NP Nursing Exam Questions with MCQs, correct answers and Rationale
1. A 43-year-old African American male is admitted with sickle
cell anemia. The
... [Show More] nurse plans to assess circulation in the lower
extremities every 2 hours. Which of the following outcome
criteria would the nurse use?
a. Body temperature of 99°F or less
b. Toes moved in active range of motion
c. Sensation reported when soles of feet are touched
d. Capillary refill of < 3 seconds
Answer D is correct. It is important to assess the extremities for blood
vessel occlusion in the client with sickle cell anemia because a change
in capillary refill would indicate a change in circulation. Body
temperature, motion, and sensation would not give information regarding
peripheral circulation; therefore, answers A, B, and C are incorrect.
2. A 30-year-old male from Haiti is brought to the emergency
department in sickle cell crisis. What is the best position for
this client?
a. Side-lying with knees flexed
b. Knee-chest
c. High Fowler's with knees flexed
d. Semi-Fowler's with legs extended on the bed
Answer D is correct. Placing the client in semi-Fowler’s position provides
the best oxygenation for this client. Flexion of the hips and knees, which
includes the knee-chest position, impedes circulation and is not correct
positioning for this client. Therefore, answers A, B, and C are incorrect.
3. A 25-year-old male is admitted in sickle cell crisis. Which of
the following interventions would be of highest priority for this
client?
a. Taking hourly blood pressures with mechanical cuff
b. Encouraging fluid intake of at least 200mL per hour
c. Position in high Fowler's with knee gatch raised
d. Administering Tylenol as ordered
Answer B is correct. It is important to keep the client in sickle cell crisis
hydrated to prevent further sickling of the blood. Answer A is incorrect
because a mechanical cuff places too much pressure on the arm.
Answer C is incorrect because raising the knee gatch impedes
circulation. Answer D is incorrect because Tylenol is too mild an
analgesic for the client in crisis.
4. Which of the following foods would the nurse encourage the
client in sickle cell crisis to eat?
a. Peaches
b. Cottage cheese
c. Popsicle
d. Lima beans
Answer C is correct. Hydration is important in the client with sickle cell
disease to prevent thrombus formation. Popsicles, gelatin, juice, and
pudding have high fluid content. The foods in answers A, B, and D do
not aid in hydration and are, therefore, incorrect.
5. A newly admitted client has sickle cell crisis. The nurse is
planning care based on assessment of the client. The client is
complaining of severe pain in his feet and hands. The pulse
oximetry is 92. Which of the following interventions would be
implemented first? Assume that there are orders for each
intervention.
a. Adjust the room temperature
b. Give a bolus of IV fluids
c. Start O2
d. Administer meperidine (Demerol) 75mg IV push
Answer C is correct. The most prominent clinical manifestation of sickle
cell crisis is pain. However, the pulse oximetry indicates that oxygen
levels are low; thus, oxygenation takes precedence over pain relief.
Answer A is incorrect because although a warm environment reduces
pain and minimizes sickling, it would not be a priority. Answer B is
incorrect because although hydration is important, it would not require a
bolus. Answer D is incorrect because Demerol is acidifying to the blood
and increases sickling.
6. The nurse is instructing a client with iron-deficiency anemia.
Which of the following meal plans would the nurse expect the
client to select?
a. Roast beef, gelatin salad, green beans, and peach pie
b. Chicken salad sandwich, coleslaw, French fries, ice
cream
c. Egg salad on wheat bread, carrot sticks, lettuce salad,
raisin pie
d. Pork chop, creamed potatoes, corn, and coconut cake
Answer C is correct. Egg yolks, wheat bread, carrots, raisins, and green,
leafy vegetables are all high in iron, which is an important mineral for this
client. Roast beef, cabbage, and pork chops are also high in iron, but the
side dishes accompanying these choices are not; therefore, answers A,
B, and D are incorrect.
7. Clients with sickle cell anemia are taught to avoid activities
that cause hypoxia and hypoxemia. Which of the following
activities would the nurse recommend?
a. A family vacation in the Rocky Mountains
b. Chaperoning the local boys club on a snow-skiing trip
c. Traveling by airplane for business trips
d. A bus trip to the Museum of Natural History
Answer D is correct. Taking a trip to the museum is the only answer that
does not pose a threat. A family vacation in the Rocky Mountains at high
altitudes, cold temperatures, and airplane travel can cause sickling
episodes and should be avoided; therefore, answers A, B, and C are
incorrect.
8. The nurse is conducting an admission assessment of a client
with vitamin B12 deficiency. Which of the following would the
nurse include in the physical assessment?
a. Palpate the spleen
b. Take the blood pressure
c. Examine the feet for petechiae
d. Examine the tongue
Answer D is correct. The tongue is smooth and beefy red in the client
with vitamin B12 deficiency, so examining the tongue should be included
in the physical assessment. Bleeding, splenomegaly, and blood pressure
changes do not occur, making answers A, B, and C incorrect.
9. An African American female comes to the outpatient clinic. The
physician suspects vitamin B12 deficiency anemia. Because
jaundice is often a clinical manifestation of this type of anemia,
what body part would be the best indicator?
a. Conjunctiva of the eye
b. Soles of the feet
c. Roof of the mouth
d. Shins
Answer C is correct. The oral mucosa and hard palate (roof of the
mouth) are the best indicators of jaundice in dark-skinned persons. The
conjunctiva can have normal deposits of fat, which give a yellowish hue;
thus, answer A is incorrect. The soles of the feet can be yellow if they are
calloused, making answer B incorrect; the shins would be an area of
darker pigment, so answer D is incorrect.
10. The nurse is conducting a physical assessment on a client
with anemia. Which of the following clinical manifestations
would be most indicative of the anemia?
a. BP 146/88
b. Respirations 28 shallow
c. Weight gain of 10 pounds in 6 months
d. Pink complexion
Answer B is correct. When there are fewer red blood cells, there is less
hemoglobin and less oxygen. Therefore, the client is often short of
breath, as indicated in answer B. The client with anemia is often pale in
color, has weight loss, and may be hypotensive. Answers A, C, and D
are within normal and, therefore, are incorrect.
11. The nurse is teaching the client with polycythemia vera about
prevention of complications of the disease. Which of the
following statements by the client indicates a need for further
teaching?
a. "I will drink 500mL of fluid or less each day."
b. "I will wear support hose when I am up."
c. "I will use an electric razor for shaving."
d. "I will eat foods low in iron."
Answer A is correct. The client with polycythemia vera is at risk for
thrombus formation. Hydrating the client with at least 3L of fluid per day
is important in preventing clot formation, so the statement to drink less
than 500mL is incorrect. Answers B, C, and D are incorrect because they
all contribute to the prevention of complications. Support hose promotes
venous return, the electric razor prevents bleeding due to injury, and a
diet low in iron is essential to preventing further red cell formation.
12. A 33-year-old male is being evaluated for possible acute
leukemia. Which of the following would the nurse inquire about
as a part of the assessment?
a. The client collects stamps as a hobby.
b. The client recently lost his job as a postal worker.
c. The client had radiation for treatment of Hodgkin's
disease as a teenager.
d. The client's brother had leukemia as a child.
Answer C is correct. Radiation treatment for other types of cancer can
result in leukemia. Some hobbies and occupations involving chemicals
are linked to leukemia, but not the ones in these answers; therefore,answers A and B are incorrect. Answer D is incorrect because the
incidence of leukemia is higher in twins than in siblings.
13. An African American client is admitted with acute leukemia.
The nurse is assessing for signs and symptoms of bleeding.
Where is the best site for examining for the presence of
petechiae?
a. The abdomen
b. The thorax
c. The earlobes
d. The soles of the feet
Answer D is correct. Petechiae are not usually visualized on dark skin.
The soles of the feet and palms of the hand provide a lighter surface for
assessing the client for petichiae. Answers A, B, and C are incorrect
because the skin might be too dark to make an assessment.
14. A client with acute leukemia is admitted to the oncology unit.
Which of the following would be most important for the nurse
to inquire?
a. "Have you noticed a change in sleeping habits recently?"
b. "Have you had a respiratory infection in the last 6
months?"
c. "Have you lost weight recently?"
d. "Have you noticed changes in your alertness?"
Answer B is correct. The client with leukemia is at risk for infection and
has often had recurrent respiratory infections during the previous 6
months. Insomnolence, weight loss, and a decrease in alertness also
occur in leukemia, but bleeding tendencies and infections are the
primary clinical manifestations; therefore, answers A, C, and D are
incorrect.
15. Which of the following would be the priority nursing diagnosis
for the adult client with acute leukemia?
a. Oral mucous membrane, altered related to chemotherapy
b. Risk for injury related to thrombocytopenia
c. Fatigue related to the disease process
d. Interrupted family processes related to life-threatening
illness of a family member
Answer B is correct. The client with acute leukemia has bleeding
tendencies due to decreased platelet counts, and any injury would
exacerbate the problem. The client would require close monitoring for
hemorrhage, which is of higher priority than the diagnoses in answers A,
C, and D, which are incorrect.
16. A 21-year-old male with Hodgkin's lymphoma is a senior at the
local university. He is engaged to be married and is to begin a
new job upon graduation. Which of the following diagnoses
would be a priority for this client?
a. Sexual dysfunction related to radiation therapy
b. Anticipatory grieving related to terminal illness
c. Tissue integrity related to prolonged bed rest
d. Fatigue related to chemotherapy
Answer A is correct. Radiation therapy often causes sterility in male
clients and would be of primary importance to this client. The
psychosocial needs of the client are important to address in light of the
age and life choices. Hodgkin’s disease, however, has a good prognosis
when diagnosed early. Answers B, C, and D are incorrect because they
are of lesser priority.
17. A client has autoimmune thrombocytopenic purpura. To
determine the client's response to treatment, the nurse would
monitor:
a. Platelet count
b. White blood cell count
c. Potassium levels
d. Partial prothrombin time (PTT)
Answer A is correct. Clients with autoimmune thrombocytopenic purpura
(ATP) have low platelet counts, making answer A the correct answer.
White cell counts, potassium levels, and PTT are not affected in ATP;
thus, answers B, C, and D are incorrect.
18. The home health nurse is visiting a client with autoimmune
thrombocytopenic purpura (ATP). The client's platelet count
currently is 80, It will be most important to teach the client and
family about:
a. Bleeding precautions
b. Prevention of falls
c. Oxygen therapy
d. Conservation of energy
Answer A is correct. The normal platelet count is 120,000–400, Bleeding
occurs in clients with low platelets. The priority is to prevent and
minimize bleeding. Oxygenation in answer C is important, but platelets
do not carry oxygen. Answers B and D are of lesser priority and are
incorrect in this instance.
19. A client with a pituitary tumor has had a transphenoidal
hyposphectomy. Which of the following interventions
would be appropriate for this client?
a. Place the client in Trendelenburg position for
postural drainage
b. Encourage coughing and deep breathing every 2
hours
c. Elevate the head of the bed 30°
d. Encourage the Valsalva maneuver for bowel
movements
Answer C is correct. Elevating the head of the bed 30° avoids pressure
on the sella turcica and alleviates headaches. Answers A, B, and D are
incorrect because Trendelenburg, Valsalva maneuver, and coughing all
increase the intracranial pressure.
20. The client with a history of diabetes insipidus is admitted
with polyuria, polydipsia, and mental confusion. The
priority intervention for this client is:
a. Measure the urinary output
b. Check the vital signs
c. Encourage increased fluid intake
d. Weigh the client
Answer B is correct. The large amount of fluid loss can cause fluid and
electrolyte imbalance that should be corrected. The loss of electrolytes
would be reflected in the vital signs. Measuring the urinary output is
important, but the stem already says that the client has polyuria, so
answer A is incorrect. Encouraging fluid intake will not correct the
problem, making answer C incorrect. Answer D is incorrect because
weighing the client is not necessary at this time.
21. A client with hemophilia has a nosebleed. Which nursing
action is most appropriate to control the bleeding?
a. Place the client in a sitting position with the head
hyperextended
b. Pack the nares tightly with gauze to apply pressure
to the source of bleeding
c. Pinch the soft lower part of the nose for a minimum
of 5 minutes
d. Apply ice packs to the forehead and back of the
neck
Answer C is correct. The client should be positioned upright and leaning
forward, to prevent aspiration of blood. Answers A, B, and D are
incorrect because direct pressure to the nose stops the bleeding, and ice
packs should be applied directly to the nose as well. If a pack is
necessary, the nares are loosely packed.
22. A client has had a unilateral adrenalectomy to remove a
tumor. To prevent complications, the most important
measurement in the immediate post-operative period for
the nurse to take is:
a. Blood pressure
b. Temperature
c. Output
d. Specific gravity
Answer A is correct. Blood pressure is the best indicator of
cardiovascular collapse in the client who has had an adrenal gland
removed. The remaining gland might have been suppressed due to the
tumor activity. Temperature would be an indicator of infection, decreased
output would be a clinical manifestation but would take longer to occur
than blood pressure changes, and specific gravity changes occur with
other disorders; therefore, answers B, C, and D are incorrect.
23. A client with Addison's disease has been admitted with a
history of nausea and vomiting for the past 3 days. The
client is receiving IV glucocorticoids (Solu-Medrol). Which
of the following interventions would the nurse implement?
a. Glucometer readings as ordered
b. Intake/output measurements
c. Sodium and potassium levels monitored
d. Daily weights
Answer A is correct. IV glucocorticoids raise the glucose levels and often
require coverage with insulin. Answer B is not necessary at this time,
sodium and potassium levels would be monitored when the client is
receiving mineral corticoids, and daily weights is unnecessary; therefore,
answers B, C, and D are incorrect.
24. A client had a total thyroidectomy yesterday. The client is
complaining of tingling around the mouth and in the
fingers and toes. What would the nurses' next action be?a. Obtain a crash cart
b. Check the calcium level
c. Assess the dressing for drainage
d. Assess the blood pressure for hypertension
Answer B is correct. The parathyroid glands are responsible for calcium
production and can be damaged during a thyroidectomy. The tingling is
due to low calcium levels. The crash cart would be needed in respiratory
distress but would not be the next action to take; thus, answer A is
incorrect. Hypertension occurs in thyroid storm and the drainage would
occur in hemorrhage, so answers C and D are incorrect.
25. A 32-year-old mother of three is brought to the clinic. Her
pulse is 52, there is a weight gain of 30 pounds in 4
months, and the client is wearing two sweaters. The
client is diagnosed with hypothyroidism. Which of the
following nursing diagnoses is of highest priority?
a. Impaired physical mobility related to decreased
endurance
b. Hypothermia r/t decreased metabolic rate
c. Disturbed thought processes r/t interstitial edema
d. Decreased cardiac output r/t bradycardia
Answer D is correct. The decrease in pulse can affect the cardiac output
and lead to shock, which would take precedence over the other choices;
therefore, answers A, B, and C are incorrect.
26. The client presents to the clinic with a serum cholesterol
of 275mg/dL and is placed on rosuvastatin (Crestor).
Which instruction should be given to the client?
a. Report muscle weakness to the physician.
b. Allow six months for the drug to take effect.
c. Take the medication with fruit juice.
d. Ask the doctor to perform a complete blood count
before starting the medication.
Answer A is correct. The client taking antilipidemics should be
encouraged to report muscle weakness because this is a sign of
rhabdomyositis. The medication takes effect within 1 month of beginning
therapy, so answer B is incorrect. The medication should be taken with
water because fruit juice, particularly grapefruit, can decrease the
effectiveness, making answer C incorrect. Liver function studies should
be checked before beginning the medication, not after the fact, making
answer D incorrect.
27. The client is admitted to the hospital with hypertensive
crises. Diazoxide (Hyperstat) is ordered. During
administration, the nurse should:
a. Utilize an infusion pump
b. Check the blood glucose level
c. Place the client in Trendelenburg position
d. Cover the solution with foil
Answer B is correct. Hyperstat is given IV push for hypertensive crises,
but it often causes hyperglycemia. The glucose level will drop rapidly
when stopped. Answer A is incorrect because the hyperstat is given by
IV push. The client should be placed in dorsal recumbent position, not a
Trendelenburg position, as stated in answer C. Answer D is incorrect
because the medication does not have to be covered with foil.
28. The 6-month-old client with a ventral septal defect is
receiving Digitalis for regulation of his heart rate. Which
finding should be reported to the doctor?
a. Blood pressure of 126/80
b. Blood glucose of 110mg/dL
c. Heart rate of 60bpm
d. Respiratory rate of 30 per minute
Answer C is correct. A heart rate of 60 in the baby should be reported
immediately. The dose should be held if the heart rate is below 100bpm.
The blood glucose, blood pressure, and respirations are within normal
limits; thus answers A, B, and D are incorrect.
29. The client admitted with angina is given a prescription for
nitroglycerine. The client should be instructed to:
a. Replenish his supply every 3 months
b. Take one every 15 minutes if pain occurs
c. Leave the medication in the brown bottle
d. Crush the medication and take with water
Answer C is correct. Nitroglycerine should be kept in a brown bottle (or
even a special air- and water-tight, solid or plated silver or gold
container) because of its instability and tendency to become less potent
when exposed to air, light, or water. The supply should be replenished
every 6 months, not 3 months, and one tablet should be taken every 5
minutes until pain subsides, so answers A and B are incorrect. If the pain
does not subside, the client should report to the emergency room. The
medication should be taken sublingually and should not be crushed, as
stated in answer D.
30. The client is instructed regarding foods that are low in fat
and cholesterol. Which diet selection is lowest in
saturated fats?
a. Macaroni and cheese
b. Shrimp with rice
c. Turkey breast
d. Spaghetti
Answer C is correct. Turkey contains the least amount of fats and
cholesterol. Liver, eggs, beef, cream sauces, shrimp, cheese, and
chocolate should be avoided by the client; thus, answers A, B, and D are
incorrect. The client should bake meat rather than frying to avoid adding
fat to the meat during cooking.
31. The client is admitted with left-sided congestive heart
failure. In assessing the client for edema, the nurse
should check the:
a. Feet
b. Neck
c. Hands
d. Sacrum
Answer B is correct. The jugular veins in the neck should be assessed
for distension. The other parts of the body will be edematous in rightsided congestive heart failure, not left-sided; thus, answers A, C, and D
are incorrect.
32. The nurse is checking the client's central venous
pressure. The nurse should place the zero of the
manometer at the:
a. Phlebostatic axis
b. PMI
c. Erb's point
d. Tail of Spence
Answer A is correct. The phlebostatic axis is located at the fifth
intercostals space midaxillary line and is the correct placement of the
manometer. The PMI or point of maximal impulse is located at the fifth
intercostals space midclavicular line, so answer B is incorrect. Erb’s
point is the point at which you can hear the valves close simultaneously,
making answer C incorrect. The Tail of Spence (the upper outer
quadrant) is the area where most breast cancers are located and has
nothing to do with placement of a manometer; thus, answer D is
incorrect.
33. The physician orders lisinopril (Zestril) and furosemide
(Lasix) to be administered concomitantly to the client with
hypertension. The nurse should:
a. Question the order
b. Administer the medications
c. Administer separately
d. Contact the pharmacy
Answer B is correct. Zestril is an ACE inhibitor and is frequently given
with a diuretic such as Lasix for hypertension. Answers A, C, and D are
incorrect because the order is accurate. There is no need to question the
order, administer the medication separately, or contact the pharmacy.
34. The best method of evaluating the amount of peripheral
edema is:
a. Weighing the client daily
b. Measuring the extremity
c. Measuring the intake and output
d. Checking for pitting
Answer B is correct. The best indicator of peripheral edema is measuring
the extremity. A paper tape measure should be used rather than one of
plastic or cloth, and the area should be marked with a pen, providing the
most objective assessment. Answer A is incorrect because weighing the
client will not indicate peripheral edema. Answer C is incorrect because
checking the intake and output will not indicate peripheral edema.
Answer D is incorrect because checking for pitting edema is less reliable
than measuring with a paper tape measure.
35. A client with vaginal cancer is being treated with a
radioactive vaginal implant. The client's husband asks the
nurse if he can spend the night with his wife. The nurse
should explain that:
a. Overnight stays by family members is against
hospital policy.
b. There is no need for him to stay because staffing is
adequate.
c. His wife will rest much better knowing that he is at
home.
d. Visitation is limited to 30 minutes when the implant
is in place.Answer D is correct. Clients with radium implants should have close
contact limited to 30 minutes per visit. The general rule is limiting time
spent exposed to radium, putting distance between people and the
radium source, and using lead to shield against the radium. Teaching the
family member these principles is extremely important. Answers A, B,
and C are not empathetic and do not address the question; therefore,
they are incorrect.
36. The nurse is caring for a client hospitalized with a facial
stroke. Which diet selection would be suited to the client?
a. Roast beef sandwich, potato chips, pickle spear,
iced tea
b. Split pea soup, mashed potatoes, pudding, milk
c. Tomato soup, cheese toast, Jello, coffee
d. Hamburger, baked beans, fruit cup, iced tea
Answer B is correct. The client with a facial stroke will have difficulty
swallowing and chewing, and the foods in answer B provide the least
amount of chewing. The foods in answers A, C, and D would require
more chewing and, thus, are incorrect.
37. The physician has prescribed Novalog insulin for a client
with diabetes mellitus. Which statement indicates that the
client knows when the peak action of the insulin occurs?
a. "I will make sure I eat breakfast within 10 minutes of
taking my insulin."
b. "I will need to carry candy or some form of sugar
with me all the time."
c. "I will eat a snack around three o'clock each
afternoon."
d. "I can save my dessert from supper for a bedtime
snack."
Answer A is correct. Novalog insulin onsets very quickly, so food should
be available within 10–15 minutes of taking the insulin. Answer B does
not address a particular type of insulin, so it is incorrect. NPH insulin
peaks in 8–12 hours, so a snack should be eaten at the expected peak
time. It may not be 3 p.m. as stated in answer C. Answer D is incorrect
because there is no need to save the dessert until bedtime.
38. The nurse is teaching basic infant care to a group of firsttime parents. The nurse should explain that a sponge
bath is recommended for the first 2 weeks of life
because:
a. New parents need time to learn how to hold the
baby.
b. The umbilical cord needs time to separate.
c. Newborn skin is easily traumatized by washing.
d. The chance of chilling the baby outweighs the
benefits of bathing.
Answer B is correct. The umbilical cord needs time to dry and fall off
before putting the infant in the tub. Although answers A, C, and D might
be important, they are not the primary answer to the question.
39. A client with leukemia is receiving Trimetrexate. After
reviewing the client's chart, the physician orders
Wellcovorin (leucovorin calcium). The rationale for
administering leucovorin calcium to a client receiving
Trimetrexate is to:
a. Treat iron-deficiency anemia caused by
chemotherapeutic agents
b. Create a synergistic effect that shortens treatment
time
c. Increase the number of circulating neutrophils
d. Reverse drug toxicity and prevent tissue damage
Answer D is correct. Leucovorin is the antidote for Methotrexate and
Trimetrexate which are folic acid antagonists. Leucovorin is a folic acid
derivative. Answers A, B, and C are incorrect because Leucovorin does
not treat iron deficiency, increase neutrophils, or have a synergistic
effect.
40. A 4-month-old is brought to the well-baby clinic for
immunization. In addition to the DPT and polio vaccines,
the baby should receive:
a. Hib titer
b. Mumps vaccine
c. Hepatitis B vaccine
d. MMR
Answer A is correct. The Hemophilus influenza vaccine is given at 4
months with the polio vaccine. Answers B, C, and D are incorrect
because these vaccines are given later in life.
41. The physician has prescribed Nexium (esomeprazole) for
a client with erosive gastritis. The nurse should
administer the medication:
a. 30 minutes before meals
b. With each meal
c. In a single dose at bedtime
d. 30 minutes after meals
Answer B is correct. Proton pump inhibitors such as Nexium and
Protonix should be taken with meals, for optimal effect. Histamineblocking agents such as Zantac should be taken 30 minutes before
meals, so answer A is incorrect. Tagamet can be taken in a single dose
at bedtime, making answer C incorrect. Answer D does not treat the
problem adequately and, therefore, is incorrect.
42. A client on the psychiatric unit is in an uncontrolled rage
and is threatening other clients and staff. What is the
most appropriate action for the nurse to take?
a. Call security for assistance and prepare to sedate
the client.
b. Tell the client to calm down and ask him if he would
like to play cards.
c. Tell the client that if he continues his behavior he will
be punished.
d. Leave the client alone until he calms down.
Answer A is correct. If the client is a threat to the staff and to other clients
the nurse should call for help and prepare to administer a medication
such as Haldol to sedate him. Answer B is incorrect because simply
telling the client to calm down will not work. Answer C is incorrect
because telling the client that if he continues he will be punished is a
threat and may further anger him. Answer D is incorrect because if the
client is left alone he might harm himself.
43. When the nurse checks the fundus of a client on the first
postpartum day, she notes that the fundus is firm, is at
the level of the umbilicus, and is displaced to the right.
The next action the nurse should take is to:
a. Check the client for bladder distention
b. Assess the blood pressure for hypotension
c. Determine whether an oxytocic drug was given
d. Check for the expulsion of small clots
Answer A is correct. If the fundus of the client is displaced to the side,
this might indicate a full bladder. The next action by the nurse should be
to check for bladder distention and catheterize, if necessary. The
answers in B, C, and D are actions that relate to postpartal hemorrhage.
44. A client is admitted to the hospital with a temperature of
99.8°F, complaints of blood-tinged hemoptysis, fatigue,
and night sweats. The client's symptoms are consistent
with a diagnosis of:
a. Pneumonia
b. Reaction to antiviral medication
c. Tuberculosis
d. Superinfection due to low CD4 count
Answer C is correct. A low-grade temperature, blood-tinged sputum,
fatigue, and night sweats are symptoms consistent with tuberculosis. If
the answer in A had said pneumocystis pneumonia, answer A would
have been consistent with the symptoms given in the stem, but just
saying pneumonia isn’t specific enough to diagnose the problem.
Answers B and D are not directly related to the stem.
45. The client is seen in the clinic for treatment of migraine
headaches. The drug Imitrex (sumatriptan succinate) is
prescribed for the client. Which of the following in the
client's history should be reported to the doctor?
a. Diabetes
b. Prinzmetal's angina
c. Cancer
d. Cluster headaches
Answer B is correct. If the client has a history of Prinzmetal’s angina, he
should not be prescribed triptan preparations because they cause
vasoconstriction and coronary spasms. There is no contraindication for
taking triptan drugs in clients with diabetes, cancer, or cluster headaches
making answers A, C, and D incorrect.
46. The client with suspected meningitis is admitted to the
unit. The doctor is performing an assessment to
determine meningeal irritation and spinal nerve root
inflammation. A positive Kernig's sign is charted if the
nurse notes:
a. Pain on flexion of the hip and knee
b. Nuchal rigidity on flexion of the neck
c. Pain when the head is turned to the left side
d. Dizziness when changing positionsAnswer A is correct. Kernig’s sign is positive if pain occurs on flexion of
the hip and knee. The Brudzinski reflex is positive if pain occurs on
flexion of the head and neck onto the chest so answer B is incorrect.
Answers C and D might be present but are not related to Kernig’s sign.
47. The client with Alzheimer's disease is being assisted with
activities of daily living when the nurse notes that the
client uses her toothbrush to brush her hair. The nurse is
aware that the client is exhibiting:
a. Agnosia
b. Apraxia
c. Anomia
d. Aphasia
Answer B is correct. Apraxia is the inability to use objects appropriately.
Agnosia is loss of sensory comprehension, anomia is the inability to find
words, and aphasia is the inability to speak or understand so answers A,
C, and D are incorrect.
48. The client with dementia is experiencing confusion late in
the afternoon and before bedtime. The nurse is aware
that the client is experiencing what is known as:
a. Chronic fatigue syndrome
b. Normal aging
c. Sundowning
d. Delusions
Answer C is correct. Increased confusion at night is known as
"sundowning" syndrome. This increased confusion occurs when the sun
begins to set and continues during the night. Answer A is incorrect
because fatigue is not necessarily present. Increased confusion at night
is not part of normal aging; therefore, answer B is incorrect. A delusion is
a firm, fixed belief; therefore, answer D is incorrect.
49. The client with confusion says to the nurse, "I haven't had
anything to eat all day long. When are they going to bring
breakfast?" The nurse saw the client in the day room
eating breakfast with other clients 30 minutes before this
conversation. Which response would be best for the
nurse to make?
a. "You know you had breakfast 30 minutes ago."
b. "I am so sorry that they didn't get you breakfast. I'll
report it to the charge nurse."
c. "I'll get you some juice and toast. Would you like
something else?"
d. "You will have to wait a while; lunch will be here in a
little while."
Answer C is correct. The client who is confused might forget that he ate
earlier. Don’t argue with the client. Simply get him something to eat that
will satisfy him until lunch. Answers A and D are incorrect because the
nurse is dismissing the client. Answer B is validating the delusion.
50. The doctor has prescribed Exelon (rivastigmine) for the
client with Alzheimer's disease. Which side effect is most
often associated with this drug?
a. Urinary incontinence
b. Headaches
c. Confusion
d. Nausea
Answer D is correct. Nausea and gastrointestinal upset are very
common in clients taking acetlcholinesterase inhibitors such as Exelon.
Other side effects include liver toxicity, dizziness, unsteadiness, and
clumsiness. The client might already be experiencing urinary
incontinence or headaches, but they are not necessarily associated; and
the client with Alzheimer’s disease is already confused. Therefore,
answers A, B, and C are incorrect.
51. A client is admitted to the labor and delivery unit in active
labor. During examination, the nurse notes a papular
lesion on the perineum. Which initial action is most
appropriate?
a. Document the finding
b. Report the finding to the doctor
c. Prepare the client for a C-section
d. Continue primary care as prescribed
Answer B is correct. Any lesion should be reported to the doctor. This
can indicate a herpes lesion. Clients with open lesions related to herpes
are delivered by Cesarean section because there is a possibility of
transmission of the infection to the fetus with direct contact to lesions. It
is not enough to document the finding, so answer A is incorrect. The
physician must make the decision to perform a C-section, making
answer C incorrect. It is not enough to continue primary care, so answer
D is incorrect. [Show Less]