NCLEX-PN TEST BANK (Questions and correct Answers, A+ Rated)
Teaching the client with gonorrhea how to prevent reinfection and further spread is
... [Show More] 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
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 : 1 - (Topic 1)
Question No : 2 - (Topic 1)
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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
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 : 3 - (Topic 1)
Question No : 4 - (Topic 1)
Question No : 5 - (Topic 1)
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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
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
Question No : 6 - (Topic 1)
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to experience prolonged suppression of granulocyte production.Physiological Adaptation
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
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:
Question No : 7 - (Topic 1)
Question No : 8 - (Topic 1)
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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
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 : 9 - (Topic 1)
Question No : 10 - (Topic 1)
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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
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.
Question No : 11 - (Topic 1)
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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
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 : 12 - (Topic 1)
Question No : 13 - (Topic 1)
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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
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 : 14 - (Topic 1)
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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
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 : 15 - (Topic 1)
Question No : 16 - (Topic 1)
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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
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
Which of the following is the primary force in sex education in a child’s life?
Question No : 17 - (Topic 1)
Question No : 18 - (Topic 1)
Question No : 19 - (Topic 1)
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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
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 : 20 - (Topic 1)
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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
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
Question No : 21 - (Topic 1)
Question No : 22 - (Topic 1)
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of, or pain in, the arch of the foot.Basic Care and Comfort
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
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 : 23 - (Topic 1)
Question No : 24 - (Topic 1)
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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
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.
Question No : 25 - (Topic 1)
Question No : 26 - (Topic 1)
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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
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.
Question No : 27 - (Topic 1)
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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
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 : 28 - (Topic 1)
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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
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
Question No : 29 - (Topic 1)
Question No : 30 - (Topic 1)
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folic acid, rest, diet, and support.Physiological Adaptation
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
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 [Show Less]