation and prevent respiratory acidosis.
- B.
Increase oxygenation and removal of secretions.
- C.
Increase pH and facilitate balance of bicarbonate.
- D.
Prevent respiratory alkalosis by increasing oxygenation.
Correct Answer
A. Promote ventilation and prevent respiratory acidosis.Explanation
Strategy: Think about each answer choice.
(1) correct—primary purpose of this nursing measure is to improve and/or maintain good gas exchange, especially removal of carbon dioxide in order to prevent respiratory acidosis
(2) answer choice #1 is better in that it refers to ventilation rather than oxygenation
(3) increasing the pH is not desirable
(4) respiratory alkalosis is not prevented by this nursing measureRate this question:
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- 15.
The mother of a 7-year-old child is dying. The nurse anticipates the child will have which of the following concepts of death?
- A.
Death is punishment for his/her actions.
- B.
Death is inevitable and irreversible.
- C.
Death is temporary and gradual.
- D.
Death as a concept based on past experience.
Correct Answer
A. Death is punishment for his/her actions.Explanation
Strategy: Remember growth and development.
(1) correct–7-year-olds see death as a punishment
(2) by age of 9, most children begin to develop an adult concept of death and begin to understand that death is irreversible
(3) is a preschool child’s concept of death
(4) is an adolescent’s concept of deathRate this question:
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- 16.
A client with newly diagnosed type 1 diabetes says to the nurse, "I know that I have to take good care of my feet. When I buy new shoes, is there anything special I should do?" Which of the following responses by the nurse is BEST?
- A.
"It is best to buy new shoes in the morning."
- B.
"Have each foot measured every time you buy new shoes."
- C.
"Buy shoes a half-size larger than your foot size so the fit is roomy."
- D.
"Buy vinyl shoes because they won’t lose their shape easily."
Correct Answer
B. "Have each foot measured every time you buy new shoes."Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) should buy shoes in the afternoon when feet are larger than in the morning
(2) correct—feet enlarge with age, break in shoes gradually rather than all at one time, have measurements for shoes taken while standing (feet are larger)
(3) buy correct shoe size
(4) leather shoes recommended because they "breathe," vinyl could cause foot to perspire and aggravate fungal infectionsRate this question:
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- 17.
A neonate weighing 7 lb 4 oz with Apgar scores of 7 and 8 at 1 and 5 minutes, respectively, is admitted to the nursery. Because the infant’s mother is diagnosed with a type 1 diabetes, the nurse knows the infant is at GREATEST risk for developing which of the following?
- A.
Hypovolemia.
- B.
Hypoglycemia.
- C.
Hyperglycemia.
- D.
Cold stress.
Correct Answer
B. Hypoglycemia.Explanation
Strategy: Determine the cause of each answer choice.
(1) no change in blood volume for infant of diabetic mother
(2) correct—fetus produces increased insulin to match mother’s increased glucose level during pregnancy; infant continues to have high insulin output after birth, resulting in hypoglycemia
(3) infant would be at risk of hypoglycemia due to increased insulin production
(4) thermal receptors in skin are stimulated due to cold environment; increases metabolic rate; infant needs to maintain normal body temperature while producing minimal amount of heat generated from metabolic processes; not expected with diabetic motherRate this question:
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- 18.
The nurse in the outpatient clinic assists with the application of a cast to the left arm of a pre-school-aged child. After the cast is applied, the nurse should take which of the following actions?
- A.
Petal the edges of the cast to prevent irritation.
- B.
Elevate the client’s left arm on two pillows.
- C.
Apply cool, humidified air to dry the cast.
- D.
Ask the client to move the fingers to maintain mobility.
Correct Answer
B. Elevate the client’s left arm on two pillows.Explanation
Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) done when cast is completely dry, prevents crumbling of plaster into cast
(2) correct—minimizes swelling, elevated for first 24 to 48 hours, protects from pressure and flattening of cast
(3) would delay drying of cast
(4) maintaining mobility of fingers not most important after application of castRate this question:
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- 19.
The nurse cares for patients on the pediatric unit. The mother of a 2-year-old who is one day postoperative tells the nurse, "My child is so restless and overactive." The nurse should take which of the following actions?
- A.
Direct the LPN/LVN to obtain the child’s vital signs.
- B.
Ask the mother if the child’s sutures are still intact.
- C.
Tell the nursing assistant to take the child for a walk.
- D.
Check to see when the child last received pain medication.
Correct Answer
D. Check to see when the child last received pain medication.Explanation
Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? Yes. Determine the best assessment.
(1) no indication that there are any problems
(2) passing the buck
(3) implementation; should first assess
(4) correct—young children typically become restless and overactive if in pain; grimacing, clenching teeth, rocking, and aggressive behavior may also be observedRate this question:
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- 20.
The nurse plans a diet for a child diagnosed with cystic fibrosis (CF). Which of the following dietary requirements should be considered by the nurse?
- A.
High protein, high fat, and high calories.
- B.
High protein, low fat, and high calories.
- C.
Low protein, low fat, and low carbohydrate.
- D.
High protein, high fat, and low carbohydrate.
Correct Answer
B. High protein, low fat, and high calories.Explanation
Strategy: Think about each answer choice.
(1) contains high fat
(2) correct—impaired intestinal absorption due to cystic fibrosis necessitates a diet higher in protein and calories; fat is decreased because it may interfere with absorption of other nutrients
(3) not adequate for this child
(4) contains high fatRate this question:
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- 21.
A male client is admitted with urinary tract problems. A prostate-specific antigen (PSA) and acid phosphatase test are to be done. The nurse knows that
- A.
these tests are valuable screening tests for prostatic cancer.
- B.
the level of PSA is decreased in clients with renal stones.
- C.
the tests reflect the level of renal involvement in acid-base problems.
- D.
the level of PSA is elevated in clients in early-stage renal failure.
Correct Answer
A. these tests are valuable screening tests for prostatic cancer.Explanation
Strategy: Think about each answer choice.
(1) correct—PSA test has replaced acid phosphatase test in screening for prostatic cancer; test must be drawn before digital rectal exam, as manipulation of the prostate will abnormally increase PSA value
(2) inaccurate information about a PSA
(3) inaccurate information about a PSA
(4) inaccurate information about a PSARate this question:
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- 22.
A client with clear lung sounds and unlabored breathing receives aminophylline IV. Which of the following is the MOST appropriate nursing action if the client’s IV infiltrates?
- A.
Apply warm soaks to the infiltration site, start a new IV, and continue IV medications.
- B.
Wait 2 hours, reassess the client, and restart the IV if the client has wheezing or labored breathing.
- C.
Restart the IV and continue the previous medication schedule.
- D.
Call the physician and recommend that the IV medications be changed to PO.
Correct Answer
D. Call the physician and recommend that the IV medications be changed to PO.Explanation
Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) continued IV medication may not be necessary based on the current assessment
(2) physician should be notified if IV medications are not infusing as scheduled
(3) client has improved breathing, so IV medications may not be indicated
(4) correct—before a new IV is started on this client, physician should be called and PO medications recommendedRate this question:
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- 23.
A client diagnosed with bipolar disorder is in a manic phase with combative behavior. Which of the following is the INITIAL priority nursing action?
- A.
Provide adequate hygiene and nutrition.
- B.
Decrease environmental stimuli.
- C.
Slowly involve the client in unit activities.
- D.
Administer and monitor sedative and mood-stabilizing medications.
Correct Answer
D. Administer and monitor sedative and mood-stabilizing medications.Explanation
Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) is very important to ensure adequate hygiene and nutrition, but behavioral control and client/milieu safety are an initial priority
(2) decreasing environmental stimulation is an additional strategy that, when utilized in conjunction with psychopharmacologic intervention, can reduce hyperactivity and aggressive acts; just decreasing environmental stimulation will not diminish client’s internal sense of agitation and aggression
(3) this action is inappropriate at this time
(4) correct—is most important to gain control with a physically aggressive client in manic phase; client has significant sympathetic nervous system stimulation and will require psychopharmacologic intervention with both sedative medications and mood-stabilizing agentsRate this question:
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- 24.
A client is admitted to the neurosurgery unit for the removal of a cerebellar tumor. The nurse expects the patient to make which of the following statements about symptoms?
- A.
"I have been having difficulty with my hearing."
- B.
"I lose my balance easily."
- C.
"I can't tell the difference between a sweet and sour taste."
- D.
"It is not easy for me to remember names and faces."
Correct Answer
B. "I lose my balance easily."Explanation
Strategy: Remember physiology.
(1) temporal lobe contains auditory center, loss of hearing would involve CN VIII acoustic
(2) correct—cerebellum maintains balance
(3) CN IX, glossopharyngeal responsible for differentiation of taste
(4) not specific symptom of cerebellum dysfunctionRate this question:
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- 25.
Nursing management prior to an intravenous pyelogram (IVP) would include which of the following?
- A.
A fat-free meal the evening before the examination and radiopaque tablets at bedtime.
- B.
Placement of a retention urinary catheter to facilitate dilation of the bladder sphincter.
- C.
Cleansing enemas the evening before to provide for adequate visualization of the urinary tract.
- D.
Explaining the importance of following directions regarding voiding during the test.
Correct Answer
C. Cleansing enemas the evening before to provide for adequate visualization of the urinary tract.Explanation
Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired?
(1) fat-free meal is associated with a gallbladder series
(2) a retention Foley catheter may be in place, but not for the purpose of dilating the bladder sphincter
(3) correct—because of the need to visualize the abdominal area, cleansing enemas the evening before an IVP are usually ordered
(4) there are few directions the client needs to follow during the testRate this question:
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- 26.
A client is admitted to the trauma intensive care unit (ICU) with a gunshot wound of the neck. The client, diagnosed with a spinal cord injury at the level of C4, is tearful, constantly complains of discomfort, and requests to be suctioned. The nurse understands that the client’s attention-seeking behaviors may be due to which of the following?
- A.
Anger and frustration.
- B.
Awareness of vulnerability.
- C.
Increased social isolation.
- D.
Increased sensory stimulation.
Correct Answer
B. Awareness of vulnerability.Explanation
Strategy: Think about each answer choice.
(1) is not accurate for situation
(2) correct—is experiencing an increased awareness of his physical vulnerability due to his spinal cord injury; fosters increased dependency needs that are real due to his injury; is trying to determine who is consistent and trustworthy for meeting his significant physical needs
(3) is not accurate for situation
(4) is not accurate for situationRate this question:
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- 27.
A client is scheduled for electromyography (EMG). What should the nurse tell the client about the procedure?
- A.
"Your hair will be carefully washed prior to the procedure."
- B.
"This is a noninvasive procedure that takes about 30 minutes."
- C.
"A sedative will be given to you shortly before the procedure."
- D.
"You will not be allowed to eat 4 to 6 hours before the procedure."
Correct Answer
B. "This is a noninvasive procedure that takes about 30 minutes."Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) usually performed on the legs
(2) correct—electrodes are attached to legs, length of time for impulse transmission is measured
(3) may impair test results
(4) procedure does not involve general anesthesia or GI systemRate this question:
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- 28.
The nurse is aware that Rh immune globulin (RhoGAM) is administered to prevent complications in which of the following situations?
- A.
The baby is Rh-negative, the mother is Rh-negative, and the father is Rh-positive.
- B.
The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs.
- C.
The mother is Rh-positive and previously sensitized, and the baby is Rh-negative.
- D.
The mother is Rh-positive, the baby is Rh-negative, and there is a history of one incomplete pregnancy.
Correct Answer
B. The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs.Explanation
Strategy: Think about each answer choice.
(1) if both mother and baby are Rh-negative, there is no problem
(2) correct—RhoGAM is given to an Rh-negative mother who delivers an Rh-positive baby when the baby has a negative Coombs test
(3) medication is not given if the mother has been sensitized by a previous pregnancy
(4) there is no incompatibility here, but the mother needs to be evaluated regarding sensitization in the incomplete pregnancyRate this question:
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- 29.
The nurse in the outpatient clinic instructs a client diagnosed with right-sided weakness to walk down stairs using a cane. What behavior, if demonstrated by the client, indicates to the nurse that teaching is successful?
- A.
The client puts the right leg on the step, then the cane, followed by the left leg.
- B.
The client leads with the cane, followed by the right leg and then the left leg.
- C.
The client advances the right leg, followed by the left leg and the cane.
- D.
The client puts the cane on the step and advances the left leg, followed by the right leg.
Correct Answer
B. The client leads with the cane, followed by the right leg and then the left leg.Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) to go down stairs, advance weak leg and cane first; to go up stairs, advance strong leg, then weak leg and cane
(2) correct—to go down stairs, advance cane and weak leg, then strong leg; memory trick: the good goes up, the bad goes down
(3) should advance cane and weak leg first
(4) weaker leg and cane advance firstRate this question:
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- 30.
The nurse makes patient assignments on the obstetrics unit. Which of the following patients should the nurse assign to an RN who has been reassigned to the obstetrics unit from outpatient surgery?
- A.
A patient at 16 weeks’ gestation admitted with hyperemesis and receiving IV fluids.
- B.
A patient at 26 weeks’ gestation in premature labor and receiving terbutaline (Brethine).
- C.
A patient at 32 weeks’ gestation with a placenta previa and ruptured membranes.
- D.
A patient at 37 weeks’ gestation with pregnancy-induced hypertension and epigastric pain.
Correct Answer
A. A patient at 16 weeks’ gestation admitted with hyperemesis and receiving IV fluids.Explanation
Strategy: LPN/LVN and "pulled" RN receive stable patients with expected outcomes.
(1) correct—monitor IV therapy, administer antiemetics and nutritional supplements
(2) monitor patient’s response to medication and the status of the fetus
(3) prepare for delivery, closely monitor fetal response
(4) indicates impending seizures, prepare for deliveryRate this question:
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- 31.
A 2-day-old infant in the newborn nursery does not appear interested in taking formula from the mother or the nurse. An appropriate nursing diagnosis is high risk for
- A.
impaired swallowing.
- B.
failure to thrive.
- C.
fluid volume deficit.
- D.
altered health maintenance.
Correct Answer
C. fluid volume deficit.Explanation
Strategy: Think about each answer choice.
(1) no information about swallowing provided with question
(2) this is a medical diagnosis, not a nursing diagnosis
(3) correct—may become dehydrated
(4) not specific for problem describedRate this question:
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- 32.
The nurse cares for clients in the medical clinic. A nursing assessment of a client with a hiatal hernia is MOST likely to reveal which of the following?
- A.
A bulge in the lower right quadrant.
- B.
Pain at the umbilicus radiating down into the groin.
- C.
A burning sensation in the midepigastric area each day before lunch.
- D.
Complaints of awakening at night with heartburn.
Correct Answer
D. Complaints of awakening at night with heartburn.Explanation
Strategy: Think about each answer choice.
(1) suggests an inguinal hernia
(2) suggests an inguinal hernia
(3) pain usually does not develop during the day with an empty stomach
(4) correct—classic symptom of hiatal hernia associated with refluxRate this question:
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- 33.
The MOST appropriate nursing action before administering captopril (Capoten) is to check the client’s
- A.
apical pulse for 60 seconds.
- B.
blood pressure.
- C.
urine output.
- D.
temperature.
Correct Answer
B. blood pressure.Explanation
Strategy: Think about each answer choice and how it relates to Capoten.
(1) important, but not a priority
(2) correct—Capoten is an antihypertensive that necessitates assessment of BP before administration
(3) important, but not priority
(4) unnecessary to assess prior to the administration of the medicationRate this question:
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- 34.
An older client diagnosed with pneumonia is admitted to the medical/surgical unit. The nurse should place the patient in a room with which of the following patients?
- A.
A 20-year-old in traction for multiple fractures of the left lower leg.
- B.
A 35-year-old with recurrent fever of unknown origin.
- C.
A 50-year-old recovering alcoholic with cellulitis of the right foot.
- D.
An 89-year-old with Alzheimer’s disease awaiting nursing home placement.
Correct Answer
C. A 50-year-old recovering alcoholic with cellulitis of the right foot.Explanation
Strategy: Determine the transmission of organisms.
(1) patients with fractures are considered "clean"; don’t place with an infectious patient
(2) don’t know the cause of the fever
(3) correct—generalized nonfollicular infection that involves deeper connective tissue, both patients have infections
(4) elderly are high risk for developing pneumoniaRate this question:
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- 35.
An elderly man diagnosed with chronic schizophrenia is followed in a partial hospitalization program. The client has been on long-term antipsychotic medication and recently developed symptoms of tardive dyskinesia. The nurse’s documentation should include which of the following?
- A.
Assessment of ADL (self-care) ability.
- B.
Mini-Mental Status Examination (MMSE).
- C.
Abnormal Involuntary Movement Scale (AIMS).
- D.
Modified Overt Aggression Scale (MOAS).
Correct Answer
C. Abnormal Involuntary Movement Scale (AIMS).Explanation
Strategy: Think about each answer choice.
(1) assessment of client’s abilities to complete his activities of daily living (ADLs) needs to be completed and revised with a client who is aging and chronically mentally ill
(2) measures cognitive function
(3) correct is most widely accepted examination to test for the presence of tardive dyskinesia
(4) assessment tool for determining severity of aggression; usually utilized to determine nature, severity, and prevalence of aggression in an inpatient populationRate this question:
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- 36.
The nurse obtains a client’s temperature of 103°F(39.4°C). The nurse knows body compensatory mechanisms include which of the following?
- A.
Decreased respiratory rate and bradycardia.
- B.
Normal blood pressure and pulse.
- C.
Increased respiratory rate and tachycardia.
- D.
Diaphoresis with cool, clammy skin.
Correct Answer
C. Increased respiratory rate and tachycardia.Explanation
Strategy: Think about each answer choice.
(1) respirations and heart rate will increase with fever
(2) blood pressure and pulse usually increase with fever
(3) correct—hyperthermia increases the oxygen requirements, which results in faster breathing as well as an increase in the pulse rate
(4) diaphoresis may occur, but the skin will be warmRate this question:
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- 37.
A client is admitted with irritable bowel syndrome. The nurse anticipates that the client’s history will reflect which of the following?
- A.
Pattern of alternating diarrhea and constipation.
- B.
Chronic diarrhea stools occurring 10 to 12 times per day.
- C.
Diarrhea and vomiting with severe abdominal distention.
- D.
Bloody stools with increased cramping after eating.
Correct Answer
A. Pattern of alternating diarrhea and constipation.Explanation
Strategy: Think about each answer choice.
(1) correct—condition is often called spastic bowel disease; no inflammation is present
(2) refers to inflammatory bowel disease such as ulcerative colitis or Crohn’s disease
(3) refers to inflammatory bowel disease such as ulcerative colitis or Crohn’s disease
(4) bloody stools do not occur with irritable bowel syndromeRate this question:
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- 38.
The nurse cares for a client who has had an above-knee amputation (AKA) with an immediate prosthetic fitting. It is MOST important for the nurse to take which of the following actions?
- A.
Assess drainage from Penrose drains.
- B.
Observe dressings for signs of excessive bleeding.
- C.
Elevate the stump for no less than 40 hours.
- D.
Provide cast care on the affected extremity.
Correct Answer
D. Provide cast care on the affected extremity.Explanation
Strategy: Answers are a mix of assessments and implementations. Is there an appropriate assessment? No. Determine the outcome of each implementation.
(1) drains not usually used with amputations
(2) rigid cast dressing frequently used to create a socket for prosthesis
(3) elevation of extremity unnecessary; rigid cast dressing prevents swelling
(4) correct—cast applied to provide uniform compression, prevent pain and contracturesRate this question:
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- 39.
A patient is admitted to the hospital for a hypoglossectomy with lymph node dissection. The patient’s preoperative care includes frequent oral hygiene with hydrogen peroxide. The nurse knows the purpose of this treatment includes which of the following?
- A.
Minimizes the bacterial count in the mouth.
- B.
Softens the mucous membranes of the tongue before surgery.
- C.
Stimulates the microcirculation of the mouth.
- D.
Hydrates the tissues of the gums.
Correct Answer
A. Minimizes the bacterial count in the mouth.Explanation
Frequent oral hygiene with hydrogen peroxide is done to minimize the bacterial count in the mouth. Hydrogen peroxide has antimicrobial properties and can help reduce the number of bacteria in the mouth, reducing the risk of infection during and after surgery. It is important to maintain a clean oral environment to promote healing and prevent complications.Rate this question:
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- 40.
The school nurse observes a group of preschool children in the playroom. The nurse recognizes which of the following activities as appropriate behavior for a 5-year-old boy?
- A.
The boy plays with a large truck with another child.
- B.
The boy talks on a toy telephone and imitates his father.
- C.
The boy works on a puzzle with several other children.
- D.
The boy holds and cuddles a large stuffed animal.
Correct Answer
B. The boy talks on a toy telephone and imitates his father.Explanation
Strategy: Picture the child.
(1) cooperative play occurs in school-aged children
(2) correct—imitative behavior seen at this age
(3) too advanced for this age
(4) too regressed for this ageRate this question:
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- 41.
Which of the following statements, if made by the nurse, is accurate about the exercise program required for a patient with rheumatoid arthritis?
- A.
"If you are having a ‘bad’ day, postpone your exercises until the next day."
- B.
"Passive exercises are better for you than active exercises."
- C.
"When inflammation is severe, decrease the number of repetitions of the exercise."
- D.
"You can substitute your normal household tasks for your exercises to provide variety."
Correct Answer
C. "When inflammation is severe, decrease the number of repetitions of the exercise."Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) consistency is important to maintain joint mobility
(2) active exercises are better than passive or active-assistive exercises
(3) correct—should reduce repetitions when patient experiences more pain
(4) should do exercises that have been prescribed for patientRate this question:
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- 42.
The nurse assesses a client with severe bilateral peripheral edema. Which of the following is the BEST way for the nurse to determine the degree of edema in a limb?
- A.
Measure both limbs with the tape measure and compare.
- B.
Depress the skin and rank the degree of pitting.
- C.
Describe the swelling in the affected area.
- D.
Pinch the skin and note how quickly it returns to normal.
Correct Answer
B. Depress the skin and rank the degree of pitting.Explanation
Strategy: Think about each answer choice.
(1) is not the best way to evaluate for peripheral edema
(2) correct—severity of edema is characterized by grading it 1+ (2-mm pitting) to 4+ (8-mm pitting)
(3) not as objective
(4) is used for evaluating hydrationRate this question:
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- 43.
A 6-month-old infant has had all of the required immunizations. The nurse knows that this would include which of the following?
- A.
Two doses of diphtheria, tetanus, and pertussis vaccine.
- B.
Measles, mumps, and rubella vaccines.
- C.
A booster dose of the inactivated polio vaccine.
- D.
Chickenpox and smallpox vaccines.
Correct Answer
A. Two doses of diphtheria, tetanus, and pertussis vaccine.Explanation
Strategy: Think about each answer choice.
(1) correct—first dose of the DPT may be given at 2 months of age, the second is given around 4 months
(2) MMR is given at 15 months
(3) polio is given at 2 and 4 months and again at 12 to 18 months
(4) recommended for first respondersRate this question:
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- 44.
The nurse should include which of the following in a teaching plan for a client receiving tetracycline?
- A.
Take the medication with milk or antacids to decrease GI problems.
- B.
The medication should always be taken with meals.
- C.
Use a maximum-protection sunscreen when outdoors.
- D.
Crackers and juice will help decrease gastric irritation.
Correct Answer
C. Use a maximum-protection sunscreen when outdoors.Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) tetracycline should never be taken with milk or antacids because these inhibit the medication’s action
(2) should take with full glass of water at least 1 hour before or 2 hours after meals
(3) correct—because of problems related to photosensitivity, client should wear sunscreen, wide-brimmed hats, and long sleeves when at risk for sun exposure
(4) should take with full glass of water at least 1 hour before or 2 hours after mealsRate this question:
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- 45.
An elderly alcoholic client receives a long-acting benzodiazepine (Librium) for 2 days for symptom management and reduction. The client states, "Get those bugs off of me and clean them out of here." The nurse knows the client is exhibiting symptoms of which of the following?
- A.
A reaction to the sedative medication.
- B.
A worsening course of the withdrawal syndrome.
- C.
An exacerbation of the schizophrenia process.
- D.
The process of aging and the effects of delirium.
Correct Answer
B. A worsening course of the withdrawal syndrome.Explanation
Strategy: Think about each answer choice.
(1) client has been medicated with benzodiazepines and did not experience untoward reactions
(2) correct—client has most probably progressed to another level of abstinence withdrawal from polypharmacy chemical dependence; characteristic symptoms include tremors, increased heart rate, and fever, as well as psychological problems of confusion, delusions, and hallucinations
(3) schizophrenic client usually experiences an episode of auditory hallucinations, not visual or tactile hallucinations
(4) combination effect of the normal aging process and dementia could precipitate a similar reaction; however, the normal aging process does not produce delirium but rather dementiaRate this question:
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- 46.
A client is admitted for a series of tests to verify the diagnosis of Cushing syndrome. Which of the following assessment findings, if observed by the nurse, support this diagnosis? Select all that apply.
- A.
Buffalo hump.
- B.
Intolerance to heat.
- C.
Hyperglycemia.
- D.
Hypernatremia.
- E.
Intolerance to cold.
- F.
Irritability.
Correct Answer(s)
A. Buffalo hump.
C. Hyperglycemia.
D. Hypernatremia.Explanation
(1) correct—hypersecretion of adrenal hormones; other indications include weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections
(2) indication of hyperthyroidism
(3) correct—hypersecretion of adrenal hormones; other indications include weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections
(4) correct—hypersecretion of adrenal hormones; other indications include weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections
(5) indication of hypothyroidism
(6) indication of hypoparathyroidismRate this question:
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- 47.
The nurse cares for a patient several days after an above-knee amputation (AKA). Which of the following symptoms are characteristic of an infected residual limb wound?
- A.
The patient is anxious and restless.
- B.
There is a small amount of dark drainage on the dressing.
- C.
The patient complains of persistent pain at the operative site.
- D.
The skin is cool above the operative site.
Correct Answer
C. The patient complains of persistent pain at the operative site.Explanation
Strategy: Determine how each answer choice relates to an infected wound.
(1) may be due to changes in body image or pain
(2) expected, not indicative of an infection
(3) correct—pain is characteristic of inflammation and infection
(4) warm skin above operative site would indicate infectionRate this question:
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- 48.
Which of the following statements, if made by a client to the nurse, indicates that the client is using the defense mechanism of conversion?
- A.
"I love my family with all my heart, even though they don’t love me."
- B.
"I was unable to take my final exams because I was unable to write."
- C.
"I don’t believe I have diabetes. I feel perfectly fine."
- D.
"If my wife was a better housekeeper I wouldn’t have such a problem."
Correct Answer
B. "I was unable to take my final exams because I was unable to write."Explanation
Strategy: Think about each answer choice.
(1) indicates reaction formation
(2) correct—client has converted his anxiety over school performance into a physical symptom that interferes with his ability to perform
(3) indicates denial
(4) indicates projectionRate this question:
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- 49.
Which observation indicates to the nurse that the client needs further teaching before self-administering insulin?
- A.
The client draws up the regular insulin first, then the NPH.
- B.
The client gently rotates the insulin bottle before withdrawing the dose.
- C.
The client rotates injection sites following the guide on the printed diagram.
- D.
The client administers the insulin while it is still cold from the refrigerator.
Correct Answer
D. The client administers the insulin while it is still cold from the refrigerator.Explanation
Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) when mixing regular insulin with other types of insulin, the client should draw up the clear (regular) before the cloudy (NPH)
(2) bottle of insulin should never be vigorously shaken, but rather gently mixed
(3) imperative to rotate injection sites to avoid tissue irritation/infection and ensure proper absorption
(4) correct—insulin should be administered at room temperature; temperature extremes should be avoidedRate this question:
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- 50.
A client has orders for cefoxitin (Mefoxin) 2 g IV piggyback in 100 ml 5% dextrose in water. The primary IV is 5% dextrose in lactated Ringer’s and is infusing by gravity. It is MOST important for the nurse to take which of the following actions?
- A.
Administer the medication slowly, at 20 to 25 cc/h.
- B.
Change the primary IV solution.
- C.
Hang the piggyback infusion bag higher than the primary infusion bag.
- D.
Obtain an infusion pump prior to administration.
Correct Answer
C. Hang the piggyback infusion bag higher than the primary infusion bag.Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) antibiotic should be administered within 1 hour
(2) unnecessary for safe infusion
(3) correct—when using a gravity drip, piggyback fluid level needs to be higher than primary infusion
(4) unnecessary for safe infusionRate this question:
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