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NCLEX-RN EXAM WITH VERIFIED SOLUTIONS 100 % VERIFIED LATEST UPDATE
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NCLEX-RN EXAM WITH VERIFIED SOLUTIONS 100 % VERIFIED LATEST UPDATE
1. Which of the following clients is at a higher risk of developing oral health problems? a. A pregnant client b. A client with diabetes c. A client rec... [Show More] eiving chemotherapy d. Both b and c 2. Which nursing intervention is most appropriate to reduce environmental stimuli that may cause discomfort for a client? a. Loosen pressure dressings on wounds b. Use assistance to pull a client up in bed c. Check temperature of water used in a sponge bath d. Position the client prone 3. A client has developed a vitamin C deficiency. Which of the following symptoms might the nurse most likely see with this condition? a. Cracks at the corners of the mouth b. Altered mental status c. Bleeding gums and loose teeth d. Anorexia and diarrhea 4. Which of the following interventions should a nurse perform for a female client who is incontinent with impaired skin integrity? a. Turn the client at least every 8 hours b. Apply lotion to the skin before a bath 2 c. Provide perineal care after the client uses the bathroom d. Bathe the client every 3 days 5. A nurse is caring for a client who died approximately one hour ago. The nurse notes that the client's temperature has decreased in the last hour since his death. Which of the following processes explains this phenomenon? a. Rigor mortis b. Postmortem decomposition c. Algor mortis d. Livor mortis 6. A nurse is calculating a client's intake and output. During the last shift, the client has had ½ cup of gelatin, a skinless chicken breast, 1 cup of green beans, and 300 cc of water. The client has urinated 250 cc and has had 2 bowel movements. What is this client's intake and output for this shift? a. 420 cc intake, 250 cc output b. 300 cc intake, 250 cc output c. 550 cc intake, 550 cc output d. 300 cc intake, 550 cc output 7. A nurse is caring for a client with ariboflavinosis. Which of the following foods should the nurse serve this client? a. Citrus fruits b. Milk c. Fish d. Potatoes 3 8. A client is taking a walk down the hallway when she suddenly realizes that she needs to use the restroom. Although she tries to make it to the bathroom on time, she is incontinent of urine before reaching the toilet. What type of incontinence does this situation represent? a. Reflex incontinence b. Urge incontinence c. Total incontinence d. Functional incontinence 9. Which of the following is an example of a positive effect of exercise on a client? a. Decreased basal metabolic rate b. Decreased venous return c. Decreased work of breathing d. Decreased gastric motility 10. You have taken the vital signs for your patient. They are normal for the patient. What should you do next? a. Report the vital signs to the doctor b. Write the vital signs on a scrap paper c. Call the family members d. Document them on the graphic VS form 11. Penny Thornton has had a stroke, or CVA. She is having difficulty eating on her own. Soon, she will be getting some assistive devices for eating meals. Which healthcare worker will be getting Penny these assistive devices? a. A physical therapist b. A speech therapist 4 c. A social worker d. An occupational therapist 12. Which of the following is an example of emotional abuse? a. A slap to the person's hand b. Threatening the person c. Ignoring and isolating a person d. Leaving a patient soiled for hours 13. Which of the following is an example of emotional neglect? a. A slap to the person's hand b. Threatening the person c. Ignoring and isolating a person d. Leaving a patient soiled for hours 14. The duodenum: a. is the third section of the small intestine, which leads immediately to the colon. b. is the section of the stomach where the gall bladder delivers bile. c. is the section of the small intestine where the pancreas delivers insulin. d. None of the above. 15. The nurse is performing discharge teaching for Mrs. S after cardiac angioplasty. Her husband is present for the teaching. While explaining the prescription for antiplatelet medication to use at home, Mrs. S's husband states, "I don't think I can afford to refill that medication." What is the most appropriate response of the nurse? a. Don't worry, your insurance will cover it." 5 b. I'll ask the physician if he can prescribe a medication that is more affordable." c. You should apply for Medicare to see if they can help you." d. This medication is essential for her care and should be given priority over all others that she is taking." 16. The discharge planning team is discussing plans for the dismissal of a 16- year old admitted for complications associated with asthma. The client's mother has not participated in any of the discharge planning process, but has stated that she wants to be involved. Which of the following reasons might prohibit this mother from participating in discharge planning? a. The client is an emancipated minor b. The mother has to work and is unavailable c. The client has a job and a driver's license d. The mother does not speak English 17. A nurse enters a client's room and finds her lying on the floor near the bathroom door. As the nurse provides assistance, the client states, "I thought I could get up on my own." What information must the nurse document in this situation? a. A statement explaining the condition the client was found in, quoting the client's words about the situation b. An explanation of how the fall happened and when the physician was notified c. An account of the conditions of the room that contributed to the client's fall d. A description of the client's condition and the reasons why she should have had assistance to the bathroom 18. Which of the following may be a cultural barrier that impacts a nurse's ability to provide care or education to the client? a. A nurse offers educational materials to a client that are written at an 8th grade reading level b. A Vietnamese woman wants to use steaming in addition to her prescription antibiotics 6 c. A nurse uses pantomime to explain a procedure to a deaf client d. A Native American client requests a healing ritual before he will consider surgery 19. Which of the following is an example of low health literacy skills? a. A nurse's aide cannot calculate the correct IV rate for Ringer's lactate b. A client cannot read an admission form to sign it c. A nurse is unable to explain the dose, indications, side effects, and structural formula of carbamazepine d. A client does not understand the treatment for his cholecystectomy 20. A 39-year old woman presents for treatment of excessive vaginal bleeding after giving birth to twins one week ago. Which nursing diagnosis is most appropriate in this situation? a. Knowledge Deficit related to post-partum blood loss b. Self-Care Deficit related to post-partum neglect c. Fluid Volume Deficit related to post-partum hemorrhage d. Body Image Disturbance related to body changes after delivery 21. Mr. K is admitted to the orthopedic unit one morning in preparation for a total knee replacement to start in two hours. Which of the following is a priority topic to instruct this client on admission? a. The approximate length of the surgery b. The type of anticoagulants that will be prescribed c. The time of the next meal of solid food d. The length of time until the client can return to work 7 22. Which of the following is an example of the intervention phase of the individualized nursing care plan for a client who receives a colostomy after a bowel resection? a. Taking a health history and performing a physical exam prior to the procedure b. Instructing the client about how to care for his colostomy stoma c. Developing goals that state the client will ambulate three times a day d. Determining that the client may need more support at home after dismissal [Show Less]
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NCLEX-PN EXAM WITH VERIFIED SOLUTIONS 100 % ALREADY PASSED
1. 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 ... [Show More] 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 2 2 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 3 3 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 4 4 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 5 5 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 6 6 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 7 7 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? 8 8 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 9 9 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 [Show Less]
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NCLEX RN VERSIONS V12.35 (LATEST) WITH 865 QUESTIONS AND VERIFIED ANSWERS GUARANTEED 100% GRADE A
NO.1 A depressed client is seen at the mental health center for follow-up after an attempted suicide 1 week ago. She has taken phenelzine sulfate (Nardil)... [Show More] , a monoamine oxidase (MAO) inhibitor, for 7 straight days. She states that she is not feeling any better. The nurse explains that the drug must accumulate to an effective level before symptoms are totally relieved. Symptom relief is expected to occur within: A. 10 days B. 2-4 weeks C. 2 months D. 3 months Answer: B Explanation: (A) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication. (B) This answer is correct. Because MAO inhibitors are slow to act, it takes 2-4 weeks before improvement of symptoms is noted. (C) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication. (D) This answer is incorrect. Therapeutic effects of the medication are noted within 1 month of drug therapy. NO.2 Cystic fibrosis is transmitted as an autosomal recessive trait. This means that: A. Mothers carry the gene and pass it to their sons B. Fathers carry the gene and pass it to their daughters C. Both parents must have the disease for a child to have the disease D. Both parents must be carriers for a child to have the disease Answer: D Explanation: (A) Cystic fibrosis is not an X-linked or sex-linked disease. (B) The only characteristic on the Y chromosome is the trait for hairy ears. (C) Both parents do not need to have the disease but must be carriers. (D) If a trait is recessive, two genes (one from each parent) are necessary to produce an affected child. NO.3 A 24-year-old client presents to the emergency department protesting "I am God." The nurse identifies this as a: A. Delusion B. Illusion C. Hallucination D. Conversion Answer: A Explanation: 2 (A) Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion is the expression of intrapsychic conflict through sensory or motor manifestations. NO.4 In acute episodes of mania, lithium is effective in 1-2 weeks, but it may take up to 4 weeks, or 3 even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms. In addition to the lithium, which one of the following medications might the physician prescribe? A. Diazepam (Valium) B. Haloperidol (Haldol) C. Sertraline (Zoloft) D. Alprazolam (Xanax) Answer: B Explanation: (A) Diazepam is an antianxiety medication and is not designed to reduce psychotic symptoms. (B) Haloperidol is an antipsychotic medication and may be used until the lithium takes effect. (C) Sertraline is an antidepressant and is used primarily to reduce symptoms of depression. (D) Alprazolam is an antianxiety medication and is not designed to reduce psychotic symptoms. NO.5 A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints? A. Give fluids if the client requests them. B. Assess skin integrity and circulation of extremities before applying restraints and as they are removed. C. Measure vital signs at least every 4 hours. D. Release restraints every 2 hours for client to exercise. Answer: D Explanation: (A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly while the client is restrained, not only before restraints are applied and after they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains agitated in restraints, vital signs should be monitored even more closely, perhaps every 1-2 hours. (D) Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation. NO.6 The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on oral griseofulvin. The nurse should emphasize which of these instructions to the mother and/or child? A. Administer oral griseofulvin on an empty stomach for best results. B. Discontinue drug therapy if food tastes funny. C. May discontinue medication when the child experiences symptomatic relief. D. Observe for headaches, dizziness, and anorexia. Answer: D Explanation: (A) Giving the drug with or after meals may allay gastrointestinal discomfort. Giving the drug with a fatty meal (ice cream or milk) increases absorption rate. (B) Griseofulvin may alter taste sensations 4 and thereby decrease the appetite. Monitoring of food intake is important, and inadequate nutrient intake should be reported to the physician. (C) The child may experience symptomatic relief after 48- 96 hours of therapy. It is important to stress continuing the drug therapy to prevent relapse (usually about 6 weeks). (D) The incidence of side effects is low; however, headaches are common. Nausea, vomiting, diarrhea, and anorexia may occur. Dizziness, although uncommon, should be reported to the physician. NO.7 A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube. The rationale for this therapy is to: A. Prevent systemic infection B. Promote diuresis C. Decrease ammonia formation D. Acidify the small bowel Answer: C Explanation: (A) Neomycin is an antibiotic, but this is not the Rationale for administering it to a client in hepatic coma. (B) Diuretics and salt-free albumin are used to promote diuresis in clients with cirrhosis of the liver. (C) Neomycin destroys the bacteria in the intestines. It is the bacteria in the bowel that break down protein into ammonia. (D) Lactulose is administered to create an acid environment in the bowel. Ammonia leaves the blood and migrates to this acidic environment where it is trapped and excreted. NO.8 A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures should be included in the postoperative care? A. Encourage the child to cough up blood if present. B. Give warm clear liquids when fully alert. C. Have child gargle and do toothbrushing to remove old blood. D. Observe for evidence of bleeding. Answer: D Explanation: (A) The nurse should discourage the child from coughing, clearing the throat, or putting objects in his mouth. These may induce bleeding. (B) Cool, clear liquids may be given when child is fully alert. Warm liquids may dislodge a blood clot. The nurse should avoid red- or brown-colored liquids to distinguish fresh or old blood from ingested liquid should the child vomit. (C) Gargles and vigorous toothbrushing could initiate bleeding. (D) Postoperative hemorrhage, though unusual, may occur. The nurse should observe for bleeding by looking directly into the throat and for vomiting of bright red blood, continuous swallowing, and changes in vital signs. NO.9 An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his left leg that started approximately 20 minutes ago. When performing the admission assessment, the nurse would expect to observe which of the following: A. Both lower extremities warm to touch with 2_pedal pulses B. Both lower extremities cyanotic when placed in a dependent position 5 C. Decreased or absent pedal pulse in the left leg D. The left leg warmer to touch than the right leg Answer: C Explanation: (A) This statement describes a normal assessment finding of the lower extremities. (B) This assessment finding reflects problems caused by venous insufficiency. (C) Decreased or absentpedal pulses reflect a problem caused by arterial insufficiency. (D) The leg that is experiencing arterial insufficiency would be cool to touch due to the decreased circulation. NO.10 A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician? A. pH 7.39 B. White blood cell (WBC) count 10,000 WBCs/mm3 C. Hematocrit 60% D. Bleeding time of 4 minutes Answer: C Explanation: (A) Normal pH of arterial blood gases for an infant is 7.35-7.45. (B) Normal white blood cell count in an infant is 6,000-17,500 WBCs/mm3. (C) Normal hematocrit in infant is 28%-42%. A 60% hematocrit may indicate polycythemia, a common complication of cyanotic heart disease. (D) Normal bleeding time is 2-7 minutes. NO.11 A male client is experiencing extreme distress. He begins to pace up and down the corridor. What nursing intervention is appropriate when communicating with the pacing client? A. Ask him to sit down. Speak slowly and use short, simple sentences. B. Help him to recognize his anxiety. C. Walk with him as he paces. D. Increase the level of his supervision. Answer: C Explanation: (A) The nurse should not ask him to sit down. Pacing is the activity he has chosen to deal with his anxiety. The nurse dealing with this client should speak slowly and with short, simplesentences. (B) The client may already recognize the anxiety and is attempting to deal with it. (C) Walk with the client as he paces. This gives support while he uses anxiety-generated energy. (D) Increasing the level of supervision may be appropriate after he stops pacing. It would minimize self-injury and/or loss of control. NO.12 Prior to an amniocentesis, a fetal ultrasound is done in order to: A. Evaluate fetal lung maturity B. Evaluate the amount of amniotic fluid C. Locate the position of the placenta and fetus D. Ensure that the fetus is mature enough to perform the amniocentesis Answer: C 6 Explanation: (A) Amniocentesis can be performed to assess for lung maturity. Fetal ultrasound can be used for gestational dating, although it does not separately determine lung maturity. (B) Ultrasound can evaluate amniotic fluid volume, which may be used to determine congenital anomalies. (C) Amniocentesis involves removal of amniotic fluid for evaluation. The needle, inserted through the abdomen, is guided by ultrasound to avoid needle injuries, and the test evaluates the position of the placenta and the fetus. (D) Amniocentesis can be performed as early as the 15th-17th week of pregnancy. NO.13 A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Nagele's rule is: A. March 27 B. February 1 C. February 27 D. January 3 Answer: C Explanation: (A)March 27 is a miscalculation. (B) February 1 is a miscalculation. (C) February 27 is the correct answer. To calculate the estimated date of confinement using Nagele's rule, subtract 3 months from the date that the last menstrual cycle began and then add 7 days to the result. (D) January 3 is a miscalculation. NO.14 A client is now pregnant for the second time. Her first child weighed 4536 g at delivery. The client's glucose tolerance test shows elevated blood sugar levels. Because she only shows signs of diabetes when she is pregnant, she is classified as having: A. Insulin-dependent diabetes B. Type II diabetes mellitus C. Type I diabetes mellitus D. Gestational diabetes mellitus Answer: D Explanation: (A) Insulin-dependent diabetes mellitus, also known as type I diabetes, usually appears before the age of 30 years with an abrupt onset of symptoms requiring insulin for management. It is not related to onset during pregnancy. (B) Non-insulin-dependent diabetes (type II diabetes) usually appears in older adults. It has a slow onset and progression of symptoms. (C) This type of diabetes is the same as insulin-dependent diabetes. (D) Gestational diabetes mellitus has its onset of symptoms during pregnancy and usually disappears after delivery. These symptoms are usually mild and not life threatening, although they are associated with increased fetal morbidity and other fetal complications. NO.15 A 44-year-old female client is receiving external radiation to her scapula for metastasis of 7 breast cancer. Teaching related to skin care for the client would include which of the following? A. Teach her to completely clean the skin to remove all ointments and markings after each treatment . B. Teach her to cover broken skin in the treated area with a medicated ointment. C. Encourage her to wear a tight-fitting vest to support her scapula. D. Encourage her to avoid direct sunlight on the area being treated. Answer: D Explanation: (A) The skin in a treatment area should be rinsed with water and patted dry. Markings should be left intact, and the skin should not be scrubbed. (B) Clients should avoid putting any creams or lotions on the treated area. This could interfere with treatment. (C) Radiation therapy clients should wear loosefitting clothes and avoid tight, irritating fabrics. (D) The area of skin being treated is sensitive to sunlight, and the client should take care to prevent sun damage by avoiding direct sunlight and covering the area when she is in the sun. NO.16 The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue healing? A. Vitamin C B. Vitamin B1 C. Vitamin D D. Vitamin A Answer: A Explanation: (A) Vitamin C (ascorbic acid) is essential in promoting wound healing and collagen formation. (B) Vitamin B1 (thiamine) maintains normal gastrointestinal (GI) functioning, oxidizes carbohydrates, and is essential for normal functioning of nervous tissue. (C) Vitamin D regulates absorption of calcium and phosphorus from the GI tract and helps prevent rickets. (D) Vitamin A is necessary for the formation and maintenance of skin and mucous membranes. It is also essential for normal growth and development of bones and teeth. NO.17 A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony. Which of the following nursing implementations would be most effective in helping him cope with immobility? A. Providing him with books, challenging puzzles, and games as diversionary activities B. Allowing him to do as much for himself as he is able, including learning to do pin-site care under supervision C. Having a volunteer come in to sit with the client and to read him stories D. Stimulating rest and relaxation by gentle rubbing with lotion and changing the client's position frequently Answer: B 8 Explanation: (A) These activities could be frustrating for the client if he is having difficulty with problem solving and concentration. (B) Selfcare is usually well received by the child, and it is one of the most useful interventions to help the child cope with immobility. (C) This may be helpful to the client if he has no visitors, but it does little to help him develop coping skills. (D) This will helpto prevent skin irritation or breakdown related to immobility but will not help to prevent behavioral changes related to immobility. NO.18 In client teaching, the nurse should emphasize that fetal damage occurs more frequently with ingestion of drugs during: A. First trimester B. Second trimester C. Third trimester D. Every trimester Answer: A Explanation: (A) Organogenesis occurs in the first trimester. Fetus is most susceptible to malformation during this period. (B) Organogenesis has occurred by the second trimester. (C) Fetal development is complete by this time. (D) The dangerous period for fetal damage is the first trimester, not the entire pregnancy. NO.19 On admission, the client has signs and symptoms of pulmonary edema. The nurse places the client in the most appropriate position for a client in pulmonary edema, which is: A. High Fowler B. Lying on the left side C. Sitting in a chair D. Supine with feet elevated Answer: A Explanation: (A) High Fowler position decreases venous return to the heart and permits greater lung expansion so that oxygenation is maximized. (B) Lying on the left side may improve perfusion to the left lung but does not promote lung expansion. (C) Sitting in a chair will decrease venous return and promote maximal lung expansion. However, clients with pulmonary edema can deteriorate quickly and require intubation and mechanical ventilation. If a client is sitting in achair when this deterioration happens, it will be difficult to intervene quickly. (D) The supine with feet elevated position increases venous return and will worsen pulmonary edema. NO.20 A client has returned to the unit from the recovery room after having a thyroidectomy. The nurse knows that a major complication after a thyroidectomy is: A. Respiratory obstruction B. Hypercalcemia C. Fistula formation D. Myxedema 9 Answer: A Explanation: (A) Respiratory obstruction due to edema of the glottis, bilateral laryngeal nerve damage, or tracheal compression from hemorrhage is a major complication after a thyroidectomy. (B) Hypocalcemia accompanied by tetany from accidental removal of one or more parathyroid glands is a major complication, not hypercalcemia. (C) Fistula formation is not a major complication associated with a thyroidectomy. It is a major complication with a laryngectomy.(D) Myxedema is hypothyroidism that occurs in adults and is not a complication of a thyroidectomy. A thyroidectomy client tends to develop thyroid storm, which is excess production of thyroid hormone. NO.21 The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase? A. Mother is concerned about her recovery. B. Mother calls infant by name. C. Mother lightly touches infant. D. Mother is concerned about her weight gain. Answer: B Explanation: (A) This observation can be made during the taking-in phase when the mother's needs are more important. (B) This observation can be made during the taking-hold phase when the mother is actively involved with herself and the infant. (C, D) This observation can be made during the taking-in phase. NO.22 A female client has just died. Her family is requesting that all nursing staff leave the room. The family's religious leader has arrived and is ready to conduct a ceremony for the deceased in the room, requesting that only family members be present. The nurse assigned to the client should perform the appropriate nursing action, which might include: A. Inform the family that it is the hospital's policy not to conduct religious ceremonies in client rooms . B. Refuse to leave the room because the client's body is entrusted in the nurse's care until it can be brought to the morgue. C. Tell the family that they may conduct their ceremony in the client's room; however, the nurse must attend. D. Respect the client's family's wishes. Answer: D Explanation: (A) It is rare that a hospital has a specific policy addressing this particular issue. If the statement is true, the nurse should show evidence of the policy to the family and suggest alternatives, such as the hospital chapel. (B) Refusal to leave the room demonstrates a lack of understanding related to the family's need to grieve in their own manner. (C) The nurse should leave the room and allow the 10 family privacy in their grief. (D) The family's wish to conduct a religious ceremony in the client's room is part of the grief process. The request is based on specific cultural and religious differences dictating social customs. [Show Less]
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Question 1 A c. What document should be in guiding the care of this client? A) Client Self Determination Act B) Physician's treatment orders C) Advance... [Show More] 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. 3Question 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 nurseclient 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. [Show Less]
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