NCLEX-RN Practice 75 Questions Part 2
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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?
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Aggressive behaviors and angry feelings.
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Self-identity and self-esteem.
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Focusing on reality.
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Family boundary intrusions.
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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.
Quiz Preview
- 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?
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After pursed lip breathing, cough into a container.
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Upon awakening, cough deeply and expectorate into a container.
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Save all sputum for three days in a covered container.
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After respiratory treatment, expectorate into a container.
Correct Answer
A. Upon awakening, cough deeply and expectorate into a container.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 desirableRate this question:
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- 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?
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Explain that the client will walk with a prosthesis soon after surgery.
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Encourage the client to share feelings and fears about the surgery.
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Take the informed consent form to the client and ask the client to sign it.
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Evaluate how the client plans to complete schoolwork during hospitalization.
Correct Answer
A. Encourage the client to share feelings and fears about the surgery.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 periodRate this question:
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- 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?
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Cerebrospinal fluid (CSF) cloudy, Hgb 13 g/dL, HCT 38%, WBC 18,000/mm3.
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CSF with RBCs present, Hgb 10 g/dL, HCT 37%, WBC 8,000/mm3.
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CSF cloudy, Hgb 12 g/dL, HCT 37%, WBC 7,000/mm3.
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CSF clear, Hgb 15 g/dL, HCT 40%, WBC 11,000/mm3.
Correct Answer
A. Cerebrospinal fluid (CSF) cloudy, Hgb 13 g/dL, HCT 38%, WBC 18,000/mm3.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 meningitisRate this question:
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- 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?
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The nurse notes that the bladder is distended.
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The client complains of a constant urge to void.
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The nurse notes that the urine is concentrated.
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The client complains of a burning sensation.
Correct Answer
A. The nurse notes that the bladder is distended.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 infectionRate this question:
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- 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?
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Risk for activity intolerance related to decrease in red cells.
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Risk for infection related to low white cell count.
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Risk for anxiety secondary to hypoparathyroid disease.
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Risk for fluid volume deficit due to decreased fluid intake.
Correct Answer
A. Risk for infection related to low white cell count.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 clientRate this question:
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- 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?
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"You are nauseated because of the fatigue you are feeling."
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"The nausea is due to an increase in the basal metabolic rate."
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"The nausea is caused by an elevation in the hormones."
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"If you eat different kinds of foods, you won’t be nauseated."
Correct Answer
A. "The nausea is caused by an elevation in the hormones."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.Rate this question:
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- 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?
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"This test is performed by sticking my finger and measuring the results."
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"This test needs to be performed in the morning before I eat breakfast."
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"This test indicates how well my blood sugar has been controlled the past 6 to 8 weeks."
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"I must follow my diet carefully for several days before the test."
Correct Answer
A. "This test indicates how well my blood sugar has been controlled the past 6 to 8 weeks."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 testRate this question:
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- 9.
The nurse recognizes which of these symptoms as characteristic of a panic attack?
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Palpitations, decreased perceptual field, diaphoresis, fear of going crazy.
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Decreased blood pressure, chest pain, choking feeling.
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Increased blood pressure, bradycardia, shortness of breath.
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Increased respiratory rate, increased perceptual field, increased concentration ability.
Correct Answer
A. Palpitations, decreased perceptual field, diaphoresis, fear of going crazy.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 inhibitedRate this question:
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- 10.
A client develops a low intestinal obstruction. The nurse anticipates which of the following findings?
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Nausea, vomiting, abdominal distention.
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Explosive, irritating diarrhea.
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Abdominal tenderness with rectal bleeding.
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Midepigastric discomfort, tarry stool.
Correct Answer
A. Nausea, vomiting, abdominal distention.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 bleedingRate this question:
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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?
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An infant with septicemia.
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A child with a tonsillectomy.
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An infant with cleft lip repair.
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A child with meningitis.
Correct Answer
A. An infant with cleft lip repair.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 restraintsRate this question:
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- 12.
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?
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"Children develop trust from birth to 18 months of age."
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"Children develop trust from 18 months to three years of age."
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"Children develop trust from three to six years of age."
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"Children develop trust from six to twelve years of age."
Correct Answer
A. "Children develop trust from birth to 18 months of age."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 inferiorityRate this question:
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- 13.
The nurse identifies the MOST reliable client measure to evaluate the desired response of diuretic therapy includes which of the following?
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Obtain daily weights.
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Obtain urinalysis.
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Monitor Na+ and K+ levels.
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Measure intake.
Correct Answer
A. Obtain daily weights.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 priorityRate this question:
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- 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?
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Short-term memory is more efficient than long-term memory.
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The stress of an unfamiliar environment may cause confusion.
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A decline in mental status is a normal part of aging.
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Learning ability is reduced during hospitalization of the elderly client.
Correct Answer
A. The stress of an unfamiliar environment may cause confusion.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 thingsRate this question:
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- 15.
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?
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The student nurse cleans the catheter insertion site using a sterile cotton swab soaked in povidone-iodine.
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The student nurse applies two sterile precut 4 × 4s to the catheter insertion site.
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The student nurse cleans the insertion site using a circular motion from the outer abdomen toward the insertion site.
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The student nurse securely tapes the edges of the sterile dressing with paper tape.
Correct Answer
A. The student nurse cleans the insertion site using a circular motion from the outer abdomen toward the insertion site.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 procedureRate this question:
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- 16.
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?
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Nausea.
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Visual disturbances.
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Tinnitus.
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Ataxia.
Correct Answer
A. Nausea.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 seenRate this question:
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- 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?
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The nurse believes that the client’s symptoms reflect alcohol withdrawal.
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The nurse does not know if the client is allergic to this medication.
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The nurse knows that the client is not psychotic.
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The nurse routinely checks on the doctor’s orders.
Correct Answer
A. The nurse believes that the client’s symptoms reflect alcohol withdrawal.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 orderRate this question:
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- 18.
The nurse is aware that which of the following assessments indicates hypocalcemia?
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Constipation.
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Depressed reflexes.
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Decreased muscle strength.
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Positive Trousseau's sign.
Correct Answer
A. Positive Trousseau's sign.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 hypocalcemiaRate this question:
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- 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?
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During the morning hours.
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During the middle of the day.
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During the afternoon hours.
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During the evening hours.
Correct Answer
A. During the morning hours.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 declinesRate this question:
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- 20.
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?
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Provides psychosocial educational opportunities for stress and coping.
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Provides an avenue for physical exercise.
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Provides an environment for social interaction and companionship.
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Reorients and provides a reality test for confused clients.
Correct Answer
A. Provides an environment for social interaction and companionship.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 groupsRate this question:
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- 21.
The nurse reviews procedures with the health care team. The nurse should intervene if an RN staff member makes which of the following statements?
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"It is my responsibility to ensure that the consent form has been signed and is attached to the patient’s chart."
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"It is my responsibility to witness the signature of the patient before surgery is performed."
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"It is my responsibility to explain the surgery and ask the patient to sign the consent form."
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"It is my responsibility to answer questions that the patient may have before surgery."
Correct Answer
A. "It is my responsibility to explain the surgery and ask the patient to sign the consent form."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 consentRate this question:
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- 22.
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?
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"I take metformin (Glucophage) for type 2 diabetes."
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"I completed the bowel prep last evening."
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"I ate a light meal last evening."
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"I had an IVP 3 years ago."
Correct Answer
A. "I take metformin (Glucophage) for type 2 diabetes."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 physicianRate this question:
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- 23.
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?
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Tetralogy of Fallot.
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Talipes equinovarus.
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Hemolytic disease of the newborn.
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Cleft lip and palate.
Correct Answer
A. Hemolytic disease of the newborn.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 palateRate this question:
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- 24.
Which of the following is the BEST method for the nurse to use when evaluating the effectiveness of tracheal suctioning?
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Notes subjective data, such as "My breathing is much improved now."
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Notes objective findings, such as decreased respiratory rate and pulse.
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Consults with the respiratory therapist to determine effectiveness.
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Auscultates the chest for change or clearing of adventitious breath sounds.
Correct Answer
A. Auscultates the chest for change or clearing of adventitious breath sounds.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 secretionsRate this question:
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- 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?
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"The dye used in the test will turn my urine green for about 24 hours."
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"I will be put to sleep for this procedure. I will return to my room in two hours."
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"This procedure will take about 90 minutes to complete. There will be no discomfort."
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"The wires that will be attached to my head and chest will not cause me any pain."
Correct Answer
A. "This procedure will take about 90 minutes to complete. There will be no discomfort."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 usedRate this question:
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- 26.
The home care nurse plans activities for the day. Which of the following clients should the nurse see FIRST?
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A new mother is breastfeeding her 2-day-old infant who was born 5 days early.
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A man discharged yesterday following treatment with IV heparin for a deep vein thrombosis.
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An elderly woman discharged from the hospital 3 days ago with pneumonia.
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An elderly man who used all his diuretic medication and is expectorating pink-tinged mucus.
Correct Answer
A. An elderly man who used all his diuretic medication and is expectorating pink-tinged mucus.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 attentionRate this question:
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- 27.
The nurse identifies which psychosocial stage should be a priority to consider while planning care for a 20-year-old client?
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Identity versus identity diffusion.
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Intimacy versus isolation.
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Integrity versus despair and disgust.
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Industry versus inferiority.
Correct Answer
A. Intimacy versus isolation.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 ageRate this question:
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- 28.
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?
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An 18-month-old with respiratory syncytial virus.
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A 4-year-old with Kawasaki disease.
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A 10-year-old with Lyme disease.
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A 16-year-old with infectious mononucleosis.
Correct Answer
A. An 18-month-old with respiratory syncytial virus.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 precautionsRate this question:
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- 29.
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?
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Sodium.
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Protein.
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Potassium.
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Iron.
Correct Answer
A. Sodium.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 lithiumRate this question:
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- 30.
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?
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Darker skin that is more pigmented.
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Skin that is ruddy and oily.
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Skin that is puffy and scaly.
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Skin that is pale and dry.
Correct Answer
A. Darker skin that is more pigmented.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 diseaseRate this question:
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- 31.
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?
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Tinnitus, vertigo, blurred vision.
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Fever, malaise, anorexia.
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Diaphoresis, confusion, tachycardia.
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Hyperpnea, flushed face, diarrhea.
Correct Answer
A. Diaphoresis, confusion, tachycardia.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 seenRate this question:
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- 32.
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?
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Posterior and anterior base of right side.
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Right anterior chest between the fourth and sixth intercostals.
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Left of the sternum, midclavicular, at right fifth intercostal.
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Posterior chest wall, midaxillary, right side.
Correct Answer
A. Right anterior chest between the fourth and sixth intercostals.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 posteriorRate this question:
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- 33.
The nurse cares for a client during an acute manic episode. The nurse identifies which client behavior is MOST characteristic of mania?
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Agitation, grandiose delusions, euphoria, difficulty concentrating.
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Difficulty in decision-making, preoccupation with self, distorted perceptions.
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Paranoia, hallucinations, disturbed thought processes, hypervigilance.
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Fear of going crazy, somatic complaints, difficulties with intimacy, increased anxiety.
Correct Answer
A. Agitation, grandiose delusions, euphoria, difficulty concentrating.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 disordersRate this question:
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- 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?
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Time and circumstances under which the rash was noted.
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Explanation given to the client and family of the reason for the rash.
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Notation on an allergy list and notification of the doctor.
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The need for application of corticosteroid cream to decrease inflammation.
Correct Answer
A. Notation on an allergy list and notification of the doctor.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) inappropriateRate this question:
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- 35.
The clinic physician diagnoses Graves’ disease for a client. The nurse expects the client to exhibit which of the following symptoms?
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Lethargy in the early morning.
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Sensitivity to cold.
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Weight loss of 10 lb in 3 weeks.
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Reduced deep tendon reflexes.
Correct Answer
A. Weight loss of 10 lb in 3 weeks.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 hyperactiveRate this question:
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- 36.
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?
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Bradycardia.
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Tachypnea.
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General pallor.
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Irritability.
Correct Answer
A. Tachypnea.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 irritableRate this question:
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- 37.
A client receives a blood transfusion and experiences a hemolytic reaction. The nurse anticipates which of the following assessment findings?
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Hypotension, backache, low back pain, fever.
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Wet breath sounds, severe shortness of breath.
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Chills and fever occurring about an hour after the infusion started.
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Urticaria, itching, respiratory distress.
Correct Answer
A. Hypotension, backache, low back pain, fever.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 reactionRate this question:
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- 38.
The nurse recognizes which of the following nursing interventions is MOST important when caring for a client just placed in physical restraints?
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Prepare PRN dose of psychotropic medication.
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Check that the restraints have been applied correctly.
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Review hospital policy regarding duration of restraints.
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Monitor the client's needs for hydration and nutrition while restrained.
Correct Answer
A. Check that the restraints have been applied correctly.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 restrainedRate this question:
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- 39.
The nurse assesses a client immediately after an exploratory laparotomy. Which of the following nursing observations indicates the complication of intestinal obstruction?
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Protruding soft abdomen with frequent diarrhea.
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Distended abdomen with ascites.
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Minimal bowel sounds in all four quadrants.
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Distended abdomen with complaints of pain.
Correct Answer
A. Distended abdomen with complaints of pain.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 painfulRate this question:
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- 40.
The nurse anticipates a client diagnosed with a gastric ulcer to experience pain at which of the following times?
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Two to three hours after a meal.
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During the night.
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Prior to the ingestion of food.
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One-half to 1 hour after a meal.
Correct Answer
A. One-half to 1 hour after a meal.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 foodRate this question:
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- 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?
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"Listen to the patient’s breath sounds and report back to me."
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"Set up the patient’s lunch tray."
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"Obtain a diet history from the patient."
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"Instruct the patient to balance rest and activity."
Correct Answer
A. "Set up the patient’s lunch tray."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 RNRate this question:
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- 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?
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Heart palpitations.
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Dizziness when walking.
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Blurred vision.
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Digital sensitivity to cold.
Correct Answer
A. Digital sensitivity to cold.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 extremitiesRate this question:
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- 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?
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11 months of age.
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14 months of age.
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17 months of age.
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20 months of age.
Correct Answer
A. 20 months of age.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 controlRate this question:
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- 44.
The nurse determines which of the following actions has HIGHEST priority when caring for the client diagnosed with hypoparathyroidism?
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Develop a teaching plan.
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Plan measures to deal with cardiac dysrhythmias.
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Take measures to prevent a respiratory infection.
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Assess laboratory results.
Correct Answer
A. Plan measures to deal with cardiac dysrhythmias.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 diagnosisRate this question:
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- 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?
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This enables the client to read the nurse’s lips.
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The client does not have to turn her head to see the nurse.
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The nurse will have the client’s undivided attention.
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There is a decrease in client’s peripheral visual field.
Correct Answer
A. The client does not have to turn her head to see the nurse.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 fieldsRate this question:
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- 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?
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PT 12 seconds and Hgb 15 g/dL.
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BUN 18 mg/dL and creatinine 1.0 mg/dL.
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K+ 3.4 mEq/L and Ca+ 5.5 mEq/L.
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AST (SGOT) 18 U/L and ALT (SGPT) 12 U/L.
Correct Answer
A. K+ 3.4 mEq/L and Ca+ 5.5 mEq/L.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/LRate this question:
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- 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?
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Decerebrate posturing, BP 160/100, pulse 56.
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Cracked lips, urinary output of 4 L/24 h with a specific gravity of 1.004.
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Glucosuria, osmotic diuresis, loss of water and electrolytes.
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Weight gain of 5 lb, pulse 116, serum sodium 110 mEq/L.
Correct Answer
A. Cracked lips, urinary output of 4 L/24 h with a specific gravity of 1.004.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 insipidusRate this question:
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- 48.
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?
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Her diet is low in calories and high in iron.
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Her diet is low in calories and low in iron.
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Her diet is high in calories and low in iron.
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Her diet is high in calories and high in iron.
Correct Answer
A. Her diet is high in calories and low in iron.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 requiredRate this question:
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- 49.
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?
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Milk.
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Cranberry juice.
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Water.
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Tea.
Correct Answer
A. Milk.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 restrictedRate this question:
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Mar 22, 2023Quiz Edited by
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Sep 15, 2012Quiz Created by
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