NCLEX-RN Practice 75 Questions Part 2

  • NCLEX-RN
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1. The nurse develops a comprehensive care plan for a young woman diagnosed with anorexia nervosa. The nurse refers the client to assertiveness skills classes. The nurse knows that this is an appropriate intervention because this client may have problems with which of the following?

Explanation

Strategy: Think about each answer.

(1) these clients do have problems with feelings of anger; family therapy sessions can be helpful in identifying some of these feelings and difficulties with family boundaries

(2) correct—clients with eating disorders experience difficulty with self-identity and self-esteem, which inhibits their abilities to act assertively; some assertiveness techniques that are taught include giving and receiving criticism, giving and accepting compliments, accepting apologies, being able to say no, and setting limits on what they can realistically do rather than just doing what others want them to do

(3) do not have problems with reality

(4) these clients do have problems with family boundary intrusion; family therapy sessions can be helpful in identifying some of these feelings and difficulties with family boundaries

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About This Quiz
NCLEX RN Quizzes & Trivia

This NCLEX-RN practice quiz part 2 assesses knowledge and skills in patient care across various scenarios, including infection control, complications from injuries, and preoperative preparation. It is designed for nurses preparing for the NCLEX-RN exam, focusing on critical thinking and practical application in clinical settings.

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2. When obtaining a specimen from a client for sputum culture and sensitivity (C and S), the nurse identifies which of the following instructions is BEST?

Explanation

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

(1) coughing into a container is indicated, but not pursed-lip breathing

(2) correct—specimens should be obtained in the early morning because secretions develop during the night

(3) appropriate for acid-fast stain for TB

(4) earliest specimen is most desirable

Submit
3. An adolescent is scheduled for a below-knee (BK) amputation following a motorcycle accident. The nurse knows preoperative teaching for this client should include which of the following?

Explanation

Strategy: Remember therapeutic communication.

(1) fails to recognize his immediate concerns

(2) correct—discussing his feelings and fears is important in dealing with his anxiety due to a change in body image and functioning

(3) client is underage; parents will need to sign the permit

(4) is more appropriate for the postoperative period of time than for the preoperative period

Submit
4. A college student comes to the college health services complaining of a severe headache, nausea, and photophobia. The physician orders a complete blood count (CBC) and a lumber puncture (LP). Which of the following lab results would the nurse expect if a diagnosis of bacterial meningitis is made?

Explanation

(1) correct—CSF normally clear, colorless; normal WBC 5,000 to 10,000 per mm3, normal Hgb (male 13.5 to 17.5 g/dL, female 12 to 16 g/dL), normal HCT (male 41 to 53%, female 36 to 46%)

(2) indicates trauma or hemorrhage

(3) WBC too low, not typical of bacterial meningitis

(4) indicates viral meningitis

Submit
5. The nurse cares for a homebound client with a urinary catheter. The client's spouse states the catheter is obstructed. Which of the following observations by the nurse confirms this suspicion?

Explanation

Strategy: Determine how each answer relates to a urinary catheter.

(1) correct—bladder distention is one of the earliest signs of obstructed drainage tubing

(2) seen with a urinary tract infection

(3) seen with dehydration

(4) seen with a urinary tract infection

Submit
6. A client is admitted to the outpatient oncology unit for routine chemotherapy transfusion. The client's current lab report is WBC 2,500 mm3, RBC 5.1 mL/mm3, calcium 5 mEq/L. Based on the lab values, the nurse determines which of the following is the priority nursing diagnosis?

Explanation

Strategy: Think about each answer.

(1) not a priority

(2) correct—clients with a low WBC count are susceptible to infection

(3) not correctly stated as a nursing diagnosis and is not appropriate

(4) not a priority for this client

Submit
7. During a prenatal visit, the client states, "I have been very nauseated during my first trimester, and I don't understand the reason." Which of the following responses by the nurse is BEST?

Explanation

The correct answer is "The nausea is caused by an elevation in the hormones." During the first trimester of pregnancy, there is a significant increase in hormone levels, particularly human chorionic gonadotropin (hCG) and estrogen. These hormonal changes can lead to nausea and vomiting, commonly known as morning sickness. Therefore, it is important for the nurse to provide an accurate explanation to the client about the cause of her nausea.

Submit
8. A client comes to the clinic for the results of a glycosylated hemoglobin (HbA1c). Which statement, if made by the client to the nurse, indicates an understanding of the procedure?

Explanation

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

(1) 3 to 5 ml of blood is needed

(2) timing of test is not important

(3) correct—when RBCs are being formed, sugar is attached (glycosylated) and remains attached throughout the life of the RBC; normal 2.5 to 6%

(4) current blood sugar doesn't affect test

Submit
9. The nurse recognizes which of these symptoms as characteristic of a panic attack?

Explanation

Strategy: Think about each answer.

(1) correct—panic disorders are characterized by recurrent, unpredictable attacks of intense apprehension or terror that can render a client unable to control a situation or to perform simple tasks; client can experience palpitations, chest pain, shortness of breath, a decrease in perceptual field, and a fear of "losing it" or going crazy

(2) not accurate because typically the client has increased blood pressure related to stimulation of the sympathetic nervous system

(3) heart rate would be increased due to stimulation of the sympathetic nervous system

(4) client's perceptual field is decreased during a panic attack; client becomes less aware of his/her surroundings, and his/her performance is inhibited

Submit
10. A client develops a low intestinal obstruction. The nurse anticipates which of the following findings?

Explanation

Strategy: Determine how each answer relates to an intestinal obstruction.

(1) correct—there is distention above the level of obstruction and initially hyperactive bowel sounds; would be no stool, as motility distal to (below) the obstruction would cease

(2) would be no diarrhea

(3) would be no rectal bleeding, abdomen would be distended

(4) would be no GI bleeding

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11. During the development of a nursing care plan, the nurse should consider which of the following clients for the use of a restraint?

Explanation

Strategy: Think about each answer.

(1) not in need of restraints

(2) not in need of restraints

(3) correct—arm restraints are necessary to prevent infant from rubbing or otherwise disturbing suture line

(4) not in need of restraints

Submit
12. The nurse identifies the MOST reliable client measure to evaluate the desired response of diuretic therapy includes which of the following?

Explanation

Strategy: Think about each answer.

(1) correct—effectiveness of diuretic therapy is demonstrated by decreased edema and is measured by daily weights

(2) does not relate to the effects of diuretic therapy

(3) important to consider, but is not a priority

(4) important to consider, but is not a priority

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13. During an initial interview at an outpatient clinic, a 34-year-old single mother tells the nurse that she has always had difficulty forming relationships and is worried that her 7-year-old daughter will have the same problem. Which of the following statements, if made by the nurse, is BEST?

Explanation

Strategy: "BEST" indicates discrimination is required. Topic of question is unstated. Read answer choices to determine topic.

(1) correct—Erikson states that trust results from interaction with dependable, predictable primary caretaker

(2) toddler stage concerns autonomy verses shame and doubt

(3) preschool state concerns initiative versus guilt

(4) latency or school age stage concerns industry versus inferiority

Submit
14. When assessing orientation to person, place, and time for an elderly hospitalized client, which of the following principles should be understood by the nurse?

Explanation

Strategy: Think about each answer.

(1) just the opposite is true; long-term memory is more efficient than short-term memory

(2) correct—stress of an unfamiliar situation or environment may lead to confusion in elderly clients

(3) mental status and learning ability are not affected by aging, although elderly client may be slower at doing things

(4) mental status and learning ability are not affected by aging, although elderly client may be slower at doing things

Submit
15. The physician prescribes estrogen (Premarin) 0.625 mg daily for a 43-year-old woman. The nurse identifies which of the following symptoms is a common initial side effect of this medication?

Explanation

Strategy: Think about what causes each symptom and determine its relationship to Premarin.

(1) correct—common at breakfast time; will subside after weeks of medication use; take after eating to reduce incidence

(2) seen with long-term use

(3) ringing in the ears is seen with long-term use

(4) unsteady gait rarely seen

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16. Under the supervision of the registered nurse, a student nurse changes the dressing of a client with a newly inserted peritoneal dialysis catheter. Which of the following activities, if performed by the student nurse after removal of the old dressing, requires an intervention by the registered nurse?

Explanation

Strategy: "Requires an intervention" indicates incorrect behavior. All answers are implementations. Determine outcome of each answer. Is it desired?

(1) appropriate procedure

(2) appropriate procedure

(3) correct—should clean from insertion site outward toward outer abdomen

(4) appropriate procedure

Submit
17. The physician orders chlorpromazine (Thorazine) to control an alcoholic client's restlessness, agitation, and irritability following surgery. The nurse should check the order with the physician based on which of the following rationales?

Explanation

Strategy: Think about each answer.

(1) correct—medication is contraindicated for the treatment of alcohol withdrawal symptoms; medication will lower client's seizure threshold and BP, causing potentially serious medical consequences

(2) not best rationale for checking with doctor about this order

(3) not best rationale for checking with doctor about this order

(4) not best rationale for checking with doctor about this order

Submit
18. The nurse is aware that which of the following assessments indicates hypocalcemia?

Explanation

Strategy: Think about the cause of each answer.

(1) symptom associated with hypercalcemia

(2) symptom associated with hypercalcemia

(3) symptom associated with hypercalcemia

(4) correct—positive Trousseau's sign is indicative of neuromuscular hyperreflexia associated with hypocalcemia

Submit
19. A client diagnosed with an adjustment disorder with depressed mood has the greatest chance of success in activities that require psychic and physical energy if the nurse schedules activities at which of the following times?

Explanation

Strategy: Think about each answer.

(1) correct—client with reactive depression has the highest level of physical and psychic energy in the morning

(2) as the day progresses, energy level declines

(3) as the day progresses, energy level declines

(4) as the day progresses, energy level declines

Submit
20. The nurse reviews procedures with the health care team. The nurse should intervene if an RN staff member makes which of the following statements?

Explanation

Strategy: "Nurse should intervene" indicates that you should look for an incorrect statement. Question is unstated. Read answer choices for clues.

(1) describes the nurse's responsibility in obtaining consent

(2) signature indicates that the nurse saw the patient sign the form

(3) correct—physician should provide explanation and obtain patient's signature

(4) the nurse should answer questions after the physician has obtained consent

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21. The nurse prepares the client for an IV pyelography (IVP) scheduled in 2 hours. The nurse should contact the physician if the client states which of the following?

Explanation

Strategy: Think about each answer.

(1) correct—should discontinue 48 hours prior to procedure, contrast media can cause life-threatening lactic acidosis

(2) appropriate action; removes feces, fluid, and air from bowel so kidneys, ureters, and bladder will not be obscured

(3) appropriate action

(4) no reason to contact the physician

Submit
22. The geriatric residents of a long-term care facility participate in a reminiscing group. The nurse identifies which of the following as the primary goal of this type of group activity?

Explanation

Strategy: Think about each answer.

(1) is not primary goal of a reminiscing group

(2) is not primary goal of a reminiscing group

(3) correct—primary goal of a reminiscing group for geriatric clients is to review and share their life experiences with the group members

(4) groups that facilitate orientation to time, person, place, and current events are called reality orientation groups

Submit
23. Which of the following is the BEST method for the nurse to use when evaluating the effectiveness of tracheal suctioning?

Explanation

Strategy: Determine how each answer relates to suctioning.

(1) subjective data and not as conclusive

(2) correct but not as effective

(3) not appropriate

(4) correct—to assess the effectiveness of suctioning, auscultate the client's chest to determine if adventitious sounds are cleared and to ensure that the airway is clear of secretions

Submit
24. A client at 16 weeks' gestation undergoes an amniocentesis. The client asks the nurse what the physician will learn from this procedure. The nurse's response should be based on an understanding that which of the following conditions can be detected by an amniocentesis?

Explanation

Strategy: Think about each answer.

(1) cardiac abnormality detected at birth; pulmonary stenosis, ventricular septal defect, overriding aorta, hypertrophy of right ventricle

(2) congenital deformity detected at birth; foot twisted out of normal position, clubfoot

(3) correct—maternal antibodies destroy fetal RBCs; bilirubin secreted because of hemolysis

(4) congenital deformity detected at birth, midline fissure or opening into lip or palate

Submit
25. The nurse prepares a client for a magnetic resonance imaging (MRI). Which of the following client statements indicates to the nurse that teaching is successful?

Explanation

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

(1) no dye is used for an MRI

(2) client is not anesthetized for this procedure

(3) correct—procedure takes approximately 90 minutes, not painful

(4) indicates misunderstanding of MRI because no wires are used

Submit
26. The home care nurse plans activities for the day. Which of the following clients should the nurse see FIRST?

Explanation

Strategy: Determine the least stable client. Think ABCs.

(1) stable situation, not a priority

(2) assess for bleeding gums, hematuria, not the priority

(3) assess breath sounds, encourage fluids, cough and deep breathe

(4) correct—symptoms of pulmonary edema; requires immediate attention

Submit
27. The nurse identifies which psychosocial stage should be a priority to consider while planning care for a 20-year-old client?

Explanation

Strategy: Think about each answer.

(1) appropriate for adolescents

(2) correct—is the stage for 19- to 35-year-olds

(3) for 65 years and older

(4) for 6 to 12 years of age

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28. A client diagnosed with Addison's disease comes to the health clinic. When assessing the client's skin, the nurse expects to observe which of the following?

Explanation

Strategy: Determine how each answer relates to Addison's disease.

(1) correct—increase in melanocyte-stimulating hormone results in "eternal tan"

(2) not seen with Addison's disease

(3) not seen with Addison's disease

(4) not seen with Addison's disease

Submit
29. The nurse supervises care given to a group of patients on the unit. The nurse observes a staff member entering a patient's room wearing gown and gloves. The nurse knows that the staff member is caring for which of the following patients?

Explanation

Strategy: Think about each answer.

(1) correct—acute viral infection; requires contact precautions; assign to private room or with other RSV-infected children

(2) acute systemic vasculitis in children under 5; standard precautions

(3) connective tissue disease; standard precautions

(4) standard precautions

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30. An older client receives total parenteral nutrition (TPN) for several weeks. If the TPN were abruptly discontinued, the nurse expects the patient to exhibit which of the following?

Explanation

Strategy: Think about the cause of each symptom. Determine how it relates to TPN. Remember the "comma, comma, and" rule.

(1) not seen

(2) suggestive of infection

(3) correct—insulin levels remain high while glucose levels decline; results in hypoglycemia; will also see restlessness, headache, weakness, irritability, apprehension, lack of muscle coordination

(4) not seen

Submit
31. The nurse observes a student nurse auscultate the lungs of a client. The nurse knows that the student nurse is correctly auscultating the right middle lobe (RML) if the stethoscope is placed in which of the following positions?

Explanation

Strategy: Think about the anatomy of the lung.

(1) cannot auscultate the RML from the posterior

(2) correct—RML is found in the right anterior chest between the fourth and sixth intercostal spaces

(3) point of maximum impulse or apical pulse

(4) cannot auscultate the RML from the posterior

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32. The nurse cares for a client during an acute manic episode. The nurse identifies which client behavior is MOST characteristic of mania?

Explanation

Strategy: Remember the "comma, comma, and" rule. Each part of the answer must be correct.

(1) correct—characteristic behaviors associated with an acute manic episode include agitation, grandiose delusions, euphoria, and concentration problems; mania is a mood of extreme euphoria and is manifested by more extreme levels of behavior

(2) characteristic of depression

(3) indicative of schizophrenia

(4) consistent with personality disorders

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33. The physician prescribes lithium carbonate (Lithobid) 300 mg PO QID for an adult client. The nurse in the outpatient clinic instructs the client about the medication. The nurse should encourage the client to maintain an adequate intake of which of the following?

Explanation

Strategy: Think about each answer.

(1) correct—alkali metal salt acts like sodium ions in the body; excretion of lithium depends on normal sodium levels; sodium reduction causes marked lithium retention, leading to toxicity

(2) doesn't interact with lithium

(3) doesn't interact with lithium

(4) doesn't interact with lithium

Submit
34. A client returns from surgery with a fine, reddened rash noted around the area where Betadine prep had been applied prior to surgery. Nursing documentation in the client's chart should include which of the following?

Explanation

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

(1) would be noted, but is not as high a priority

(2) inappropriate

(3) correct—suspected reaction to drugs should be reported to the doctor and noted on list of possible allergies

(4) inappropriate

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35. A 4-year-old child is admitted with drooling and an inflamed epiglottis. During the assessment, the nurse identifies which of the following symptoms as indicative of an increase in respiratory distress?

Explanation

Strategy: Determine how each answer relates to respiratory distress.

(1) tachycardia occurs early in hypoxia

(2) correct—increase in the respiratory rate is an early sign of hypoxia, also for tachycardia

(3) pallor is not specific for hypoxia

(4) client may be anxious and restless, but is generally not described as irritable

Submit
36. The clinic physician diagnoses Graves' disease for a client. The nurse expects the client to exhibit which of the following symptoms?

Explanation

Strategy: Think about the indications of an increased metabolic rate.

(1) will be restless

(2) will have heat intolerance due to increased metabolic rate

(3) correct—increased metabolic rate causes weight loss even with increased appetite

(4) reflexes will be hyperactive

Submit
37. A client receives a blood transfusion and experiences a hemolytic reaction. The nurse anticipates which of the following assessment findings?

Explanation

Strategy: Think about each answer.

(1) correct—signs and symptoms of a hemolytic reaction include chills, headache, backache, dyspnea

(2) describes symptoms of circulatory overload

(3) describes a febrile or pyrogenic reaction

(4) describes an allergic reaction

Submit
38. The nurse recognizes which of the following nursing interventions is MOST important when caring for a client just placed in physical restraints?

Explanation

Strategy: Answers are a mix of assessment and implementation. Is this a situation that requires assessment? Yes. Is there an appropriate assessment? Yes.

(1) implementation; inappropriate for the client in restraints

(2) correct—assessment; while a client is restrained, physiological integrity is important; monitoring positioning, tightness, and peripheral circulation is essential; nurse documents the client's response and clinical status after being restrained

(3) implementation; all staff members involved in a restraint event must be aware of hospital policy before using restraints

(4) assessment; important to attend to client's nutrition and hydration after the client is safely restrained

Submit
39. The nurse assesses a client immediately after an exploratory laparotomy. Which of the following nursing observations indicates the complication of intestinal obstruction?

Explanation

Strategy: Determine how each answer relates to an intestinal obstruction.

(1) does not support intestinal obstruction

(2) does not support intestinal obstruction

(3) immediately after postoperative abdominal surgery, bowel sounds are absent or decreased; would be no passage of stool; ascites not often seen

(4) correct—if an obstruction is present, the abdomen will become distended and painful

Submit
40. The nurse anticipates a client diagnosed with a gastric ulcer to experience pain at which of the following times?

Explanation

Strategy: Think about each answer.

(1) feature of a duodenal ulcer

(2) feature of a duodenal ulcer

(3) feature of a duodenal ulcer

(4) correct—pain related to a gastric ulcer occurs about 0.5 to 1 hour after a meal and rarely at night; is not helped by ingestion of food

Submit
41. A nursing assistant reports to the RN that a patient with anemia complains of weakness. Which of the following responses by the nurse to the nursing assistant is BEST?

Explanation

Strategy: Topic of question not clearly stated.

(1) requires assessment; should be performed by the RN

(2) correct—standard, unchanging procedure; decreases cardiac workload

(3) involves assessment; should be performed by the RN

(4) assessment and teaching required; performed by the RN

Submit
42. A clinic nurse obtains a health history from a client newly diagnosed with Buerger's disease. The nurse expects the client's complaints to include which of the following?

Explanation

Strategy: Determine the cause of each sympton and how it relates to Buerger's disease.

(1) no cardiac involvement

(2) dizziness not seen; intermittent claudication (pain with exercise) seen

(3) optic nerve not affected

(4) correct—vasculitis of blood vessels in upper and lower extremities

Submit
43. The school nurse conducts a class on childcare at the local high school. During the class, one of the participants asks the nurse what age is best to start toilet training a child. Which of the following is the BEST response by the nurse?

Explanation

Strategy: Think about growth and development.

(1) not able to physiologically control sphincters until 18 months of age

(2) not able to physiologically control sphincters until 18 months of age

(3) not able to physiologically control sphincters until 18 months of age

(4) correct—by 24 months may be able to achieve daytime bladder control

Submit
44. The nurse determines which of the following actions has HIGHEST priority when caring for the client diagnosed with hypoparathyroidism?

Explanation

Strategy: ABCs.

(1) not highest priority action related to the diagnosis

(2) correct—cardiac dysrhythmias related to low serum calcium would be the highest priority

(3) potential for respiratory infection is not a major threat

(4) not highest priority action related to the diagnosis

Submit
45. The nurse cares for a client diagnosed with Ménière's syndrome. The nurse stands directly in front of the client when speaking. Which of the following BEST describes the rationale for the nurse's position?

Explanation

Strategy: Think about each answer.

(1) client is not hard of hearing

(2) correct—by decreasing movement of client's head, vertigo attacks may be decreased

(3) there is no problem with visual fields

(4) there is no problem with visual fields

Submit
46. An older adult receives dexamethasone (Decadron) 3 mg PO TID for chronic lymphocytic leukemia. It is MOST important for the nurse to report which of the following findings to the physician?

Explanation

Strategy: "Most important to report to the physician" indicates a complication.

(1) normal PT 11 to 15 sec, normal Hgb male: 13.5 to 17.5 g/dL, female: 12.1 to 16.0 g/dL

(2) normal BUN 10 to 20 mg/dL, normal creatine 0.6 to 1.2 mg/dL

(3) correct—normal K+ 3.5 to 5.0 mEq/L, normal Ca+ 4.5 to 5.3 mEq/L, indicates hypokalemia and hypercalcemia

(4) normal AST (SGOT) 8 to 20 U/L, normal ALT (SGPT) 8 to 20 U/L

Submit
47. The nurse cares for a patient admitted 2 days ago with a diagnosis of closed head injury. If the patient develops diabetes insipidus, the nurse will observe which of the following symptoms?

Explanation

Strategy: Determine how each answer relates to diabetes insipidus.

(1) late signs of increased intracranial pressure or brain damage

(2) correct—signs of dehydration, increased output, low specific gravity, normal 1.010 to 1.030

(3) signs of hyperglycemia due to diabetes mellitus

(4) symptoms of SIADH (syndrome of inappropriate antidiuretic hormone) opposite of diabetes insipidus

Submit
48. The nurse cares for a client diagnosed with a recurrent urinary tract infection. The physician orders methenamine mandelate (Mandelamine). The nurse should instruct the client to limit intake of which of the following fluids?

Explanation

(1) correct—should limit intake of alkaline foods and fluids

(2) should be increased to acidify urine

(3) does not need to be restricted

(4) does not need to be restricted

Submit
49. The nurse evaluates the nutritional intake of an adolescent girl attending camp. The adolescent eats all of the food provided to her at the camp cafeteria. Each of the day's three meals contains foods from all areas of the food pyramid, and each meal averages about 900 calories and 3 mg of iron. The girl has been menstruating monthly for about two years. Which of the following descriptions, if made by the nurse, BEST describes the girl's intake if her weight is appropriate for her height?

Explanation

Strategy: Think about each answer.

(1) only 1,200 to 1,500 kcal/day required, and 15 mg/day of iron

(2) only 1,200 to 1,500 kcal/day required

(3) correct–900 × 3 = 2,700 calories/day and women need 1,200 to 1,500 kcal/day (men need 1,500 to 1,800 kcal/day); 3 mg × 3 = 9 mg/day of iron and women need 15 mg/day of iron (men need 10 mg/day); with pregnancy 30 mg/day required

(4) 18 mg/day of iron required

Submit
50. A client returns from surgery after a right mastectomy with an IV of 0.9% NaCl infusing at 100 ml/h into her left forearm. Several hours later, the IV infiltrates. The nurse supervises a student nurse preparing to insert a new peripheral intravenous catheter. The nurse should intervene in which of the following situations?

Explanation

Strategy: "Nurse should intervene" indicates an incorrect action.

(1) acceptable site selection

(2) acceptable site selection

(3) correct inappropriate; movement in area could cause displacement

(4) acceptable procedure

Submit
51. The nursing team consists of one RN, two LPNs/LVNs, and three nursing assistants. The RN should care for which of the following patients?

Explanation

Strategy: Determine the skill level involved with each patient's care. The RN cares for patients who require assessment, teaching, and nursing judgment.

(1) stable patient with an expected outcome; assign to the LPN/LVN

(2) stable patient with an expected outcome; assign to the LPN/LVN

(3) standard, unchanging procedure; assign to the nursing assistant

(4) correct—requires assessment skills of the RN

Submit
52. Which of the following statements is both a correctly stated nursing diagnosis and a high priority for an older client immediately following a modified radical mastectomy and axillary dissection?

Explanation

Strategy: Think about each answer.

(1) is stated incorrectly with "related to the mastectomy"

(2) is stated incorrectly with "related to the mastectomy"

(3) correct—immediately after surgery the priority is optimizing the client's comfort

(4) is not an immediate priority

Submit
53. The physician suggests play therapy for a 7-year-old child having some difficulty adjusting to the parents' impending divorce. The nurse identifies this type of therapy is effective for which of the following reasons?

Explanation

Strategy: Think about each answer.

(1) correct—children have difficulty putting feelings into words; play is how they express themselves

(2) somewhat true, but not best reason for play therapy

(3) not reason play therapy is used; is used because it is the best way for children to express themselves

(4) may encourage child to act out earlier developmental stage to reveal underlying conflicts

Submit
54. Promethazine hydrochloride (Phenergan) 25 mg IV push is ordered for a patient. Prior to administering this medication to the patient, the nurse should check which of the following?

Explanation

Strategy: Determine how each assessment relates to the medication.

(1) is true, but not as high a priority as answer choice (4)

(2) no relevance to the question asked

(3) Phenergan is used as an adjunct to analgesics but has no analgesic activity itself

(4) correct—is very important to determine absolute patency of the vein; extravasation will cause necrosis

Submit
55. An adult client is admitted to the hospital unit diagnosed with hepatitis A. The nurse knows that the client's overall care during hospitalization should include which of the following?

Explanation

Strategy: Think about each answer.

(1) required with patient care activities that require physical skin-to-skin contact, or occurs by contact with contaminated inanimate objects in the patient’s environment

(2) unnecessary; used with pathogens transmitted by airborne route

(3) correct—standard precautions should be used on everyone; sources for this virus are saliva, feces, and blood; use contact isolation if fecal incontinence

(4) unnecessary; used when pathogens transmitted by infectious droplets

Submit
56. Which of the following assessment findings should the nurse recognize as pertinent to a diagnosis of Cushing's syndrome?

Explanation

Strategy: Think about each answer.

(1) BP increases and client gains weight

(2) correct—clients with Cushing's syndrome tend to lose weight in their legs and have petechiae and bruising

(3) no correlation with urinary output; potassium decreases

(4) no correlation with Cushing's syndrome

Submit
57. A client with acquired immunodeficiency syndrome (AIDS) is admitted with a tentative diagnosis of late AIDS dementia complex. The nursing assessment is most likely to reveal which of the following?

Explanation

Strategy: Think about each answer and how it relates to AIDS-related dementia.

(1) not relevant to this condition

(2) not relevant to this condition

(3) correct—approximately 65% of AIDS clients demonstrate a progressive dementia staged according to severity of debilitation; late stage is typified by cognitive confusion and disorientation

(4) is a sign of early-onset dementia

Submit
58. The home care nurse performs an assessment of a client diagnosed with pneumonia secondary to chronic pulmonary disease. Which of the following nursing goals is MOST appropriate?

Explanation

Strategy: Determine the outcome of each answer.

(1) primary problem is not level of oxygenation, but the level of carbon dioxide contributing to an acidotic state

(2) correct—to improve the quality of ventilation refers to levels of carbon dioxide and oxygen

(3) not appropriate for the situation

(4) not appropriate for the situation

Submit
59. The nurse plans care for a client diagnosed with paranoid schizophrenia. The nurse knows that questioning the client about the client's false ideas will elicit which of the following responses?

Explanation

Strategy: Think about each answer.

(1) correct—contraindicated; encourages patient to engage in further distortion of reality

(2) needs reality testing from nurse, not questioning

(3) questioning is nontherapeutic; may cause patient to avoid nurse physically

(4) needs defense; questioning will further distort reality or elaborate on delusion

Submit
60. The nurse cares for a client receiving haloperidol (Haldol). The nurse should anticipate which of the following side effects?

Explanation

Strategy: Think about each answer.

(1) correct—major side effects of haloperidol (Haldol) include hematologic problems, primarily blood dyscrasia and extrapyramidal symptoms (EPS)

(2) not seen with haloperidol

(3) not seen with haloperidol

(4) not seen with haloperidol

Submit
61. The nurse prepares discharge teaching for the parents of a newborn. Which of the following information should the nurse provide to the parents regarding the accuracy of a PKU (phenylketonuria) test?

Explanation

Strategy: Think about each answer.

(1) correct—if initial specimen is collected before newborn is 24 hours old, a repeat test should be performed by 2 weeks of age

(2) no restriction on formula intake

(3) test may be repeated within 2 weeks to ensure accuracy

(4) only one blood sample is needed

Submit
62. In planning discharge teaching for a client after a lumbar laminectomy, the nurse should instruct the client to exercise regularly to strengthen which muscles?

Explanation

Strategy: Think about each answer.

(1) does not contribute to support of the lumbar spine

(2) correct—strengthening the abdominal muscles adds support for the muscles supporting the lumbar spine

(3) does not contribute to support of the lumbar spine

(4) does not contribute to support of the lumbar spine

Submit
63. The nurse knows which of the following is an important consideration in the care of a newborn with fetal alcohol syndrome?

Explanation

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

(1) not highest priority

(2) infant needs to be held and cuddled due to a poorly developed CNS

(3) usually unnecessary

(4) correct—frequently, maternal diet is poor and infant is malnourished; adequate intake of B complex vitamins is necessary for normal CNS function

Submit
64. A patient with type 1 diabetes asks the nurse why the doctor ordered human insulin instead of beef or pork insulin. Which of the following responses by the nurse is BEST?

Explanation

Strategy: Think about each answer.

(1) reactions caused by preservatives in insulin, which is same for all types of insulin

(2) no change in incidence of hypoglycemia or hyperglycemia

(3) complications are caused by blood vessel damage from sugar and fat deposits, not type of insulin used

(4) correct—protein molecules are identical to human insulin

Submit
65. A nurse discusses changes due to aging with a group at the senior citizen center. The nurse knows that which of the following changes in the pattern of urinary elimination normally occurs with aging?

Explanation

Strategy: Think about each answer.

(1) frequency increases because bladder capacity decreases

(2) correct—decreased ability to concentrate urine increases urine formation and increased nocturnal urine production lead to need to awaken to void

(3) ureters, bladder, and urethra lose muscle tone; results in stress and urge incontinence

(4) blood in urine- sign of cancer, infection, or trauma of urinary tract, glomerular disease, renal calculi, bleeding disorders

Submit
66. A patient has a Levin tube connected to intermittent low suction. At 7 A.M., the nurse charts that there is 235 ml of greenish drainage in the suction container. At 3 P.M., the nurse notes that there is 445 ml of greenish drainage in the suction container. Twice during the shift, the nurse irrigates the Levin tube with 30 ml of normal saline, as ordered by the physician. What is the actual amount of drainage from the nasogastric tube for the 7 to 3 shift?

Explanation

Strategy: Think about each answer.

(1) correct–445 − 235 = 210 − 60 = 150

(2) does not subtract 60 ml of fluid used to irrigate Levin tube

(3) does not take into account solution added to container during day shift; does not subtract for fluids used to irrigate Levin tube

(4) does not subtract 235 ml that was in container from night shift

Submit
67. An older client with a history of hypertension and closed-angle glaucoma visits the clinic for a routine check-up. Which of the following medications, if ordered by the physician, should the nurse question?

Explanation

Strategy: "Medication should the nurse question" indicates a contraindication.

(1) antihypertensive, beta-blocker used as an antianginal, reduces cardiac oxygen demand, no effect on glaucoma

(2) calcium channel blocker used as antianginal; not contraindicated

(3) correct—contraindicated; ophthalmic vasoconstrictor, contraindicated with closed angle glaucoma; use cautiously with hypertension

(4) reduces aqueous formation and increases outflow, used for glaucoma

Submit
68. A client receives morphine sulfate after admission to the emergency department in acute respiratory distress. The client is very anxious, edematous, and cyanotic. Which of the following should the nurse recognize as the desired response to the medication?

Explanation

Strategy: Think about each answer.

(1) is not affected by morphine sulfate

(2) correct—morphine sulfate is administered to minimize anxiety associated with respiratory distress from pulmonary edema

(3) is not the action of the medication

(4) medication does not improve ventilation

Submit
69. The nurse cares for a patient the first day postoperative after a transurethral prostatectomy (TURP). The patient has a continuous bladder irrigation (CBI). The patient's wife asks why the client has the CBI. Which of the following responses by the nurse is BEST?

Explanation

Strategy: Think about each answer.

(1) refers to a possible preoperative complication of infection due to the enlarged prostate

(2) not the reason for the CBI

(3) correct—continuous bladder irrigation prevents formation of clots that can lead to obstruction and spasm in the postoperative TURP client

(4) medication is not routinely administered via a CBI in a first-day postop TURP

Submit
70. The nurse cares for a patient during a radium implant. During the removal of the implant, it is MOST important for the nurse to take which of the following actions?

Explanation

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

(1) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant

(2) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant

(3) correct—important that accurate documentation be maintained on the internal radium implant

(4) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant

Submit
71. A Miller-Abbott tube is ordered for a client. The nurse knows that the main reason this tube is inserted is because of which of the following?

Explanation

Strategy: Think about each answer.

(1) tube would be placed in an area of reduced peristalsis and would slowly work past an obstruction

(2) describes a tube such as a Levin or Salem Sump, which decompresses the stomach

(3) tube provides for decompression instead of instillation of medications

(4) correct—Miller-Abbott tube provides for intestinal decompression; intestinal tube is often used for treatment of paralytic ileus

Submit
72. A middle-aged woman is brought to the emergency department after being raped in her home. The client asks the nurse to call her husband to come to the emergency department. The nurse knows that the most common reaction of significant others to a rape victim is reflected in which of the following statements?

Explanation

Strategy: Think about each answer.

(1) significant others may want to be helpful; however, they generally do not have the immediate coping strategies to do so

(2) rarely feel disconnected

(3) usually family members will need and respond well to psychological intervention

(4) correct—sexual assault by rape is a crisis situation for victim and family members and friends

Submit
73. When caring for a client with myasthenia gravis, it is MOST important for the nurse to consider which of the following?

Explanation

Strategy: Answers are a mix of assessment and implementation. Is there an appropriate assessment? Yes.

(1) does not experience vertigo

(2) fluid and electrolytes usually not a problem for this patient

(3) increased intracranial pressure is not associated with myasthenia gravis

(4) correct—client has increased muscle fatigue, needs more assistance toward end of day

Submit
74. A client diagnosed with metastatic lung cancer is admitted to the hospital. The client's orders include do not resuscitate (DNR) and morphine 2 mg/h by continuous IV infusion. When the nurse assesses the client, the client's BP is 86/50, respirations are 8, and the client is nonresponsive. Naloxone hydrochloride (Narcan), 0.4 mg IV is ordered stat. In planning care for this client, it is IMPORTANT for the nurse to consider which of the following?

Explanation

Strategy: Think about each answer.

(1) will not change without Narcan, respirations increase within 2 min

(2) DNR indicates no resuscitation should be done if heart stops; does not preclude administration of drugs to correct iatrogenic problems

(3) correct—half-life of Narcan is short; may go back into respiratory depression; may need to be repeated

(4) used for respiratory depression of opiates, not used with barbiturates or sedatives

Submit
75. The nurse assesses a client diagnosed with a spinal cord injury. Which of the following assessment findings by the nurse suggests the complication of autonomic dysreflexia? Select all that apply.

Explanation

Strategy: Think about each answer.

(1) may be the cause of autonomic dysreflexia due to overfilling of the bladder, but pain is not perceived

(2) correct—severe headache results from rapid onset of hypertension

(3) correct—especially of forehead

(4) pulse will slow

(5) BP will increase

(6) correct—also causes piloerection (goose flesh)

Submit
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