NCLEX Test 74 Questions
NCLEX Test 74 Questions
- 1.
The nurse cares for clients in the outpatient clinic. Which of the following messages should the nurse return FIRST?
- A.
A mother reports the umbilical cord of her 5-day-old infant is dry and hard to the touch.
- B.
A mother reports the "soft spot" on the head of her 4-day-old infant feels slightly elevated when the baby sleeps.
- C.
A mother reports that the circumcision of her 3-day-old infant is covered with yellowish exudate.
- D.
A father reports that he bumped the crib of his 2-day-old infant and she violently extended her extremities and returned them to their previous position.
Correct Answer
B. A mother reports the "soft spot" on the head of her 4-day-old infant feels slightly elevated when the baby sleeps.Explanation
(2) correct—fontanelle should feel soft and flat; fullness or bulging indicates increased intracranial pressureRate this question:
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- 2.
The parents of a child diagnosed with hemophilia ask the nurse to explain the cause of the disease. Which of the following responses by the nurse is BEST?
- A.
"The father transmits the gene to his son."
- B.
"Both the mother and the father carry a recessive trait."
- C.
"The mother transmits the gene to her son."
- D.
"There is a 50% chance that the mother will pass the trait to each of her daughters."
Correct Answer
C. "The mother transmits the gene to her son."Explanation
(3) correct—hemophilia is a sex-linked disorderRate this question:
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- 3.
A 6-month-old is brought to the clinic for a well-baby checkup. During the exam, the nurse expects to observe which of the following?
- A.
A pincer grasp.
- B.
Sitting with support.
- C.
Tripling of the birth weight.
- D.
Presence of the posterior fontanelle.
Correct Answer
B. Sitting with support.Explanation
(2) correct–6-month-old should sit with helpRate this question:
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- 4.
A client with an endotracheal tube requires suctioning. Which of the following statements is an accurate description of how the nurse should perform the procedure?
- A.
Insert the suction catheter 4 in into the tube. Apply suction for 30 seconds, using a twirling motion as the catheter is withdrawn.
- B.
Hyperoxygenate the client. Insert the suction catheter into the tube, and suction while removing the catheter in a back and forth motion.
- C.
Explain the procedure to the patient. Insert the catheter gently while applying suction, and withdraw using a twisting motion.
- D.
Insert the suction catheter until resistance is met, and then withdraw it slightly. Apply suction intermittently as the catheter is withdrawn.
Correct Answer
D. Insert the suction catheter until resistance is met, and then withdraw it slightly. Apply suction intermittently as the catheter is withdrawn.Explanation
(4) correct—insert suction catheter until resistance is met without applying suction, withdraw 0.4 to 0.8 inches (1 to 2 cm), and apply intermittent suction with twirling motionRate this question:
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- 5.
A client comes to the outpatient psychiatric clinic for treatment of a fear of heights. The nurse knows that phobias involve which of the following?
- A.
Projection and displacement.
- B.
Sublimation and internalization.
- C.
Rationalization and intellectualization.
- D.
Reaction formation and symbolization.
Correct Answer
A. Projection and displacement.Explanation
(1) correct—projection (attributing one’s thoughts or impulses to another) and displacement (shifting of emotion concerning person or object to another neutral or less dangerous person or object)
(2) sublimation (diversion of unacceptable drives into socially acceptable channels) and internalization (incorporation of someone else’s opinion as one’s own)
(3) rationalization (attempt to make behavior appear to be the result of logical thinking) and intellectualization (excessive reasoning or logic used to avoid experiencing disturbing feelings)
(4) reaction formation (development of conscious attitudes and behavior patterns into opposite of what one really wants to do) and symbolization (something represents something else); symbolization is involved in phobiasRate this question:
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- 6.
The nurse cares for prenatal client at 8 weeks’ gestation with a positive VDRL. When the nurse prepares the teaching plan, it is MOST important for the nurse to include which of the following?
- A.
Advise the client to not take any over-the-counter medications.
- B.
Instruct the client on the importance of taking the penicillin for the prescribed time.
- C.
Inform the client to refrain from sexual activity.
- D.
Maintain the confidentiality of sexual partners or contacts.
Correct Answer
B. Instruct the client on the importance of taking the penicillin for the prescribed time.Explanation
Strategy: Think "Maslow."
(1) physical, should not take medication over the counter unless prescribed by a doctor, but not highest priority
(2) correct—physical, vitally important to complete all the penicillin
(3) physical, more important to be treated for disease
(4) psychosocial, communicable diseases are reportable; partners or contacts need to be found and notified so that they may be treatedRate this question:
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- 7.
An elderly client recently immobilized is ordered to begin passive range-of-motion (ROM) exercises. What should the nurse understand about ROM before initiating this order?
- A.
Passive ROM exercises increase muscle strength.
- B.
A full ROM must be completed for the elderly client.
- C.
Exercises should be completed to the point of discomfort.
- D.
A sufficient ROM assists the elderly to carry out activities of daily living (ADLs).
Correct Answer
D. A sufficient ROM assists the elderly to carry out activities of daily living (ADLs).Explanation
Strategy: Think about each answer.
(1) inaccurate statement
(2) ROM may be limited
(3) should not be done to point of discomfort
(4) correct—full ROM may not be needed or accomplished without discomfort for an elderly client; emphasis should be on ROMs that support ADLsRate this question:
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- 8.
The nurse cares for an older patient scheduled for a colon resection this morning. The nurse notes the patient had polyethylene glycol-electrolyte solution (GoLYTELY) and a soapsuds enema the previous evening. This morning the patient passes a medium amount of soft brown stool. Which of the following conclusions by the nurse is MOST accurate?
- A.
The bowel preparation is incomplete.
- B.
The patient ate something after midnight.
- C.
This is an expected finding before this type of surgery.
- D.
The patient passed the last stool left in the colon.
Correct Answer
A. The bowel preparation is incomplete.Explanation
Strategy: Think about each answer.
(1) correct—colon should not have remaining soft stool
(2) anything eaten after midnight would not appear as stool by the next morning
(3) not expected; need to clean gastrointestinal tract for surgery
(4) assumption; not substantiatedRate this question:
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- 9.
The nurse cares for a newborn infant diagnosed with fetal alcohol syndrome. The nurse expects to see which of the following physical characteristics?
- A.
An infant large for gestational age (LGA), craniofacial abnormalities, and hydrocephalus.
- B.
An infant with a small head circumference, low birth weight, and undeveloped cheekbones.
- C.
An infant with a large head circumference, low birth weight, and excessive rooting and sucking behaviors.
- D.
An infant with a normal head circumference, low birth weight, and respiratory distress syndrome.
Correct Answer
B. An infant with a small head circumference, low birth weight, and undeveloped cheekbones.Explanation
Strategy: All answers are assessment. Determine how each assessment relates to fetal alcohol syndrome.
(1) usually small for gestational age
(2) correct—seen with fetal alcohol syndrome
(3) may have feeding difficulties and poor sucking ability
(4) head circumference usually small, respiratory distress related to preterm birth, neurologic damage, small trachea, floppy epiglottisRate this question:
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- 10.
The physician orders hydromorphone hydrochloride (Dilaudid) 15 mg IM for a patient. The nurse should observe for which of the following side effects?
- A.
Photosensitivity and constipation.
- B.
Hypotension and respiratory depression.
- C.
Tardive dyskinesia and diplopia.
- D.
Dry mouth and tinnitus.
Correct Answer
B. Hypotension and respiratory depression.Explanation
Strategy: Recall the classification of the drug.
(1) these side effects are not seen with this medication
(2) correct—narcotic analgesic used for moderate to severe pain, monitor vital signs frequently
(3) these side effects are not seen with this medication
(4) these side effects are not seen with this medicationRate this question:
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- 11.
The outpatient clinic nurse cares for an elderly client diagnosed with type 1 diabetes. Because the client is unwilling to perform blood glucose monitoring, the client tests urine for sugar and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because of which of the following?
- A.
The renal threshold for glucose is elevated in the elderly.
- B.
Blood glucose monitoring is easier and less costly for clients to perform.
- C.
Urine testing for glucose provides false-positive readings.
- D.
Determination of the color on a reagent strip varies from person to person.
Correct Answer
A. The renal threshold for glucose is elevated in the elderly.Explanation
Strategy: Think about each answer.
(1) correct—the level at which glucose starts to appear in the urine increases, leading to false-negative readings; results in elevated glucose levels
(2) more expensive procedure
(3) provides false-negative readings; may be negative from 0 to 180 mg/dL
(4) results are expressed as a percentage according to color changeRate this question:
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- 12.
At 32 weeks’ gestation, a client has an order for an ultrasound. The nurse determines the client understands the procedure if the client states which of the following?
- A.
"The results will inform us of the gestational age."
- B.
"This test will evaluate the baby’s lungs."
- C.
"The test will show us if there is any problem in the spinal cord."
- D.
"Early problems with the baby’s blood can be identified with this test."
Correct Answer
A. "The results will inform us of the gestational age."Explanation
Strategy: Think about each answer.
(1) correct—ultrasound detects the gestational age
(2) determined with lecithin/sphingomyelin (L/S) ratio by an amniocentesis
(3) determined with an amniocentesis
(4) determined with an amniocentesisRate this question:
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- 13.
The nurse cares for a child diagnosed with pediculosis capitis (head lice) and is being treated with 1% gamma benzene hexachloride (Kwell) shampoo. The nurse should include which of the following when instructing the child’s parents?
- A.
Continue treatment every other day for 1 week.
- B.
Wash the child’s clothing and personal belongings in soap and cool water.
- C.
Repeat the application of the shampoo in 7 to 10 days.
- D.
One treatment with Kwell kills both lice and nits.
Correct Answer
C. Repeat the application of the shampoo in 7 to 10 days.Explanation
Strategy: Answers are implementation. Determine the outcome of each answer. Is it desired?
(1) too frequent an application of the shampoo
(2) very hot water and a special detergent (RID) need to be used for cleansing clothing and personal belongings
(3) correct—Kwell is an organic solvent, can be toxic, absorbed through scalp; may be repeated 5 to 7 days after first application
(4) must be repeated after the eggs hatch; permethrin 1% crème rinse (Nix) kills both lice and nits after one applicationRate this question:
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- 14.
The nurse supervises an LPN/LVN administering an enema to a patient. The nurse determines the LPN/LVN’s actions are appropriate if which of the following is observed?
- A.
The LPN/LVN places the solution 20 inches above the anus.
- B.
The LPN/LVN adjusts the temperature of the solution.
- C.
The LPN/LVN inserts the tube 6 inches.
- D.
The LPN/LVN positions the patient left side-lying (Sim’s) with knee flexed.
Correct Answer
D. The LPN/LVN positions the patient left side-lying (Sim’s) with knee flexed.Explanation
Strategy: Answers are all implementation. Determine the outcome of each answer. Is it desired?
(1) could cause rapid infusion and possible painful distention of the colon
(2) is not feasible during the administrative phase
(3) tube should be inserted no more than 4 inches
(4) correct—allows solution to flow downward along the natural curve of the sigmoid colon and rectum, which improves retention of solutionRate this question:
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- 15.
An 18-month-old is admitted to the unit with a diagnosis of laryngotracheobronchitis (LTB). During the initial assessment, the nurse expects to find which of the following early symptoms?
- A.
Kussmaul respirations and bradycardia.
- B.
Elevated temperature and slow respiratory rate
- C.
Expiratory wheezing and substernal retractions.
- D.
Inspiratory stridor and restlessness.
Correct Answer
D. Inspiratory stridor and restlessness.Explanation
Strategy: Determine how each answer relates to croup.
(1) Kussmaul respirations are associated with diabetic ketoacidosis; hypoxia and anxiety are associated with tachycardia
(2) respiratory rate would be increased
(3) more often noted with respiratory distress of the newborn
(4) correct—this condition is characterized by edema and inflammation of upper airwaysRate this question:
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- 16.
The nurse cares for a patient receiving chlorpromazine hydrochloride (Thorazine). The nurse notes the patient is restless, unable to sit still, and complains of insomnia and fine tremors of the hands. The nurse identifies which of the following as the BEST explanation about why these symptoms are occurring?
- A.
A side effect of the medication that will disappear as time passes.
- B.
The reason the patient is receiving this medication.
- C.
Extrapyramidal side effects resulting from this medication.
- D.
An indication that the dosage of the medication needs to be increased.
Correct Answer
C. Extrapyramidal side effects resulting from this medication.Explanation
Strategy: Determine how each answer relates to Thorazine.
(1) untrue statement; dosage may need to be decreased because of side effect of medication; antiparkinsonian drug such as Cogentin may be ordered
(2) not accurate; antipsychotic medication
(3) correct—side effects include akathisia (motor restlessness), dystonias (protrusion of tongue, abnormal posturing), pseudoparkinsonism (tremors, rigidity), and dyskinesia (stiff neck, difficulty swallowing)
(4) dosage may be decreased; antiparkinsonian drug such as Cogentin may be orderedRate this question:
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- 17.
The nurse cares for a client with a tracheostomy. Which of the following is the priority nursing diagnosis for this client?
- A.
Impaired verbal communication related to absence of speaking ability.
- B.
Ineffective airway clearance related to increased tracheobronchial secretions.
- C.
Risk for impaired skin integrity related to tracheostomy incision.
- D.
Alteration in comfort: pain related to tracheostomy.
Correct Answer
B. Ineffective airway clearance related to increased tracheobronchial secretions.Explanation
Strategy: Think about each answer.
(1) correct diagnosis; however, answer choice 2 is a priority
(2) correct—ineffective airway clearance is the top priority for clients with a tracheostomy because loss of the upper airway increases the amount and viscosity of secretions
(3) correct diagnosis; however, answer choice 2 is a priority
(4) tracheostomy is not usually painfulRate this question:
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- 18.
Which of the following types of foods should the nurse encourage for a client diagnosed with hypoparathyroidism?
- A.
Foods high in phosphorus.
- B.
Foods high in calcium.
- C.
Foods low in sodium.
- D.
Foods low in potassium.
Correct Answer
B. Foods high in calcium.Explanation
Strategy: Think about each answer.
(1) diet should be low in phosphorus; hypoparathyroidism is decreased secretion of parathyroid hormone; indications include tetany, muscular irritability, carpopedal spasms, dysphagia, paresthesia, and laryngeal spasm
(2) correct—diet for the client should provide high calcium and low phosphorus because the parathyroid controls calcium balance
(3) not regulated by the parathyroid
(4) not regulated by the parathyroidRate this question:
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- 19.
A client arrives at the hospital in active labor, and the admitting nurse attaches an internal fetal monitor. The nurse knows which of the following is the MOST important reason for the fetal monitor?
- A.
To evaluate the progress of the client’s labor.
- B.
To assess the strength and duration of the client’s contractions.
- C.
To monitor the oxygen status of the fetus during labor.
- D.
To determine if an oxytocin drip is necessary.
Correct Answer
C. To monitor the oxygen status of the fetus during labor.Explanation
Strategy: Think about each answer.
(1) clinical assessments provide information about progress of labor (dilation and effacement)
(2) not most important reason for monitoring
(3) correct—goal is early detection of mild fetal hypoxia
(4) fetal well-being is most important reason for fetal monitoringRate this question:
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- 20.
The nurse prepares an adult client diagnosed with mental retardation for discharge. The physician ordered warfarin sodium (Coumadin), 5 mg each day. To maintain client safety, which of the following actions should the nurse take FIRST?
- A.
Instruct a significant other about the medication regimen.
- B.
Determine the client’s comprehension of the medication administration.
- C.
Prepackage the medication to encourage correct administration.
- D.
Encourage a return demonstration of medication self-administration.
Correct Answer
B. Determine the client’s comprehension of the medication administration.Explanation
Strategy: Answers are a mix of assessment and implementation. Does this situation require assessment? Yes.
(1) implementation; might be done after assessment of the comprehension level
(2) correct—assessment; mentally retarded client should be carefully evaluated to ensure complete comprehension of the dosage regimen to prevent overdosage and underdosage
(3) implementation; might be done after assessment of the comprehension level
(4) implementation; might be done after evaluation of the comprehension levelRate this question:
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- 21.
A client, gravida 2 para 1, is admitted with hypertension and complains that her wedding band is tight. The nurse should assess which of the following indications of early pre-eclampsia?
- A.
Blurred vision and proteinuria.
- B.
Epigastric pain and headache.
- C.
Facial swelling and proteinuria.
- D.
Polyuria and hypertonic reflexes.
Correct Answer
C. Facial swelling and proteinuria.Explanation
Strategy: Determine how each answer relates to pre-eclampsia.
(1) only partially correct; blurred vision appears later, with eclampsia
(2) contains signs of eclampsia before a seizure
(3) correct—represents the complete triad seen with pre-eclampsia
(4) oliguria is seen later with eclampsiaRate this question:
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- 22.
The nurse cares for clients in a drug rehabilitation facility. Which of the following complications of IV drug abuse is the nurse MOST likely to observe?
- A.
Jaundice.
- B.
Rash.
- C.
Bruising.
- D.
Cellulitis.
Correct Answer
D. Cellulitis.Explanation
Strategy: Determine how each answer relates to IV drug abuse.
(1) jaundice can develop because of hepatitis B and cirrhosis, which may occur in narcotic abusers who use intravenous drugs
(2) may occur because of the chemicals that are used in cutting the drugs by the client or the drug dealer
(3) may occur because of the chemicals that are used in cutting the drugs by the client or drug dealer
(4) correct—most narcotic addicts do not inject sterile purified material with aseptic techniques; cellulitis is a common complication because of skin popping or using an infected drug apparatusRate this question:
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- 23.
The nurse cares for a client admitted with a diagnosis of cerebrovascular accident (CVA) and facial paralysis. Nursing care should be planned to prevent which of the following complications?
- A.
Inability to talk.
- B.
Loss of the gag reflex.
- C.
Inability to open the affected eye.
- D.
Corneal abrasion.
Correct Answer
D. Corneal abrasion.Explanation
[Show/hide explanation]
Strategy: Think about each answer.
(1) may occur, but nursing care cannot prevent it
(2) may occur, but nursing care cannot prevent it
(3) may occur, but nursing care cannot prevent it
(4) correct—client will be unable to close eye voluntarily; when facial nerve (cranial nerve VII) is affected, the lacrimal gland will no longer supply secretions that protect eyeRate this question:
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- 24.
The nurse cares for a client who is to receive docusate sodium (Colace) 100 mg through a gastric tube. The solution contains 150 mg/15 mL. The nurse should administer how much solution to the client?
- A.
1.5 mL.
- B.
10 mL.
- C.
15 mL.
- D.
20 mL.
Correct Answer
B. 10 mL.Explanation
Strategy:Set up a ratio.
(1) inaccurate
(2) correct– 100 mg/150 mg = x mL/15 mL = 10 mL
(3) inaccurate
(4) inaccurateRate this question:
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- 25.
The nurse recognizes which of the following are early signs of lithium toxicity?
- A.
Restlessness, shuffling gait, involuntary muscle movements.
- B.
Ataxia, confusion, seizures.
- C.
Fine tremors, nausea, vomiting, diarrhea.
- D.
Elevated white blood cell count, fever, orthostatic hypotension.
Correct Answer
C. Fine tremors, nausea, vomiting, diarrhea.Explanation
Strategy: Think about each answer.
(1) indicative of side effects associated with antipsychotic agents, not lithium
(2) indicative of severe lithium toxicity, which requires prompt medical management
(3) correct—nurse should be alert to early signs/symptoms of lithium toxicity; include fine tremors of fingers, wrists, and hands; and nausea, vomiting, and diarrhea
(4) indicative of side effects associated with antipsychotic agents, not lithiumRate this question:
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- 26.
The nurse cares for a client diagnosed with reflux due to a hiatal hernia. The client asks the nurse why he has been instructed to withhold food and fluids just before going to bed. Which of the following responses by the nurse is MOST appropriate?
- A.
“You are less likely to awaken during the night with heartburn if the stomach is empty.”
- B.
“Early-morning vomiting will be less of a problem if the stomach is empty.”
- C.
“Drinking or eating before lying down causes decreased respirations due to increased pressure on the lungs.”
- D.
“You may develop fluid overload if fluids are taken just before going to bed.”
Correct Answer
A. “You are less likely to awaken during the night with heartburn if the stomach is empty.”Explanation
Strategy: Think about each answer.
(1) correct—full stomach is more likely to slide (reflux) through the hernia, causing regurgitation and heartburn
(2) vomiting, decreased respirations, and fluid overload are not related to hiatal hernia
(3) vomiting, decreased respirations, and fluid overload are not related to hiatal hernia
(4) vomiting, decreased respirations, and fluid overload are not related to hiatal herniaRate this question:
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- 27.
The home care nurse visits a new mother and her 2-week-old infant. The client asks the nurse when she should start giving her child solid foods. The nurse’s response should be based on which of the following statements?
- A.
Rice cereal is usually the first solid food and is started around 4 to 5 months.
- B.
Strained fruits are well tolerated as the first solid food, and infants like them.
- C.
Introduction of solid foods is not important at this time.
- D.
Solid foods are usually not started until the infant is around 6 months old.
Correct Answer
A. Rice cereal is usually the first solid food and is started around 4 to 5 months.Explanation
Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?
(1) correct—infants are less likely to be allergic to rice cereal than to any other solid food; usually started between 4 and 5 months of age; breast-fed infants may be started on solids even later
(2) inaccurate
(3) does not answer the mother’s question
(4) usually started between 4 and 5 months of ageRate this question:
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- 28.
The nurse cares for a client with an order for IV fluid of D5 0.45% normal saline 1,000 ml to run from 9 A.M. to 9 P.M. The drip factor on the delivery tubing is 15 gtt/ml. The nurse determines the IV is infusing correctly if the infusion is set at which of the following rates?
- A.
12 gtt/min.
- B.
21 gtt/min.
- C.
25 gtt/min.
- D.
31 gtt/min.
Correct Answer
B. 21 gtt/min.Explanation
Strategy: Remember the formula.
(1) incorrect
(2) correct—IV is to run in 12 hours, or 720 minutes
(3) incorrect
(4) incorrectRate this question:
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- 29.
The nurse understands that the primary reason elderly adults have problems with constipation is because of which of the following?
- A.
Elderly adults eat a small volume of food with decreased bulk.
- B.
Elderly adults have less activity and decreased muscle tone.
- C.
Elderly adults have neurological changes in the gastrointestinal tract.
- D.
Elderly adults have decreased sensation in the gastrointestinal tract.
Correct Answer
B. Elderly adults have less activity and decreased muscle tone.Explanation
Strategy: Think about each answer.
(1) decreased intake of high-fiber foods due to chewing difficulties is seen but is not a major cause of constipation
(2) correct—reduced gastrointestinal motility due to decreased muscle tone, decreased exercise; other factors include prolonged use of laxatives, ignoring urge to defecate, side effect of medications, emotional problems, insufficient fluid intake, and excessive dietary fat
(3) decreased response to stretch receptors in rectum and anal canal occurs but is not a major cause of constipation
(4) decreased response to stretch receptors in rectum and anal canal occurs but is not a major cause of constipationRate this question:
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- 30.
The nurse is discussing growth and development with the parents of a 4-year-old child. The nurse identifies which of the following as the type of play characteristic of this age group?
- A.
Solitary play
- B.
Parallel play
- C.
Associative play
- D.
Aggressive play
Correct Answer
C. Associative playExplanation
Strategy: Picture a 4-year-old.
(1) describes play for an infant
(2) describes play for a toddler
(3) correct—this is the play that characterizes 4-year-olds
(4) is not play but a behaviorRate this question:
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- 31.
Which of the following should be charted by the nurse to reflect a client’s emotional adjustment to being hospitalized in the intensive care unit?
- A.
"The client is unable to complete activities of daily living without assistance."
- B.
"The client appears to be depressed and anxious regarding his/her surgery."
- C.
"The client constantly calls for nurses and cries uncontrollably."
- D.
"The family is unable to visit more often than once a week because they live far away."
Correct Answer
C. "The client constantly calls for nurses and cries uncontrollably."Explanation
Strategy: Good charting is the objective.
(1) does not describe emotional adjustment
(2) draws conclusions without supporting data
(3) correct—gives an objective description of the client’s behavior and affect
(4) describes the client’s family, not the clientRate this question:
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- 32.
Which of the following observations suggests to the nurse that the client has developed an addisonian crisis?
- A.
Muscular weakness and fatigue.
- B.
Restlessness and rapid, weak pulse.
- C.
Dark pigmentation of the skin.
- D.
Gastrointestinal disturbances and anorexia
Correct Answer
B. Restlessness and rapid, weak pulse.Explanation
Strategy: Determine how each answer relates to Addison’s.
(1) signs and symptoms of Addison’s disease, but do not indicate a crisis
(2) correct—may be signs of shock related to an addisonian crisis
(3) signs and symptoms of Addison’s disease, but do not indicate a crisis
(4) signs and symptoms of Addison’s disease, but do not indicate a crisisRate this question:
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- 33.
A postoperative cataract client is cautioned about not making sudden movements or bending over. The nurse understands that the rationale for this recommendation is to prevent which of the following complications?
- A.
Impairment of cerebral blood flow and headaches.
- B.
Increased intracranial pressure.
- C.
Pressure on the ocular suture line.
- D.
Displacement of the lens implant.
Correct Answer
C. Pressure on the ocular suture line.Explanation
Strategy: Think about each answer.
(1) not relevant to this situation
(2) not relevant to this situation
(3) correct—sudden changes in position, constipation, vomiting, stooping, or bending over increase the intraocular pressure and put pressure on the suture line
(4) occurs because of pressure on suture area; not all clients have lens implants; answer choice 3 is a more comprehensive answerRate this question:
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- 34.
Which information should the nurse recognize as being the MOST pertinent to the diagnosis of cholecystitis?
- A.
Flatulence.
- B.
Nausea and vomiting.
- C.
Right upper abdominal pain.
- D.
Dyspepsia.
Correct Answer
C. Right upper abdominal pain.Explanation
Strategy: Think about each answer.
(1) indicates other gastrointestinal problem
(2) indicate other gastrointestinal problem
(3) correct—will experience pain in the upper-right abdominal quadrant
(4) indicates other gastrointestinal problemRate this question:
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- 35.
Which of the following might alert the nurse to consider an alcohol problem in a client hospitalized for a physical illness?
- A.
Depression, difficulty falling asleep, decreased concentration.
- B.
Elevated liver enzymes, cirrhosis, decreased platelets.
- C.
Tremors, elevated temperature, nocturnal leg cramps, complaints of pain symptoms.
- D.
Flulike symptoms, night sweats, elevated temperature, decreased deep tendon reflexes.
Correct Answer
C. Tremors, elevated temperature, nocturnal leg cramps, complaints of pain symptoms.Explanation
Strategy: Remember the "comma, comma, and" rule.
(1) is more indicative of a dysphoric or depressed client
(2) could warrant a further exploration of alcohol use but is not the best indication
(3) correct—when a client is admitted for another physical problem to a general medical, surgical, or critical care unit, the nurse many times becomes the case finder and must be alert for subtle symptoms of an alcohol-related problem; client who has several complaints of pain that do not appear to be correlated to the admissions problem requires further investigation; tremors, elevated temperature, and pain symptoms are indicative of an alcohol-related problem
(4) is more indicative of withdrawal from narcotics or an infective problem such as tuberculosisRate this question:
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- 36.
A 7-year-old girl is seen in the clinic with a diagnosis of pituitary dwarfism. Which of the following clinical manifestations is the nurse MOST likely to observe?
- A.
Abnormal body proportions.
- B.
Early sexual maturation.
- C.
Delicate features.
- D.
Coarse, dry skin.
Correct Answer
C. Delicate features.Explanation
Strategy: Determine how each answer relates to dwarfism.
(1) see small size but normal body proportions
(2) usually have delayed sexual maturity
(3) correct—appear younger than chronological age
(4) usually see fine, smooth skinRate this question:
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- 37.
The physician orders mannitol (Osmitrol) for a client with a closed head injury. Which of the following should the nurse recognize as the desired response to this medication?
- A.
The blood pressure increases to 150/90.
- B.
Urinary output increases to 175 cc/hour.
- C.
There is a decrease in the level of activity.
- D.
There is an absence of fine tremors of the fingers.
Correct Answer
B. Urinary output increases to 175 cc/hour.Explanation
Strategy: Think about each answer.
(1) increase in blood pressure is not desired
(2) correct—mannitol (Osmitrol) is an osmotic diuretic; increases urinary output and decreases intracranial pressure
(3) does not indicate desired effect of medication
(4) does not indicate desired effect of medicationRate this question:
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- 38.
The nurse knows that according to Erikson’s stages of psychosocial development, which of the following best represents a 50-year-old client?
- A.
Integrity versus despair and disgust.
- B.
Generativity versus stagnation.
- C.
Intimacy versus isolation.
- D.
Identity versus role diffusion.
Correct Answer
B. Generativity versus stagnation.Explanation
Strategy: Think about each answer.
(1) appropriate for ages 65 and older
(2) correct—stage of development is appropriate for 45 to 64 years of age
(3) appropriate for the young adult
(4) appropriate for the adolescentRate this question:
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- 39.
A client develops a postoperative infection and receives ceftriaxone sodium (Rocephin) IV every day. It is MOST important for the nurse to monitor which of the following?
- A.
The surface of the tongue.
- B.
Hemoglobin and hematocrit.
- C.
Skin surfaces in skin folds.
- D.
Changes in urine characteristics.
Correct Answer
A. The surface of the tongue.Explanation
Strategy: Answer choices indicates a complication.
(1) correct—cephalosporin, long-term use of Rocephin can cause overgrowth of organisms; monitoring of tongue and oral cavity is recommended
(2) does not reflect a problem with this medication
(3) does not reflect a problem with this medication
(4) does not reflect a problem with this medicationRate this question:
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- 40.
The nurse should caution the client with hypothyroidism to avoid which of the following?
- A.
Warm environmental temperatures.
- B.
Narcotic sedatives.
- C.
Increased physical exercise.
- D.
A diet high in fiber.
Correct Answer
B. Narcotic sedatives.Explanation
Strategy: Think about each answer.
(1) client with hypothyroidism cannot tolerate cold temperatures
(2) correct—client is very sensitive to narcotics, barbiturates, and anesthetics
(3) should not be avoided
(4) requires high fiber, high cellulose foods to prevent constipationRate this question:
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- 41.
The nurse performs the Rinne tests on a 6-year-old girl. Which of the following is an accurate statement of how this test should be performed?
- A.
The stem of a vibrating tuning fork is held against the auditory canal until the child indicates that she can no longer hear the sound. Then the tuning fork is moved away from the canal.
- B.
The stem of a vibrating tuning fork is held against the mastoid bone until the child indicates that she can no longer hear the sound. Then the tuning fork is moved in front of the auditory canal.
- C.
The stem of a vibrating tuning fork is held in the middle of the forehead, and the girl’s hearing is assessed in both ears.
- D.
The stem of a vibrating tuning fork is positioned 2 in behind the girl’s head, and the length of time she hears the sound is documented.
Correct Answer
B. The stem of a vibrating tuning fork is held against the mastoid bone until the child indicates that she can no longer hear the sound. Then the tuning fork is moved in front of the auditory canal.Explanation
Strategy: Think about each answer.
(1) inaccurate
(2) correct—child should hear sound again when tuning fork is moved from mastoid bone to the front of the auditory canal because air conduction is better than bone conduction
(3) the Weber test
(4) inaccurateRate this question:
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- 42.
The nurse cares for a client diagnosed with type 1 diabetes complaining of decreased vision. The client asks the nurse what caused the visual changes. The nurse’s response is based on which of the following?
- A.
The client’s decreased vision is caused by bleeding into the inner ocular chamber of the eye.
- B.
The client’s decreased vision is caused by gradual separation of the retina from the base of the eye.
- C.
The client’s decreased vision is caused by an increase in the size of the vessels in the back of the eye.
- D.
The client’s decreased vision is caused by gradual destruction and degeneration of the retina.
Correct Answer
D. The client’s decreased vision is caused by gradual destruction and degeneration of the retina.Explanation
Strategy: Think about each answer.
(1) complication of postoperative eye surgery or traumatic injury (hyphema)
(2) describes a retinal detachment
(3) destruction of the vessels, as well as edema, occurs
(4) correct—gradual destruction occurs because of deterioration of the retinal vesselsRate this question:
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- 43.
A woman is evaluated for infertility, and the physician prescribes clomiphene citrate (Clomid) 50 mg daily for 5 days. The client asks the nurse about how the medication works. Which of the following responses by the nurse is BEST?
- A.
Clomiphene citrate (Clomid) induces ovulation by changing hormonal effects on the ovary.
- B.
Clomiphene citrate (Clomid) changes the uterine lining to be more conducive to implantation.
- C.
Clomiphene citrate (Clomid) alters the vaginal pH to increase sperm motility.
- D.
Clomiphene citrate (Clomid) produces multiple pregnancy for those who desire twins.
Correct Answer
A. ClomipHene citrate (Clomid) induces ovulation by changing hormonal effects on the ovary.Explanation
Strategy: Think about each answer.
(1) correct—clomiphene citrate (Clomid) induces ovulation by altering estrogen and stimulating follicular growth to produce a mature ovum
(2) infertility problem, but Clomid does not affect it
(3) infertility problem, but Clomid does not affect it
(4) not a desired effectRate this question:
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- 44.
A client had a kidney transplant yesterday, and the client’s son has come to visit. The nurse should instruct the son to do which of the following?
- A.
No special isolation techniques are necessary.
- B.
Wear a double mask and gloves.
- C.
Perform good hand washing.
- D.
Wear a gown and a mask.
Correct Answer
C. Perform good hand washing.Explanation
Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?
(1) inaccurate
(2) inaccurate; masks are unnecessary for this patient
(3) correct—good hand washing is the most effective method of reducing infection; very important with immunosuppressed clients
(4) inaccurate; masks are unnecessary for this patientRate this question:
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- 45.
The physician orders naproxen sodium (Naprosyn) for an elderly client. The nurse should assess the patient for which of the following?
- A.
Stomatitis and photosensitivity.
- B.
Brachycardia and dry mouth.
- C.
Fluid retention and dizziness.
- D.
Gynecomastia and impotence.
Correct Answer
C. Fluid retention and dizziness.Explanation
Strategy: Determine how each answer relates to Naprosyn.
(1) not side effects seen with this medication; may see headache, nausea
(2) not side effects seen with this medication; may see epigastric distress and rash
(3) correct—NSAID (nonsteroidal anti-inflammatory drug) used as analgesic; side effects include headache, dizziness, gastrointestinal distress, pruritus, and rash
(4) not side effects seen with this medication; may see nephrotoxicity and pruritusRate this question:
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- 46.
The nurse cares for a postoperative client diagnosed with type 2 diabetes controlled with oral antihyperglycemic agents. The client asks why the physician ordered subcutaneous insulin injections after surgery. The nurse’s response should be based on which of the following statements?
- A.
Tissue injury after surgery decreases blood sugar.
- B.
Anesthesia acts to increase glycogen stores.
- C.
Being NPO inhibits normal blood sugar control.
- D.
Surgery often leads to insulin dependency.
Correct Answer
C. Being NPO inhibits normal blood sugar control.Explanation
Strategy: Think about each answer.
(1) inaccurate
(2) inaccurate
(3) correct—inability to control diabetes mellitus by diet and oral agents, coupled with surgically induced metabolic changes, being NPO both before and after surgery, and the infusion of intravenous fluids necessitates temporary control by insulin
(4) inaccurateRate this question:
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- 47.
Which of the following would be MOST important for the rehabilitation nurse to assess during a new client’s admission?
- A.
The client’s expectations of family members.
- B.
The client’s understanding of available supportive services.
- C.
The client’s personal goals for rehabilitation.
- D.
The client’s past experiences in the hospital.
Correct Answer
C. The client’s personal goals for rehabilitation.Explanation
Strategy: Determine the outcome and how it relates to rehabilitation.
(1) important to assess but is not as crucial for future success as the client’s goals
(2) important to assess but is not as crucial for future success as the client’s goals
(3) correct—it is important for the nurse to understand what the client expects from the rehabilitation program for future success
(4) important to assess but is not as crucial for future success as the client’s goalsRate this question:
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- 48.
The nurse knows that cortisol is responsible for which of the following?
- A.
Preparing the body for "flight or fight."
- B.
Regulating the calcium metabolism.
- C.
Converting proteins and fat into glucose.
- D.
Enhancing musculoskeletal activity.
Correct Answer
C. Converting proteins and fat into glucose.Explanation
Strategy: Think about each answer.
(1) action of epinephrine
(2) action of parathyroid hormone parathormone
(3) correct—action of cortisol; is also an anti-inflammatory agent
(4) action of norepinephrineRate this question:
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- 49.
A middle-aged client is admitted to an inpatient psychiatric unit. The client complains that a family member is trying to steal the client’s property. The client is diagnosed with paranoid disorder. The nurse knows that the client is demonstrating which of the following?
- A.
Delusions of persecution.
- B.
Command hallucinations.
- C.
Delusions of reference.
- D.
Persecution hallucinations.
Correct Answer
A. Delusions of persecution.Explanation
Strategy: Think about each answer.
(1) correct—client has delusions of persecution; delusion is a strongly held belief that is not validated by reality; the idea that his brother is trying to steal his property is a belief not validated by reality
(2) hallucinations are sensory perceptions that take place without external stimuli; most common are auditory, or hearing voices; other types of hallucinations are tactile, visual, gustatory, and olfactory; command hallucinations involve client experiencing auditory hallucinations that are telling him/her to do something; for example, to kill someone
(3) delusions of reference are a false belief that public events or people are directly related to the individual
(4) are not hallucinationsRate this question:
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- 50.
The nurse administers oral verapamil (Calan) to a client. Before administering the medication, the nurse should check which of the following?
- A.
The client’s electrolytes.
- B.
The client’s urine output.
- C.
The client’s weight.
- D.
The client’s heart rate.
Correct Answer
D. The client’s heart rate.Explanation
Strategy: Think about the action of the drug.
(1) unnecessary action
(2) unnecessary action
(3) unnecessary action
(4) correct—verapamil is indicated for the treatment of supraventricular tachycardias, so the client’s heart rate should be checked prior to administrationRate this question:
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Mar 22, 2023Quiz Edited by
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Sep 14, 2012Quiz Created by
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