NCLEX-RN 150 Practice Questions

1. The nurse returns to the desk and finds four phone messages to return. Which of the following messages should the nurse return FIRST?

A woman in the first trimester of pregnancy complains of heartburn.

A man complains of heartburn that radiates to the jaw.

A woman complains of hot flashes and difficulty sleeping.

A boy complains of knee pain after playing basketball.

Strategy: Determine the least stable client.

(1) caused by reflux of gastric contents into esophagus, treatment is small, frequent meals, don't consume fluids with food, don't wear tight clothing

(2) correct—indicates chest pain, needs to seek medical attention immediately

(3) caused by menopause, treat with hormone replacement therapy (HRT)

(4) should treat with rest and ice

Explanation

Strategy: Determine the least stable client.

(1) caused by reflux of gastric contents into esophagus, treatment is small, frequent meals, don't consume fluids with food, don't wear tight clothing

(2) correct—indicates chest pain, needs to seek medical attention immediately

(3) caused by menopause, treat with hormone replacement therapy (HRT)

(4) should treat with rest and ice

2. The nurse monitors the fluid status of an older patient receiving IV fluids following surgery. Which of the following symptoms suggests to the nurse that the patient has fluid volume overload?

Temperature 101°F (38.3°C), BP 96/60, pulse 96 and thready.

Cool skin, respiratory crackles, pulse 86 and bounding.

Complaints of a headache, abdominal pain, and lethargy.

Urinary output 700 ml/24 h, CVP of 5, and nystagmus.

Strategy:

(1) indicates dehydration

(2) correct—will see bounding pulse, elevated BP, distended neck veins, edema, headache, polyuria, diarrhea, liver enlargement

(3) symptoms could be from causes other than volume overload

(4) slightly reduced output, CVP would be elevated, normal CVP 3 to 12 mm/H2O, involuntary eye movements not seen

Explanation

Strategy:

(1) indicates dehydration

(2) correct—will see bounding pulse, elevated BP, distended neck veins, edema, headache, polyuria, diarrhea, liver enlargement

(3) symptoms could be from causes other than volume overload

(4) slightly reduced output, CVP would be elevated, normal CVP 3 to 12 mm/H2O, involuntary eye movements not seen

3. After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a 5-year-old is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse 3 hours after admission, should be reported to the physician?

The client has slight edema of the eyelids.

There is clear fluid draining from the client's right ear.

There is some bleeding from the child's lacerations.

The client withdraws in response to painful stimuli.

Strategy: Think about how each answer choice relates to a head injury.

(1) not priority

(2) correct—indicates a rupture of meninges and presents a potential complication of meningitis

(3) not priority

(4) is not a change in assessment

Explanation

Strategy: Think about how each answer choice relates to a head injury.

(1) not priority

(2) correct—indicates a rupture of meninges and presents a potential complication of meningitis

(3) not priority

(4) is not a change in assessment

4. The school nurse instructs a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates further teaching is necessary?

"The poison control center number is stored on all the phones in our house."

"I should induce vomiting if my child swallows lighter fluid."

"If I carry medication in my purse, it should be in a child-proof container."

"Proper storage is the key to poison prevention in the home."

Strategy: "Further teaching is necessary" indicates an incorrect statement.

(1) Appropriate action; terminate exposure to the poison and then contact poison control for further instructions

(2) correct—vomiting contraindicated when child ingests hydrocarbons because of danger of aspiration

(3) 'poison-proofs' the medication

(4) store in locked cabinets

Explanation

Strategy: "Further teaching is necessary" indicates an incorrect statement.

(1) Appropriate action; terminate exposure to the poison and then contact poison control for further instructions

(2) correct—vomiting contraindicated when child ingests hydrocarbons because of danger of aspiration

(3) 'poison-proofs' the medication

(4) store in locked cabinets

5. The nursing assistant reports to the nurse that a client who is 1 day postoperative after an angioplasty refuses to eat and states, "I just don't feel good." Which of the following actions by the nurse is BEST?

Talk with the client about how the client is feeling.

Instruct the nursing assistant to sit with the client while the client eats.

Contacts the physician to obtain an order for an antacid.

Evaluate the most recent vital signs recorded in the chart.

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is the assessment appropriate? Yes.

(1) correct—assessment required; monitor for closure of vessel, bleeding, hypotension, dysrhythmias

(2) assess cause of problem before implementing

(3) assess cause of problem before implementing

(4) more important to assess what is happening now

Explanation

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is the assessment appropriate? Yes.

(1) correct—assessment required; monitor for closure of vessel, bleeding, hypotension, dysrhythmias

(2) assess cause of problem before implementing

(3) assess cause of problem before implementing

(4) more important to assess what is happening now

6. The nurse cares for clients on a medical/surgical unit and determines that several situations need to be addressed. Which of the following situations should the nurse attend to FIRST?

The nursing assistant is 30 minutes overdue from a dinner break in the cafeteria for the third time this week.

The physician calls the unit to ask the nurse to obtain a client's latest serum electrolyte results from the lab.

Strategy: Determine the least stable situation

(1) important issue that needs to be addressed after tending to the client who is bleeding

(2) patients take priority over personnel issues

(3) can be delegated to another staff member

(4) correct—should assess client to determine amount and cause of bleeding

Explanation

Strategy: Determine the least stable situation

(1) important issue that needs to be addressed after tending to the client who is bleeding

(2) patients take priority over personnel issues

(3) can be delegated to another staff member

(4) correct—should assess client to determine amount and cause of bleeding

7. Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of the body?

Counseling regarding problems of body image.

Maintain airborne precautions.

Maintain aseptic technique during procedures.

Encourage peers to visit on a regular basis.

Strategy: Think "Maslow."

(1) psychosocial, not highest priority

(2) physical, use standard precautions

(3) correct—safety is a priority for the client who is at high risk for infection

(4) psychosocial, important for an adolescent but is not highest priority

Explanation

Strategy: Think "Maslow."

(1) psychosocial, not highest priority

(2) physical, use standard precautions

(3) correct—safety is a priority for the client who is at high risk for infection

(4) psychosocial, important for an adolescent but is not highest priority

8. The nurse cares for clients in outpatient surgery. The mother of a 4-year-old asks the nurse how to prepare her daughter for eye surgery. Which of the following statements by the nurse is BEST?

"Draw a picture of the eye to explain what will happen."

"Tell your daughter that the procedure will take 1 hour."

"Use dolls or puppets to explain how to get ready for surgery."

"Read an age-appropriate illustrated book about eye surgery to your daughter."

Strategy: Think about growth and development.

(1) appropriate for school-aged child

(2) preschooler can't relate to the concept of 1 hour

(3) correct—use puppet or doll to show where procedure is performed; explain procedure in simple terms and what the child will see, hear, taste, smell, and feel

(4) appropriate for school-aged child

Explanation

Strategy: Think about growth and development.

(1) appropriate for school-aged child

(2) preschooler can't relate to the concept of 1 hour

(3) correct—use puppet or doll to show where procedure is performed; explain procedure in simple terms and what the child will see, hear, taste, smell, and feel

(4) appropriate for school-aged child

9. A woman has been diagnosed with systemic lupus (SLE) and shares with the nurse, "I am thinking about getting pregnant, but I don't know how I will be able to tolerate a pregnancy because I have lupus." Which of the following responses by the nurse is BEST?

"Most women find that they feel better when they are pregnant."

"How long have you been in remission?"

"Women with lupus frequently have slightly longer gestations."

"It is best to become pregnant within the first 6 months of diagnosis."

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) maternal morbidity and mortality are increased with SLE (2) correct—should be in remission for at least 5 months prior to conceiving (3) gestation not affected by SLE (4) recommended that a woman wait 2 years following diagnosis before conceiving

Explanation

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) maternal morbidity and mortality are increased with SLE (2) correct—should be in remission for at least 5 months prior to conceiving (3) gestation not affected by SLE (4) recommended that a woman wait 2 years following diagnosis before conceiving

10. A client at 32 weeks' gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, indicates a possible complication?

The client's urine test is positive for glucose and acetone.

The client has 1+ pedal edema in both feet at the end of the day.

The client complains of an increase in vaginal discharge.

The client says that she feels pressure against her diaphragm when the baby moves.

Strategy: Determine how each answer choice relates to pregnancy.

(1) correct—abnormal finding, could indicate gestational diabetes (GDM), hazard of placental insufficiency

(2) not unusual, caused by pressure of enlarging uterus on veins returning blood from lower extremities

(3) common near term with increased vascularity of vagina and perineum, only abnormal if bloody, foul-smelling, or abnormally colored

(4) not unusual, due to pressure of enlarging uterus

Explanation

Strategy: Determine how each answer choice relates to pregnancy.

(1) correct—abnormal finding, could indicate gestational diabetes (GDM), hazard of placental insufficiency

(2) not unusual, caused by pressure of enlarging uterus on veins returning blood from lower extremities

(3) common near term with increased vascularity of vagina and perineum, only abnormal if bloody, foul-smelling, or abnormally colored

(4) not unusual, due to pressure of enlarging uterus

11. The nurse cares for clients on the neurology unit. What is the MOST appropriate action for the nurse to take after noting that a client suddenly develops a fixed and dilated pupil?

Reassess in 5 minutes.

Check the client's visual acuity.

Lower the head of the client's bed.

Contact the physician.

Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment or validation? No. Determine the outcome of the implementations.

(1) assessment; situation does not require validation

(2) assessment; has symptoms of increased intracranial pressure (ICP)

(3) implementation; would increase the ICP

(4) correct—implementation; fixed and dilated pupil represents a neurological emergency

Explanation

Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment or validation? No. Determine the outcome of the implementations.

(1) assessment; situation does not require validation

(2) assessment; has symptoms of increased intracranial pressure (ICP)

(3) implementation; would increase the ICP

(4) correct—implementation; fixed and dilated pupil represents a neurological emergency

12. A young adult is involved in a motorcycle accident and is brought to the emergency room. The physician diagnoses a closed head injury with suspected subdural hematoma. Although complaining of a severe headache, the client is alert and answers questions appropriately. The nurse should question which of the following orders?

"Promethazine (Phenergan) 25 mg IM 3 h."

"Morphine sulfate 10 mg IM q3 4h."

"Docusate sodium (Colace) 50 mg PO bid."

"Ranitidine (Zantac) 50 mg IVPB q12h."

Strategy: "Question which of the following orders" indicates an incorrect order.

(1) H1 receptor blocker, used as an antiemetic

(2) correct—narcotic analgesic, causes CNS and respiratory depression, contraindicated in head injury because it masks signs of increased intracranial pressure

(3) stool softener, used for an immobilized patient

(4) H2 histamine antagonist, reduces acid production in stomach, prevents stress ulcers

Explanation

Strategy: "Question which of the following orders" indicates an incorrect order.

(1) H1 receptor blocker, used as an antiemetic

(2) correct—narcotic analgesic, causes CNS and respiratory depression, contraindicated in head injury because it masks signs of increased intracranial pressure

(3) stool softener, used for an immobilized patient

(4) H2 histamine antagonist, reduces acid production in stomach, prevents stress ulcers

13. The nurse cares for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions?

Take the client to the dining room with 1:1 supervision.

Inform the client that he may go to the dining room when he controls his behavior.

Hold the meal until the client is able to come out of seclusion.

Serve the meal to the client in the seclusion room.

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

(1) should remain in the seclusion room

(2) should have meal at regular time

(3) should have meal at regular time

(4) correct—should eat at regular time; remain in the seclusion room for client's safety

Explanation

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

(1) should remain in the seclusion room

(2) should have meal at regular time

(3) should have meal at regular time

(4) correct—should eat at regular time; remain in the seclusion room for client's safety

14. The nurse cares for clients in the student health center. A client confides to the nurse that the client's boyfriend informed her that he tested positive for hepatitis B. Which of the following responses by the nurse is BEST?

"That must have been a real shock to you."

"You should be tested for hepatitis B."

"You'll receive the hepatitis B immune globulin (HBIG)."

"Have you had unprotected sex with your boyfriend?"

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes.

(1) nurse is interjecting own feelings

(2) will require testing; not best response initially

(3) implementation; receive HBIG for postexposure prophylaxis; may also receive HBV vaccine

(4) correct—assessment; transmitted through parenteral drug abuse and sexual contact; determine exposure before implementing

Explanation

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes.

(1) nurse is interjecting own feelings

(2) will require testing; not best response initially

(3) implementation; receive HBIG for postexposure prophylaxis; may also receive HBV vaccine

(4) correct—assessment; transmitted through parenteral drug abuse and sexual contact; determine exposure before implementing

15. A client received six units of regular insulin 3 hours ago. The nurse is MOST concerned if which of the following is observed?

Kussmaul respirations and diaphoresis.

Anorexia and lethargy.

Diaphoresis and trembling.

Headache and polyuria.

Strategy: "MOST concerned" indicates a complication.

(1) Kussmaul respirations are signs of hyperglycemia

(2) not indicative of hypoglycemia

(3) correct—regular insulin peaks in 2 to 4 hours; indicates hypoglycemia; give skim milk

(4) not indicative of hypoglycemia

Explanation

Strategy: "MOST concerned" indicates a complication.

(1) Kussmaul respirations are signs of hyperglycemia

(2) not indicative of hypoglycemia

(3) correct—regular insulin peaks in 2 to 4 hours; indicates hypoglycemia; give skim milk

(4) not indicative of hypoglycemia

16. The nurse administers morphine 6 mg IV push to a patient for postoperative pain. Following administration of the drug, the nurse observes the following: BP 100/68, pulse 68, respirations 8, client sleeping quietly. Which of the following nursing actions is MOST appropriate?

Allow the client to sleep undisturbed.

Administer oxygen via face mask or nasal prongs.

Administer naloxone (Narcan).

Place epinephrine 1:1,000 at the bedside.

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

(1) should be given Narcan for low respiratory rate

(2) problem is low respirations; this may be administered after medication

(3) correct—IV naloxone (Narcan) should be given to reverse respiratory depression; respiratory rate of 8 is too low and necessitates a nursing action

(4) unnecessary

Explanation

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

(1) should be given Narcan for low respiratory rate

(2) problem is low respirations; this may be administered after medication

(3) correct—IV naloxone (Narcan) should be given to reverse respiratory depression; respiratory rate of 8 is too low and necessitates a nursing action

(4) unnecessary

17. The nurse cares for patient placed in balanced suspension traction with a Thomas splint and Pearson attachment because of a fractured right femur. The nurse notes that the patient's left leg is externally rotated. The nurse should take which of the following actions?

Place a trochanter roll on the outer aspect of the thigh.

Perform resistive range of motion of the left leg.

Adduct and internally rotate the left leg.

Instruct the patient to maintain the left leg in a neutral position.

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

(1) correct—holds hip in neutral position and leg in normal alignment, entire weight of leg cannot be held by props placed below knee

(2) exercise would not prevent future external rotation of the leg

(3) adduction (add to midline of body) does not change external rotation, internal rotation is not beneficial, normal alignment is required

(4) leg will externally rotate unless propped in proper alignment

Explanation

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

(1) correct—holds hip in neutral position and leg in normal alignment, entire weight of leg cannot be held by props placed below knee

(2) exercise would not prevent future external rotation of the leg

(3) adduction (add to midline of body) does not change external rotation, internal rotation is not beneficial, normal alignment is required

(4) leg will externally rotate unless propped in proper alignment

18. A patient is admitted to the surgical unit with a diagnosis with rule out (R/O) intestinal obstruction. The nurse prepares to insert a Salem sump NG tube as ordered. It is BEST for the nurse to place the patient in which of the following positions?

Head of bed elevated 30–45°.

Head of bed elevated 60–90°.

Side-lying with head elevated 15°.

Lying flat with head turned to the left side.

Strategy: Remember the positioning strategy.

(1) head of bed not elevated enough

(2) correct—facilitates swallowing and movement of tube through gastrointestinal tract

(3) not the best position

(4) not the best position

Explanation

Strategy: Remember the positioning strategy.

(1) head of bed not elevated enough

(2) correct—facilitates swallowing and movement of tube through gastrointestinal tract

(3) not the best position

(4) not the best position

19. The nurse prepares a 5-year-old child for surgery. The nurse notes that the child's parents are divorced and have joint legal custody. The informed consent for surgery has been signed by the mother. Which of the following actions by the nurse is BEST?

Notify the physician.

Inform surgery.

Contact the father to obtain consent.

Continue the child's preoperative preparation.

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

(1) no reason to notify the physician

(2) no reason to call the OR

(3) consent from either divorced parent is sufficient

(4) correct—parent or legal guardian required to give informed consent prior to surgical procedure

Explanation

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

(1) no reason to notify the physician

(2) no reason to call the OR

(3) consent from either divorced parent is sufficient

(4) correct—parent or legal guardian required to give informed consent prior to surgical procedure

20. The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time?

Confirm that all staff members understand and comply with the treatment plan.

Establish mutually agreed-upon, realistic goals.

Ensure that the potent reinforcers (rewards) are important to the client.

Establish a fixed interval schedule for reinforcement.

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

(1) correct—to implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program

(2) not of primary importance in designing an effective behavior modification program

(3) not of primary importance in designing an effective behavior modification program

(4) not of primary importance in designing an effective behavior modification program

Explanation

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

(1) correct—to implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program

(2) not of primary importance in designing an effective behavior modification program

(3) not of primary importance in designing an effective behavior modification program

(4) not of primary importance in designing an effective behavior modification program

21. Prochlorperazine maleate (Compazine) 10 mg IM is ordered for a client. The client is also to receive butorphanol (Stadol) 2 mg IM. Before administering these medications, the nurse should take which of the following actions?

Obtain respirations and temperature.

Dilute with 9 ml of NS.

Draw the medications in separate syringes.

Verify the route of administration.

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

(1) should monitor blood pressure and heart rate for orthostatic hypotension; respiration and temperature are not as high a priority

(2) inappropriate

(3) correct—Compazine should be considered incompatible in a syringe with all other medications

(4) unnecessary

Explanation

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

(1) should monitor blood pressure and heart rate for orthostatic hypotension; respiration and temperature are not as high a priority

(2) inappropriate

(3) correct—Compazine should be considered incompatible in a syringe with all other medications

(4) unnecessary

22. A client diagnosed with a peptic ulcer has a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the nurse should caution the client about which of the following?

Sit up for at least 30 minutes after eating.

Avoid fluids between meals.

Increase the intake of high-carbohydrate foods.

Avoid eating large meals that are high in simple sugars and liquids.

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

(1) client should recline for 30 minutes after eating

(2) fluids should be given between meals

(3) intake of carbohydrates should be reduced along with highly spiced foods

(4) correct—basic guidelines to teach a postgastrectomy client are measures to prevent dumping syndrome, which include: lying down for 30 minutes after meals, drinking fluids between meals, and reducing intake of carbohydrates

Explanation

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

(1) client should recline for 30 minutes after eating

(2) fluids should be given between meals

(3) intake of carbohydrates should be reduced along with highly spiced foods

(4) correct—basic guidelines to teach a postgastrectomy client are measures to prevent dumping syndrome, which include: lying down for 30 minutes after meals, drinking fluids between meals, and reducing intake of carbohydrates

23. The home health care nurse cares for a client diagnosed with type 1 diabetes. The client is maintained on a regimen of NPH and regular insulin and a 1,800-calorie diabetic diet with normal blood sugar levels. Morning self-monitoring blood sugar (SMBG) readings the past 2 days were 205 and 233 mg/dL. The nurse expects the physician to take which of the following actions?

Reduce the client's diet to 1,500 calorie ADA.

Order three additional units of NPH insulin at 10 P.M.

Order an additional 10 units of regular insulin at 8 P.M.

Eliminate the client's bedtime snack.

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

(1) diet should not be reduced

(2) correct—dawn phenomena, treatment is to adjust evening diet, bedtime snack, insulin dose, and exercise to prevent early morning hyperglycemia

(3) peaks in 4 to 6 hours, would not prevent dawn phenomena

(4) would adjust snack, not eliminate it

Explanation

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

(1) diet should not be reduced

(2) correct—dawn phenomena, treatment is to adjust evening diet, bedtime snack, insulin dose, and exercise to prevent early morning hyperglycemia

(3) peaks in 4 to 6 hours, would not prevent dawn phenomena

(4) would adjust snack, not eliminate it

24. A psychiatric nurse is assigned to conduct an admission nursing history on a new client. The admission should include which of the following?

The nurse's opinion regarding the mental and emotional status of the client.

Data addressing the client's emotional state.

Data addressing a biopsychosocial approach, including a family system assessment.

Specific data detailing the client's mental status.

Strategy: Think about each answer choice.

(1) depends on opinions that are not based on a complete assessment

(2) limits the degree of information that is obtained from the client

(3) correct—complete nursing history includes biopsychosocial data; client's psychosocial and physical status are evaluated along with an assessment of the client's family system and social support network; evaluation of the client's cognitive ability is important during the physiological status assessment

(4) is necessary information about mental status but is also an incomplete assessment

Explanation

Strategy: Think about each answer choice.

(1) depends on opinions that are not based on a complete assessment

(2) limits the degree of information that is obtained from the client

(3) correct—complete nursing history includes biopsychosocial data; client's psychosocial and physical status are evaluated along with an assessment of the client's family system and social support network; evaluation of the client's cognitive ability is important during the physiological status assessment

(4) is necessary information about mental status but is also an incomplete assessment

25. After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions is MOST appropriate?

Irrigate the nasogastric tube with distilled water.

Aspirate the gastric contents with a syringe.

Administer an antiemetic medicine.

Insert a new nasogastric tube.

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

(1) tube would be irrigated with normal saline after the position of the tube was evaluated

(2) correct—to confirm placement, nurse should aspirate and test the pH of the aspirate; results should be 0 to 4

(3) does not assess status of nasogastric tube

(4) does not assess status of nasogastric tube

Explanation

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

(1) tube would be irrigated with normal saline after the position of the tube was evaluated

(2) correct—to confirm placement, nurse should aspirate and test the pH of the aspirate; results should be 0 to 4

(3) does not assess status of nasogastric tube

(4) does not assess status of nasogastric tube

26. A woman is admitted to the labor and delivery unit in a sickle cell crisis. Which of the following nursing actions is the HIGHEST priority?

Administer oxygen.

Turn her to the right side.

Provide adequate hydration.

Start antibiotics.

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

(1) not a priority

(2) not a priority

(3) correct—adequate hydration is a priority for any client with sickle cell crisis

(4) not a priority

Explanation

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

(1) not a priority

(2) not a priority

(3) correct—adequate hydration is a priority for any client with sickle cell crisis

(4) not a priority

27. A mother brings her 2-year-old to the pediatrician's office. Which of the following symptoms suggests to the nurse that the child has strabismus?

The child places his head close to the table when drawing.

The child rubs his eyes frequently.

The child closes one eye to see a poster on the wall.

The child is unable to see objects in the periphery of his visual field.

Strategy: Think about each answer choice.

(1) suggestive of refractive error, myopia (nearsightedness), able to see objects at close range

(2) suggestive of refractive error

(3) correct—visual axes are not parallel, so the brain receives two images

(4) suggestive of cataracts or problem with peripheral vision

Explanation

Strategy: Think about each answer choice.

(1) suggestive of refractive error, myopia (nearsightedness), able to see objects at close range

(2) suggestive of refractive error

(3) correct—visual axes are not parallel, so the brain receives two images

(4) suggestive of cataracts or problem with peripheral vision

28. A middle-aged woman, mother of two, has a mastectomy for breast cancer. When she returns to the physician's office a month later for a routine checkup, the nurse asks the client how she has been. Which of the following responses, if made by the client to the nurse, indicates that the client is experiencing a normal reaction to the surgery?

"I have been helping my family deal with their feelings about the surgery."

"I have been having difficulty coping with the surgery and cry frequently."

"I have been unable to leave the house or talk to my friends about the surgery."

"I am doing just great since the surgery and have gone back to work at my job."

Strategy: Think about each answer choice. Does it describe an expected response to a crisis situation?

(1) will not be able to help others this soon after surgery

(2) correct—normal reaction 1 month later

(3) excessive, abnormal reaction

(4) indicates integration, too early for this stage

Explanation

Strategy: Think about each answer choice. Does it describe an expected response to a crisis situation?

(1) will not be able to help others this soon after surgery

(2) correct—normal reaction 1 month later

(3) excessive, abnormal reaction

(4) indicates integration, too early for this stage

29. A nurse cares for a client diagnosed with metastatic ovarian cancer admitted for nausea and vomiting. The physician orders total parenteral nutrition (TPN), a nutritional consult, and diet recall. Which of the following is the BEST indication that the patient's nutritional status has improved after 4 days?

The patient eats most of the food served to her.

The patient has gained 1 pound since admission.

The patient's albumin level is 4.0 g/dL.

The patient's hemoglobin is 8.5 g/dL.

Strategy: Determine how each answer choice relates to nutritional status.

(1) appetite is not the best indicator

(2) weight gain may be fluid retention (ascites)

(3) correct—albumin levels are best indicators of long-term nutritional status

(4) low levels are caused by chemotherapy or cancer, not a good indicator because it takes long time to increase levels

Explanation

Strategy: Determine how each answer choice relates to nutritional status.

(1) appetite is not the best indicator

(2) weight gain may be fluid retention (ascites)

(3) correct—albumin levels are best indicators of long-term nutritional status

(4) low levels are caused by chemotherapy or cancer, not a good indicator because it takes long time to increase levels

30. A young adult patient constantly seeks attention from the nurses, stomping away from the nurses' station and pouting when requests are refused. Which of the following responses by the nurse is MOST appropriate?

Encourage the patient to establish trust with one staff person with whom therapeutic interventions should occur.

Give the patient unsolicited attention when the patient is exhibiting acceptable behaviors.

Ignore the patient when the patient exhibits attention-seeking behavior.

Rotate the staff so that the patient will learn to relate to more than one nurse.

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

(1) staff should use a consistent undivided approach

(2) correct—reward non–attention-seeking behaviors by giving the patient unsolicited attention

(3) remain nonjudgmental, carry out limit-setting

(4) staff should use a consistent undivided approach

Explanation

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

(1) staff should use a consistent undivided approach

(2) correct—reward non–attention-seeking behaviors by giving the patient unsolicited attention

(3) remain nonjudgmental, carry out limit-setting

(4) staff should use a consistent undivided approach

31. The nurse prepares a patient for a cesarean section. The patient says that she had major surgery several years ago and asks if she will receive a similar "shot" before surgery. The nurse's response should be based on an understanding that the preoperative medication given before a cesarean section

Contains a lower overall dosage of medication than is given before general surgery.

Contains lower amounts of sedatives and hypnotics than are given before general surgery.

Contains lower amounts of narcotics than are given before general surgery.

Contains medications similar in type and dosages to those given before general surgery.

Strategy: Think about the action of the medications.

(1) decreased dosage of narcotics are used

(2) dosages of sedatives and hypnotics will be similar

(3) correct—decreased so that less narcotic crosses the placental barrier, causing respiratory depression in the infant

(4) dosages of narcotics are reduced

Explanation

Strategy: Think about the action of the medications.

(1) decreased dosage of narcotics are used

(2) dosages of sedatives and hypnotics will be similar

(3) correct—decreased so that less narcotic crosses the placental barrier, causing respiratory depression in the infant

(4) dosages of narcotics are reduced