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NCSBN - for the NCLEX-RN & NCLEX-PN Examination Question and Answers with Review Information Question 1 A c. What document should be in guiding the car... [Show More] e of this client? A) Client Self Determination Act B) Physician's treatment orders C) Advance Directives. D) Clinical Pathway protocols Review Information: The correct answer is: C) Advance Directives. This document specifies the client's wishes Question 2 You are the of a health care team that consists of one licensed practical/vocational nurse, one nursing assistant, a nursing student and yourself. To whom is it appropriate to assign complete care for A) Yourself B) The nursing student C) The licensed vocational nurse D) The nursing assistant Review Information: The correct answer is:A) Yourself. While the nurse may delegate a bed bath for a stable client, this care should be performed by an RN for a new admission. Only tasks that do not require independent judgment should be delegated. Question 3 A mother brings her the clinic, complaining that the child seems to be .The nurse expects to find which of the following on the initial history and physical assessment? A) Increased temperature and lethargy B) Rash and restlessness C) Increased sleeping and listlessness D) Diarrhea and poor skin turgor Review Information: The correct answer is: B) Rash and restlessness. Question 4 As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? A) "The child has been listless and has lost weight." B) "Her urine is dark yellow and small in amounts." C) "Clothes are becoming tighter across her abdomen." D+) "We notice muscle weakness and some unsteadiness." Review Information: The correct answer is:C) "Clothes are becoming tighter across her abdomen.". One of the most common signs of neuroblastoma is increasing abdominal girth. The parents'' report that clothing is tight is significant, and should be followed by additional assessments. Question 5 A 16 year-old presents to the emergency department. The triage nurse finds that this teenager is legally married and signed the consent form for treatment. What would be the appropriate INITIAL action by the nurse? A) Refuse to see the client until a parent or legal guardian can be contacted B) Withhold treatment until telephone consent can be obtained from the spouse C) Refer the client to a community pediatric hospital emergency room D) Assess and treat in the same manner as any adult client Review Information: The correct answer is:D) Assess and treat in the same manner as any adult client. Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation, independent living or service in the military. Therefore, this client, who is married, has the legal capacity of an adult. Question 6 A newly admitted elderly client is severely dehydrated. When planning care for this client, which one of the following is an appropriate task for an Unlicensed Assistive Personnel (UAP)? A) Obtain a history of fluid loss B) Report output of less than 30 ml/hr C) Monitor response to IV fluids D) Check skin turgor every four hours Review Information: The correct answer is:B) Report output of less than 30 ml/hr. When directing a UAP, the nurse must communicate clearly about each delegated task with specific instructions on what must be reported. Because the RN is responsible for all care-related decisions,only implementation tasks should be assigned because they do not require independent judgment. Question 7 The nurse is assessing a 4 year-old for possible rheumatic fever. Which of the following would the nurse suspect is related to this diagnosis? A) Diagnosis of chickenpox six months ago B) Exposure to strep throat in daycare last month C) Treatment for ear infection two months ago D) Episode of fungal skin infection last week Review Information: The correct answer is:B) Exposure to strep throat in daycare last month. Evidence supports a strong relationship between infection with Group A streptococci and subsequent rheumatic fever (usually within 2-6 weeks). Therefore, the history of playmates recovering from strep throat would indicate that the child diagnosed with rheumatic fever most likely also had strep throat. Sometimes, such an infection has no clinical symptoms. Question 8 When the nurse becomes aware of feeling reluctant to interact with a manipulative client, the BEST action by the nurse is to A) Discuss the feeling of reluctance with an objective peer or supervisor B) Limit contacts with the client to avoid reinforcing the manipulative behavior C) Confront the client regarding the negative effects of his/her behavior on others D) Develop a behavior modification plan that will promote more functional behavior Review Information: The correct answer is:A) Discuss the feeling of reluctance with an objective peer or supervisor. The nurse who is experiencing stress in the therapeutic relationship can gain objectivity through supervision. The nurse must attempt to discover attitudes and feelings in the self that influence the nurse-client relationship. Question 9 A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action A) May result in charges of unlawful seclusion and restraint B) Leaves the nurse vulnerable for charges of assault and battery C) Was appropriate in view of the client's history of violence D) Was necessary to maintain the therapeutic milieu of the unit Review Information: The correct answer is:A) May result in charges of unlawful seclusion and restraint. Seclusion should only be used when there is an immediate threat of violence or threatening behavior. Question 10 A client has been admitted to the Coronary Care Unit with a Myocardial Infarction. Which of the following nursing diagnosis should have PRIORITY? A) Pain related to ischemia B) Risk for altered elimination: constipation C) Risk for complication: dysrhythmias D) Anxiety Review Information: The correct answer is:A) Pain related to ischemia. Pain is related to ischemia, and relief of pain will decrease myocardial oxygen demands, reduce blood pressure and heart rate and relieve anxiety. Pain also stimulates the sympathetic nervous system and increased preload, further increasing myocardial demands. Question 11 The nurse manager who is responsible for hiring professional nursing staff is required to comply with the Americans with Disabilities Act. The provisions of the law require the nurse manager to A) Maintain an environment free from hazards B) Provide reasonable accommodations for disabled individuals C) Make all necessary accommodations for disabled individuals D) Consider only physical disabilities in making employment decisions Review Information: The correct answer is:B) Provide reasonable accommodations for disabled individuals. The law is designed to permit persons with disabilities access to job opportunities. Employers must evaluate an applicant's ability to perform the job and not discriminate on the basis of a disability. Employers also must make "reasonable accommodations. Question 12 The mother of a school-aged child in a long leg cast asks the nurse how to relieve itching inside the cast. Which of the following is appropriate for the nurse to suggest as a remedy? A) Scratching the outside of the cast vigorously, applying pressure over the area B) Blowing a hair dryer or heat lamp on the cast over the area that is itching C) Using a long, smooth piece of wood to gently scratch the affected area D) Applying an ice pack over the area of the cast that is affected Review Information: The correct answer is:D) Applying an ice pack over the area of the cast that is affected. Applying ice is a safe method of relieving the itching. Question 13 Which of the following BEST describes the application of time management strategies in the role of the nurse manager? A) Scheduling staff efficiently to cover client needs B) Assuming a fair share of the client care as a role model C) Setting daily goals to prioritize work D) Delegating tasks to reduce work load Review Information: The correct answer is:C) Setting daily goals to prioritize work. Time management strategies must include setting priorities and meeting goals. Question 14 The clinic nurse assesses a toddler with a tentative diagnosis of neuroblastoma. Symptoms the nurse observes that suggest this problem include A) Lymphedema and nerve palsy B) Hearing loss and ataxia C) Headaches and vomiting D) Abdominal mass and weakness Review Information: The correct answer is:D) Abdominal mass and weakness. Clinical manifestations of neuroblastoma include an irregular abdominal mass that crosses the midline, weakness, pallor, anorexia, weight loss and irritability. Question 15 A fifteen year-old client has been placed in a Milwaukee Brace. Which one of the following statements from the client indicates the need for additional teaching? A) "I will only have to wear this for six months." B) "I should inspect my skin daily." C) "The brace will be worn day and night." D) "I can take it off when I shower." Review Information: The correct answer is:A) "I will only have to wear this for six months.". The brace must be worn long-term, usually for 1-2 years. Question 16 The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that A) Quality of care will improve B) Staff turnover should decrease C) Flexible scheduling will occur D) Team morale will improve Review Information: The correct answer is:D) Team morale will improve. Nurses are more satisfied with autonomy and control. The nurse manager becomes the facilitator of scheduling rather than the decision-maker of the schedule. Question 17 A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? A) Diffuse expiratory wheezing B) Loose, productive cough C) No relief from inhalant D) Fever and chills Review Information: The correct answer is:A) Diffuse expiratory wheezing. In asthma, the airways are narrowed - creating difficulty getting air in and a wheezing sound. Question 18 The nurse manager hears a physician loudly criticizing one of the staff nurses in the hearing of others. The employee does not respond to the physician's complaints. The nurse manager's FIRST action should be A) Walk up to the physician and quietly ask that this unacceptable behavior stop B) Allow the staff nurse to handle this situation without interference C) Notify the Nursing Director and Medical Staff Chief of a breech of professional conduct D) Request an immediate private meeting with the physician and staff nurse Review Information: The correct answer is:D) Request an immediate private meeting with the physician and staff nurse. Assertive communication respects the needs of all parties to express themselves, but not at the expense of others. The nurse manager needs first to protect clients and other staff from this display and come to the assistance of the nurse employee. Question 19 A client voluntarily admits herself to the hospital due to suicidal ideation. The client has been on the unit for two days and is now demanding to be released. The MOST appropriate action is for the nurse to A) Tell the client that she cannot be released because she is still suicidal B) Inform the client that she can be released only if she signs a no suicide contract C) Discuss with the client the decision to leave and prepare for her discharge D) Instruct her regarding her right to sign out upon receipt of the physician's discharge order Review Information: The correct answer is:C) Discuss with the client the decision to leave and prepare for her discharge. Clients voluntarily admitted to the hospital have a right to demand and obtain release. Discussing the decision allows opportunity for other interventions. Question 20 A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition? A) Dyspnea B) Heart murmur C) Macular rash D) Hemorrhage Review Information: The correct answer is:B) Heart murmur. Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off, causing emboli and leaving ulcerations on the valve leaflets. These emboli produce symptoms of cardiac murmur, fever, anorexia, malaise and neurologic sequelae of emboli. Furthermore, the vegetations may travel to various organs such as spleen, kidney, coronary artery, brain and lungs and obstruct blood flow. Question 21 A nurseadmits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based on the fact that the MOST likely cause of this problem stems from the infant's inability to A) Stabilize thermoregulation B) Maintain alveolar surface tension C) Begin normal pulmonary blood flow D) Regulate intracardiac pressure Review Information: The correct answer is:B) Maintain alveolar surface tension. Respiratory distress syndrome is primarily a disease related to developmental delay in lung maturation. Although many factors lead to the development of the problem, the central factor relates to the lack of a normally functioning surfactant system due to immaturity in lung development. Question 22 An 18 year-old client is admitted to intensive care from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse's PRIORITY assessment should be A) Response to stimuli B) Bladder control C) Respiratory function D) Muscle weakness Review Information: The correct answer is: C) Respiratory function. Spinal injury at the C-2 level results in quadriplegia. While the client will experience all of the problems identified, respiratory assessment is a priority. Question 23 The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care? A) Hourly urine output B) White blood count C) Blood glucose every four hours D) Temperature every two hours Review Information: The correct answer is:A) Hourly urine output. Clients who have had an episode of decreased glomerular perfusion are at risk for pre-renal failure. This is caused by any abnormal decline in kidney perfusion that reduces glomerular perfusion. Pre-renal failure occurs when the effective arterial blood volume falls. Examples of this phenomena include a drop in circulating blood volume as in a cardiac arrest state or in low cardiac perfusion states such as congestive heart failure associated with a cardiomyopathy. Close observation of hourly urinary output is necessary for early detection of this condition. Question 24 The nurse admitting a 5 month-old who vomited nine times in the past six hours should observe for signs of A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis Review Information: The correct answer is:B) Metabolic alkalosis. Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss and lead to metabolic alkalosis. Question 25 A child is injured on the school playground and appears to have a fractured leg. The FIRST action the school nurse should take is A) Call for emergency transport to the hospital B) Immobilize the limb and joints above and below the injury C) Assess the child and the extent of the injury D) Apply cold compresses to the injured area Review Information: The correct answer is:C) Assess the child and the extent of the injury. When applying the nursing process, assessment is the first step in providing care. The 5 "Ps" of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis). Question 26 As the nurse interviews the parents of a child with asthma, it is a PRIORITY to ask about A) Household pets B) New furniture C) Lead based paint D) Plants such as cactus Review Information: The correct answer is:A) Household pets. Animal dander is a very common allergen affecting persons with asthma. Other triggers may include pollens, carpeting and household dust. Question 27 An 80 year-old client was admitted with a diagnosis of possible cerebral vascular accident. Blood pressure has ranged from 180/110 to 160/100. Over the past several hours, the nurse noted increasing lethargy. Which of the following assessments should the nurse report IMMEDIATELY to the physician? A) Slurred speech B) Incontinence C) Muscle weakness D) Rapid pulse Review Information: The correct answer is:A) Slurred speech. Changes in speech patterns and level of conscious can be indicators of continued intercranial bleeding. Treatment options may change based on further diagnostic tests. Question 28 A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night." Based on these complaints, the nurse would INITIALLY assess for A) Allergies B) Hyperactivity C) Regression D) Pinworms Review Information: The correct answer is:D) Pinworms. Signs of pinworm infection include intense perianal itching, poor sleep patterns, general irritability, restlessness, bed-wetting, distractibility and short attention span. Question 29 A 72 year-old client with osteomyelitis requires a six week course of intravenous antibiotics. In planning for home care, the MOST important action by the nurse is A) Investigating the client's insurance coverage for home IV antibiotic therapy B) Determining if there are adequate hand washing facilities in the home C) Assessing the client's ability to participate in self care and/or the reliability of a caregiver D) Selecting the appropriate venous access device Review Information: The correct answer is:C) Assessing the client''s ability to participate in self care and/or the reliability of a caregiver. The cognitive ability of the client as well as the availability and reliability of a caregiver must be assessed to determine if home care is a feasible option. Question 30 The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. The BEST response by the nurse is A) "Folic acid should be taken before and after conception." B) "Multivitamin supplements are recommended during pregnancy." C) "A well balanced diet promotes normal fetal development." D) "Increased dietary iron improves the health of mother and fetus." Review Information: The correct answer is:A) "Folic acid should be taken before and after conception.". The American Academy of Pediatrics recommends that all childbearing women increase folic acid from dietary sources and/or supplements. There is evidence that increased amounts of folic acid prevents neural tube defects. Question 31 The nurse is caring for a newborn with a neural tube defect. The BEST covering for the lesion is A) Telfa dressing with antibiotic ointment B) Moist sterile nonadherent dressing C) Dry sterile dressing D) Sterile occlusive pressure dressing Review Information: The correct answer is:B) Moist sterile nonadherent dressing. Before surgical closure the sac is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. Dressings are changed frequently to keep them moist. Question 32 A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning? A) Use ready-to-feed commercial infant formula B) Boil the tap water for 10 minutes prior to preparing the formula C) Let tap water run for 2 minutes before adding to concentrate D) Buy bottled water labeled "lead free" to mix the formula Review Information: The correct answer is:C) Let tap water run for 2 minutes before adding to concentrate. Use of lead-contaminated water to prepare formula is a major source of poisoning in infants. Drinking water may be contaminated by lead from old lead pipes or lead solder used insealing water pipes. Letting tap water run for several minutes will diminish the lead contamination. Question 33 A client is admitted to the rehabilitation unit following a CVA and mild dysphagia. The MOST appropriate intervention for this client is A) Position client in upright position while eating B) Place client on a clear liquid diet C) Tilt head back to facilitate swallowing reflex D) Offer finger foods such as crackers or pretzels Review Information: The correct answer is:A) Position client in upright position while eating. An upright position facilitates proper chewing and swallowing. Question 34 The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, "I will receive tissue from A) a tissue bank." B) a pig." C) my thigh." D) synthetic skin." Review Information: The correct answer is:C) my thigh.". Autografts are done with tissue transplanted from the client''s own skin. Question 35 The nurse is caring for a newborn with tracheoesophageal fistula. Which of the following nursing diagnoses is a PRIORITY? A) Risk for dehydration B) Ineffective airway clearance C) Altered nutrition D) Risk for injury Review Information: The correct answer is:B) Ineffective airway clearance. The most common form of TEF is one in which the proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by a short fistula at or near the bifurcation. Thus, a priority is maintaining an open airway, preventing aspiration. Other nursing diagnoses are then addressed. Question 36 A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The MOST important reason for the nurse to elevate the casted leg is to A) Promote the client's comfort B) Reduce the drying time C) Decrease irritation to the skin D) Improve venous return Review Information: The correct answer is:D) Improve venous return. Elevating the leg both improves venous return and reduces swelling. Question 37 A nurse is working with family members of a newly diagnosed client with Alzheimer's disease. Which of the following interventions is MOST helpful? A) Teaching relaxation techniques B) Implementing a daily exercise routine C) Improving daily nutritional intake D) Suggesting communication strategies Review Information: The correct answer is:D) Suggesting communication strategies. Since Alzheimer''s disease is a progressive chronic illness that greatly challenges caregivers, the nurse can be of greatest assistance in helping family to identify language changes, and select verbal and nonverbal communication strategies to minimize aberrant behavior. Question 38 The nurse is teaching a client with non-insulin dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to A) Maintain previous calorie intake B) Keep a candy bar available at all times C) Reduce carbohydrates intake to 25% of total calories D) Keep a regular schedule of meals and snacks Review Information: The correct answer is:D) Keep a regular schedule of meals and snacks. Currently, calorie-controlled diets with strict mealplans are rarely suggested for clients who have diabetes. Try to incorporate schedule or food changes into clients'' existing dietary patterns. Help clients learn to read labels and identify specific canned foods, frozen entrees, or other foods which are acceptable and those which should be avoided. Question 39 The mother of a two month-old baby calls the nurse at a well-baby clinic two days after the first DTaP immunization. She reports that the baby feels very warm, has cried inconsolably for as long as three hours, and has had several shaking spells. The response of the nurse should be to A) instruct the mother to call 911 for an ambulance to transport the infant B) suggest that these are expected reactions and to begin every 4 hour antipyretics C) tell the mother to take the infant immediately to the nearest emergency room D) give instructions to bring the infant to the clinic now Review Information: The correct answer is:A)instruct the mother to call 911 for an ambulance to transport the infant The exhibited findings of the infant indicate a severe reaction to the immunizations. Immediate attention is needed & an ambulance with trained staff needs to transport because of the risk of grand mal seizures from potential encephalopathy which is a critical reaction. The mother would need to be instructed after this acute reaction to inform the provider of this reaction to the first dose of DTaP. Based on the need and risk involved to the infant, the health care provider may decide that further DTaP immunizations are contraindicated for life. The clinic nurse would need to document in the notes for this infant: the instructions given, findings reported by the mother and specific follow-up needs for the next clinic visit in relation to teaching and evaluation of the outcome of this event. Question 40 The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk? A) Donating blood B) Using public bathrooms C) Unprotected sex D) Touching a person with AIDS Review Information: The correct answer is:C) Unprotected sex. Because HIV is spread through exposure to bodily fluids, unprotected intercourse and shared drug paraphernalia remain the highest risk for infection. Question 41 A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has short palpebral fissures, thinned upper lip, and hypoplastic philtrum of the upper lip. The mother states that the child seems to have problems in learning to count and recognizing basic colors. Based on this data, the nurse suspects that the child is MOST likely showing the effects of A) Congenital abnormalities B) Chronic toxoplasmosis C) Fetal alcohol syndrome D) Lead poisoning Review Information: The correct answer is:C) Fetal alcohol syndrome. Major features of fetal alcohol syndrome consist of facial and associated physical features, such as short palpebral fissure, hypoplastic philtrum, thinned upper lip, short, upturned nose. Behavioral problems, cognitive impairment and psychosocial deficits are also associated with this syndrome. Question 42 The nurse is performing the admission assessment of a client with an acute episode of asthma. Which of the following assessments would the nurse anticipate finding? A) Prolonged inspiration B) Expiratory wheezes C) Expectorating large amounts of purulent mucous D) Lethargy Review Information: The correct answer is:B) Expiratory wheezes. Asthma is characterized by expiratory wheezes caused by obstruction of the airways. Wheezes are a high pitched musical sounds produced by air moving through narrowed airways. Clients often associate wheezes with the feeling of tightness in the chest. Question 43 The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which of the following dinner menus would be BEST? A) Fish sticks, french fries, banana, cookies, milk B) Ground beef patty, lima beans, wheat roll, raisins, milk C) Chicken nuggets, macaroni, peas, cantaloupe, milk D) Peanut butter and jelly sandwich, apple slices, milk Review Information: The correct answer is:B) Ground beef patty, lima beans, wheat roll, raisins, milk. Iron rich foods include red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, dried fruits such as raisins. This dinner is the best choice, high in iron and is appropriate for a toddler. Question 44 A ten year-old client is recovering from a splenectomy following a traumatic injury. The clients laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The BEST approach for the nurse to use is to A) Limit milk and milk products B) Encourage bed activities and games C) Plan nursing care around lengthy rest periods D) Promote a diet rich in iron Review Information: The correct answer is:C) Plan nursing care around lengthy rest periods. The initial priority for this client is rest due to the inability of red blood cells to carry oxygen. Question 45 The nurse planning care for a 12 year-old child with sickle cell disease in a vaso-occlusive crisis of the elbow should include which one of the following as a PRIORITY? A) Limit fluids B) Client controlled analgesia C) Cold compresses to elbow D) Passive range of motion exercise Review Information: The correct answer is:B) Client controlled analgesia. Management of a crisis is directed towards supportive and symptomatic treatment. The priority of care is pain relief. In a 12 year-old child, client controlled analgesia promotes maximum comfort. Question 46 As the nurse provides discharge teaching to the parents of a 15 month-old child with Kawasaki Disease who has received immunoglobulin therapy, which one of the following instructions would be MOST appropriate? A) High doses of aspirin will be continued for some time B) Complete recovery is expected within several days C) Active range of motion exercises should be done frequently [Show Less]
NCLEX-PN Test-Bank (200 Questions with Answers and Explanation) 1. The nurse is caring for a client scheduled for removal of a pituitary tumor using the... [Show More] transsphenoidal approach. The nurse should be particularly alert for: A. Nasal congestion B. Abdominal tenderness C. Muscle tetany D. Oliguria Answer A: Removal of the pituitary gland is usually done by a transsphenoidal approach, through the nose. Nasal congestion further interferes with the airway. Answers B, C, and D are not correct because they are not directly associated with the pituitary gland. 2. A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following? A. Hypernatremia B. Hypokalemia C. Myelosuppression D. Leukocytosis Answer B: Hypokalemia is evident from the lab values listed. The other laboratory findings are within normal limits, making answers A, C, and D incorrect. 3. A 24-year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse? A. Taking the vital signs B. Obtaining the permit C. Explaining the procedure D. Checking the lab work Answer A: The primary responsibility of the nurse is to take the vital signs before any surgery. The actions in answers B, C, and D are the responsibility of the doctor and, therefore, are incorrect for this question. 4. The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority? A. Starting an IV B. Applying oxygen C. Obtaining blood gases D. Medicating the client for pain Answer B: The client with burns to the neck needs airway assessment and supplemental oxygen, so applying oxygen is the priority. The next action should be to start an IV and medicate for pain, making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor. 5. The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client? A. Rest in bed after taking the medication for at least 30 minutes B. Avoid rapid movements after taking the medication C. Take the medication with water only D. Allow at least 1 hour between taking the medicine and taking other medications Answer B: The client with burns to the neck needs airway assessment and supplemental oxygen, so applying oxygen is the priority. The next action should be to start an IV and medicate for pain, making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor. 6. The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside? A. A pair of forceps B. A torque wrench C. A pair of wire cutters D. A screwdriver Answer B: A torque wrench is kept at the bedside to tighten and loosen the screws of crutchfield tongs. This wrench controls the amount of pressure that is placed on the screws. A pair of forceps, wire cutters, and a screwdriver, in answers A, C, and D, would not be used and, thus, are incorrect. 7. An infant weighs 7 pounds at birth. The expected weight by 1 year should be: A. 10 pounds B. 12 pounds C. 18 pounds D. 21 pounds Answer D: A birth weight of 7 pounds would indicate 21 pounds in 1 year, or triple his birth weight. Answers A, B, and C therefore are incorrect. 8. A client is admitted with a Ewing’s sarcoma. Which symptoms would be expected due to this tumor’s location? A. Hemiplegia B. Aphasia C. Nausea D. Bone pain Answer D: Sarcoma is a type of bone cancer; therefore, bone pain would be expected. Answers A, B, and C are not specific to this type of cancer and are incorrect. 9. The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug? A. Uric acid of 5mg/dL B. Hematocrit of 33% C. WBC 2,000 per cubic millimeter D. Platelets 150,000 per cubic millimeter Answer C: Tegretol can suppress the bone marrow and decrease the white blood cell count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers A and D are within normal limits, and answer B is a lower limit of normal; therefore, answers A, B, and D are incorrect. 10. A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis? A. “Tell me about his pain.” B. “What does his vomit look like?” C. “Describe his usual diet.” D. “Have you noticed changes in his abdominal size?” Answer C: The least-helpful questions are those describing his usual diet. A, B, and D are useful in determining the extent of disease process and, thus, are incorrect. 11. The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided? A. Bran B. Fresh peaches C. Cucumber salad D. Yeast rolls Answer C: The client with diverticulitis should avoid foods with seeds. The foods in answers A, B, and D are allowed; in fact, bran cereal and fruit will help prevent constipation. 12. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? A. Teaching how to irrigate the illeostomy B. Stopping electrolyte loss in the incisional area C. Encouraging a high-fiber diet D. Facilitating perineal wound drainage Answer D: The client with a perineal resection will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illeostomy, as in answer A; he will have some electrolyte loss, but treatment is not focused on preventing the loss, so answer B is incorrect. A high-fiber diet, in answer C, is not ordered at this time. 13. The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client’s diet? A. Roasted chicken B. Noodles C. Cooked broccoli D. Custard Answer C: The client with diverticulitis should avoid eating foods that are gas forming and that increase abdominal discomfort, such as cooked broccoli. Foods such as those listed in answers A, B, and D are allowed. 14. The nurse is caring for a new mother. The mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is: A. The baby is dehydrated due to polyuria. B. The baby is hypoglycemic due to lack of glucose. C. The baby is allergic to the formula the mother is giving him. D. The baby can lose up to 10% of weight due to meconium stool, loss of extracellular fluid, and initiation of breast-feeding. Answer D: After birth, meconium stool, loss of extracellular fluid, and initiation of breastfeeding cause the infant to lose body mass. There is no evidence to indicate dehydration, hypoglycemia, or allergy to the infant formula; thus, answers A, B, and C are incorrect. 15. The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis? A. Foul breath B. Dysphagia C. Diarrhea D. Chronic hiccups Answer C: Diarrhea is not common in clients with mouth and throat cancer. All the findings in answers A, B, and D are expected findings. 16. A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usually be included in the plan? A. Closed chest drainage B. A tracheostomy C. A mediastinal tube D. Percussion vibration and drainage Answer A: The client with a lung resection will have chest tubes and a drainage-collection device. He probably will not have a tracheostomy or mediastinal tube, and he will not have an order for percussion, vibration, or drainage. Therefore, answers B, C, and D are incorrect. 17. Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as: A. A cephalohematoma B. Molding C. Subdural hematoma D. Caput succedaneum Answer A: A swelling over the right parietal area is a cephalohematoma, an area of bleeding outside the cranium. This type of hematoma does not cross the suture line because it is outside the cranium but beneath the periosteum. Answer B, molding, is overlapping of the bones of the cranium and, thus, incorrect. In answer C, a subdural hematoma, or intracranial bleeding, is ominous and can be seen only on a CAT scan or x-ray. A caput succedaneum, in answer D, crosses the suture line and is edema. 18. The nurse is assisting the RN with discharge instructions for a client with an implantable defibrillator. What discharge instruction is essential? A. “You cannot eat food prepared in a microwave.” B. “You should avoid moving the shoulder on the side of the pacemaker site for 6 weeks.” C. “You should use your cellphone on your right side.” D. “You will not be able to fly on a commercial airliner with the defibrillator in place.” Answer C: The client with an internal defibrillator should learn to use any battery-operated machinery on the opposite side. He should also take his pulse rate and report dizziness or fainting. Answers A, B, and D are incorrect because the client can eat food prepared in the microwave, move his shoulder on the affected side, and fly in an airplane. 19. A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure? A. Bradycardia B. Tachycardia C. Premature ventricular beats D. Heart block Answer A: Suctioning can cause a vagal response and bradycardia. Answer B is unlikely and, therefore, not most important, although it can occur. Answers C and D can occur as well, but they are less likely. 20. The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period? A. Assessment of the client’s level of anxiety B. Evaluation of the client’s exercise tolerance C. Identification of peripheral pulses D. Assessment of bowel sounds and activity Answer C: The assessment that is most crucial to the client is the identification of peripheral pulses because the aorta is clamped during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities. Answer A is of lesser concern, answer B is not advised at this time, and answer D is of lesser concern than answer A. 21. A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session? A. “You will be sitting for the examination procedure.” B. “Portions of the procedure will cause pain or discomfort.” C. “You will be given some medication to anesthetize the area.” D. “You will not be able to drink fluids for 24 hours before the study.” Answer B: Portions of the exam are painful, especially when the sample is being withdrawn, so this should be included in the session with the client. Answer A is incorrect because the client will be positioned prone, not in a sitting position, for the exam. Anesthesia is not commonly given before this test, making answer C incorrect. Answer D is incorrect because the client can eat and drink following the test. 22. The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis? A. A weight loss of 10 pounds in 2 weeks B. Complaints of numbness and tingling in the extremities C. A red, beefy tongue D. A hemoglobin level of 12.0gm/dL Answer C: A red, beefy tongue is characteristic of the client with pernicious anemia. Answer A, a weight loss of 10 pounds in 2 weeks, is abnormal but is not seen in pernicious anemia. Numbness and tingling, in answer B, can be associated with anemia but are not particular to pernicious anemia. This is more likely associated with peripheral vascular diseases involving vasculature. In answer D, the hemoglobin is low normal. 23. A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for: A. Trendelenburg position B. Ice to the entire extremity C. Buck’s traction D. An abduction pillow Answer C: The client with a fractured femur will be placed in Buck’s traction to realign the leg and to decrease spasms and pain. The Trendelenburg position is the wrong position for this client, so answer A is incorrect. Ice might be ordered after repair, but not for the entire extremity, so answer B is incorrect. An abduction pillow is ordered after a total hip replacement, not for a fractured femur; therefore, answer D is incorrect. 24. A client with cancer is to undergo an intravenous pyelogram. The nurse should: A. Force fluids 24 hours before the procedure B. Ask the client to void immediately before the study C. Hold medication that affects the central nervous system for 12 hours pre- and post-test D. Cover the client’s reproductive organs with an x-ray shield Answer B: The client having an intravenous pyelogram will have orders for laxatives or enemas, so asking the client to void before the test is in order. A full bladder or bowel can obscure the visualization of the kidney ureters and urethra. In answers A, C, and D, there is no need to force fluids before the procedure, to withhold medications, or to cover the reproductive organs. 25. The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor: A. That cannot be assessed B. That is in situ C. With increasing lymph node involvement D. With distant metastasis Answer B: Cancer in situ means that the cancer is still localized to the primary site. Cancer is graded in terms of tumor, grade, node involvement, and mestatasis. Answer A is incorrect because it is an untrue statement. Answer C is incorrect because T indicates tumor, not node involvement. Answer D is incorrect because a tumor that is in situ is not metastasized. 26. A client is 2 days post-operative colon resection. After a coughing episode, the client’s wound eviscerates. Which nursing action is most appropriate? A. Reinsert the protruding organ and cover with 4×4s B. Cover the wound with a sterile 4×4 and ABD dressing C. Cover the wound with a sterile saline-soaked dressing D. Apply an abdominal binder and manual pressure to the wound Answer C: If the client eviscerates, the abdominal content should be covered with a sterile saline-soaked dressing. Reinserting the content should not be the action and will require that the client return to surgery; thus, answer A is incorrect. Answers B and D are incorrect because they are not appropriate to this case. 27. The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery? A. Hearing aid B. Contact lenses C. Wedding ring D. Artificial eye Answer B: It is most important to remove the contact lenses because leaving them in can lead to corneal drying, particularly with contact lenses that are not extended-wear lenses. Leaving in the hearing aid or artificial eye will not harm the client. Leaving the wedding ring on is also allowed; usually, the ring is covered with tape. Therefore, answers A, C, and D are incorrect. 28. The nurse on the 3–11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action? A. Call the surgeon and ask him or her to see the client to clarify the information B. Explain the procedure and complications to the client C. Check in the physician’s progress notes to see if understanding has been documented D. Check with the client’s family to see if they understand the procedure fully Answer A: It is the responsibility of the physician to explain and clarify the procedure to the client. Answers B, C, and D are incorrect because they are not within the nurse’s purview. 29. When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain? A. A history of radiation treatment in the neck region B. A history of recent orthopedic surgery C. A history of minimal physical activity D. A history of the client’s food intake Answer A: Previous radiation to the neck might have damaged the parathyroid glands, which are located on the thyroid gland, and interfered with calcium and phosphorus regulation. Answer B has no significance to this case; answers C and D are more related to calcium only, not to phosphorus regulation. 30. A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170meq/L. What behavior changes would be most common for this client? A. Anger B. Mania C. Depression D. Psychosis Answer B: The client with serum sodium of 170meq/L has hypernatremia and might exhibit manic behavior. Answers A, C, and D are not associated with hypernatremia and are, therefore, incorrect. 31. The nurse is obtaining a history of an 80-year-old client. Which statement made by the client might indicate a possible fluid and electrolyte imbalance? A. “My skin is always so dry.” B. “I often use a laxative for constipation.” C. “I have always liked to drink a lot of ice tea.” D. “I sometimes have a problem with dribbling urine.” Answer B: Frequent use of laxatives can lead to diarrhea and electrolyte loss. Answers A, C, and D are not of particular significance in this case and, therefore, are incorrect. 32. A client visits the clinic after the death of a parent. Which statement made by the client’s sister signifies abnormal grieving? A. “My sister still has episodes of crying, and it’s been 3 months since Daddy died.” B. “Sally seems to have forgotten the bad things that Daddy did in his lifetime.” C. “She really had a hard time after Daddy’s funeral. She said that she had a sense of longing.” D. “Sally has not been sad at all by Daddy’s death. She acts like nothing has happened.” Answer D: Abnormal grieving is exhibited by a lack of feeling sad; if the client’s sister appears not to grieve, it might be abnormal grieving. This family member might be suppressing feelings of grief. Answers A, B, and C are all normal expressions of grief and, therefore, incorrect. 33. The nurse recognizes that which of the following would be most appropriate to wear when providing direct care to a client with a cough? A. Mask B. Gown C. Gloves D. Shoe covers Answer A: If the nurse is exposed to the client with a cough, the best item to wear is a mask. If the answer had included a mask, gloves, and a gown, all would be appropriate, but in this case, only one item is listed; therefore, answers B and C are incorrect. Shoe covers are not necessary, so answer D is incorrect. 34. The nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention? A. Suggest that the client take warm showers B.I.D. B. Add baby oil to the client’s bath water C. Apply powder to the client’s skin D. Suggest a hot-water rinse after bathing Answer B: Oils can be applied to help with the dry skin and to decrease itching, so adding baby oil to bath water is soothing to the skin. Answer A is incorrect because bathing twice a day is too frequent and can cause more dryness. Answer C is incorrect because powder is also drying. Rinsing with hot water, as stated in answer D, dries out the skin as well. 35. A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate? A. Blood pressure every 15 minutes B. Insertion of a Levine tube C. Cardiac monitoring D. Dressing changes two times per day Answer B: The client with pancreatitis frequently has nausea and vomiting. Lavage is often used to decompress the stomach and rest the bowel, so the insertion of a Levine tube should be anticipated. Answers A and C are incorrect because blood pressures are not required every 15 minutes, and cardiac monitoring might be needed, but this is individualized to the client. Answer D is incorrect because there are no dressings to change on this client. 36. The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because: A. The client is at risk for evisceration. B. The client will require frequent dressing changes. C. The straps provide support for drains that are inserted in the incision. D. No sutures or clips are used to secure the incision. Answer B: Montgomery straps are used to secure dressings that require frequent dressing changes because the client with a cholecystectomy usually has a large amount of drainage on the dressing. Montgomery straps are also used for clients who are allergic to several types of tape. This client is not at higher risk of evisceration than other clients, so answer A is incorrect. Montgomery straps are not used to secure the drains, so answer C is incorrect. Sutures or clips are used to secure the wound of the client who has had gallbladder surgery, so answer D is incorrect. 37. The physician has ordered that the client’s medication be administered intrathecally. The nurse is aware that medications will be administered by which method? A. Intravenously B. Rectally C. Intramuscularly D. Into the cerebrospinal fluid Answer D: Intrathecal medications are administered into the cerebrospinal fluid. This method of administering medications is reserved for the client with metastases, the client with chronic pain, or the client with cerebrospinal infections. Answers A, B, and C are incorrect because intravenous, rectal, and intramuscular injections are entirely different procedures. 38. Which client can best be assigned to the newly licensed practical nurse? A. The client receiving chemotherapy B. The client post–coronary bypass C. The client with a TURP D. The client with diverticulitis Answer D: The best client to assign to the newly licensed nurse is the most stable client; in this case, it is the client with diverticulitis. The client receiving chemotherapy and the client with a coronary bypass both need nurses experienced in these areas, so answers A and B are incorrect. Answer D is incorrect because the client with a transurethral prostatectomy might bleed, so this client should be assigned to a nurse who knows how much bleeding is within normal limits. 39. The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the registered nurse? A. Notify the police department as a robbery B. Report this behavior to the charge nurse C. Monitor the situation and note whether any items are missing D. Ignore the situation until items are reported missing Answer B: The best action at this time is to report the incident to the charge nurse. Further action might be needed, but it should be determined by the charge nurse. Answers A, C, and D are incorrect because notifying the police is overreacting at this time, and monitoring or ignoring the situation is an inadequate response. 40. The nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should: A. Change the nursing assistant’s assignment B. Explore the interaction with the nursing assistant C. Discuss the matter with the client’s family D. Initiate a group session with the nursing assistant Answer B: The best action for the nurse to take is to explore the interaction with the nursing assistant. This will allow for clarification of the situation. Changing the assignment in answer A might need to be done, but talking to the nursing assistant is the first step. Answer C is incorrect because discussing the incident with the family is not necessary at this time; it might cause more problems. Answer C is not a first step, even though initiating a group session might be a plan for the future. 41. A home health nurse is planning for her daily visits. Which client should the home health nurse visit first? A. A client with AIDS being treated with Foscarnet B. A client with a fractured femur in a long leg cast C. A client with laryngeal cancer with a laryngetomy D. A client with diabetic ulcers to the left foot Answer C: The client with laryngeal cancer has a potential airway alteration and should be seen first. The clients in answers A, B, and D are not in immediate danger and can be seen later in the day. 42. The nurse is assigned to care for an infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin? A. Increasing the infant’s fluid intake B. Maintaining the infant’s body temperature at 98.6°F C. Minimizing tactile stimulation D. Decreasing caloric intake Answer A: Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temperature is important but will not assist in eliminating bilirubin; therefore, answer B is incorrect. Answers C and D are incorrect because they do not relate to the question. 43. The graduate licensed practical nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority? A. Maintain the client’s systolic blood pressure at 70mmHg or greater B. Maintain the client’s urinary output greater than 300cc per hour C. Maintain the client’s body temperature of greater than 33°F rectal D. Maintain the client’s hematocrit less than 30% Answer A: When the cadaver client is being prepared to donate an organ, the systolic blood pressure should be maintained at 70mmHg or greater to ensure a blood supply to the donor organ. Answers B, C, and D are incorrect because they are unnecessary actions for organ donation. 44. Which action by the novice nurse indicates a need for further teaching? A. The nurse fails to wear gloves to remove a dressing. B. The nurse applies an oxygen saturation monitor to the ear lobe. C. The nurse elevates the head of the bed to check the blood pressure. D. The nurse places the extremity in a dependent position to acquire a peripheral blood sample. Answer A: The nurse who fails to wear gloves to remove a contaminated dressing needs further instruction. Answers B, C, and D are incorrect because they indicate an understanding of the correct method of completing these tasks. 45. The nurse is preparing a client for mammography. To prepare the client for a mammogram, the nurse should tell the client: A. To restrict her fat intake for 1 week before the test B. To omit creams, powders, or deodorants before the exam C. That mammography replaces the need for self-breast exams D. That mammography requires a higher dose of radiation than an x-ray Answer B: The client having a mammogram should be instructed to omit deodorants or powders beforehand because powders and deodorants can be interpreted as abnormal. Answer A is incorrect because there is no need for dietary restrictions before a mammogram. Answer C is incorrect because the mammogram does not replace the need for self-breast exams. Answer D is incorrect because a mammogram does not require higher doses of radiation than an x-ray. 46. Which of the following roommates would be best for the client newly admitted with gastric resection? A. A client with Crohn’s disease B. A client with pneumonia C. A client with gastritis D. A client with phlebitis Answer D: The most suitable roommate for the client with gastric resection is the client with phlebitis because phlebitis is an inflammation of the blood vessel and is not infectious. Crohn’s disease clients, in answer A, have frequent stools that might spread infections to the surgical client. The client in answer B with pneumonia is coughing and will disturb the gastric client. The client with gastritis, in answer C, is vomiting and has diarrhea, which also will disturb the gastric client. 47. The licensed practical nurse is working with a registered nurse and a patient care assistant. Which of the following clients should be cared for by the registered nurse? A. A client 2 days post-appendectomy B. A client 1 week post-thyroidectomy C. A client 3 days post-splenectomy D. A client 2 days post-thoracotomy Answer D: The most critical client should be assigned to the registered nurse; in this case, that is the client 2 days post-thoracotomy. The clients in answers A and B are ready for discharge, and the client in answer C who had a splenectomy 3 days ago is stable enough to be assigned to an LPN. 48. The licensed practical nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching? A. The graduate places the client in a supine position to read the manometer. B. The graduate turns the stop-cock to the off position from the IV fluid to the client. C. The graduate instructs the client to perform the Valsalva maneuver during the CVP reading. D. The graduate notes the level at the top of the meniscus. Answer C: The client should breathe normally during a central venous pressure monitor reading. Answer A indicates understanding because the client should be placed supine if he can tolerate being in that position. Answers B and D indicate understanding because the stop-cock should be turned off to the IV fluid, and the reading should be done at the top of the meniscus. 49. Which of the following roommates would be most suitable for the client with myasthenia gravis? A. A client with hypothyroidism B. A client with Crohn’s disease C. A client with pylonephritis D. A client with bronchitis Answer A: The most suitable roommate for the client with myasthenia gravis is the client with hypothyroidism because he is quiet. The client with Crohn’s disease in answer B will be up to the bathroom frequently; the client with pylonephritis in answer C has a kidney infection and will be up to urinate frequently. The client in answer D with bronchitis will be coughing and will disturb any roommate. 50. The nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care? A. A 10-year-old with lacerations of the face B. A 15-year-old with sternal bruises C. A 34-year-old with a fractured femur D. A 50-year-old with dislocation of the elbow Answer B: The teenager with sternal bruising might be experiencing airway and oxygenation problems and, thus, should be seen first. In answer A, the 10-year-old with lacerations might look bad but is not in distress. The client in answer C with a fractured femur should be immobilized but can be seen after the client with sternal bruising. The client in answer D with the dislocated elbow can be seen later as well. 51. The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should: A. Document the finding B. Send a specimen to the lab C. Strain the urine D. Obtain a complete blood count Answer B: If the dialysate returns cloudy, infection might be present and must be evaluated. Documenting the finding, as stated in answer A, is not enough; straining the urine, in answer C, is incorrect; and dialysate, in answer D, is not urine at all. However, the physician might order a white blood cell count. [Show Less]
NCLEX-PN 2020 EXAM 1. A 24-year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nu... [Show More] rse? A. Taking the vital signs B. Obtaining the permit C. Explaining the procedure D. Checking the lab work 2. The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority? A. Starting an IV B. Applying oxygen C. Obtaining blood gases D. Medicating the client for pain 3. The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client? A. Rest in bed after taking the medication for at least 30 minutes B. Avoid rapid movements after taking the medication C. Take the medication with water only D. Allow at least 1 hour between taking the medicine and taking other medications 4. The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside? A. A pair of forceps B. A torque wrench C. A pair of wire cutters D. A screwdriver 5. An infant weighs 7 pounds at birth. The expected weight by 1 year should be: A. 10 pounds B. 12 pounds C. 18 pounds D. 21 pounds 6. A client is admitted with a Ewing’s sarcoma. Which symptoms would be expected due to this tumor’s location? A. Hemiplegia B. Aphasia C. Nausea D. Bone pain 7. The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug? A. Uric acid of 5mg/dL B. Hematocrit of 33% C. WBC 2,000 per cubic millimeter D. Platelets 150,000 per cubic millimeter 8. A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis? A. “Tell me about his pain.” B. “What does his vomit look like?” C. “Describe his usual diet.” D. “Have you noticed changes in his abdominal size?” 9. The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided? A. Bran B. Fresh peaches C. Cucumber salad D. Yeast rolls 10. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? A. Teaching how to irrigate the illeostomy B. Stopping electrolyte loss in the incisional area C. Encouraging a high-fiber diet D. Facilitating perineal wound drainage 11. The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client’s diet? A. Roasted chicken B. Noodles C. Cooked broccoli D. Custard 12. A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for: A. Trendelenburg position B. Ice to the entire extremity C. Buck’s traction D. An abduction pillow 13. A client with cancer is to undergo an intravenous pyelogram. The nurse should: A. Force fluids 24 hours before the procedure B. Ask the client to void immediately before the study C. Hold medication that affects the central nervous system for 12 hours pre- and post-test D. Cover the client’s reproductive organs with an x-ray shield 14. The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor: A. That cannot be assessed B. That is in situ C. With increasing lymph node involvement D. With distant metastasis 15. A client is 2 days post-operative colon resection. After a coughing episode, the client’s wound eviscerates. Which nursing action is most appropriate? A. Reinsert the protruding organ and cover with 4×4s B. Cover the wound with a sterile 4×4 and ABD dressing C. Cover the wound with a sterile saline-soaked dressing D. Apply an abdominal binder and manual pressure to the wound 16. The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery? A. Hearing aid B. Contact lenses C. Wedding ring D. Artificial eye 17. The nurse on the 3–11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action? A. Call the surgeon and ask him or her to see the client to clarify the information B. Explain the procedure and complications to the client C. Check in the physician’s progress notes to see if understanding has been documented D. Check with the client’s family to see if they understand the procedure fully 18. The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client’s ability to care for himself. Which statement made by the client would indicate a need for follow-up after discharge? A. “I live by myself.” B. “I have trouble seeing.” C. “I have a cat in the house with me.” D. “I usually drive myself to the doctor.” 19. The client is receiving total parenteral nutrition (TPN). Which lab test should be evaluated while the client is receiving TPN? A. Hemoglobin B. Creatinine C. Blood glucose D. White blood cell count 20. The client with a myocardial infarction comes to the nurse’s station stating that he is ready to go home because there is nothing wrong with him. Which defense mechanism is the client using? A. Rationalization B. Denial C. Projection D. Conversion reaction 21. Which laboratory test would be the least effective in making the diagnosis of a myocardial infarction? A. AST B. Troponin C. CK-MB D. Myoglobin 22. The licensed practical nurse assigned to the post-partal unit is preparing to administer Rhogam to a postpartum client. Which woman is not a candidate for RhoGam? A. A gravida IV para 3 that is Rh negative with an Rh-positive baby B. A gravida I para 1 that is Rh negative with an Rh-positive baby C. A gravida II para 0 that is Rh negative admitted after a stillbirth delivery D. A gravida IV para 2 that is Rh negative with an Rh-negative baby 23. The first exercise that should be performed by the client who had a mastectomy is: A. Walking the hand up the wall B. Sweeping the floor C. Combing her hair D. Squeezing a ball 24. The client is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication should be kept available during the test? A. Atropine sulfate B. Furosemide C. Prostigmin D. Promethazine 25. The client is scheduled for a pericentesis. Which instruction should be given to the client before the exam? A. “You will need to lay flat during the exam.” B. “You need to empty your bladder before the procedure.” C. “You will be asleep during the procedure.” D. “The doctor will inject a medication to treat your illness during the procedure.” 26. To ensure safety while administering a nitroglycerine patch, the nurse should: A. Wear gloves B. Shave the area where the patch will be applied C. Wash the area thoroughly with soap and rinse with hot water D. Apply the patch to the buttocks 27. The physician has prescribed tranylcypromine sulfate (Parnate) 10mg bid. The nurse should teach the client to refrain from eating foods containing tyramine because it may cause: A. Hypertension B. Hyperthermia C. Melanoma D. Urinary retention 28. The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient’s mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy? A. “She is very irritable lately.” B. “She sleeps quite a bit of the time.” C. “Her gums look too big for her teeth.” D. “She has gained about 10 pounds in the last 6 months.” 29. A 5-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery? A. Decreased appetite B. A low-grade fever C. Chest congestion D. Constant swallowing 30. A 6-year-old with cerebral palsy functions at the level of an 18-month- old. Which finding would support that assessment? A. She dresses herself. B. She pulls a toy behind her. C. She can build a tower of eight blocks. D. She can copy a horizontal or vertical line. 31. Which information obtained from the mother of a child with cerebral palsy most likely correlates to the diagnosis? A. She was born at 42 weeks gestation. B. She had meningitis when she was 6 months old. C. She had physiologic jaundice after delivery. D. She has frequent sore throats. 32. A 10-year-old is being treated for asthma. Before administering Theodur, the nurse should check the: A. Urinary output B. Blood pressure C. Pulse D. Temperature 33. An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with a fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals and cloudiness in the IV medication? A. Discard the solution and order a new bag B. Warm the solution C. Continue the infusion and document the finding D. Discontinue the medication 34. The client is diagnosed with multiple myoloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client? A. “Walk about a mile a day to prevent calcium loss.” B. “Increase the fiber in your diet.” C. “Report nausea to the doctor immediately.” D. “Drink at least eight large glasses of water a day.” 35. The client is taking rifampin 600mg po daily to treat his tuberculosis. Which action by the nurse indicates understanding of the medication? A. Telling the client that the medication will need to be taken with juice B. Telling the client that the medication will change the color of the urine C. Telling the client to take the medication before going to bed at night D. Telling the client to take the medication if night sweats occur 36. The client is taking prednisone 7.5mg po each morning to treat his systemic lupus errythymatosis. Which statement best explains the reason for taking the prednisone in the morning? A. There is less chance of forgetting the medication if taken in the morning. B. There will be less fluid retention if taken in the morning. C. Prednisone is absorbed best with the breakfast meal. D. Morning administration mimics the body’s natural secretion of corticosteroid. 37. A 20-year-old female has a prescription for tetracycline. While teaching the client how to take her medicine, the nurse learns that the client is also taking Ortho-Novum oral contraceptive pills. Which instructions should be included in the teaching plan? A. The oral contraceptives will decrease the effectiveness of the tetracycline. B. Nausea often results from taking oral contraceptives and antibiotics. C. Toxicity can result when taking these two medications together. D. Antibiotics can decrease the effectiveness of oral contraceptives, so the client should use an alternate method of birth control. 38. A 60-year-old diabetic is taking glyburide (Diabeta) 1.25mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching? A. “I will keep candy with me just in case my blood sugar drops.” B. “I need to stay out of the sun as much as possible.” C. “I often skip dinner because I don’t feel hungry.” D. “I always wear my medical identification.” 39. The physician prescribes regular insulin, 5 units subcutaneous. Regular insulin begins to exert an effect: A. In 5–10 minutes B. In 10–20 minutes C. In 30–60 minutes D. In 60–120 minutes 40. Vitamin K (aquamephyton) is administered to a newborn shortly after birth for which of the following reasons? A. To prevent dehydration B. To treat infection C. To replace electrolytes D. To facilitate clotting 41. The client with an ileostomy is being discharged. Which teaching should be included in the plan of care? A. Use Karaya powder to seal the bag. B. Irrigate the ileostomy daily. C. Stomahesive is the best skin protector. D. Neosporin ointment can be used to protect the skin. 42. The client has an order for FeSo4 liquid. Which method of administration would be best? A. Administer the medication with milk B. Administer the medication with a meal C. Administer the medication with orange juice D. Administer the medication undiluted 43. The client arrives in the emergency room with a hyphema. Which action by the nurse would be best? A. Elevate the head of the bed and apply ice to the eye B. Place the client in a supine position and apply heat to the knee C. Insert a Foley catheter and measure the intake and output D. Perform a vaginal exam and check for a discharge 44. The nurse is making assignments for the day. Which client should be assigned to the nursing assistant? A. The 18-year-old with a fracture to two cervical vertebrae B. The infant with meningitis C. The elderly client with a thyroidectomy 4 days ago D. The client with a thoracotomy 2 days ago 45. The client arrives in the emergency room with a “bull’s eye” rash. Which question would be most appropriate for the nurse to ask the client? A. “Have you found any ticks on your body?” B. “Have you had any nausea in the last 24 hours?” C. “Have you been outside the country in the last 6 months?” D. “Have you had any fever for the past few days?” 46. Which of the following is the best indicator of the diagnosis of HIV? A. White blood cell count B. ELISA C. Western Blot D. Complete blood count 47. The nurse is evaluating nutritional outcomes for an elderly client with anorexia. Which data best indicates that the plan of care is effective? A. The client selects a balanced diet from the menu. B. The client’s hematocrit improves. C. The client’s tissue turgor improves. D. The client gains weight. 48. The client is admitted following repair of a fractured femur with cast application. Which nursing assessment should be reported to the doctor? A. Pain B. Warm toes C. Pedal pulses rapid D. Paresthesia of the toes 49. Which would be an expected finding during injection of dye with a cardiac catheterization? A. Cold extremity distant to the injection site B. Warmth in the extremity C. Extreme chest pain D. Itching in the extremities 50. Which action by the healthcare worker indicates a need for further teaching? A. The nursing assistant wears gloves while giving the client a bath. B. The nurse wears goggles while drawing blood from the client. C. The doctor washes his hands before examining the client. D. The nurse wears gloves to take the client’s vital signs. 51. The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective? A. The client loses consciousness. B. The client vomits. C. The client’s ECG indicates tachycardia. D. The client has a grand mal seizure. 52. A 5-year-old is being tested for pinworms. To collect a specimen for assessment of pinworms, the nurse should teach the mother to: A. Examine the perianal area with a flashlight 2–3 hours after the child is asleep and to collect any eggs on a clear tape B. Scrape the skin with a piece of cardboard and bring it to the clinic C. Obtain a stool specimen in the afternoon D. Bring a hair sample to the clinic for evaluation 53. Which instruction should be given regarding the medication used to treat enterobiasis (pinworms)? A. Treatment is not recommended for children less than 10 years of age. B. The entire family should be treated. C. Medication therapy will continue for 1 year. D. Intravenous antibiotic therapy will be ordered. 54. Which client should be assigned to the pregnant licensed practical nurse? A. The client who just returned after receiving linear accelerator radiation therapy for lung cancer B. The client with a radium implant for cervical cancer C. The client who has just been administered soluble brachytherapy for thyroid cancer D. The client who has returned from placement of iridium seeds for prostate cancer 55. Which client should be assigned to a private room if only one is available? A. The client with Cushing’s syndrome B. The client with diabetes C. The client with acromegaly D. The client with myxedema 56. The nurse caring for a client on the pediatric unit administers adult- strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with: A. Negligence B. Tort C. Assault D. Malpractice 57. Which assignment should not be performed by the licensed practical nurse? A. Inserting a Foley catheter B. Discontinuing a nasogastric tube C. Obtaining a sputum specimen D. Initiating a blood transfusion 58. A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most likely to occur when: A. Estrogen levels are low. B. Lutenizing hormone is high. C. The endometrial lining is thin. D. The progesterone level is low. 59. A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of the rhythm method depends on the: A. Age of the client B. Frequency of intercourse C. Regularity of the menses D. Range of the client’s temperature 60. A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes? A. Intrauterine device B. Oral contraceptives C. Diaphragm D. Contraceptive sponge 61. The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of ectopic pregnancy? A. Painless vaginal bleeding B. Abdominal cramping C. Throbbing pain in the upper quadrant D. Sudden, stabbing pain in the lower quadrant 62. The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client? A. Hamburger pattie, green beans, French fries, and iced tea B. Roast beef sandwich, potato chips, baked beans, and cola C. Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea D. Fish sandwich, gelatin with fruit, and coffee 63. The client with hyperemesis gravidarum is at risk for developing: A. Respiratory alkalosis without dehydration B. Metabolic acidosis with dehydration C. Respiratory acidosis without dehydration D. Metabolic alkalosis with dehydration 64. A client with a fractured hip has been placed in traction. Which statement is true regarding balanced skeletal traction? Balanced skeletal traction: A. Utilizes a pin through bones B. Requires that both legs be secured C. Utilizes Kirschner wires D. Is used primarily to heal the fractured hips 65. The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the client for: A. Hypovolemia B. Pain C. Nutritional status D. Immobilizer 66. Which statement made by the family member caring for the client with a percutaneous gastrotomy tube indicates understanding of the nurse’s teaching? A. “I must flush the tube with water after feedings and clamp the tube.” B. “I must check placement four times per day.” C. “I will report to the doctor any signs of indigestion.” D. “If my father is unable to swallow, I will discontinue the feeding and call the clinic.” 67. The nurse is assessing the client with a total knee replacement 2 hours post-operative. Which information requires notification of the doctor? A. Bleeding on the dressing is 2cm in diameter. B. The client has a low-grade temperature. C. The client’s hemoglobin is 6g/dL. D. The client voids after surgery. 68. The nurse is caring for the client with a 5-year-old diagnosed with plumbism. Which information in the health history is most likely related to the development of plumbism? A. The client has traveled out of the country in the last 6 months. B. The client’s parents are skilled stained-glass artists. C. The client lives in a house built in 1990. D. The client has several brothers and sisters. 69. A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with prevention of dislocation of the prosthesis? A. An abduction pillow B. A straight chair C. A pair of crutches D. A soft mattress 70. The client with a joint replacement is scheduled to receive Lovenox (enoxaparin). Which lab value should be reported to the doctor? A. PT of 20 seconds B. PTT of 300 seconds C. Protime of 30 seconds D. INR 3 71. The nurse is responsible for performing a neonatal assessment on a full- term infant. At 1 minute, the nurse could expect to find: A. An apical pulse of 100 B. Absence of tonus C. Cyanosis of the feet and hands D. Jaundice of the skin and sclera 72. A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client’s need for: A. Supplemental oxygen B. Fluid restriction C. Blood transfusion D. Delivery by Caesarean section 73. A client with diabetes has an order for ultrasonography. Preparation for an ultrasound includes: A. Increasing fluid intake B. Limiting ambulation C. Administering an enema D. Withholding food for 8 hours 74. An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at 1 year? A. 14 pounds B. 16 pounds C. 18 pounds D. 24 pounds 75. A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test: A. Determines the lung maturity of the fetus B. Measures the activity of the fetus C. Shows the effect of contractions on the fetal heart rate D. Measures the neurological well-being of the fetus 76. A full-term male has hypospadias. Which statement describes hypospadias? A. The urethral opening is absent. B. The urethra opens on the dorsal side of the penis. C. The penis is shorter than usual. D. The urethra opens on the ventral side of the penis. 77. A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client’s cervix is 8cm dilated withcomplete effacement. The priority nursing diagnosis at this time is: [Show Less]
NCLEX Exam NCLEX-PN Questions with Answers and Explanations. Question No : 1 - Teaching the client with gonorrhea how to prevent reinfection and... [Show More] further spread is an example of: A. primary prevention. B. secondary prevention. C. tertiary prevention. D. primary health care prevention. Answer: B Explanation: Secondary prevention targets the reduction of disease prevalence and disease morbidity through early diagnosis and treatment. Physiological Adaptation Question No : 2 - Which of the following foods is a complete protein? A. corn B. eggs C. peanutsDsunflower seeds Answer: B Explanation: Eggs are a complete protein. The remaining options are incomplete proteins. Health Promotion and Maintenance Question No : 3 - Broccoli, oranges, dark greens, and dark yellow vegetables can be eaten to: A. supplement vitamin pills. B. balance body molecules. C. cure many diseases. D. help improve body defenses. Answer: D Explanation: Controversy over what types of food to eat and not eat is still under investigation. Certain foods can help improve body defenses to possibly prevent certain diseases. Nonpharmacological Therapies Question No : 4 - The major electrolytes in the extracellular fluid are: A. potassium and chloride. B. potassium and phosphate. C. sodium and chloride. D. sodium and phosphate. Answer: C Explanation: Sodium and chloride are the major electrolytes in the extracellular fluid. Physiological Adaptation Question No : 5 - Which of the following nursing diagnoses might be appropriate as Parkinson’s disease progresses and complications develop? A. Impaired Physical Mobility B. Dysreflexia C. Hypothermia D. Impaired Dentition Answer: A Explanation: The client with Parkinson’s disease can develop a shuffling gait and rigidity, causing impaired physical mobility. The other diagnoses do not necessarily relate to a client with Parkinson’s disease. Reduction of Risk Potential Question No : 6 - Which of the following is an inappropriate item to include in planning care for a severely neutropenic client? A. Transfuse netrophils (granulocytes) to prevent infection. B. Exclude raw vegetables from the diet. C. Avoid administering rectal suppositories. D. Prohibit vases of fresh flowers and plants in the client’s room. Answer: A Explanation: Granulocyte transfusion is not indicated to prevent infection. Produced in the bone marrow, granulocytes normally comprise 70% of all WBCs. They are subdivided into three types based on staining properties: neutrophils, eosinophils, and basophils. They can be beneficial in a selected population of infected, severely granulocytopenic clients (less than 500/mm3) who do not respond to antibiotic therapy and who are expected to experience prolonged suppression of granulocyte production. Physiological Adaptation Question No : 7 - A primary belief of psychiatric mental health nursing is: A. most people have the potential to change and grow. B. every person is worthy of dignity and respect. C. human needs are individual to each person. D. some behaviors have no meaning and cannot be understood. Answer: B Explanation: Every person is worthy of dignity and respect. Every person has the potential to change and grow. All people have basic human needs in common with others. All behavior has meaning and can be understood from the client’s perspective. Psychosocial Integrity Question No : 8 - A teenage client is admitted to the hospital because of acetaminophen (Tylenol) overdose. Overdoses of acetaminophen can precipitate life- threatening abnormalities in which of the following organs? A. lungs B. liver C. kidneys D. adrenal glands Answer: B Explanation: Acetaminophen is extensively metabolized in the liver. Choices 1, 3, and 4 are incorrect because prolonged use of acetaminophen might result in an increased risk of renal dysfunction, but a single overdose does not precipitate life-threatening problems in the respiratory system, renal system, or adrenal glands. Pharmacological Therapies Question No : 9 - All of the following factors, when identified in the history of a family, are correlated with poverty except: A. high infant mortality rate. B. frequent use of Emergency Departments. C. consultation with folk healers. D. low incidence of dental problems. Answer: D Explanation: Dental problems are prevalent because of the lack of preventive care and access to care. High infant mortality is one of the most significant problems correlated with poverty. Pregnant women who do not have access to care might come to the Emergency Department when in labor. Those in poverty are likely to use Emergency Departments because they may not be turned away. Those in poverty might also turn to folk healers or other persons in their community for care who might be easier to access and might not demand payment. Health Promotion and Maintenance Question No : 10 - Acyclovir is the drug of choice for: A. HIV. B. HSV 1 and 2 and VZV. C. CMV. D. influenza A viruses. Answer: B Explanation: Acyclovir (Zovirax) is specific for treatment of herpes virus infections. There is no cure for herpes. Acyclovir is excreted unchanged in the urine and therefore must be used cautiously in the presence of renal impairment. Drugs that treat herpes inhibit viral DNA replication by competing with viral substrates to form shorter, ineffective DNA chains. Physiological Adaptation Question No : 11 - Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley’s level of anxiety as: A. mild. B. moderate. C. severe. D. panic. Answer: C Explanation: The person whose anxiety is assessed as severe is unable to solve problems and has a poor grasp of what’s happening in his or her environment. Somatic symptoms such as those described by Ashley are usually present. Vital sign changes are observed. The individual with mild anxiety might report being mildly uncomfortable and might even find performance enhanced. The individual with moderate anxiety grasps less information about the situation, has some difficulty problem-solving, and might have mild changes in vital signs. The individual in panic demonstrates markedly disturbed behavior and might lose touch with reality. Psychosocial Integrity Question No : 12 - Which of the following methods of contraception is able to reduce the transmission of HIV and other STDs? A. intrauterine device (IUD) B. Norplant C. oral contraceptives D. vaginal sponge Answer: D Explanation: The vaginal sponge is a barrier method of contraception that, when used with foam or jelly contraception, reduces the transmission of HIV and other STDs as well as reducing the risk of pregnancy. IUDs, Norplant, and oral contraceptives can prevent pregnancy but not the transmission HIV and STDs. Clients using the contraceptive methods in Choices 1, 2, and 3 should be counseled to use a chemical or barrier contraceptive to decrease transmission of HIV or STDs. Health Promotion and Maintenance Question No : 13 - Which fetal heart monitor pattern can indicate cord compression? A. variable decelerations B. early decelerations C. bradycardia D. tachycardia Answer: A Explanation: Variable decelerations can be related to cord compression. The other patterns are not.Reduction of Risk Potential Question No : 14 - The nurse teaching about preventable diseases should emphasize the importance of getting the following vaccines: A. human papilloma virus, genital herpes, measles. B. pneumonia, HIV, mumps. C. syphilis, gonorrhea, pneumonia. D. polio, pertussis, measles. Answer: D Explanation: Vaccines are one of the most effective methods of preventing and controlling certain communicable diseases. The smallpox vaccine is not currently in use because the smallpox virus has been declared eradicated from the world’s population. Diseases such as polio, diphtheria, pertussis, and measles are mostly controlled by routine childhood immunization. They have not, however, been eradicated, so children need to be immunized against these diseases. Physiological Adaptation Question No : 15 - Which of the following conditions is mammography used to detect? A. pain B. tumor C. edema D. epilepsy Answer: B Explanation: Mammography is used to detect tumors or cysts in the breasts, not the other conditions. Reduction of Risk Potential Question No : 16 - When the nurse is determining the appropriate size of an oropharyngeal airway to insert, what part of a client’s body should she measure? A. corner of the mouth to the tragus of the ear B. corner of the eye to the top of the ear C. tip of the chin to the sternum D. tip of the nose to the earlobe Answer: A Explanation: An oropharyngeal airway is measured from the corner of the client’s mouth, to the tragus of the ear. Reduction of Risk Potential Question No : 17 - Which sign might the nurse see in a client with a high ammonia level? A. coma B. edema C. hypoxia D. polyuria Answer: A Explanation: Coma might be seen in a client with a high ammonia level. Reduction of Risk Potential Question No : 18 - What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36mmHg, and HCO3 24 mEq/L? A. metabolic alkalosis B. homeostasis C. respiratory acidosis D. respiratory alkalosis Answer: B Explanation: These ABG values are within normal limits. Choices 1, 3, and 4 are incorrect because the ABG values indicate none of these acid-base disturbances. Physiological Adaptation Question No : 19 - Which of the following is the primary force in sex education in a child’s life? A. school nurse B. peers C. parents D. media Answer: C Explanation: Parents are the primary force in sex education in a child’s life. The school nurse is involved with formal sex education and counseling. Peers become more important in sex education during adolescence but might lack correct information. The media play a powerful role in what children learn about sex through movies, TV, and video games. Health Promotion and Maintenance Question No : 20 - The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to examine? A. 6 B. 8 C. 12 D. 16 Answer: C Explanation: In general, children begin dentition around 6 months of age. During the first 2 years of life, a quick guide to the number of teeth a child should have is as follows: Subtract the number 6 from the number of months in the age of the child. In this example, the child is 18 months old, so the formula is 18 – 6 = 12. An 18-month-old child should have approximately 12 teeth.Health Promotion and Maintenance Question No : 21 - Which of the following medications is a serotonin antagonist that might be used to relieve nausea and vomiting? A. metoclopramide (Reglan) B. onedansetron (Zofran) C. hydroxyzine (Vistaril) D. prochlorperazine (Compazine) Answer: B Explanation: Zofran is a serotonin antagonist that can be used to relieve nausea and vomiting. The other medications can be used for nausea and vomiting, but they have different mechanisms of action. Physiological Adaptation Question No : 22 - A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as: A. plantar fasciitis. B. hallux valgus. C. hammertoe. D. Morton’s neuroma. Answer: D Explanation: Morton’s neuroma is a small mass or tumor in a digital nerve of the foot. Hallux valgus is referred to in lay terms as abunion.Hammertoe is where one toe is cocked up over another toe. Plantar fasciitis is an inflammation of, or pain in, the arch of the foot.Basic Care and Comfort Question No : 23 - For a client with suspected appendicitis, the nurse should expect to find abdominal tenderness in which quadrant? A. upper right B. upper left C. lower right D. lower left Answer: C Explanation: The nurse should expect to find abdominal tenderness in the lower-right quadrant in a client with appendicitis. Physiological Adaptation Question No : 24 - Assessment of a client with a cast should include: A. capillary refill, warm toes, no discomfort. B. posterior tibial pulses, warm toes. C. moist skin essential, pain threshold. D. discomfort of the metacarpals. Answer: A Explanation: Assessment for adequate circulation is necessary. Signs of impaired circulation include slow capillary refill, cool fingers or toes, and pain.Basic Care and Comfort Question No : 25 - Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority? A. open leg fracture B. open head injury C. stab wound to the chest D. traumatic amputation of a thumb Answer: C Explanation: A stab wound to the chest might result in lung collapse and mediastinal shift that, if untreated, could lead to death. Treatment of an obstructed airway or a chest wound is a higher priority than hemorrhage. The principle of ABC (airway, breathing, and circulation) prioritizes care decisions.Physiological Adaptation Question No : 26 - Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma? A. The clothing is the property of another and must be treated with care. B. Such care facilitates repair and salvage of the clothing. C. The clothing of a trauma victim is potential evidence with legal implications. D. Such care decreases trauma to the family members receiving the clothing. Answer: C Explanation: Trauma in any client, living or dead, has potential legal and/or forensic implications. Clothing, patterns of stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death, and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health care facilities have policies governing the collection of forensic evidence. The chain of evidence custody must be followed to ensure the integrity and credibility of the evidence. The chain of evidence custody is the pathway that evidence follows from the time it is collected until is has served its purpose in the legal investigation of an incident.Physiological Adaptation Question No : 27 - Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care? A. “I should put alcohol on my baby’s cord 3–4 times a day.” B. “I should put the baby’s diaper on so that it covers the cord.” C. “I should call the physician if the cord becomes dark.” D. “I should wash my hands before and after I take care of the cord.” Answer: D Explanation: Parents should be taught to wash their hands before and after providing cord care. This prevents transferring pathogens to and from the cord. Folding the diaper below the cord exposes the cord to air and allows for drying. It also prevents wet or soiled diapers from coming into contact with the cord. Current recommendations include cleaning the area around the cord 3–4 times a day with a cotton swab but do not include putting alcohol or other antimicrobials on the cord. It is normal for the cord to turn dark as it dries.Health Promotion and Maintenance Question No : 28 - A middle-aged woman tells the nurse that she has been experiencing irregular menses for the past six months. The nurse should assess the woman for other symptoms of: A. climacteric. B. menopause. C. perimenopause. D. postmenopause. Answer: C Explanation: Perimenopause refers to a period of time in which hormonal changes occur gradually, ovarian function diminishes, and menses become irregular. Perimenopause lasts approximately five years. Climacteric is a term applied to the period of life in which physiologic changes occur and result in cessation of a woman’s reproductive ability and lessened sexual activity in males. The term applies to both genders. Climacteric and menopause are interchangeable terms when used for females. Menopause is the period when permanent cessation of menses has occurred. Postmenopause refers to the period after the changes accompanying menopause are complete.Health Promotion and Maintenance Question No : 29 - Which of the following might be an appropriate nursing diagnosis for an epileptic client? A. Dysreflexia B. Risk for Injury C. Urinary Retention D. Unbalanced Nutrition Answer: B Explanation: The epileptic client is at risk for injury due to the complications of seizure activity, such as possible head trauma associated with a fall. The other choices are not related to the question.Reduction of Risk Potential Question No : 30 - Which of the following diseases or conditions is least likely to be associated with increased potential for bleeding? A. metastatic liver cancer B. gram-negative septicemia C. pernicious anemia D. iron-deficiency anemia Answer: C Explanation: Pernicious anemia results from vitamin B12 deficiency due to lack of intrinsic factor. This can result from inadequate dietary intake, faulty absorption from the GI tract due to a lack of secretion of intrinsic factor normally produced by gastric mucosal cells and certain disorders of the small intestine that impair absorption. The nurse should instruct the client in the need for lifelong replacement of vitamin B12, as well as the need for folic acid, rest, diet, and support.Physiological Adaptation Question No : 31 - When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula? A. 2 liters/minute B. 4 liters/minute C. 6 liters/minute D. 8 liters/minute Answer: C Explanation: The highest flow rate that oxygen can be delivered via nasal cannula is 6 liters/minute. Higher flow rates must be delivered by mask.Reduction of Risk Potential Question No : 32 - The kind of man who beats a woman is: A. from a minority culture in a low-income group. B. from a majority culture in a middle-income group. C. one who was never allowed to compete as a child. D. from any walk of life, race, income group, or profession. Answer: D Explanation: Batterers cannot be predicted by demographic features related to age, ethnicity, race, religious denomination, education, socioeconomic status, or class. Ninety-five percent of domestic abuse cases involve male perpetrators and female victims.Psychosocial Integrity Question No : 33 - All of the following should be performed when fetal heart monitoring indicates fetal distress except: A. increase maternal fluids. B. administer oxygen. C. decrease maternal fluids. D. turn the mother. Answer: C Explanation: Decreasing maternal fluids is the only intervention that shouldnotbe performed when fetal distress is indicated.Reduction of Risk Potential Question No : 34 - What interpersonal relief behavior is Ashley using? A. acting out B. somatizing C. withdrawal D. problem-solving Answer: B Explanation: Somatizing means one experiences an emotional conflict as a physical symptom. Ashley manifests several physical symptoms associated with severe anxiety. Acting out refers to behaviors such as anger, crying, laughter, and physical or verbal abuse. Withdrawal is a reaction in which psychic energy is withdrawn from the environment and focused on the self in response to anxiety. Problem-solving takes place when anxiety is identified and the unmet need is met.Psychosocial Integrity Question No : 35 - A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client’s weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as: A. within normal limits, so a weight-reduction diet is unnecessary. B. lower than normal, so education about nutrient-dense foods is needed. C. indicating obesity because the BMI is 35. D. indicating overweight status because the BMI is 27. Answer: C Explanation: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. It is calculated by utilizing a chart or nomogram that plots height and weight. This client’s BMI is 35, indicating obesity. Goals of diet therapy are aimed at decreasing weight and increasing activity to healthy levels based on a client’s BMI, activity status, and energy requirements.Physiological Adaptation Question No : 36 - Which of the following instructions should the nurse give a client who will be undergoing mammography? A. Be sure to use underarm deodorant. B. Do not use underarm deodorant. C. Do not eat or drink after midnight. D. Have a friend drive you home. Answer: B Explanation: Underarm deodorant should not be used because it might cause confusing shadows on the X-ray film. There are no restrictions on food or fluid intake. No sedation is used, so the client can drive herself home.Reduction of Risk Potential Question No : 37 - Teaching about the need to avoid foods high in potassium is most important for which client? A. a client receiving diuretic therapy B. a client with an ileostomy C. a client with metabolic alkalosis D. a client with renal disease Answer: D Explanation: Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. Choices 1, 2, and 3 are incorrect because clients receiving diuretics with ileostomy or with metabolic alkalosis are at risk for hypokalemia and should be encouraged to eat foods high in potassium.Physiological Adaptation Question No : 38 - A diet high in fiber content can help an individual to: A. lose body weight fast. B. reduce diabetic ketoacidosis. C. lower cholesterol. D. reduce the need for folate. Answer: C Explanation: Fiber-rich foods (such as grains, apples, potatoes, and beans) can help lower cholesterol.Nonpharmacological Therapies Question No : 39 - When administering intravenous electrolyte solution, the nurse should take which of the following precautions? A. Infuse hypertonic solutions rapidly. B. Mix no more than 80 mEq of potassium per liter of fluid. C. Prevent infiltration of calcium, which causes tissue necrosis and sloughing. D. As appropriate, reevaluate the client’s digitalis dosage. He might need an increased dosage because IV calcium diminishes digitalis’s action. Answer: C Explanation: Preventing tissue infiltration is important to avoid tissue necrosis. Choice 1 is incorrect because hypertonic solutions should be infused cautiously and checked with the RN if there is a concern. Choice 2 is incorrect because potassium, mixed in the pharmacy per physician order, is mixed at a concentration no higher than 60 mEq/L. Physiological Adaptation Question No : 40 - How often should the nurse change the intravenous tubing on total parenteral nutrition solutions? A. every 24 hours B. every 36 hours C. every 48 hours D. every 72 hours Answer: A Explanation: The nurse should change the intravenous tubing on total parenteral nutrition solutions every 24 hours, due to the high risk of bacterial growth.Health Promotion and Maintenance Question No : 41 - A woman asks, “How much alcohol can I safely drink while pregnant?” The nurse’s best response is: A. “The amount of alcohol that is safe during pregnancy is unknown.” B. “Consuming one or two beers or glasses of wine a day is considered safe for a healthy pregnant woman.” C. “Drinking three or more drinks on any given occasion is the only harmful type of drinking during pregnancy.” D. “You can have a drink to help you relax and get to sleep at night.” [Show Less]
NCLEX-PN FUNDAMENTALS 2020 EXAM QUESTIONS, ANSWERS AND RATIONALES 1. Which educational nursing program takes 2 to 5 years to complete? a. Nursing assis... [Show More] tant (NA) program b. Practical nursing (LPN, LVN) program c. Professional nursing program d. Advanced practice nursing (APN) program The professional nursing program (RN) requires 2 to 5 years of education, depending on the type of degree sought. An NA program takes 6 to 8 weeks. An LPN/LVN program takes 12 to 18 months. An APN program takes more than 4 years. 2. Who established the Henry Street Settlement Service in New York City? a. Lillian Wald b. Dorothea Dix c. Florence Nightingale d. Richard Bradley Lillian Wald took nursing into the community and established the Henry Street Settlement Service in 1893. Dorothea Dix organized volunteers to provide nursing care to soldiers during the Civil War. Florence Nightingale trained women to care for the sick during the Crimean War. Richard Bradley opened a practical nursing school in 1907. 3. Which is included in the six levels of care within the health care system? a. Skilled b. Post-acute c. Restorative d. Hospice The six levels of care within the health care system include: preventative, primary, secondary, tertiary, restorative, and continuing care. 4. In the 20th century, nurses moved into: a. Hospitals b. Long-term care facilities c. The community d. State mental health facilities In the 20th century nurses began working in the community with the poor, providing midwifery services and education regarding prenatal, obstetrics, and child care. 5. What was the intent of diagnosis-related groups (DRGs)? a. Offer more health care services b. Extend hospital stays c. Improve health care d. Contain health care costs DRGs were created by the Medicare program in 1983 as an attempt to contain health care costs. DRGs do not offer more services. The intent of DRGs was not to extend hospitalizations. The purpose of DRGs was specifically to contain costs. 6. The goals of nursing include: Select all that apply. a. to promote wellness. b. to prevent illness. c. to facilitate coping. d. to restore health. The four common goals of nursing care are to promote wellness, prevent illness, facilitate coping, and restore health. 7. Which educational nursing program attracts the majority of registered nurse (RN) students? a. Associate degree program b. Diploma program c. Baccalaureate program d. Graduate program The associate degree program attracts the majority of RN students. The number of diploma schools has decreased. Baccalaureate programs take longer to complete and have fewer students. Graduate programs take longer to complete and have fewer students. 8. What is the third step of the nursing process? a. Planning b. Evaluation c. Implementation d. Nursing diagnosis Planning is the third step of the nursing process. Evaluation is the last step of the nursing process. Implementation occurs after planning. Nursing diagnosis is the second step of the nursing process. 9. One of the highest priorities of nursing care is: a. adequate nutrition. b. maintaining skin integrity. c. pain control. d. airway management. In prioritizing care, physiologic needs for basic survival take precedence. Airway management always comes first. Without an adequate airway, a patient will die. Nutrition, maintaining skin integrity, and pain control are lower priorities of care than airway management. 10. A nurse is educating a group of elderly patients in an assisted-living facility about urinary incontinence. Information offered during the encounter may include: a. Avoidance of Kegel exercises b. Wear adult diapers day and night to prevent leakage c. Condom catheters may be used by males d. Indwelling Foley catheters are recommended for management of all types of incontinence Condom catheters are appropriate for males if used correctly. Kegel exercises are recommended and may greatly reduce or stop incontinence. Adult diapers are not to be worn 24 hours a day as a result of an increased risk of skin breakdown. Indwelling Foley catheters are not appropriate for all types of incontinence, and the risks associated with trauma and infection may outweigh the benefits. 11. A nurse should notify the physician if: a. 24-hour urine output is 700 mL b. 24-hour urine output is 800 mL c. 24-hour urine output is 720 mL d. 24-hour urine output is 1000 mL Average hourly urine output is 30 mL, therefore 700 mL in a 24 hour period is abnormal because it averages to less than 30 mL/hour. The remaining options reflect urine output within normal range for a 24-hour period. 12. A female patient has had a knee replacement and is experiencing difficulty voiding. What should the nurse recommend? a. Pour warm water over the perineum while patient attempts to void b. Catheterize the patient to avoid problems c. Use Crede’s maneuver per nursing order d. Use a sitz bath per nursing order Warm water may help patients to initiate the voiding reflex. Catheterization is used after other techniques have been unsuccessful. A physician order is needed for use of Crede's maneuver and/or a sitz bath. 13. Which bacterium is most often responsible for cystitis? a. Proteus b. Escherichia coli c. Pseudomonas d. Enterococcus Escherichia coli is often the bacterium responsible for cystitis, especially in females. Proteus, Pseudomonas, and Enterococcus may cause cystitis but are not considered the most common causes. 14. Who was the first visiting nurse? a. Florence Nightingale b. Phoebe c. Dorothea Dix d. Clara Barton Phoebe was a practical nurse in Rome and became the first visiting nurse. Florence Nightingale trained women to care for the sick during the Crimean War. Dorothea Dix organized women volunteers to provide nursing care for soldiers during the Civil War. Clara Barton took volunteers into the field hospitals to care for soldiers of both armies during the Civil War. 15. Which was the first care delivery system for practical nurses? a. Team nursing b. Functional nursing care c. Total patient care d. Primary nursing Functional nursing care was the first care delivery system for the practical nurse. Team nursing evolved in the 1950s. Total patient care came after team nursing. Primary nursing appeared in the late 1960s and 1970s. 16. Which is considered a low-priority patient in the emergency room? a. Patient with a laceration to the leg b. Patient with an ankle fracture c. Patient with a sore throat d. Patient with a gunshot wound to the chest A sore throat is of low priority compared with the other aforementioned medical problems. A patient with a laceration to the leg or an ankle fracture is of higher priority than the patient with a sore throat. Life-threatening problems are of a high priority; therefore a patient with a gunshot wound to the chest is of highest priority. 17. Which are components of the nursing process? Select all that apply. a. Assessment b. Nursing diagnosis c. Management d. Evaluation Assessment, nursing diagnosis, and evaluation are three of the five components of the nursing process (accompanied by planning and implementation). Management is not one of the five components of the nursing process. 18. The steps of the problem-solving process include: a. nursing diagnosis. b. identification of problem. c. critical thinking. d. management of problem. The first step is to define the problem clearly. Nursing diagnosis and management are not steps in the problem-solving process. Critical thinking is required, but is not an actual step in the process. 19. Critical thinking involves: a. randomly organizing tasks. b. utilization of past solutions. c. purposeful mental activity. d. traditional problem-solving methods. Critical thinking is a directed and purposeful mental activity. Critical thinking involves priority setting, production of new solutions, and creative problem solving. 20. Prioritizing patient problems is usually based on: a. Maslow's hierarchy of needs. b. the nurse-to-nurse report. c. managerial influence. d. nonspecific data collection. Maslow's hierarchy of needs is used to set priorities in nursing situations. Priority setting is not based on the nurse-to-nurse report or managerial influence. Gathering of information specific to each patient is necessary for priority setting. 21. What do concept maps do? a. Solve nursing dilemmas b. Require the problem-solving process c. Promote critical thinking d. Are used only by student nurses Concept mapping helps to gather data in a logical manner and then group the data in a meaningful way in an effort to promote critical thinking skills. Concept mapping does not solve nursing dilemmas, but shows relationships between concepts. Concept mapping does not require the problem-solving process, but it may be helpful. Concept mapping is not used only by student nurses. 22. Which statement is true regarding a plan of care for a patient? a. Plans of care should not change so continuity is maintained. b. LPNs/LVNs are responsible for initiating nursing care plans. c. Patient input is not beneficial. d. Plans of care should be a collaborative process. Plans of care should be a collaborative process among nurses, patients, and other health team members. Plans of care should be altered as clients' conditions change. RNs are officially responsible for initiating nursing care plans. Patient input in the planning stage results in more success with the care plan. 23. What is the initial nursing intervention in preventing polypharmacy? a. Obtain a thorough medication history. b. Discontinue all herbal preparations. c. Refer the patient to a geriatric practitioner. d. Consult a pharmacist to review all medications. A thorough medication history is the initial step in preventing polypharmacy. A comprehensive assessment can help maintain a therapeutic medication regimen, identify educational needs, eliminate unnecessary medications, and reduce the risk of adverse drug reactions. Discontinuation of vitamins, herbs, and medications is not a nursing intervention. A referral should be ordered by a physician. Consultation with a pharmacist would be beneficial, but a thorough medication history is the first intervention. 24. Which statement is true regarding falls in the elderly? a. Most falls occur in the garage. b. Hip fractures resulting from falls are a leading cause of placement in long-term care facilities. c. Fall risk decreases with addition of medications. d. Sedatives reduce the risk of falls. Hip fractures are a leading cause of hospitalization and placement in long-term care facilities. Most falls occur in the bedroom or bathroom. With each additional medication consumed, the risk of falls is increased. Sedatives can decrease alertness and reaction times which can lead to falls. 25. Appropriate nursing care for a patient with urinary incontinence is to: a. insert an indwelling Foley catheter. b. order oxybutynin chloride (Ditropan). c. encourage fluids to decrease the urine concentration so it is less irritating. d. recommend herbal approaches to reduce incontinence. Encouraging fluids can decrease the urine concentration so it is less irritating, less predisposing to urinary tract infections, and less odoriferous. Indwelling catheters are not recommended. Nurses may not order/prescribe medications. Nurses should not recommend herbal preparations without first consulting with the physician. 26. Which age-related changes predispose the elderly patient to drug toxicity and extended duration of action of drugs? Select all that apply. a. Decreased body water b. Increased ratio of muscle to fat c. Low serum albumin d. Reduced blood flow to liver Decreased body water, low serum albumin, and reduced blood flow to the liver are age-related changes that predispose the elderly patient to drug toxicity. The elderly have an increased ratio of fat to muscle. 27. A patient with dysphagia is: a. fed only for pleasure b. at low risk for nutritional deficits c. at higher risk for pneumonia d. able to drink thin liquids Patients with dysphagia (difficulty swallowing) should be positioned upright or in a high Fowler's position and fed very small amounts to avoid aspiration and aspiration pneumonia. A patient with dysphagia is at higher risk for developing a nutritional deficit. Liquids may need to be thickened. 28. Which is of highest priority for a nurse on a general medical unit? a. Patient with chest pain b. Patient with diarrhea c. Patient with productive cough d. Patient with a low-grade fever Life-threatening problems are of a high priority. Chest pain can be life-threatening, requires immediate attention, and is of the highest priority for the nurse. A patient with diarrhea, a productive cough, and/or a low-grade fever is not of the highest priority. 29. A registered nurse (RN) delegates to a licensed practical nurse the task of monitoring intake and output for all patients who have been treated for heart failure on a cardiac medical unit. The unit manager is reviewing the effectiveness of heart failure management on the unit. Delegation is included in which component of the nursing process? a. Implementation b. Nursing diagnosis c. Develop solutions d. Planning Delegation may be used in the implementation process. Delegation is not a nursing diagnosis. Delegation is not a part of the development of solutions, which is a component of the scientific method process. Delegation is more applicable in the implementation step than the planning step. 30. A licensed practical nurse (LPN) may supervise which of the following? Select all that apply. a. Nursing assistants (NAs) b. Nurse technicians c. LPNs d. Registered nurses (RNs) An LPN may supervise NAs, nurse technicians, and other LPNs. An LPN may not supervise RNs. 31. Nurses work in patient situations that give them permission to do what is usually not permitted in other circumstances. This is consistent with which legal term? a. Ethics b. Privilege c. Advocacy d. Competency Nurses are given privilege to a client's body and emotions. Laws define the boundaries of that privilege. Ethics or ethical principles are rules of conduct that have been agreed to by a particular group and used to determine right and wrong. Advocacy is defined as the act of supporting a cause or a purpose. To be competent is to be mentally and emotionally able to understand and act (make choices). 32. Psychiatric patients can be held against their will in which situation? a. Unable to provide for basic needs b. Major depression c. Homelessness d. Substance abuse Patients with psychiatric disorders in most states cannot be held against their will for more than 3 days, unless they are a distinct danger to self or others, or are gravely disabled (unable to provide for basic needs). Major depression, homelessness, and substance abuse alone are not reasons to hold patients against their will. 33. Informed consent may be given by a: a. stepparent of a non-adopted child. b. 80-year-old with dementia. c. 72-year-old who has just taken morphine sulfate. d. competent 19-year-old who has just taken Tylenol. A competent person over the age of 18 may give informed consent. Tylenol is not a mind-altering drug. Stepparents usually cannot give consent unless the child is legally adopted. Cognitively impaired individuals may not give informed consent. Informed consent may not be given by an individual under the influence of a narcotic. 34. Which is a true statement? a. Employers may ask about health status on an employment application. b. Sexual harassment is illegal when it interferes with job performance. c. Student nurses are not held to the same standards as a licensed nurse. d. In a case of child abuse, the account of injury given by the caregiver is consistent with physical signs and symptoms. Sexual harassment is illegal when used as a condition of employment or promotion or when it interferes with job performance. Employers may not ask about health status. Student nurses are held to the same standards as a licensed nurse. The account of injury is often inconsistent with signs and symptoms. 35. Which statement is true regarding advance directives? a. Advance directives expire. b. Emergency medical technicians may honor advance directives. c. A living will is a type of advance directive. d. Do-not-resuscitate (DNR) orders are written by nurses. A living will and medical power of attorney are two types of advance directives. Advance directives do not expire. EMTs cannot honor advance directives. DNRs are written by physicians. 36. Which age-related change in the urinary system should a nurse expect? a. Increased bladder tone b. Episodes of incontinence c. Increased red blood cells (RBCs) in the urine d. Reduced rate of renal filtration Reduced rate of renal filtration occurs with aging and may lead to a decrease in renal function. The bladder tone decreases with aging. Incontinence is not a normal part of aging. Increased RBCs is not an age-related change. 37. A nurse is collecting a voided specimen for urinalysis. The nurse should: a. Tell the patient it is necessary to fill the container b. Send the urine to the laboratory within 20 minutes c. Tell the patient to use sterile technique d. Tell the patient that only about 1.5 inches of urine is needed When collecting a voided specimen for urinalysis, it is not necessary to fill the container with urine; only about 1.5 inches of urine is needed. Send the urine within 5 to 10 minutes. Sterile technique is not needed. 38. What are the functions of the urinary structures for elimination? Select all that apply. a. The urethra carries urine from the kidneys to the bladder b. Urine output is related to the amount of fluid intake c. Waste products are diluted with water and excreted as urine d. A bladder can hold 2500 mL of urine Urine output is related to fluid intake and can vary considerably. Waste products are excreted as urine. Ureters carry urine from the kidneys to the bladder. A bladder can hold 1000 to 1800 mL of urine. 39. One of the most common charges brought against nurses is: a. Discrimination b. Defamation c. Incompetence d. Libel The most common charges brought against nurses include substance abuse, incompetence, and negligence. A nurse can be charged with incompetence if something was done that could or did harm a patient, such as a medication error. Discrimination, defamation, and libel are not common charges against nurses. 40. Which is true regarding assisted suicide? a. A constitutional right exists for physician-assisted suicide. b. Participation in assisted suicide is a violation of the American Nurses Association (ANA) Code for Nurses. c. Assisted suicide is a crime in all states. d. Assisted suicide is the same as euthanasia. Participation in assisted suicide violates the ethical principle of "do no harm." No constitutional right exists for assisted suicide. (Assisted suicide is not a crime in Oregon.) Assisted suicide is not the same as euthanasia, which is described as mercy killing. 41. An unexpected patient care occurrence that results in death or serious injury to the patient is: a. negligence. b. malpractice. c. a tort. d. a sentinel event. A sentinel event is an unexpected patient care event that results in death or serious injury (or risk of injury) to the patient. Negligence is failing to do something a reasonable prudent person would or would not do. Malpractice is negligence by a professional person. A tort is a violation of a civil law. 42. Age-related eye changes may include: a. increased visual accommodation b. macular degeneration c. non-preventable blindness as a result of glaucoma d. decreased ability of pupil to respond to light changes Because of macular degeneration, an elderly person gradually loses acute, central, and color vision. Visual accommodation decreases. Glaucoma is a frequent cause of preventable blindness. With age, the iris has decreased ability to respond to light changes. 43. Nurses' knowledge of sexuality in the older adult population should include: a. Chronic illness may affect the ability to participate in sexual activity. b. Sexual response time is unchanged. c. Ability to achieve orgasm declines. d. Dryness of the vaginal walls is associated with pelvic inflammatory disease. Chronic illness or disability may affect the ability to participate in sexual activity. Sexual response time slows with age. Ability to achieve orgasm continues. Vaginitis may occur as a result of thinning and dryness of the vaginal walls. 44. A nursing intervention for a patient with constipation is to: a. avoid the urge to defecate b. limit fluid intake c. give prune juice with a noncarbonated drink d. encourage bran cereal or whole-grain breads Patient teaching for the client with constipation should include encouraging bran cereal and/or whole-grain breads for increased fiber intake. Encourage the patient to heed the urge to defecate quickly. Encourage fluid intake of at least 2500 mL/day. Prune juice with carbonated drink may be recommended. 45. What should the nurse include in the teaching plan for self-medication practices of older adults? a. Eliminate unnecessary medications b. Substitute herbal preparations for certain prescribed medications c. Develop a drug reminder system and schedule d. Pharmacy shop for the cheapest medications. A drug reminder system and schedule can help decrease confusion and increase compliance with medications. Recommend physician review of all medicines. The physician should discontinue unnecessary medications. Nurses should not substitute for any medications unless ordered by the physician. Recommend that most or all medications be obtained from one pharmacy to avoid medication inconsistencies and problems. 46. Which is a long-term goal for a patient? a. Pain management b. Stroke rehabilitation c. Adequate fluid intake d. Treatment of a urinary tract infection (UTI) Long-term goals often relate to rehabilitation. Stroke rehabilitation will require more time than short-term goals, which are achievable within 7 to 10 days. Pain management, adequate fluid intake, and treatment of UTI are considered short-term goals. 47. To conduct a physical examination of a patient, which examination technique is used? a. Percussion of an area b. Weighing of a patient c. History taking d. Communication Inspection, auscultation, palpation, and percussion are examination techniques. Weighing a patient, history taking, and communication are not considered examination techniques. 48. Which stages are included in an interview? Select all that apply. a. Opening b. Body c. Discussion d. Closing The opening, the body, and the closing are stages in an interview. Discussion is not a stage in an interview. 49. For Medicare, a reassessment of a patient in a long-term care facility must be done every: a. 30 days. b. 60 days. c. 90 days. d. 120 days. For Medicare patients, a reassessment by a registered nurse is necessary every 90 days. 50. Which is an example of objective data? a. Pain b. Temperature c. Headache d. Lightheadedness Information obtained through the senses and hands-on physical examinations are objective data. Vital signs, including temperatures, are objective data. Pain, headache, and lightheadedness are considered subjective data. [Show Less]
NCLEX PN MENTAL 1. Shortly after being told that he has 90blockage of three major coronary arteries and needs emergency coronary artery bypass surgery, ... [Show More] the patient is noted by the nurse to appear dazed. His thoughts are scattered, as evidenced by the fact that his conversation jumps from topic to topic. He frequently states, “I’m overwhelmed. I don’t know what to do.” He is unable to give direction to his wife when she asks him whom he wants her to notify. His pulse rate rises 15 points. The level of anxiety the patient is experiencing: “Severe Anxiety” 2. Which nursing intervention would be helpful in caring for patients with anxiety disorders? “Help the patient link feelings and behaviors” 3. An effective treatment for patient with obsessive-compulsive disorder is: “clomipramine(Anafranil)” 4. A patient tells the nurse, “I feel as though something terrible is going to happen to me.” Assessment findings include increased vital signs, dilated pupils, urinary frequency, rigid muscles, and decreased hearing. Which level of anxiety is evident? “Severe” 5. What is the most appropriate nursing diagnosis for a patient with anxiety and the following assessment findings: avoidance, poor concentration, nightmares, hypervigilance, exaggerated startle response, detachment, numbing, and flashbacks? “Post-trauma syndrome” 6. Select the most appropriate discharge criterion for a patient with generalized anxiety disorder. The patient will: “Identify situations and events that trigger anxiety” 7. Which comment by a patient who washes hands compulsively identifies the thinking typical of a person with obsessive-compulsive disorder? “I feel driven to wash my hands, although I don’t like doing it.” 8. Which assessment finding for a patient experiencing severe anxiety would indicate possibility of posttraumatic stress disorder? “I keep reliving the rape.” 9. Nursing interventions helpful in lowering a patients’ level of anxiety from severe to moderate include: “listening for themes the patient expresses” 10. Ms. Turner is preoccupied with persistent intrusive thoughts and impulses and performs ritualistic acts repetitively. She expresses distress and that her attention is so consumed that she cannot accomplish her usual daily activities. Which DSM-IV-TR diagnosis should the nurse anticipate? “Obsessive-compulsive disorder” 11. What is the best criterion for evaluation of the anxiety level of a patient with anxiety disorder? “ Attention Span and Concentration” 12. One possible explanation of the existence of anxiety disorders may be: “abnormalities of benzodiazepines receptors” 13. A strategy nurses can employ to help patients with anxiety disorders replace negative self-talk is: “counseling to promote cognitive restructuring” 14. A patient is hospitalized with agoraphobia accompanied by panic attacks. Which symptom should the nurse expect the patient to experience during a panic attack? “paresthesias” 15. Defense mechanisms are: “a means of managing conflict” 16. For a patient experiencing panic-level anxiety, which intervention is the priority? “reduce stimuli” 17. In addition to prescribing SSRIs to treat a patients’ panic disorder, which type of therapy will the nurse psychotherapist likely implement? “cognitive-behavioral therapy” 18. A nurse plans health teaching for a patient with generalized anxiety disorder who began a new prescription for lorazepam(Ativan) . Which topic should be included? “caffeine restriction” 19. One year ago, the patient was driving across a bridge when an earthquake caused it to collapse. The patient continues to have nightmares and feelings of fear and isolation associated with being trapped in a car in swirling water. He avoids driving on bridges and complains that relationships have not been “normal” since the event. The data collected are consistent with which diagnosis? “Posttraumatic stress disorder” Chapter 19 Personality Disorders 20. Which best describes people with personality disorders? “have difficulty working with and loving others” 21. Which assessment finding should a nurse expect to find in a patient diagnosed with schizotypal personality disorder? “incorrect interpretation of external events” 22. Which finding indicates improvement in a patient with the nursing diagnosis risk for self-mutilation related to feelings of abandonment and impulsivity? “controls self-destructive impulses when feeling empty or upset” 23. An individual demonstrates behaviors and verbalizations that indicate a lack of guilt feelings. Desired outcomes will be facilitated by interventions that: “provide external limits on the individual’s behavior” 24. Which nursing diagnosis should be considered for an individual with any personality disorder? “impaired social interaction” 25. For which patient should the nurse make minimization of overtly manipulative behavior a priority intervention? A patient who has been diagnosed with : “borderline PD” 26. Which assessment finding will be most likely for an individual with any personality disorder? “behaviors are flexible and dysfunctional” 27. Which emotional state should the nurse anticipate in a patient with a personality disorder? “anger” 28. A nurse caring for an individual with schizoid personality disorder should expect which assessment finding? “few interactions with others and little verbalization” 29. A nursing intervention undertaking by the nurse dealing with patients with personality disorders is: “setting limits” 30. Which behavior should a nurse expect while interacting with an individual with narcissitic behavior personality disorder? “attention-seeking” 31. Limit setting would be an essential intervention for which behavior? “manipulation” 32. When planning limit-setting strategies for use with manipulative patient, which step(s) would be most important? Select all that apply. • Establish realistic limits • Inform the patient of limits • Ensure that the limits are enforceable • Inform the patient of consequences for violating limits 33. A nurse working with an individual with borderline personality disorder must anticipate strategies for intervening with: “mood shifts, impulsivity, and manipulation” 34. Which distinguish characteristic of antisocial personality disorder is absent in most other personality disorders? “disregarding the rights of others” 35. If a nurse wants to assess patient’s interpersonal relationships, which comment would elicit most data? “describe your relationship with friends” 36. Which statement provides a foundation for understanding patients with personality disorders? “The tendency to develop a PD may have biological determinants” 37. Which problem is most likely to when a nurse sets unrealistically high goals for an individual with an antisocial personality disorder? “The nurse becomes frustrated and angry with the individual when goals are not met” 38. When caring for a patient with dependent personality disorder, which behavior should the nurse reinforce positively? “choosing which outfit to wear” 39. A patient with paranoid personality disorder tells the nurse, “Most people don’t like me and some even want to hurt me.” Which defense mechanism is evident? “Projection” 40. An individual who undergoes a court-ordered psychiatric examination after an arrest for embezzlement from an employer blames others for problems, becomes defensive and angry when criticized, and says , “I didn’t do anything wrong. My company didn’t pay me what I’m worth, so I took what was due to me.” These findings are most closely associated with which personality disorder? “Antisocial” Chapter 18 Addictive Disorders 41. A psychiatric mental health nurse conducts a community health education series on substance abuse. What description of abuse and addiction should the nurse include? “addiction is characterized by both psychological and physiological withdrawal symptoms” 42. The wife of a patient with alcoholism says, “I ended all outside relationships over the past 20 years ad devoted my life to helping my husband remain sober.” The nurse assesses the wife behavior as an indication of: “enmeshment” 43. Alcohol dependence is differentiated from abuse by: “ a physiological need to use the substance” 44. Which findings would support a nurse’s suspicion that a patient has been abusing inhalants? “Confusion, mouth ulcers, ataxia” 45. The optimal time to begin group therapy for a patient with dual diagnosis is: “during inpatient treatment” 46. A patient with paranoid schizophrenia and cocaine abuse tells the nurse, “I don’t think I ever be well and maybe I don’t want to. The voices insult me, but when I use cocaine, I like the good feelings I get.” Which nursing diagnosis is most appropriate? “Impaired adjustment related to lack of intention to change maladaptive behavior” 47. Which statement provides a basis for planning care for a patient who has abused CNS stimulants? “symptoms of intoxication include dilation of the pupils, dryness of the oronasal cavity, and excessive motor activity” 48. The probability of the occurrence of withdrawal symptoms in a patient with a long-term alcohol abuse is most accurately assessed by determining: “drinking history, quantity consumed, and the time of last drink” 49. A patient is hospitalized for treatment of pneumonia and has a history of substance abuse. Twenty-four hours after admission, the patient shows tremulousness, anorexia, hypertension, and confusion. The nurse should recognize these as signs of: “alcohol withdrawal delirium” 50. Milieu management for a patient who has injested a hallucinogen should create what type of environment? Select all that apply • Safe • Simple 51. A principle of initial counseling intervention that should be observed by the nurse caring for a chemically dependent patient is to: “look for therapeutic leverage by making sobriety and abstinence worthwhile” 52. As the nurse evaluates the patient’s progress, which treatment outcome would indicate a poor general prognosis for long-term recovery from substance abuse? The patient demonstrates: “positive expectations for ongoing drug use” 53. The provision of optimal care for patients withdrawing from substances and of abuse is facilitated when the nurse understands that severe morbidity and mortality are often associated with withdrawal from: “Alcohol and CNS Depressants” 54. A patient has had severe depression for a year and responded poorly to antidepressants. Which statement by the patient supports a dual diagnosis? “When I drink, things look better and I feel almost human.” 55. A patient with chronic pain tells the nurse, “I’ve been using increased doses of oxycodone because the smaller doses didn't work anymore.” The nurse should assess this phenomenon as a result of: “tolerance” 56. At a meeting for family members of alcoholics, one woman describes trying to help her husband keep his job by calling the employer and lying when he was too intoxicated to go to work. This type of behavior is known as: “codependence” 57. When intervening with a patient who is intoxicated from alcohol, it is useful for the nurse to first: “ask what drugs other than alcohol the patient has recently used” 58. Which goal of treatment of alcoholism is the priority? “achieving physiological stability” CHAPTER 22 Somatorm & Dissociative Disorders 59. Which nursing diagnosis will likely apply to a patient with hypochondriasis? “Deficient diversional activity” 60. When working with a patient that has dissociative amnesia, the nurse should begin by: “identifying and supporting patient’s strength” 61. Which nursing diagnosis is most appropriate for a patient with somatoform disorder who has little energy for activities or interactions with friends? “Impaired social interaction” 62. Which symptom should a nurse expect is a patient dissociative fugue? “patient will travel away from home and assumption of new identity” 63. The wife of a patient with hypochondriasis tells the nurse, “I don’t know what to do. Just when I think we’ve solved our financial problems. He gets sick and takes time off. I worked a full-time and part-time job, do all the work at home and take care of him. “Based on this data, the nurse should consider which nursing diagnosis? “Caregiver Role Strain” 64. Which principle should be applied when caring for a patient that has conversion disorder? “give attention to patient, not the symptom” 65. A patient presents with a history of having an assumed new identity in a distant locale and having no recollection of his former identity? Which DSM-IV-TR diagnosis should the nurse expect the Psychiatrist to assign? “Dissociative Fugue” 66. If a patient has pain in at least four different sites, and cannot be explained by a known general medical condition, which diagnosis is most likely? “Somatoform Disorder” 67. Which intervention should the nurse select to help a patient with chronic pain disorder cope more effectively? “Relaxation Techniques” 68. Which intervention would be more effective when addressing memory problems with a patient with dissociative disorders? “observe for cues that the patient ready to receive information” 69. The information that is least relevant when assessing a patient with suspected somatoform disorder? “potential for violence” 70. During assessment of a patient with somatoform disorder, which finding is most likely? The patient: “exaggerates misinterpretation physical symptoms” 71. Select the appropriate nursing intervention to assist a patient with somatoform disorder increase self-esteem? “focus attention on the patient as an individual rather than on the symptoms” 72. Dissociative identity disorders is thought to be related to: “severe childhood trauma” 73. What is a suitable outcome criterion for the nursing diagnosis ineffective coping related to dependence on pain relievers to treat chronic pain of psychological disorder? “cope adaptively as evidenced by use of alternative coping stratigies” 74. Which nursing diagnosis would be least likely to be considered for a patient with hypochondrosis? “Ineffective Denial” 75. Which assessment question would help to identify secondary gains? “What can’t you do now that you were formerly able to do” Chapter 17 Cognitive Disorders 76. When formulating long-term goals for a patient with Alzheimer’s disease , the nurse should be aware of the need to: “modify expectations as the patient’s abilities deteriorate” 77. Which action should a nurse recommend for a family that has a member with moderate Alzheimer’s? “Apply an identification bracelet to the person” 78. What is the appropriate nursing intervention for a patient with dementia who develops a catastrophic reaction? “Eliminate or reduce environmental stimulation” 79. Which is the best example of a cognitive impairment? “inability to name a familiar object” 80. When a nurse gives anticipatory guidance the family of a patient with early Alzheimer’s disease, which behavioral problem common to that stage of the disease should be mentioned? “inability to carry on an in-depth conversation” 81. A reasonable outcome that would be appropriate of a patient with cognitive impairment related to delirium would be that the patient will: “return to premorbid level of functioning” 82. Medications approved for the treatment of cognitive impairment in patients with Alzheimer’s disease include: “cholinesterase inhibitors” 83. Which intervention should a nurse incorporate into the care plan for a patient with dementia in order to support short-term memory? “Daily activity schedule” 84. An objective sign that frequently accompanies symptoms of delirium is: “disturbed sleep/wake cycle” 85. Which nursing technique is appropriate for successful interaction with a patient diagnosed with Alzheimer’s disease? “encourage communication and maintain a calm demeanor” 86. A nurse notes that an older adult patient has fluctuating levels of awareness and seems anxious. The patient says, “I saw my granddaughter standing at the foot of the bed during the night.” Later, the nurse sees the patient’s hands waving and picking things out of the air. The nurse should suspect which problem? “Delirium” 87. The husband of a patient with moderately advanced Alzheimer’s disease tells the nurse, “My wife becomes very distressed several times a week. She sees strangers walking around the house and thinks they are taking her things.” How the nurse should responds? Select all that apply: • Suggest he try to divert her attention through alternative activities • Recognize how challenging and frustrating these experiences can be 88. The nurse assessing patient with suspected delirium should expect to find that the symptoms developed: “over a period of hours to days” 89. A nurse note that an older adult patient has fluctuating levels of awareness and seems anxious. The patient says, “I saw my granddaughter standing at the foot of my bed during the night,” later, the nurse sees that patient hands waving and picking out things out of the air. The nurse should suspect which problem? “Delirium” 90. A patient with delirium is unable to name a knife but describes the function as “the thing you cut meat with.” Which term should the nurse use to document this finding? “Agnosia” 91. If a patient is hospitalized with delirium of unknown etiology, which assessment finding should the nurse suspect? “fluctuating levels of consciousness” 92. The nurse should recognize that a patient is experiencing an illusion when the patient: “misinterprets shadows on a wall as frightening faces” 93. The nursing diagnosis of the highest priority for patients with Alzheimer’s disease is: “risk for injury” Chapter 26- Child, Older Adult, and Intimate Partner Abuse 94. Identifying people at high risk and providing health teaching about recognizing behaviors and situations that might trigger abuse and violence are examples of: “Primary Prevention” 95. When making assessments, the nurse should bear in mind that a common characteristic of an abusing parent is: “having poor coping skills” 96. Which of the following is a “red flag” for suspecting physical violence during assessment of a patient? “Explanation does not match the injury” 97. Which example of thinking is not a misconception that would keep a woman locked in an abusive relationship? “no adult has the right to control or harm another” 98. Which nursing diagnosis should be considered for the following family? The husband is disabled, unable to work, drinks episodically, and abuses the two preschool children when in this cycle. The wife works outside the home. “disabled family coping” CHAPTER 16-Eating Disorders 99. When assessing a patient newly admitted an eating disorders unit, the nurse asks, “How do you feel about being here today?” The purpose of this question is to: “determine the patient’s willingness to engage in treatment.” 100. Which medication, prescribed by the physician, will the nurse most likely administer to patients with eating disorders? “An SSRI such as Fluoxetine” 101. Which behavior modification approach would be most appropriate for a patient with anorexia nervosa? “restriction to the unit until patient has gained 3 pounds” 102. While monitoring the weight-restoration phase, the nurse recognizes that a patient with anorexia nervosa should not gain more than 5lb per week to avoid: “pulmonary edema” 103. When a patient with anorexia nervosa is hospitalized, the nurse’s priority intervention will be directed toward: “supervision of patient activities” 104. Which assessment finding should the nurse expect among individuals with eating disorders? “deficits in hunger and satiety sensations” 105. Which of the following is the most persuasive cognitive distortion nurses will identify among patients with eating disorders? “thinness equates self-worth” 106. Which patient with an eating disorder will be at greatest risk for hypokalemia? “A patient with anorexia, who purges to promote weight loss” 107. Which risk factor for eating disorders is most commonly identified in the histories of adolescents with eating disorders? “dieting” 108. A patient with an eating disorder asks to be excused from the meal to use the restroom. What is the best response by the nurse? “I will go to the restroom with you” 109. Nursing assessment of a bulimic patient often reveals: “hoarseness” 110. The nurse performs a physical assessment of a patient bulimia nervosa. Which assessment findings would confirm the patient’s use of purging behaviors? Select all that apply • Enlarged parotid glands • Dental erosions 111. Select the priority nursing diagnosis for a patient who restricts food and is more than 15% underweight. “imbalanced nutrition, less than body requirements” 112. What behavior by a nurse caring for a patient with anorexia nervosa indicates a need for supervision? “using an accepting, nonjudgmental manner” 113. When assessing a patient with binge-purge type bulimia, the nurse should be particularly alert for signs and symptoms of: “hypokalemia” 114. Which assessment finding should the nurse attribute to purging? “dental enamel erosion” 115. A patient with anorexia nervosa tells the nurse, “I can’t get weighed this morning because I drank glass of juice a few minutes before breakfast.” What is the best response by the nurse? “This is weighed day. Please step on the scale” 116. Which intervention should be initiated first for a newly admitted patient with anorexia nervosa who has malnutrition, extreme weight loss, weakness and fatigue? “determine electrolyte levels” 117. An early step in the nurse-patient relationship with a patient with anorexia nervosa is: “formulating a nurse-patient contract” 118. A nurse teaches patients with eating disorders and their family members about the disorder, symptoms, and management. What is the rationale for including family in this teaching? “knowledge promotes power and reduces fear and anxiety” [Show Less]
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