NCLEX Test 74 Questions

1. An adolescent is brought to the hospital for treatment of deep partial thickness and full thickness burns sustained in a house fire. An intravenous infusion is started in the patient's left forearm. The nurse identifies the primary purpose of the IV is which of the following?

Provide a route for pain medications.

Maintain fluid balance.

Prevent gastrointestinal upset.

Obtain blood specimens for analysis.

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

(1) route used for pain medication to ensure absorption, but not primary purpose of IV

(2) correct—loss of fluid occurs from open burn surfaces; maintaining circulation is life-saving requirement

(3) threat of gastrointestinal upset not primary importance; IV’s primary purpose to maintain fluid and electrolyte balance

(4) peripheral IV not used for this purpose

Explanation

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

(1) route used for pain medication to ensure absorption, but not primary purpose of IV

(2) correct—loss of fluid occurs from open burn surfaces; maintaining circulation is life-saving requirement

(3) threat of gastrointestinal upset not primary importance; IV’s primary purpose to maintain fluid and electrolyte balance

(4) peripheral IV not used for this purpose

2. 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?

1.5 mL.

10 mL.

15 mL.

20 mL.

Strategy:Set up a ratio.

(1) inaccurate

(2) correct– 100 mg/150 mg = x mL/15 mL = 10 mL

(3) inaccurate

(4) inaccurate

Explanation

Strategy:Set up a ratio.

(1) inaccurate

(2) correct– 100 mg/150 mg = x mL/15 mL = 10 mL

(3) inaccurate

(4) inaccurate

3. The nurse cares for a client with a tracheostomy. Which of the following is the priority nursing diagnosis for this client?

Impaired verbal communication related to absence of speaking ability.

Ineffective airway clearance related to increased tracheobronchial secretions.

Risk for impaired skin integrity related to tracheostomy incision.

Alteration in comfort: pain related to tracheostomy.

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 painful

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 painful

4. 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?

The LPN/LVN places the solution 20 inches above the anus.

The LPN/LVN adjusts the temperature of the solution.

The LPN/LVN inserts the tube 6 inches.

The LPN/LVN positions the patient left side-lying (Sim’s) with knee flexed.

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 solution

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 solution

5. 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?

12 gtt/min.

21 gtt/min.

25 gtt/min.

31 gtt/min.

Strategy: Remember the formula.

(1) incorrect

(2) correct—IV is to run in 12 hours, or 720 minutes

(3) incorrect

(4) incorrect

Explanation

Strategy: Remember the formula.

(1) incorrect

(2) correct—IV is to run in 12 hours, or 720 minutes

(3) incorrect

(4) incorrect

6. Which information should the nurse recognize as being the MOST pertinent to the diagnosis of cholecystitis?

Flatulence.

Nausea and vomiting.

Right upper abdominal pain.

Dyspepsia.

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 problem

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 problem

7. Prior to sending a client for a cardiac catheterization, it is MOST important for the nurse to report which of the following?

The client has an allergy to shellfish.

The client has diminished palpable peripheral pulses.

The client has cool lower extremities bilaterally.

The client is anxious about the pending procedure.

Strategy: Think about the significance of each answer and how it relates to a cardiac catheterization.

(1) correct—allergies to iodine and/or seafood must be reported immediately before a cardiac catheterization to avoid anaphylactic shock during the procedure

(2) may be normal finding before the test

(3) may be normal finding before the test

(4) may be normal finding before the test

Explanation

Strategy: Think about the significance of each answer and how it relates to a cardiac catheterization.

(1) correct—allergies to iodine and/or seafood must be reported immediately before a cardiac catheterization to avoid anaphylactic shock during the procedure

(2) may be normal finding before the test

(3) may be normal finding before the test

(4) may be normal finding before the test

8. The nurse understands that the primary reason elderly adults have problems with constipation is because of which of the following?

Elderly adults eat a small volume of food with decreased bulk.

Elderly adults have less activity and decreased muscle tone.

Elderly adults have neurological changes in the gastrointestinal tract.

Elderly adults have decreased sensation in the gastrointestinal tract.

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 constipation

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 constipation

9. Which of the following types of foods should the nurse encourage for a client diagnosed with hypoparathyroidism?

Foods high in phosphorus.

Foods high in calcium.

Foods low in sodium.

Foods low in potassium.

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 parathyroid

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 parathyroid

10. 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?

“You are less likely to awaken during the night with heartburn if the stomach is empty.”

“Early-morning vomiting will be less of a problem if the stomach is empty.”

“Drinking or eating before lying down causes decreased respirations due to increased pressure on the lungs.”

“You may develop fluid overload if fluids are taken just before going to bed.”

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 hernia

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 hernia

11. 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 pincer grasp.

Sitting with support.

Tripling of the birth weight.

Presence of the posterior fontanelle.

(2) correct–6-month-old should sit with help

Explanation

(2) correct–6-month-old should sit with help

12. 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?

The blood pressure increases to 150/90.

Urinary output increases to 175 cc/hour.

There is a decrease in the level of activity.

There is an absence of fine tremors of the fingers.

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 medication

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 medication

13. Which of the following would be MOST important for the rehabilitation nurse to assess during a new client's admission?

The client’s expectations of family members.

The client’s understanding of available supportive services.

The client’s personal goals for rehabilitation.

The client’s past experiences in the hospital.

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 goals

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 goals

14. The physician writes an order for a stat dose of Demerol 50 mg IM for pain. Three hours later the client again complains of pain, and the nurse administers a second injection of Demerol. Which of the following describes the nurse's liability?

The nurse administered the medication appropriately; there is no liability.

The nurse violated the narcotic law in not having an order to administer the Demerol a second time.

The client was not injured; if injury did not occur, then the nurse is not liable.

The nurse should have waited at least 4 hours; then there would be no liability.

Strategy: Think about each answer.

(1) does not address the fact that there was no order for the Demerol to be repeated

(2) correct—order for a stat dose does not state PRN; nurse had an order for only the first injection, not the second one

(3) does not address the fact that there was no order for the Demerol to be repeated

(4) does not address the fact that there was no order for the Demerol to be repeated

Explanation

Strategy: Think about each answer.

(1) does not address the fact that there was no order for the Demerol to be repeated

(2) correct—order for a stat dose does not state PRN; nurse had an order for only the first injection, not the second one

(3) does not address the fact that there was no order for the Demerol to be repeated

(4) does not address the fact that there was no order for the Demerol to be repeated

15. If the nurse cares for a client with ataxia, which of the following actions is MOST important?

Supervise ambulation.

Measure the intake and output accurately.

Consult the speech therapist.

Elevate the foot of the bed.

Strategy: Think about each answer.

(1) correct—client’s coordination is poor; the only relevant nursing action is to supervise ambulation

(2) unnecessary

(3) not relevant

(4) not relevant

Explanation

Strategy: Think about each answer.

(1) correct—client’s coordination is poor; the only relevant nursing action is to supervise ambulation

(2) unnecessary

(3) not relevant

(4) not relevant

16. The physician orders hydromorphone hydrochloride (Dilaudid) 15 mg IM for a patient. The nurse should observe for which of the following side effects?

Photosensitivity and constipation.

Hypotension and respiratory depression.

Tardive dyskinesia and diplopia.

Dry mouth and tinnitus.

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 medication

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 medication

17. 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?

To evaluate the progress of the client’s labor.

To assess the strength and duration of the client’s contractions.

To monitor the oxygen status of the fetus during labor.

To determine if an oxytocin drip is necessary.

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 monitoring

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 monitoring

18. The nurse administers oral verapamil (Calan) to a client. Before administering the medication, the nurse should check which of the following?

The client’s electrolytes.

The client’s urine output.

The client’s weight.

The client’s heart rate.

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 administration

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 administration

19. The nursing team consists of an RN who has been practicing for 6 months, an LPN/LVN who has been practicing for 15 years, and a nursing assistant who has been caring for clients for 3 years. The RN should care for which of the following clients?

A client 1 day postop after an internal fixation of a fractured left femur.

A client receiving diltiazem (Cardizem) and phenytoin (Dilantin).

A client ordered to receive two units of packed cells prior to an upper endoscopy procedure.

A client admitted yesterday with exhaustion and a diagnosis of acute bipolar disorder.

Strategy: The RN cares for clients that require assessment, teaching, and nursing judgment.

(1) care can be assigned to the nursing assistant; standard, unchanging procedure

(2) medication can be given by the LPN

(3) correct—requires the assessment and teaching skills of the RN

(4) offer food and fluids; assign to the LPN

Explanation

Strategy: The RN cares for clients that require assessment, teaching, and nursing judgment.

(1) care can be assigned to the nursing assistant; standard, unchanging procedure

(2) medication can be given by the LPN

(3) correct—requires the assessment and teaching skills of the RN

(4) offer food and fluids; assign to the LPN

20. 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?

"The results will inform us of the gestational age."

"This test will evaluate the baby’s lungs."

"The test will show us if there is any problem in the spinal cord."

"Early problems with the baby’s blood can be identified with this test."

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 amniocentesis

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 amniocentesis

21. 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 side effect of the medication that will disappear as time passes.

The reason the patient is receiving this medication.

Extrapyramidal side effects resulting from this medication.

An indication that the dosage of the medication needs to be increased.

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 ordered

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 ordered

22. The mother of a child with chickenpox asks the physician's office nurse why her child will not come down with chickenpox again if exposed to the virus at school at a later date. The nurse's response should be based on which of the following?

Natural passive immunity occurs because the child receives antibodies from outside the body.

Artificial active immunity occurs because the child receives specific antigens against the chickenpox virus.

Natural active immunity occurs because the child’s body actively makes antibodies against the chickenpox virus.

Artificial passive immunity occurs because of the inflammatory process of chickenpox.

The correct answer is natural active immunity occurs because the child's body actively makes antibodies against the chickenpox virus. This is because when a person is infected with a virus like chickenpox, their immune system responds by producing antibodies specific to that virus. These antibodies help to fight off the infection and also provide long-term protection against future exposure to the same virus. This is why the child will not come down with chickenpox again if exposed to the virus at a later date.

Explanation

The correct answer is natural active immunity occurs because the child's body actively makes antibodies against the chickenpox virus. This is because when a person is infected with a virus like chickenpox, their immune system responds by producing antibodies specific to that virus. These antibodies help to fight off the infection and also provide long-term protection against future exposure to the same virus. This is why the child will not come down with chickenpox again if exposed to the virus at a later date.

23. The nurse cares for an elderly client admitted with a possible fractured right hip. During the initial nursing assessment, which of the following observations of the right leg validates or supports this diagnosis?

The leg appears to be shortened and is adducted and externally rotated.

Plantar flexion is observed with sciatic pain radiating down the leg.

From the hip, the leg appears to be longer and is externally rotated.

There is evidence of paresis with decreased sensation and limited mobility.

Strategy: Think about each symptom and how it relates to hip fracture.

(1) correct—accurate assessments of the position of a fractured hip prior to repair

(2) plantar flexion occurs with foot drop

(3) leg would not appear to be longer

(4) occurs with injury to the lumbar disc area

Explanation

Strategy: Think about each symptom and how it relates to hip fracture.

(1) correct—accurate assessments of the position of a fractured hip prior to repair

(2) plantar flexion occurs with foot drop

(3) leg would not appear to be longer

(4) occurs with injury to the lumbar disc area

24. The nurse knows that according to Erikson's stages of psychosocial development, which of the following best represents a 50-year-old client?

Integrity versus despair and disgust.

Generativity versus stagnation.

Intimacy versus isolation.

Identity versus role diffusion.

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 adolescent

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 adolescent

25. Several days after the delivery of a stillborn, the parents say, "We wish we could talk with other couples who have gone through this trauma." Which of the following responses by the nurse is BEST?

"SIDS will provide you with this opportunity."

"SHARE will provide you with this opportunity."

"RESOLVE will provide you with this opportunity."

"CANDLELIGHTERS will provide you with this opportunity."

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Explanation

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26. 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?

No special isolation techniques are necessary.

Wear a double mask and gloves.

Perform good hand washing.

Wear a gown and a mask.

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 patient

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 patient

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?

Rice cereal is usually the first solid food and is started around 4 to 5 months.

Strained fruits are well tolerated as the first solid food, and infants like them.

Introduction of solid foods is not important at this time.

Solid foods are usually not started until the infant is around 6 months old.

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 age

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 age

28. 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?

Clomiphene citrate (Clomid) induces ovulation by changing hormonal effects on the ovary.

Clomiphene citrate (Clomid) changes the uterine lining to be more conducive to implantation.

Clomiphene citrate (Clomid) alters the vaginal pH to increase sperm motility.

Clomiphene citrate (Clomid) produces multiple pregnancy for those who desire twins.

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 effect

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 effect

29. In the process of a normal adjustment to a terminal illness, the nurse knows that the client's initial denial and isolation will give way to the second stage. The second stage is characterized by which of the following?

Acceptance.

Bargaining.

Anger.

Depression.

Strategy: Think about each answer.

(1) this is the fifth stage

(2) this is the third stage

(3) correct—second stage is characterized by anger

(4) this is the fourth stage

Explanation

Strategy: Think about each answer.

(1) this is the fifth stage

(2) this is the third stage

(3) correct—second stage is characterized by anger

(4) this is the fourth stage

30. 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?

The client’s decreased vision is caused by bleeding into the inner ocular chamber of the eye.

The client’s decreased vision is caused by gradual separation of the retina from the base of the eye.

The client’s decreased vision is caused by gradual destruction and degeneration of the retina.

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 vessels

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 vessels

31. Which of the following is the BEST way for a nurse to assess the fluid balance of an elderly client?

Assess the client’s blood pressure.

Check the client’s tissue turgor.

Ask the client if he/she is thirsty.

Maintain an accurate intake and output.

Strategy: Determine how each answer relates to hydration.

(1) may be elevated because of age-related hypertension

(2) not accurate because of changes in skin elasticity from the aging process

(3) not reliable indicator; may have diminished sensation of thirst

(4) correct—best indicator of fluid status

Explanation

Strategy: Determine how each answer relates to hydration.

(1) may be elevated because of age-related hypertension

(2) not accurate because of changes in skin elasticity from the aging process

(3) not reliable indicator; may have diminished sensation of thirst

(4) correct—best indicator of fluid status

32. The nurse recognizes which of the following are early signs of lithium toxicity?

Restlessness, shuffling gait, involuntary muscle movements.

Ataxia, confusion, seizures.

Fine tremors, nausea, vomiting, diarrhea.

Elevated white blood cell count, fever, orthostatic hypotension.

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 lithium

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 lithium

33. 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?

Delusions of persecution.

Command hallucinations.

Delusions of reference.

Persecution hallucinations.

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 hallucinations

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 hallucinations

34. 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?

Advise the client to not take any over-the-counter medications.

Instruct the client on the importance of taking the penicillin for the prescribed time.

Inform the client to refrain from sexual activity.

Maintain the confidentiality of sexual partners or contacts.

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 treated

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 treated

35. 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?

The bowel preparation is incomplete.

The patient ate something after midnight.

This is an expected finding before this type of surgery.

The patient passed the last stool left in the colon.

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 substantiated

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 substantiated

36. 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?

Solitary play

Parallel play

Associative play

Aggressive play

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 behavior

Explanation

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 behavior

37. Which of the following instructions should the nurse give to an adult client to prepare for a plasma cholesterol screening?

Eat a vegetarian diet for 1 week before the test.

Limit alcohol intake to two glasses of wine the day before the test.

Abstain from dairy products for 48 hours before the test.

Only sips of water should be taken for 12 hours before the test.

The nurse should instruct the adult client to only consume sips of water for 12 hours before the plasma cholesterol screening. This is because consuming any food or beverages, other than water, can affect the accuracy of the test results. By abstaining from food and other drinks, the client ensures that the cholesterol levels measured in the blood sample are not influenced by recent consumption.

Explanation

The nurse should instruct the adult client to only consume sips of water for 12 hours before the plasma cholesterol screening. This is because consuming any food or beverages, other than water, can affect the accuracy of the test results. By abstaining from food and other drinks, the client ensures that the cholesterol levels measured in the blood sample are not influenced by recent consumption.

38. 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?

Blurred vision and proteinuria.

Epigastric pain and headache.

Facial swelling and proteinuria.

Polyuria and hypertonic reflexes.

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 eclampsia

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 eclampsia

39. The nurse should caution the client with hypothyroidism to avoid which of the following?

Warm environmental temperatures.

Narcotic sedatives.

Increased physical exercise.

A diet high in fiber.

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 constipation

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 constipation

40. 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?

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) inaccurate

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) inaccurate

41. In planning diet teaching for a child in the early stages of nephrotic syndrome, the nurse should discuss with the parents which of the following dietary changes?

Adequate protein, low sodium intake.

Low protein, low potassium intake.

Low potassium, low calorie intake.

Limited protein, high carbohydrate intake.

Strategy: Think about each answer.

(1) correct—if child can tolerate the protein intake, then this diet is encouraged to speed healing; sodium is usually restricted

(2) low protein contraindicated in renal clients

(3) does not address protein need at all

(4) may be appropriate only if the child cannot tolerate protein intake

Explanation

Strategy: Think about each answer.

(1) correct—if child can tolerate the protein intake, then this diet is encouraged to speed healing; sodium is usually restricted

(2) low protein contraindicated in renal clients

(3) does not address protein need at all

(4) may be appropriate only if the child cannot tolerate protein intake

42. The nurse knows which of the following would have the greatest impact on an elderly client's ability to complete activities of daily living (ADLs)?

Perseveration.

Aphasia.

Mnemonic disturbance.

Apraxia.

Strategy: Think about each answer.

(1) speech disturbance, which would have the greatest impact on communication ability

(2) speech disturbance, which would have the greatest impact on communication ability

(3) speech disturbance, which would have the greatest impact on communication ability

(4) correct—apraxia is loss of purposeful movement in the absence of motor or sensory impairment; when it affects an ADL, such as dressing, the client may not be able to put clothes on properly

Explanation

Strategy: Think about each answer.

(1) speech disturbance, which would have the greatest impact on communication ability

(2) speech disturbance, which would have the greatest impact on communication ability

(3) speech disturbance, which would have the greatest impact on communication ability

(4) correct—apraxia is loss of purposeful movement in the absence of motor or sensory impairment; when it affects an ADL, such as dressing, the client may not be able to put clothes on properly

43. The nurse cares for a newborn infant diagnosed with fetal alcohol syndrome. The nurse expects to see which of the following physical characteristics?

An infant large for gestational age (LGA), craniofacial abnormalities, and hydrocephalus.

An infant with a small head circumference, low birth weight, and undeveloped cheekbones.

An infant with a large head circumference, low birth weight, and excessive rooting and sucking behaviors.

An infant with a normal head circumference, low birth weight, and respiratory distress syndrome.

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 epiglottis

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 epiglottis

44. A toddler diagnosed with lead poisoning is admitted to the pediatric unit. The physician writes and order to encourage fluids. Which of the following fluids is BEST for the nurse to offer to the toddler?

Milk.

Water.

Orange juice

Fruit punch.

Strategy: Determine how each answer relates to lead poisoning.

(1) correct—milk provides a large amount of vitamin D; vitamin D optimizes deposition of lead in the long bones; purpose of the treatment is to remove lead from the blood and soft tissues

(2) good for fluid replacement; does not relate to the lead poisoning

(3) good for fluid replacement; does not relate to the lead poisoning

(4) good for fluid replacement; does not relate to the lead poisoning

Explanation

Strategy: Determine how each answer relates to lead poisoning.

(1) correct—milk provides a large amount of vitamin D; vitamin D optimizes deposition of lead in the long bones; purpose of the treatment is to remove lead from the blood and soft tissues

(2) good for fluid replacement; does not relate to the lead poisoning

(3) good for fluid replacement; does not relate to the lead poisoning

(4) good for fluid replacement; does not relate to the lead poisoning

45. 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?

Continue treatment every other day for 1 week.

Wash the child’s clothing and personal belongings in soap and cool water.

Repeat the application of the shampoo in 7 to 10 days.

One treatment with Kwell kills both lice and nits.

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 application

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 application

46. The nurse knows which of the following mood-altering drugs is most often associated with an increased risk for HIV infection related to intravenous drug use?

Benzodiazepines.

Marijuana.

Barbiturates.

Narcotics.

Strategy: Think about how each drug is administered.

(1) not commonly used intravenously

(2) not commonly used intravenously

(3) not commonly used intravenously

(4) correct—narcotics are most often used intravenously

Explanation

Strategy: Think about how each drug is administered.

(1) not commonly used intravenously

(2) not commonly used intravenously

(3) not commonly used intravenously

(4) correct—narcotics are most often used intravenously

47. The nurse leads a parenting class for a group of expectant mothers. The nurse should advise that the breast-feeding mother should increase her daily caloric intake by how many calories?

200.

300.

400.

500.

Strategy: Think about each answer.

(1) inadequate amount

(2) inadequate amount

(3) inadequate amount

(4) correct—milk production requires an increase of 500 calories per day

Explanation

Strategy: Think about each answer.

(1) inadequate amount

(2) inadequate amount

(3) inadequate amount

(4) correct—milk production requires an increase of 500 calories per day

48. The nurse collects the following data: anger directed by client toward staff in the form of frequent sarcastic or crude comments, increased wringing of hands, and purposeless pacing, particularly after the client has used the telephone. Based on these data, the nurse should make which nursing diagnosis?

Impaired social interaction related to conversion reaction.

Risk for potential activity intolerance as evidenced by purposeless pacing

Powerlessness in hospital situation.

Ineffective individual coping related to recent anger and anxiety

Strategy: Think about each answer.

(1) not warranted with the data indicated

(2) not warranted with the data indicated

(3) not warranted with the data indicated

(4) correct—client is displaying evidence of anger and anxiety and an inability to directly deal with concerns, which is ineffective coping

Explanation

Strategy: Think about each answer.

(1) not warranted with the data indicated

(2) not warranted with the data indicated

(3) not warranted with the data indicated

(4) correct—client is displaying evidence of anger and anxiety and an inability to directly deal with concerns, which is ineffective coping

49. 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?

Impairment of cerebral blood flow and headaches.

Increased intracranial pressure.

Pressure on the ocular suture line.

Displacement of the lens implant.

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 answer

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 answer

50. The nurse cares for a patient diagnosed with a pneumothorax resulting from a motor vehicle accident three days ago. The client has a chest tube connected to a three-chamber water-seal drainage system (Pleur-evac) with 20 cm suction. The nurse determines the lung has re-expanded if which of the following is observed?

There is no drainage in the collection chamber for 3 hours.

The fluid in the water-seal chamber does not fluctuate with respirations.

There is continuous bubbling in the water-seal chamber.

There is gentle bubbling in the suction-control chamber.

Strategy: Determine how each observation relates to a chest tube.

(1) doesn’t indicate re-expansion

(2) correct—indicates no more air leaking into pleural space

(3) indicates air leak; need to check for location of leak; clamp tubing close to chest and check for bubbling, and then clamp tubing close to container and check for bubbling

(4) normal finding

Explanation

Strategy: Determine how each observation relates to a chest tube.

(1) doesn’t indicate re-expansion

(2) correct—indicates no more air leaking into pleural space

(3) indicates air leak; need to check for location of leak; clamp tubing close to chest and check for bubbling, and then clamp tubing close to container and check for bubbling

(4) normal finding

51. In preparing a teaching plan regarding colostomy irrigations, the nurse should include which of the following?

The colostomy needs to be irrigated at the same time every day.

Irrigate the colostomy after meals to increase peristalsis.

Insert the catheter about 10 inches into the stoma.

The solution should be very warm to increase dilation and flow.

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

(1) correct—colostomy irrigation should be done at same time each day to assist in establishing a normal pattern of elimination

(2) colostomy should be irrigated only once a day

(3) catheter should never be inserted more than 4 inches.

(4) solution should be at body temperature; increasing the temperature does not make irrigation more efficient

Explanation

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

(1) correct—colostomy irrigation should be done at same time each day to assist in establishing a normal pattern of elimination

(2) colostomy should be irrigated only once a day

(3) catheter should never be inserted more than 4 inches.

(4) solution should be at body temperature; increasing the temperature does not make irrigation more efficient

52. 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?

The renal threshold for glucose is elevated in the elderly.

Blood glucose monitoring is easier and less costly for clients to perform.

Urine testing for glucose provides false-positive readings.

Determination of the color on a reagent strip varies from person to person.

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 change

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 change

53. The nurse cares for a 3-month-old infant scheduled for a barium swallow in the morning. Prior to the procedure, it is MOST appropriate for the nurse to take which of the following actions?

Offer the infant only clear liquids.

Make the infant NPO for 3 hours.

Feed the infant regular formula.

Maintain the infant NPO for 6 hours.

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

(1) inappropriate

(2) correct—infant should be NPO 3 hours prior to the procedure

(3) inappropriate

(4) unnecessary for an infant to be NPO for 6 hours

Explanation

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

(1) inappropriate

(2) correct—infant should be NPO 3 hours prior to the procedure

(3) inappropriate

(4) unnecessary for an infant to be NPO for 6 hours

54. The physician orders naproxen sodium (Naprosyn) for an elderly client. The nurse should assess the patient for which of the following?

Stomatitis and photosensitivity.

Brachycardia and dry mouth.

Fluid retention and dizziness.

Gynecomastia and impotence.

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 pruritus

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 pruritus

55. 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?

Tissue injury after surgery decreases blood sugar.

Anesthesia acts to increase glycogen stores.

Being NPO inhibits normal blood sugar control.

Surgery often leads to insulin dependency.

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) inaccurate

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) inaccurate

56. 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?

Instruct a significant other about the medication regimen.

Determine the client’s comprehension of the medication administration.

Prepackage the medication to encourage correct administration.

Encourage a return demonstration of medication self-administration.

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 level

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 level

57. The nurse cares for clients in the outpatient clinic. Which of the following messages should the nurse return FIRST?

A mother reports the umbilical cord of her 5-day-old infant is dry and hard to the touch.

A mother reports the "soft spot" on the head of her 4-day-old infant feels slightly elevated when the baby sleeps.

A mother reports that the circumcision of her 3-day-old infant is covered with yellowish exudate.

(2) correct—fontanelle should feel soft and flat; fullness or bulging indicates increased intracranial pressure

Explanation

(2) correct—fontanelle should feel soft and flat; fullness or bulging indicates increased intracranial pressure

58. 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?

"The client is unable to complete activities of daily living without assistance."

"The client appears to be depressed and anxious regarding his/her surgery."

"The client constantly calls for nurses and cries uncontrollably."

"The family is unable to visit more often than once a week because they live far away."

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 client

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 client

59. The nurse cares for a client receiving a blood transfusion for approximately 30 minutes. Which of these assessments, if made by the nurse, indicates an allergic reaction?

Hypotension.

Chills.

Respiratory wheezing.

Lower back discomfort.

Strategy: Think about each answer.

(1) indicative of a hemolytic transfusion reaction

(2) indicative of a hemolytic transfusion reaction

(3) correct—allergic reaction is characterized by wheezing, urticaria (hives), facial flushing, and epiglottal edema

(4) indicative of a hemolytic transfusion reaction

Explanation

Strategy: Think about each answer.

(1) indicative of a hemolytic transfusion reaction

(2) indicative of a hemolytic transfusion reaction

(3) correct—allergic reaction is characterized by wheezing, urticaria (hives), facial flushing, and epiglottal edema

(4) indicative of a hemolytic transfusion reaction

60. 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?

Jaundice.

Rash.

Bruising.

Cellulitis.

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 apparatus

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 apparatus

61. 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?

"The father transmits the gene to his son."

"Both the mother and the father carry a recessive trait."

"The mother transmits the gene to her son."

"There is a 50% chance that the mother will pass the trait to each of her daughters."

(3) correct—hemophilia is a sex-linked disorder

Explanation

(3) correct—hemophilia is a sex-linked disorder

62. Which of the following observations suggests to the nurse that the client has developed an addisonian crisis?

Muscular weakness and fatigue.

Restlessness and rapid, weak pulse.

Dark pigmentation of the skin.

Gastrointestinal disturbances and anorexia

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 crisis

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 crisis

63. The nurse prepares an older client for an intravenous pyelogram (IVP). The client asks the nurse to explain the reason why the procedure is performed. The nurse's response should be based on which of the following?

The health care provider is able to directly observe the renal pelvis.

An IVP assesses glomerular filtration rate.

The health care provider is able to examine the urinary tract by x-ray.

Medication is injected into the urinary system.

Strategy: Think about each answer.

(1) would involve invasive procedure, such as cystoscopy

(2) not primary purpose

(3) correct—x-rays of entire urinary tract taken, evaluates kidney function

(4) not primary purpose

Explanation

Strategy: Think about each answer.

(1) would involve invasive procedure, such as cystoscopy

(2) not primary purpose

(3) correct—x-rays of entire urinary tract taken, evaluates kidney function

(4) not primary purpose

64. 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?

Passive ROM exercises increase muscle strength.

A full ROM must be completed for the elderly client.

Exercises should be completed to the point of discomfort.

A sufficient ROM assists the elderly to carry out activities of daily living (ADLs).

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 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 ADLs

65. 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?

Projection and displacement.

Sublimation and internalization.

Rationalization and intellectualization.

Reaction formation and symbolization.

(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 phobias

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 phobias

66. Which of the following might alert the nurse to consider an alcohol problem in a client hospitalized for a physical illness?

Depression, difficulty falling asleep, decreased concentration.

Elevated liver enzymes, cirrhosis, decreased platelets.

Tremors, elevated temperature, nocturnal leg cramps, complaints of pain symptoms.

Flulike symptoms, night sweats, elevated temperature, decreased deep tendon reflexes.

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 tuberculosis

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 tuberculosis

67. The physician inserts a temporary pacemaker in a client following a myocardial infarction. The nurse knows that the primary purpose of the pacemaker is which of the following?

Increases the force of myocardial contraction.

Increases the cardiac output.

Prevents premature ventricular contractions (PVCs).

Prevents systemic overload.

Strategy: Think about each answer.

(1) action of cardiac glycosides such as digoxin

(2) correct—acts to regulate cardiac rhythm

(3) action of antiarrhythmics such as quinidine

(4) action of diuretics such as Lasix

Explanation

Strategy: Think about each answer.

(1) action of cardiac glycosides such as digoxin

(2) correct—acts to regulate cardiac rhythm

(3) action of antiarrhythmics such as quinidine

(4) action of diuretics such as Lasix

68. 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?

Explain the procedure to the patient. Insert the catheter gently while applying suction, and withdraw using a twisting motion.

(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 motion

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 motion

69. The nurse knows that cortisol is responsible for which of the following?

Preparing the body for "flight or fight."

Regulating the calcium metabolism.

Converting proteins and fat into glucose.

Enhancing musculoskeletal activity.

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 norepinephrine

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 norepinephrine

70. The nurse on a psychiatric unit of the hospital refuses to agree to a patient's request to organize a party on the unit for the patient's friends. The patient becomes angry and uses abusive language toward the nurse. Which of the following statements indicates that the nurse has an understanding of the patient's behavior?

Allowing the patient to use abusive language will undermine the authority of the nurse.

Responding in kind to a patient who uses abusive language will perpetuate the behavior.

Abusive language is one of the behaviors symptomatic of the patient’s illness.

The nurse should model acceptable behavior and language for all patients.

Strategy: Think about each answer.

(1) inaccurate; doesn’t undermine authority of staff

(2) shows lack of understanding of cause for patient’s behavior

(3) correct—symptoms will respond to treatment

(4) suggests that using acceptable language will change patient’s behavior; shows lack of understanding of patient’s behavior

Explanation

Strategy: Think about each answer.

(1) inaccurate; doesn’t undermine authority of staff

(2) shows lack of understanding of cause for patient’s behavior

(3) correct—symptoms will respond to treatment

(4) suggests that using acceptable language will change patient’s behavior; shows lack of understanding of patient’s behavior

71. 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?

Kussmaul respirations and bradycardia.

Elevated temperature and slow respiratory rate

Expiratory wheezing and substernal retractions.

Inspiratory stridor and restlessness.

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 airways

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 airways

72. 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?

Abnormal body proportions.

Early sexual maturation.

Delicate features.

Coarse, dry skin.

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 skin

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 skin

73. 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?

The surface of the tongue.

Hemoglobin and hematocrit.

Skin surfaces in skin folds.

Changes in urine characteristics.

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 medication

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 medication

74. 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?

Inability to talk.

Loss of the gag reflex.

Inability to open the affected eye.

Corneal abrasion.

[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 eye

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 eye