NURSING REVIEW Nclex review Completed with Solutions
NO.1 A depressed client is seen at the mental health center for follow-up afer an atempted
... [Show More] suicide
1 week ago. She has taken phenelzine sulfate (Nardil), a monoamine oxidase
(MAO) inhibitor, for 7 straight days. She states that she is not feeling any beter. The nurse explains
that the drug must accumulate to an effectve 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
Explanaton:
(A) This answer is incorrect. It can take up to 1 month for therapeutc effect of the medicaton. (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 therapeutc effect of the medicaton. (D)
This answer is incorrect. Therapeutc effects of the medicaton are noted within 1 month of drug
therapy.
NO.2 Cystc fbrosis is transmited 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
Explanaton:
(A) Cystc fbrosis is not an X-linked or sex-linked disease. (B) The only characteristc 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 protestng "I am God." The nurse
identfes this as a:
A. Delusion
B. Illusion
1C. Hallucinaton
D. Conversion
Answer: A
Explanaton:
(A) Delusion is a false belief. (B) Illusion is the misrepresentaton of a real, external sensory
experience. (C) Hallucinaton is a false sensory percepton involving any of the senses. (D) Conversion
is the expression of intrapsychic conflict through sensory or motor manifestatons.
NO.4 In acute episodes of mania, lithium is effectve in 1-2 weeks, but it may take up to 4 weeks, or
even a few months, to treat symptoms fully. Sometmes an antpsychotc agent is prescribed during
the frst few days or weeks of an acute episode to manage severe behavioral excitement and acute
psychotc symptoms. In additon to the lithium, which one of the following medicatons might the
physician prescribe? A. Diazepam (Valium)
B. Haloperidol (Haldol)
C. Sertraline (Zolof)
D. Alprazolam (Xanax)
Answer: B
Explanaton:
(A) Diazepam is an antanxiety medicaton and is not designed to reduce psychotc symptoms. (B)
Haloperidol is an antpsychotc medicaton and may be used untl the lithium takes effect. (C)
Sertraline is an antdepressant and is used primarily to reduce symptoms of depression. (D)
Alprazolam is an antanxiety medicaton and is not designed to reduce psychotc symptoms.
NO.5 A violent client remains in restraints for several hours. Which of the following interventons is
most appropriate while he is in restraints? A. Give fluids if the client requests them.
B. Assess skin integrity and circulaton of extremites before applying restraints and as they
areremoved.
C. Measure vital signs at least every 4 hours.
D. Release restraints every 2 hours for client to exercise.
Answer: D
Explanaton:
(A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or refuses)
them or not. (B) Skin integrity and circulaton of the extremites should be checked regularly while the
client is restrained, not only before restraints are applied and afer 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 tme, to maintain muscle tone, skin and joint integrity, and
circulaton.
NO.6 The pediatrician has diagnosed tnea capits in an 8- year-old girl and has placed her on oral
griseofulvin. The nurse should emphasize which of these instructons to the mother and/or child?
A. Administer oral griseofulvin on an empty stomach for best results.
B. Discontnue drug therapy if food tastes funny.
C. May discontnue medicaton when the child experiences symptomatc relief.
D. Observe for headaches, dizziness, and anorexia.
2Answer: D
Explanaton:
(A) Giving the drug with or afer meals may allay gastrointestnal discomfort. Giving the drug with a
faty meal (ice cream or milk) increases absorpton rate. (B) Griseofulvin may alter taste sensatons
and thereby decrease the appette. Monitoring of food intake is important, and inadequate nutrient
intake should be reported to the physician. (C) The child may experience symptomatc relief afer
4896 hours of therapy. It is important to stress contnuing the drug therapy to prevent relapse
(usually about 6 weeks). (D) The incidence of side effects is low; however, headaches are common.
Nausea, vomitng, 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 ratonale for this therapy is to:
A. Prevent systemic infecton
B. Promote diuresis
C. Decrease ammonia formaton
D. Acidify the small bowel
Answer: C
Explanaton:
(A) Neomycin is an antbiotc, but this is not the Ratonale for administering it to a client in hepatc
coma. (B) Diuretcs and salt-free albumin are used to promote diuresis in clients with cirrhosis of the
liver. (C) Neomycin destroys the bacteria in the intestnes. 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 postoperatve 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
Explanaton:
(A) The nurse should discourage the child from coughing, clearing the throat, or putng 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
distnguish fresh or old blood from ingested liquid should the child vomit. (C) Gargles and vigorous
toothbrushing could initate bleeding. (D) Postoperatve hemorrhage, though unusual, may occur. The
nurse should observe for bleeding by looking directly into the throat and for vomitng of bright red
blood, contnuous 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 lef
leg that started approximately 20 minutes ago. When performing the admission assessment, the
nurse would expect to observe which of the following:
3A. Both lower extremites warm to touch with 2_pedal pulses
B. Both lower extremites cyanotc when placed in a dependent positon
C. Decreased or absent pedal pulse in the lef leg
D. The lef leg warmer to touch than the right leg
Answer: C
Explanaton:
(A) This statement describes a normal assessment fnding of the lower extremites. (B) This
assessment fnding reflects problems caused by venous insufciency. (C) Decreased or absentpedal
pulses reflect a problem caused by arterial insufciency. (D) The leg that is experiencing arterial
insufciency would be cool to touch due to the decreased circulaton.
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 notfcaton of physician?
A. pH 7.39
B. White blood cell (WBC) count 10,000 WBCs/mm3
C. Hematocrit 60%
D. Bleeding tme of 4 minutes
Answer: C
Explanaton:
(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 complicaton of cyanotc heart disease. (D) Normal bleeding
tme is 2-7 minutes.
NO.11 A male client is experiencing extreme distress. He begins to pace up and down the corridor.
What nursing interventon is appropriate when communicatng 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
Explanaton:
(A) The nurse should not ask him to sit down. Pacing is the actvity 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 atemptng 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 afer 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 amniotc fluid
C. Locate the positon of the placenta and fetus
D. Ensure that the fetus is mature enough to perform the amniocentesis
4Answer: C
Explanaton:
(A) Amniocentesis can be performed to assess for lung maturity. Fetal ultrasound can be used for
gestatonal datng, although it does not separately determine lung maturity. (B) Ultrasound can
evaluate amniotc fluid volume, which may be used to determine congenital anomalies. (C)
Amniocentesis involves removal of amniotc fluid for evaluaton. The needle, inserted through the
abdomen, is guided by ultrasound to avoid needle injuries, and the test evaluates the positon 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 frst child. She schedules an
obstetric examinaton with the nurse practtoner to determine the status of her possible pregnancy.
Her last menstrual period began May 20, and her estmated date of confnement using Nagele's rule
is:
A. March 27
B. February 1
C. February 27
D. January 3
Answer: C
Explanaton:
(A)March 27 is a miscalculaton. (B) February 1 is a miscalculaton. (C) February 27 is the correct
answer. To calculate the estmated date of confnement 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
miscalculaton.
NO.14 A client is now pregnant for the second tme. Her frst 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 classifed as having:
A. Insulin-dependent diabetes
B. Type II diabetes mellitus
C. Type I diabetes mellitus
D. Gestatonal diabetes mellitus
Answer: D
Explanaton:
(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) Gestatonal diabetes mellitus has its onset of symptoms during
pregnancy and usually disappears afer delivery. These symptoms are usually mild and not life
threatening, although they are associated with increased fetal morbidity and other fetal
complicatons.
NO.15 A 44-year-old female client is receiving external radiaton to her scapula for metastasis of
breast cancer.
5Teaching 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 afer each treatment
.
B. Teach her to cover broken skin in the treated area with a medicated ointment.
C. Encourage her to wear a tght-ftng vest to support her scapula.
D. Encourage her to avoid direct sunlight on the area being treated.
Answer: D
Explanaton:
(A) The skin in a treatment area should be rinsed with water and pated dry. Markings should be lef
intact, and the skin should not be scrubbed. (B) Clients should avoid putng any creams or lotons on
the treated area. This could interfere with treatment. (C) Radiaton therapy clients should wear
looseftng clothes and avoid tght, irritatng fabrics. (D) The area of skin being treated is sensitve 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 assistng a 4th-day postoperatve cholecystectomy client in planning her meals for
tomorrow's menu. Which vitamin is the most essental in promotng tssue healing? A. Vitamin C
B. Vitamin B1
C. Vitamin D
D. Vitamin AAnswer: A Explanaton:
(A) Vitamin C (ascorbic acid) is essental in promotng wound healing and collagen formaton. (B)
Vitamin B1 (thiamine) maintains normal gastrointestnal (GI) functoning, oxidizes carbohydrates, and
is essental for normal functoning of nervous tssue. (C) Vitamin D regulates absorpton of calcium
and phosphorus from the GI tract and helps prevent rickets. (D) Vitamin A is necessary for the
formaton and maintenance of skin and mucous membranes. It is also essental 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 tracton. He is exhibitng
behavioral changes including restlessness, difculty with problem solving, inability to concentrate on
actvites, and monotony. Which of the following nursing implementatons would be most effectve in
helping him cope with immobility?
A. Providing him with books, challenging puzzles, and games as diversionary actvites
B. Allowing him to do as much for himself as he is able, including learning to do pin-site care
undersupervision
C. Having a volunteer come in to sit with the client and to read him stories
D. Stmulatng rest and relaxaton by gentle rubbing with loton and changing the client's
positonfrequently Answer: B
Explanaton:
(A) These actvites could be frustratng for the client if he is having difculty with problem solving and
concentraton. (B) Selfcare is usually well received by the child, and it is one of the most useful
interventons to help the child cope with immobility. (C) This may be helpful to the client if he has no
visitors, but it does litle to help him develop coping skills. (D) This will helpto prevent skin irritaton or
breakdown related to immobility but will not help to prevent behavioral changes related to
immobility.
6NO.18 In client teaching, the nurse should emphasize that fetal damage occurs more frequently with
ingeston of drugs during:
A. First trimester
B. Second trimester
C. Third trimester
D. Every trimester
Answer: A
Explanaton:
(A) Organogenesis occurs in the frst trimester. Fetus is most susceptble to malformaton during this
period. (B) Organogenesis has occurred by the second trimester. (C) Fetal development is complete by
this tme. (D) The dangerous period for fetal damage is the frst trimester, not the entre pregnancy.
NO.19 On admission, the client has signs and symptoms of pulmonary edema. The nurse places the
client in the most appropriate positon for a client in pulmonary edema, which is:
A. High Fowler
B. Lying on the lef side
C. Sitng in a chair
D. Supine with feet elevated
Answer: A
Explanaton:
(A) High Fowler positon decreases venous return to the heart and permits greater lung expansion so
that oxygenaton is maximized. (B) Lying on the lef side may improve perfusion to the lef lung but
does not promote lung expansion. (C) Sitng in a chair will decrease venous return and promote
maximal lung expansion. However, clients with pulmonary edema can deteriorate quickly and require
intubaton and mechanical ventlaton. If a client is sitng in achair when this deterioraton happens,
it will be difcult to intervene quickly. (D) The supine with feet elevated positon increases venous
return and will worsen pulmonary edema.
NO.20 A client has returned to the unit from the recovery room afer having a thyroidectomy. The
nurse knows that a major complicaton afer a thyroidectomy is:
A. Respiratory obstructon
B. Hypercalcemia
C. Fistula formaton
D. Myxedema
Answer: A
Explanaton:
(A)
Respiratory obstructon due to edema of the glots, bilateral laryngeal nerve damage, or tracheal
compression from hemorrhage is a major complicaton afer a thyroidectomy.
(B)
Hypocalcemia accompanied by tetany from accidental removal of one or more parathyroid glands is a
major complicaton, not hypercalcemia. (C) Fistula formaton is not a major complicaton associated
with a thyroidectomy. It is a major complicaton with a laryngectomy.(D) Myxedema is
7hypothyroidism that occurs in adults and is not a complicaton of a thyroidectomy. A thyroidectomy
client tends to develop thyroid storm, which is excess producton 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
Explanaton:
(A) This observaton can be made during the taking-in phase when the mother's needs are more
important. (B) This observaton can be made during the taking-hold phase when the mother is
actvely involved with herself and the infant. (C, D) This observaton can be made during the taking-in
phase.
NO.22 A female client has just died. Her family is requestng 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,
requestng that only family members be present. The nurse assigned to the client should perform the
appropriate nursing acton, 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 untl it can
bebrought to the morgue.
C. Tell the family that they may conduct their ceremony in the client's room; however, the nursemust
atend.
D. Respect the client's family's wishes.
Answer: D
Explanaton:
(A) It is rare that a hospital has a specifc policy addressing this partcular issue. If the statement is
true, the nurse should show evidence of the policy to the family and suggest alternatves, 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 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 specifc cultural and religious differences dictatng social
customs.
NO.23 A woman diagnosed with multple sclerosis is disturbed with diplopia. The nurse will teach her
to:
A. Limit actvites which require focusing (close vision)
B. Take more frequent naps
C. Use artfcial tears
D. Wear a patch over one eye
Answer: D
Explanaton:
(A)
8Limitng actvites requiring close vision will not alleviate the discomfort of double vision.
(B)
Frequent naps may be comfortng, but they will not prevent double vision. (C) Artfcial tears are
necessary in the absence of a corneal reflex, but they have no effect on diplopia.
(D)
An eye patch over either eye will eliminate the effects of double vision during the tme the eye patch
is worn. An eye patch is safe for a person with an intact corneal reflex.
NO.24 One of the most reliable assessment tools for adequacy of fluid resuscitaton in burned
children is:
A. Blood pressure
B. Level of consciousness
C. Skin turgor
D. Fluid intake
Answer: B
Explanaton:
(A)
Blood pressure can remain normotensive in a state of hypovolemia. (B) Capillary refll, alteratons in
sensorium, and urine output are the most reliable indicators for assessing hydraton. (C) Skin turgor is
not a reliable indicator for assessing hydraton in a burn client.
(D)
Fluid intake does not indicate adequacy of fluid resuscitaton in a burn client.
NO.25 Which one of the following is considered a reliable indicator for assessing the adequacy of fluid
resuscitaton in a 3-year-old child who suffered partal- and fullthickness burns to 25% of her body?
A. Urine output
B. Edema
C. Hypertension
D. Bulging fontanelle
Answer: A
Explanaton:
(A) Urinary output is a reliable indicator of renal perfusion, which in turn indicates that fluid
resuscitaton is adequate. IV fluids are adjusted based on the urinary output of the child during fluid
resuscitaton. (B) Edema is an indicaton of increased capillary permeability following a burn injury. (C)
Hypertension is an indicator of fluid volume excess. (D) Fontanelles close by 18 months of age.
NO.26 A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because
this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and
report:
A. Dizziness and tachypnea
B. Circumoral pallor and lightheadedness
C. Headache and facial flushing
D. Pallor and itching of the face and neck
9Answer: C
Explanaton:
(A) Tachypnea is not a symptom. (B) Circumoral pallor is not a symptom. (C) Autonomic dysreflexia is
an uninhibited and exaggerated reflex of the autonomic nervous system to stmulaton, which results
in vasoconstricton and elevated blood pressure. (D) Pallor and itching are not symptoms.
NO.27 A client states to his nurse that "I was told by the doctor not to take one of my drugs because it
seems to have caused decreasing blood cells." Based on this informaton, which drug might the nurse
expect to be discontnued?
A. Prednisone
B. Timolol maleate (Blocadren)
C. Garamycin (Gentamicin)
D. Phenytoin (Dilantn)
Answer: D
Explanaton:
(A) Prednisone is not linked with hematological side effects. (B) Timolol, a -adrenergic blocker is
metabolized by the liver. It has not been linked to blood dyscrasia. (C) Gentamicin is ototoxic and
nephrotoxic. (D) Phenytoin usage has been linked to blood dyscrasias such as aplastc anemia. The
drug most commonly linked to aplastc anemia is chloramphenicol (Chlormycetn).
NO.28 A client has been taking lithium 300 mg po bid for the past two weeks. This morning her
lithium level was 1 mEq/L. The nurse should:
A. Notfy the physician immediately
B. Hold the morning lithium dose and contnue to observe the client
C. Administer the morning lithium dose as scheduled
D. Obtain an order for benztropine (Cogentn)
Answer: C
Explanaton:
(A) There is no need to phone the physician because the lithium level is within therapeutc range and
because there are no indicatons of toxicity present. (B) There is no reason to withhold the lithium
because the blood level is within therapeutc range. Also, it is necessary to give the medicaton as
scheduled to maintain adequate blood levels. (C) The lab results indicate that the client's lithium level is
within therapeutc range (0.2-1.4 mEq/L), so the medicaton should be given as ordered. (D) Benztropine
is an antparkinsonism drug frequently given to counteractextrapyramidal symptoms associated with the
administraton of antpsychotc drugs (not lithium).
NO.29 The primary focus of nursing interventons for the child experiencing sickle cell crisis is aimed
toward:
A. Maintaining an adequate level of hydraton
B. Providing pain relief
C. Preventng infecton
D. O2 therapy
Answer: A
Explanaton:
10(A) Maintaining the hydraton level is the focus for nursing interventon because dehydraton
enhances the sickling process. Both oral and parenteral fluids are used. (B) The pain is a result of the
sickling process. Analgesics or narcotcs will be used for symptom relief, but the underlying cause of
the pain will be resolved with hydraton. (C) Serious bacterial infectons may result owing to splenic
dysfuncton. This is true at all tmes, not just during the acute period of a crisis. (D) O2 therapy is used
for symptomatc relief of the hypoxia resultng from the sickling process. Hydraton is the primary
interventon to alleviate the dehydraton that enhances the sickling process.
NO.30 Three weeks following discharge, a male client is readmited to the psychiatric unit for
depression. His wife stated that he had threatened to kill himself with a handgun. As the nurse
admits him to the unit, he says, "I wish I were dead because I am worthless to everyone; I guess I am
just no good." Which response by the nurse is most appropriate at this tme? A. "I don't think you
are worthless. I'm glad to see you, and we will help you."
B. "Don't you think this is a sign of your illness?"
C. "I know with your wife and new baby that you do have a lot to live for."
D. "You've been feeling sad and alone for some tme now?"
Answer: D
Explanaton:
(A)
This response does not acknowledge the client's feelings.
(B)
This is a closed queston and does not encourage communicaton.
(C)
This response negates the client's feelings and does not require a response from the client. (D) This
acknowledges the client's implied thoughts and feelings and encourages a response.
NO.31 A 52-year-old client is scheduled for a small-bowel resecton in the morning. In conjuncton
with other preoperatve preparaton, the nurse is teaching her diaphragmatc breathing exercises.
She will teach the client to:
A. Inhale slowly and deeply through the nose untl the lungs are fully expanded, hold the breath
acouple of seconds, and then exhale slowly through the mouth. Repeat 2-3 more tmes to
complete the series every 1-2 hours while awake
B. Purse the lips and take quick, short breaths approximately 18-20 tmes/min
C. Take a large gulp of air into the mouth, hold it for 10-15 seconds, and then expel it through
thenose. Repeat 4-5 tmes to complete the series
D. Inhale as deeply as possible and then immediately exhale as deeply as possible at a rate
ofapproximately 20-24 tmes/min
Answer: A
Explanaton:
(A) This is the correct method of teaching diaphragmatc breathing, which allows full lung expansion
to increase oxygenaton, prevent atelectasis, and move secretons up and out of the lungs to decrease
risk of pneumonia. (B) Quick, short breaths do not allow for full lung expansion and movement of
secretons up and out of the lungs. Quick, short breaths may lead to O2 depleton, hyperventlaton,
and hypoxia. (C) Expelling breaths through the nose does not allow for full lung expansion and the
11use of diaphragmatc muscles to assist in moving secretons up and out of the lungs. (D) Inhaling and
exhaling at a rate of 20-24 tmes/min does not allow tme for full lung expansion to increase
oxygenaton. This would most likely lead to O2 depleton and hypoxia.
NO.32 The nurse enters the playroom and fnds an 8-year-old child having a grand mal seizure. Which
one of the following actons should the nurse take? A. Place a tongue blade in the child's mouth.
B. Restrain the child so he will not injure himself.
C. Go to the nurses staton and call the physician.
D. Move furniture out of the way and place a blanket under his head.
Answer: D
Explanaton:
(A) The nurse should not put anything in the child's mouth during a seizure; this acton could obstruct
the airway. (B) Restraining the child's movements could cause constrictve injury. (C) Staying with the
child during a seizure provides protecton and allows the nurse to observe the seizure actvity. (D) The
nurse should provide safety for the child by moving objects and protectng the head.
NO.33 An 11-year-old boy has received a partal-thickness burn to both legs. He presents to the
emergency room approximately 15 minutes afer the accident in excruciatng pain with charred
clothing to both legs. What is the frst nursing acton? A. Apply ice packs to both legs.
B. Begin debridement by removing all charred clothing from wound.
C. Apply Silvadene cream (silver sulfadiazine).
D. Immerse both legs in cool water.
Answer: D
Explanaton:
(A)
Ice creates a dramatc temperature change in the tssue, which can cause further thermal injury. (B)
Charred clothing should not be removed from wound frst. This creates further tssue damage.
Debridement is not the frst nursing acton. (C) Applying silver sulfadiazine cream frst insulates heat
in injured tssue and increases potental for infecton.
(D)
Emergency care of a thermal burn is immersing both legs in cool water. Cool water permits gradual
temperature change and prevents further thermal damage.
NO.34 The nurse notes scatered crackles in both lungs and 1+ pitng edema when assessing a
cardiac client. The physician is notfed and orders furosemide (Lasix) 80 mg IV push stat. Which of
the following diagnostc studies is monitored to assess for a major complicaton of this therapy?
A. Serum electrolytes
B. Arterial blood gases
C. Complete blood count
D. 12-Lead ECG
Answer: A
Explanaton:
(A) Furosemide, a potassium-depletng diuretc, inhibits the reabsorpton of sodium and chloride from
the loop of Henle and the distal renal tubules. Serum electrolytes are monitored for hypokalemia. (B)
Severe acid-base imbalances influence the movement of potassium into and out of the cells, but
12arterial blood gases to not measure the serum potassium level. (C) Furosemide is a potassiumdepletng diuretc. A complete blood count does not reflect potassium levels. (D) Abnormalites in
potassium (both hyperkalemia and hypokalemia) are reflected in ECG changes, but these changes do
not occur untl the abnormality is severe.
NO.35 A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client
insight and behavioral change by which of the following client statements?
A. "When I get home, I will need to take my medicines and call my therapist if I have any side
effectsor begin to hear voices."
B. "If I have any side effects from my medicines, I will take an extra dose of Cogentn."
C. "When I get home, I should be able to taper myself off the Haldol because the voices are
gonenow."
D. "As soon as I leave here, I'm throwing away my medicines. I never thought I needed themanyway."
Answer: A
Explanaton:
(A)
The client verbalizes that he is responsible for compliance and keeping the treatment team member
informed of progress. This behavior puts him at the lowest risk for relapse.
(B)
Noncompliance is a major cause of relapse. This statement reflects lack of responsibility for his own
health maintenance. (C) This statement reflects lack of insight into the importance of compliance. (D) This
statement reflects no insight into his illness or his responsibility in health maintenance.
NO.36 A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routne
examinaton and screening. Which of these plans by the nurse would be most successful? A.
Examine the 4 year old frst.
B. Provide tme for play and becoming acquainted.
C. Have the mother leave the room with one child, and examine the other child privately.
D. Examine painful areas frst to get them "over with."
Answer: B
Explanaton:
(A)
The 6 month old should be examined frst. If several children will be examined, begin with the most
cooperatve and less anxious child to provide modeling. (B) Providing tme for play and getng
acquainted minimizes stress and anxiety associated with assessment of body parts. (C) Children
generally cooperate best when their mother remains with them.
(D)
Painful areas are best examined last and will permit maximum accuracy of assessment.
NO.37 Diagnostc assessment fndings for an infant with possible coarctaton of the aorta would
include:
A. A third heart sound
B. A diastolic murmur
C. Pulse pressure difference between the upper extremites
13D. Diminished or absent femoral pulses
Answer: D
Explanaton:
(A) S1 and S2 in an infant with coarctaton of the aorta are usually normal. S3 and S4 do not exist with
this diagnosis. (B) Either no murmur will be heard or a systolic murmur from an associated cardiac
defect will be heard along the lef upper sternal border. A diastolic murmur is not associated with
coarctaton of the aorta. (C) Pulse pressure differences of>20 mm Hg exist between the upper
extremites and the lower extremites. It is important to evaluate the upper and lower extremites
with the appropriate- sized cuffs. (D) Femoral and pedal pulses will be diminished or absent in infants
with coarctaton of the aorta.
NO.38 During a client's frst postpartum day, the nurse assessed that the fundus was located laterally
to the umbilicus.
This may be due to:
A. Endometrits
B. Fibroid tumor on the uterus
C. Displacement due to bowel distenton
D. Urine retenton or a distended bladder
Answer: D
Explanaton:
(A, B) Endometrits, urine retenton, or bladder distenton provide good distractors because they may
delay involuton but do not usually cause the uterus to be lateral. (C) Bowel distenton and
constpaton are common in the postpartum period but do not displace the uterus laterally. (D) Urine
retenton or bladder distenton commonly displaces the uterus to the right and may delay involuton.
NO.39 An 80-year-old widow is living with her son and daughter- in-law. The home health nurse has
been making weekly visits to draw blood for a prothrombin tme test. The client is taking 5 mg of
coumadin per day. She appears more debilitated, and bruises are noted on her face. Elder abuse is
suspected. Which of the following are signs of persons who are at risk for abusing an elderly person?
A. A family member who is having marital problems and is regularly abusing alcohol
B. A person with adequate communicaton and coping skills who is employed by the family
C. A friend of the family who wants to help but is minimally competent
D. A lifelong friend of the client who is ofen confused
Answer: A
Explanaton:
(A)
This answer is correct. Two risk factors are identfed in this answer. (B) This answer is incorrect.
Persons at risk tend to lack communicaton skills and effectve coping paterns.
(C)
This answer is incorrect. Persons at risk are usually family members or those reluctant to provide care.
(D) This answer is incorrect. This individual has a vested interest in providing care.
NO.40 A 32-year-old female client is being treated for Guillain- Barre syndrome. She complains of
gradually increasing muscle weakness over the past several days. She has notced an increased
14difculty in ambulatng and fell yesterday. When conductng a nursing assessment, which fnding
would indicate a need for immediate further evaluaton?
A. Complaints of a headache
B. Loss of superfcial and deep tendon reflexes
C. Complaints of shortness of breath
D. Facial paralysis
Answer: C
Explanaton:
(A) Headaches are not associated with Guillain-Barre syndrome. (B) Loss of superfcial and deep
tendon reflexes is expected with this diagnosis. (C) Complaints of shortness of breath must be further
evaluated. Forty percent of all clients have some detectable respiratory weakness and should be
prepared for a possible tracheostomy. Pneumonia is also a common complicaton of this syndrome.
(D) Facial paralysis is expected and is not considered abnormal.
NO.41 Plans for the care of a client with an ulcer caused by emotonal problems need to take into
consideraton that:
A. His priority needs are limited to medical management
B. There is no real psychological basis for his illness
C. The disorder is a threat to his physical well-being
D. He is unable to partcipate in planning his care
Answer: C
Explanaton:
(A)
There may be a medical emergency that takes top priority; however, the basis of the problem is
emotonal. (B) The problem is a physical manifestaton of an emotonal conflict.
(C)
The bleeding ulcer can be life threatening. (D) For lifestyle change to occur, the client must partcipate
in the planning of his care so that he is commited to changes that will have positve results.
NO.42 A 55-year-old man has recently been diagnosed with hypertension. His physician orders a
lowsodium diet for him. When he asks, "What does salt have to do with high blood pressure?'' the
nurse's inital response would be:
A. "The reason is not known why hypertension is associated with a high-salt diet."
B. "Large amounts of salt in your diet can cause you to retain fluid, which increases your
bloodpressure."
C. "Salt affects your blood vessels and causes your blood pressure to be high."
D. "Salt is needed to maintain blood pressure, but too much causes hypertension."
Answer: B
Explanaton:
(A) This response is untrue. (B) Decreasing salt intake reduces fluid retenton and decreases blood
pressure. (C) Salt does not have an effect on the blood vessels themselves, but on fluid retenton,
which accompanies salt intake. (D) This response is untrue.
NO.43 A client is medically cleared for ECT and is tentatvely scheduled for six treatments over a
2week period. Her husband asks, "Isn't that a lot?" The nurse's best response is:
15A. "Yes, that does seem like a lot."
B. "You'll have to talk to the doctor about that. The physician knows what's best for the client."
C. "Six to 10 treatments are common. Are you concerned about permanent effects?"
D. "Don't worry. Some clients have lots more than that."
Answer: C
Explanaton:
(A) This response indicates that the nurse is unsure of herself and not knowledgeable about ECT. It
also reinforces the husband's fears. (B) This response is "passing the buck" unnecessarily. The
informaton needed to appropriately answer the husband's queston is well within the nurse's
knowledge base. (C) The most common range for affectve disorders is 6-10 treatments. This response
confrms and reinforces the physician's plan for treatment. It also opens communicatonwith the
husband to identfy underlying fears and knowledge defcits. (D) This response offers false
reassurance and dismisses the husband's underlying concerns about his wife.
NO.44 A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening
complicatons may occur initally, so the nurse will monitor him closely for serum:
A. Chloride level of 99 mEq/L
B. Sodium level of 136 mEq/L
C. Potassium level of 3.1 mEq/L
D. Potassium level of 6.3 mEq/L
Answer: D
Explanaton:
(A) The chloride level is within acceptable limits. (B) The sod [Show Less]