RN NCLEX Questions And Answers
2022
A nurse is caring for an older adult client who has a new diagnosis of type 2 diabetes
mellitus and reports
... [Show More] difficulty following the diet and remembering to take the
prescribed medication.
Which of the following actions should the nurse take to promote client compliance?
(SATA)
A. Ask the dietitian to assist with meal planning
B. Contact the client's support system
C. Assess for age-related cognitive awareness
D. Encourage the use of a daily medication dispenser
E. Provide educational materials for home use - Answer- A, B, D, E
A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 8%. On
the basis of this test result, the nurse plans to teach the client about the need for
which measure?
A. Avoiding infection
B. Taking in adequate fluids
C. Preventing and recognizing hypoglycemia
D. Preventing and recognizing hyperglycemia - Answer- D
Rationale:
The normal reference range for the glycosylated hemoglobin A1c is less than 6.0%.
This test measures the amount of glucose that has become permanently bound to
the red blood cells from circulating glucose. Erythrocytes live for about 120 days,
giving feedback about blood glucose for the past 120 days. Elevations in the blood
glucose level will cause elevations in the amount of glycosylation. Thus, the test is
useful in identifying clients who have periods of hyperglycemia that are undetected in
other ways. The estimated average glucose for a glycosylated hemoglobin A1c of
8% is 205 mg/dL (11.42 mmol/L). Elevations indicate continued need for teaching
related to the prevention of hyperglycemic episodes.
The nurse is instructing a client how to perform a testicular self-examination (TSE).
The nurse should explain that which is the best time to perform this exam?
A. After a shower or bath
B. While standing to void
C. After having a bowel movement
D. While lying in bed before arising - Answer- A
Rationale:
The nurse needs to teach the client how to perform a TSE. The nurse should instruct
the client to perform the exam on the same day each month. The nurse should also
instruct the client that the best time to perform a TSE is after a shower or bath when
the hands are warm and soapy and the scrotum is warm. Palpation is easier and the
client will be better able to identify any abnormalities. The client would stand to
perform the exam, but it would be difficult to perform the exam while voiding. Having
a bowel movement is unrelated to performing a TSE.
The clinic nurse prepares to perform a focused assessment on a client who is
complaining of symptoms of a cold, a cough, and lung congestion. Which should the
nurse include for this type of assessment? Select all that apply.
A. Auscultating lung sounds
B. Obtaining the client's temperature
C. Assessing the strength of peripheral pulses
D. Obtaining information about the client's respirations
E. Performing a musculoskeletal and neurological examination
F. Asking the client about a family history of any illness or disease - Answer- A, B, D
Rationale:
A focused assessment focuses on a limited or short-term problem, such as the
client's complaint. Because the client is complaining of symptoms of a cold, a cough,
and lung congestion, the nurse would focus on the respiratory system and the
presence of an infection. A complete assessment includes a complete health history
and physical examination and forms a baseline database. Assessing the strength of
peripheral pulses relates to a vascular assessment, which is not related to this
client's complaints. A musculoskeletal and neurological examination also is not
related to this client's complaints. However, strength of peripheral pulses and a
musculoskeletal and neurological examination would be included in a complete
assessment. Likewise, asking the client about a family history of any illness or
disease would be included in a complete assessment.
The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral
development with a parent. The nurse should tell the parent that which factor
motivates good and bad actions for the child at the preconventional level?
A. Peer pressure
B. Social pressure
C. Parents' behavior
D. Punishment and reward - Answer- D
Rationale:
In the preconventional stage, morals are thought to be motivated by punishment and
reward. If the child is obedient and is not punished, then the child is being moral. The
child sees actions as good or bad. If the child's actions are good, the child is praised.
If the child's actions are bad, the child is punished. Options 1, 2, and 3 are not
associated factors for this stage of moral development.
The maternity nurse is providing instructions to a new mother regarding the
psychosocial development of the newborn infant. Using Erikson's psychosocial
development theory, the nurse instructs the mother to take which measure?
A. Allow the newborn infant to signal a need.
B. Anticipate all needs of the newborn infant.
C. Attend to the newborn infant immediately when crying.
D. Avoid the newborn infant during the first 10 minutes of crying. - Answer- A
Rationale:According to Erikson, the caregiver should not try to anticipate the
newborn infant's needs at all times but must allow the newborn infant to signal
needs. If a newborn infant is not allowed to signal a need, the newborn will not learn
how to control the environment. Erikson believed that a delayed or prolonged
response to a newborn infant's signal would inhibit the development of trust and lead
to mistrust of others.
A nursing student is presenting a clinical conference to peers regarding Freud's
psychosexual stages of development, specifically the anal stage. The student
explains to the group that which characteristic relates to the anal stage?
A. This stage is associated with toilet training.
B. This stage is characterized by the gratification of self.
C. This stage is characterized by a tapering off of conscious biological and sexual
urges.
D. This stage is associated with pleasurable and conflicting feelings about the genital
organs. - Answer- A
Rationale:
In general, toilet training occurs during the anal stage. According to Freud, the child
gains pleasure from the elimination of feces and from their retention. Option 2 relates
to the oral stage. Option 3 relates to the latency period. Option 4 relates to the phallic
stage.
The nurse is describing Piaget's cognitive developmental theory to pediatric nursing
staff. The nurse should tell that staff that which child behavior is characteristic of the
formal operations stage?
A. The child has the ability to think abstractly.
B. The child begins to understand the environment.
C. The child is able to classify, order, and sort facts.
D. The child learns to think in terms of past, present, and future. - Answer- A
Rationale:
In the formal operations stage, the child has the ability to think abstractly and
logically. Option 2 identifies the sensorimotor stage. Option 3 identifies the concrete
operational stage. Option 4 identifies the preoperational stage.
The mother of an 8-year-old child tells the clinic nurse that she is concerned about
the child because the child seems to be more attentive to friends than anything else.
Using Erikson's psychosocial development theory, the nurse should make which
response?
A. "You need to be concerned."
B. "You need to monitor the child's behavior closely."
C. "At this age, the child is developing his own personality."
D. "You need to provide more praise to the child to stop this behavior." - Answer- C
Rationale:According to Erikson, during school-age years (6 to 12 years of age), the
child begins to move toward peers and friends and away from the parents for
support. The child also begins to develop special interests that reflect his or her own
developing personality instead of the parents'. Therefore, options 1, 2, and 4 are
incorrect responses.
The nurse educator is preparing to conduct a teaching session for the nursing staff
regarding the theories of growth and development and plans to discuss Kohlberg's
theory of moral development. What information should the nurse include in the
session? Select all that apply
A. Individuals move through all 6 stages in a sequential fashion.
B. Moral development progresses in relationship to cognitive development.
C. A person's ability to make moral judgments develops over a period of time.
D. The theory provides a framework for understanding how individuals determine a
moral code to guide their behavior.
E. In stage 1 (punishment-obedience orientation), children are expected to reason as
mature members of society.
F. In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain
rewards or have favors returned. - Answer- B, C, D, F
Rationale:
Kohlberg's theory states that individuals move through stages of development in a
sequential fashion but that not everyone reaches stages 5 and 6 in his or her
development of personal morality. The theory provides a framework for
understanding how individuals determine a moral code to guide their behavior. It
states that moral development progresses in relationship to cognitive development
and that a person's ability to make moral judgments develops over a period of time.
In stage 1, ages 2 to 3 years (punishment-obedience orientation), children cannot
reason as mature members of society. In stage 2, ages 4 to 7 years (instrumentalrelativist orientation), the child conforms to rules to obtain rewards or have favors
returned.
A parent of a 3-year-old tells a clinic nurse that the child is rebelling constantly and
having temper tantrums. Using Erikson's psychosocial development theory, which
instructions should the nurse provide to the parent? Select all that apply.
A. Set limits on the child's behavior.
B. Ignore the child when this behavior occurs.
C. Allow the behavior, because this is normal at this age period.
D. Provide a simple explanation of why the behavior is unacceptable.
E. Punish the child every time the child says "no" to change the behavior. - AnswerA, D
Rationale:
According to Erikson, the child focuses on gaining some basic control over self and
the environment and independence between ages 1 and 3 years. Gaining
independence often means that the child has to rebel against the parents' wishes.
Saying things like "no" or "mine" and having temper tantrums are common during
this period of development. Being consistent and setting limits on the child's behavior
are necessary elements. Providing a simple explanation of why certain behaviors are
unacceptable is an appropriate action. Options 2 and 3 do not address the child's
behavior. Option 5 is likely to produce a negative response during this normal
developmental pattern.
A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The
child is fearful of the hospitalization. Which nursing intervention should be
implemented to alleviate the child's fears?
A. Encourage the child's parents to stay with the child.
B. Encourage play with other children of the same age.
C. Advise the family to visit only during the scheduled visiting hours.
D. Provide a private room, allowing the child to bring favorite toys from home. -
Answer- A
Rationale:
Although the preschooler already may be spending some time away from parents at
a day care center or preschool, illness adds a stressor that makes separation more
difficult. The child may ask repeatedly when parents will be coming for a visit or may
constantly want to call the parents. Options 3 and 4 increase stress related to
separation anxiety. Option 2 is unrelated to the subject of the question and, in
addition, may not be appropriate for a child who may be immunocompromised and at
risk for infection.
A 16-year-old client is admitted to the hospital for acute appendicitis and an
appendectomy is performed. Which nursing intervention is most appropriate to
facilitate normal growth and development postoperatively?
A. Encourage the client to rest and read.
B. Encourage the parents to room in with the client.
C. Allow the family to bring in the client's favorite computer games. D. Allow the
client to interact with others in his or her same age group. - Answer- D
Rationale:
Adolescents often are not sure whether they want their parents with them when they
are hospitalized. Because of the importance of their peer group, separation from
friends is a source of anxiety. Ideally, the members of the peer group will support
their ill friend. Options 1, 2, and 3 isolate the client from the peer group.
The nurse is caring for a client with heart failure. On assessment, the nurse notes
that the client is dyspneic, and crackles are audible on auscultation. What additional
manifestations would the nurse expect to note in this client if excess fluid volume is
present?
A. Weight loss and dry skin
B. Flat neck and hand veins and decreased urinary output
C. An increase in blood pressure and increased respirations
D. Weakness and decreased central venous pressure (CVP) - Answer- C
Rationale:
A fluid volume excess is also known as overhydration or fluid overload and occurs
when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment
findings associated with fluid volume excess include cough, dyspnea, crackles,
tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP,
weight gain, edema, neck and hand vein distention, altered level of consciousness,
and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary
output, and decreased CVP are noted in fluid volume deficit. Weakness can be
present in either fluid volume excess or deficit.
Potassium chloride intravenously is prescribed for a client with heart failure
experiencing hypokalemia. Which actions should the nurse take to plan for
preparation and administration of the potassium? Select all that apply.
A. Obtain an intravenous (IV) infusion pump.
B. Monitor urine output during administration.
C. Prepare the medication for bolus administration.
D. Monitor the IV site for signs of infiltration or phlebitis.
E. Ensure that the medication is diluted in the appropriate volume of fluid.
F. Ensure that the bag is labeled so that it reads the volume of potassium in the
solution. - Answer- A, B, D, E, F
Rationale:
Potassium chloride administered intravenously must always be diluted in IV fluid and
infused via an infusion pump. Potassium chloride is never given by bolus (IV push).
Giving potassium chloride by IV push can result in cardiac arrest. The nurse should
ensure that the potassium is diluted in the appropriate amount of diluent or fluid. The
IV bag containing the potassium chloride should always be labeled with the volume
of potassium it contains. The IV site is monitored closely, because potassium
chloride is irritating to the veins and there is risk of phlebitis. In addition, the nurse
should monitor for infiltration. The nurse monitors urinary output during
administration and contacts the primary health care provider if the urinary output is
less than 30 mL/hr.
The nurse is assessing a client with a lactose intolerance disorder for a suspected
diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to
note in the client?
A. Twitching
B. Hypoactive bowel sounds
C. Negative Trousseau's sign
D. Hypoactive deep tendon reflexes - Answer- A
Rationale:
A client with lactose intolerance is at risk for developing hypocalcemia, because food
products that contain calcium also contain lactose. The normal serum calcium level
is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL
(2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias
followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's
or Chvostek's sign. Additional signs of hypocalcemia include increased
neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and
anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive
bowel sounds, abdominal cramping, and diarrhea.
The nurse is caring for a client with Crohn's disease who has a calcium level of 8
mg/dL (2 mmol/L). Which patterns would the nurse watch for on the
electrocardiogram? Select all that apply.
A. U waves
B. Widened T wave
C. Prominent U wave
D. Prolonged QT interval
E. Prolonged ST segment - Answer- D, E
Rationale:
A client with Crohn's disease is at risk for hypocalcemia. The normal serum calcium
level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9
mg/dL (2.25 mmol/L) indicates hypocalcemia. Electrocardiographic changes that
occur in a client with hypocalcemia include a prolonged QT interval and prolonged
ST segment. A shortened ST segment and a widened T wave occur with
hypercalcemia. ST depression and prominent U waves occur with hypokalemia.
The nurse reviews the electrolyte results of a client with chronic kidney disease and
notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the
nurse watch for on the cardiac monitor as a result of the laboratory value? Select all
that apply.
A. ST depression
B. Prominent U wave
C. Tall peaked T waves
D. Prolonged ST segment
E. Widened QRS complexes - Answer- C, E
Rationale:
The client with chronic kidney disease is at risk for hyperkalemia. The normal
potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level
greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic
changes associated with hyperkalemia include flat P waves, prolonged PR intervals,
widened QRS complexes, and tall peaked T waves. ST depression and a prominent
U wave occurs in hypokalemia. A prolonged ST segment occurs in hypocalcemia.
The nurse is assigned to care for a group of clients. On review of the clients' medical
records, the nurse determines that which client is most likely at risk for a fluid volume
deficit?
A. A client with an ileostomy
B. A client with heart failure
C. A client on long-term corticosteroid therapy
D. A client receiving frequent wound irrigations - Answer- A
Rationale:
A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid
needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea,
conditions that cause increased respirations or increased urinary output, insufficient
intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or
colostomy. A client with heart failure or on long-term corticosteroid therapy or a client
receiving frequent wound irrigations is most at risk for fluid volume excess.
The nurse is caring for a client with a nasogastric tube that is attached to low suction.
The nurse monitors the client for manifestations of which disorder that the client is at
risk for?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis - Answer- B
Rationale:
Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an
excess of base (bicarbonate) that results from the accumulation of base or from a
loss of acid without a comparable loss of base in the body fluids. This occurs in
conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate
intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of
gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a
result of the loss of hydrochloric acid. The remaining options are incorrect
interpretations.
A client with a 3-day history of nausea and vomiting presents to the emergency
department. The client is hypoventilating and has a respiratory rate of 10 breaths per
minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate
of 120 beats per minute. Arterial blood gases are drawn and the nurse reviews the
results, expecting to note which finding?
A. A decreased pH and an increased Paco2
B. An increased pH and a decreased Paco2
C. A decreased pH and a decreased HCO3-
D. An increased pH and an increased HCO3- - Answer- D
Rationale:
Clients experiencing nausea and vomiting would most likely present with metabolic
alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to
increase. Symptoms experienced by the client would include a decrease in the
respiratory rate and depth, and tachycardia. Option 1 reflects a respiratory acidotic
condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a
metabolic acidotic condition.
The nurse is caring for a client with diabetic ketoacidosis and documents that the
client is experiencing Kussmaul's respirations. Which patterns did the nurse
observe? Select all that apply.
A. Respirations that are shallow
B. Respirations that are increased in rate
C. Respirations that are abnormally slow
D. Respirations that are abnormally deep
E. Respirations that cease for several seconds - Answer- B, D
Rationale:
Kussmaul's respirations are abnormally deep and increased in rate. These occur as
a result of the compensatory action by the lungs. In bradypnea, respirations are
regular but abnormally slow. Apnea is described as respirations that cease for
several seconds.
The nurse is caring for a client with several broken ribs. The client is most likely to
experience what type of acid-base imbalance?
A. Respiratory acidosis from inadequate ventilation
B. Respiratory alkalosis from anxiety and hyperventilation
C. Metabolic acidosis from calcium loss due to broken bones
D. Metabolic alkalosis from taking analgesics containing base products - Answer- A
Rationale:
Respiratory acidosis is most often caused by hypoventilation. The client with broken
ribs will have difficulty with breathing adequately and is at risk for hypoventilation and
resultant respiratory acidosis. The remaining options are incorrect. Respiratory
alkalosis is associated with hyperventilation. There are no data in the question that
indicate calcium loss or that the client is taking analgesics containing base products.
A client with atrial fibrillation who is receiving maintenance therapy of warfarin
sodium has a prothrombin time (PT) of 35 seconds. On the basis of these laboratory
values, the nurse anticipates which prescription?
A. Adding a dose of heparin sodium
B. Holding the next dose of warfarin
C. Increasing the next dose of warfarin
D. Administering the next dose of warfarin - Answer- B
Rationale:
The normal PT is 11 to 12.5 seconds (conventional therapy and SI units). A
therapeutic PT level is 1.5 to 2 times higher than the normal level. Because the value
of 35 seconds is high, the nurse should anticipate that the client would not receive
further doses at this time. Therefore, the prescriptions noted in the remaining options
are incorrect.
A staff nurse is precepting a new graduate nurse and the new graduate is assigned
to care for a client with chronic pain. Which statement, if made by the new graduate
nurse, indicates the need for further teaching regarding pain management?
A. "I will be sure to ask my client what his pain level is on a scale of 0 to 10."
B. "I know that I should follow up after giving medication to make sure it is effective."
C. "I will be sure to cue in to any indicators that the client may be exaggerating their
pain."
D. "I know that pain in the older client might manifest as sleep disturbances or
depression." - Answer- C
Rationale:
Pain is a highly individual experience, and the new graduate nurse should not
assume that the client is exaggerating his pain. Rather, the nurse should frequently
assess the pain and intervene accordingly through the use of both
nonpharmacological and pharmacological interventions. The nurse should assess
pain using a number-based scale or a picture-based scale for clients who cannot
verbally describe their pain to rate the degree of pain. The nurse should follow up
with the client after giving medication to ensure that the medication is effective in
managing the pain. Pain experienced by the older client may be manifested
differently than pain experienced by clients in other age groups, and they may have
sleep disturbances, changes in gait and mobility, decreased socialization, and
depression; the nurse should be aware of this attribute in this population.
A client has been admitted to the hospital for gastroenteritis and dehydration. The
nurse determines that the client has received adequate volume replacement if the
blood urea nitrogen (BUN) level drops to which value?
A. 1.3 mg/dL (1.08 mmol/L)
B. 2.15 mg/dL (5.4 mmol/L)
C. 3.29 mg/dL (10.44 mmol/L)
D. 4.35 mg/dL (12.6 mmol/L) - Answer- B
Rationale:
The normal BUN level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Values of 29 mg/dL
(10.44 mmol/L) and 35 mg/dL (12.6 mmol/L) reflect continued dehydration. A value
of 3 mg/dL (1.08 mmol/L) reflects a lower than normal value, which may occur with
fluid volume overload, among other conditions.
A client is receiving a continuous intravenous infusion of heparin sodium to treat
deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65
seconds. The nurse anticipates that which action is needed?
A. Discontinuing the heparin infusion
B. Increasing the rate of the heparin infusion
C. Decreasing the rate of the heparin infusion
D. Leaving the rate of the heparin infusion as is - Answer- D
Rationale:
The normal aPTT varies between 30 and 40 seconds (30 and 40 seconds),
depending on the type of activator used in testing. The therapeutic dose of heparin
for treatment of deep vein thrombosis is to keep the aPTT between 1.5 (45 to 60)
and 2.5 (75 to 100) times normal. This means that the client's value should not be
less than 45 seconds or greater than 100 seconds. Thus, the client's aPTT is within
the therapeutic range and the dose should remain unchanged.
A client with a history of heart failure is due for a morning dose of furosemide. Which
serum potassium level, if noted in the client's laboratory report, should be reported
before administering the dose of furosemide?
A. 3.2 mEq/L (3.2 mmol/L)
B. 3.8 mEq/L (3.8 mmol/L)
C. 4.2 mEq/L (4.2 mmol/L)
D. 4.8 mEq/L (4.8 mmol/L) - Answer- A
Rationale:
The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L (3.5 to 5.0
mmol/L). The correct option is the only value that falls below the therapeutic range.
Administering furosemide to a client with a low potassium level and a history of
cardiac problems could precipitate ventricular dysrhythmias. The remaining options
are within the normal range.
The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering
information on the client's medication history and determines it is necessary to
contact the primary health care provider (PHCP) if the client is also taking which
medications? Select all that apply.
A. Warfarin
B. Glimepiride
C. Amlodipine
D. Simvastatin
E. Atorvastatin - Answer- A, B, C
Rationale:
Nonsteroidal antiinflammatory drugs (NSAIDs) can amplify the effects of
anticoagulants; therefore, these medications should not be taken together.
Hypoglycemia may result for the client taking ibuprofen if the client is concurrently
taking an oral antidiabetic agent such as glimepiride; these medications should not
be combined. A high risk of toxicity exists if the client is taking ibuprofen concurrently
with a calcium channel blocker such as amlodipine; therefore, this combination
should be avoided. There is no known interaction between ibuprofen and simvastatin
or atorvastatin.
The nurse is caring for a client with a diagnosis of breast cancer who is
immunosuppressed. The nurse would consider implementing neutropenic
precautions if the client's white blood cell count was which value?
A. 2000 mm3 (2.0 × 109/L)
B. 5800 mm3 (5.8 × 109/L)
C. 8400 mm3 (8.4 × 109/L)
D. 11,500 mm3 (11.5 × 109/L) - Answer- A
Rationale:
The normal WBC count ranges from 5000 to 10,000 mm3 (5 to 10 × 109/L). The
client who has a decrease in the number of circulating WBCs is immunosuppressed.
The nurse implements neutropenic precautions when the client's values fall
sufficiently below the normal level. The specific value for implementing neutropenic
precautions usually is determined by agency policy. The remaining options are
normal values.
The nurse is caring for a postoperative client who is receiving demand-dose
hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The
nurse enters the client's room and finds the client drowsy and records the following
vital signs: temperature 97.2° F (36.2° C) orally, pulse 52 beats per minute, blood
pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93%
on 3 liters of oxygen via nasal cannula. Which action should the nurse take next?
A. Document the findings.
B. Attempt to arouse the client.
C. Contact the primary health care provider (PHCP) immediately.
D. Check the medication administration history on the PCA pump - Answer- B
Rationale:
The primary concern with opioid analgesics is respiratory depression and
hypotension. Based on the assessment findings, the nurse should suspect opioid
overdose. The nurse should first attempt to arouse the client and then reassess the
vital signs. The vital signs may begin to normalize once the client is aroused,
because sleep can also cause decreased heart rate, blood pressure, respiratory
rate, and oxygen saturation. The nurse should also check to see how much
medication has been taken via the PCA pump and should continue to monitor the
client closely to determine whether further action is needed. The nurse should
contact the PHCP and document the findings after all data are collected, after the
client is stabilized, and if an abnormality still exists after arousing the client.
An adult female client has a hemoglobin level of 10.8 g/dL (108 mmol/L). The nurse
interprets that this result is most likely caused by which condition noted in the client's
history?
A. Dehydration
B. Heart failure
C. Iron deficiency anemia
D. Chronic obstructive pulmonary disease - Answer- C
Rationale:
The normal hemoglobin level for an adult female client is 12 to 16 g/dL (120 to 160
mmol/L). Iron deficiency anemia can result in lower hemoglobin levels. Dehydration
may increase the hemoglobin level by hemoconcentration. Heart failure and chronic
obstructive pulmonary disease may increase the hemoglobin level as a result of the
body's need for more oxygen-carrying capacity.
A client with a history of upper gastrointestinal bleeding has a platelet count of
300,000 mm3 (300 × 109/L). The nurse should take which action after seeing the
laboratory results?
A. Report the abnormally low count.
B. Report the abnormally high count.
C. Place the client on bleeding precautions.
D. Place the normal report in the client's medical record. - Answer- D
Rationale:
A normal platelet count ranges from 150,000 to 400,000 mm3 (300 × 109/L) is not an
elevated count. The count also is not low; therefore, bleeding precautions are not
needed.
A couple comes to the family planning clinic and asks about sterilization procedures.
Which question by the nurse should determine whether this method of family
planning would be most appropriate?
A. "Have you ever had surgery?"
B. "Do you plan to have any other children?"
C. "Do either of you have diabetes mellitus?"
D. "Do either of you have problems with high blood pressure?" - Answer- B
Rationale:
Sterilization is a method of contraception for couples who have completed their
families. It should be considered a permanent end to fertility, because reversal
surgery is not always successful. The nurse would ask the couple about their plans
for having children in the future. Options 1, 3, and 4 are unrelated to this procedure.
A 55-year-old male client confides in the nurse that he is concerned about his sexual
function. What is the nurse's best response?
A. "How often do you have sexual relations?"
B. "Please share with me more about your concerns."
C. "You are still young and have nothing to be concerned about." D. "You should not
have a decline in testosterone until you are in your 80s." - Answer- B
Rationale:
The nurse needs to establish trust when discussing sexual relationships with men.
The nurse should open the conversation with broad statements to determine the true
nature of the client's concerns. The frequency of intercourse is not a relevant first
question to establish trust. Testosterone declines with the aging process.
A client calls the emergency department and tells the nurse that he came directly
into contact with poison ivy shrubs. The client tells the nurse that he cannot see
anything on the skin and asks the nurse what to do. The nurse should make which
response?
A. "Come to the emergency department."
B. "Apply calamine lotion immediately to the exposed skin areas." C. "Take a shower
immediately, lathering and rinsing several times." D. "It is not necessary to do
anything if you cannot see anything on your skin." - Answer- C
Rationale:
When an individual comes in contact with a poison ivy plant, the sap from the plant
forms an invisible film on the human skin. The client should be instructed to cleanse
the area by showering immediately and to lather the skin several times and rinse
each time in running water. Removing the poison ivy sap will decrease the likelihood
of irritation. Calamine lotion may be one product recommended for use if dermatitis
develops. The client does not need to be seen in the emergency department at this
time.
A client is being admitted to the hospital for treatment of acute cellulitis of the lower
left leg. During the admission assessment, the nurse expects to note which finding?
A. An inflammation of the epidermis only
B. A skin infection of the dermis and underlying hypodermis
C. An acute superficial infection of the dermis and lymphatics
D. An epidermal and lymphatic infection caused by Staphylococcus - Answer- B
Rationale:
Cellulitis is an infection of the dermis and underlying hypodermis that results in a
deep red erythema without sharp borders and spreads widely throughout tissue
spaces. The skin is erythematous, edematous, tender, and sometimes nodular.
Erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and
lymphatics. The infection is not superficial and extends deeper than the epidermis.
The clinic nurse assesses the skin of a client with psoriasis after the client has used
a new topical treatment for 2 months. The nurse identifies which characteristics as
improvement in the manifestations of psoriasis? Select all that apply.
A. Presence of striae
B. Palpable radial pulses
C. Absence of any ecchymosis on the extremities
D. Thinner and decrease in number of reddish papules
E. Scarce amount of silvery-white scaly patches on the arms - Answer- D, E
Rationale:
Psoriasis skin lesions include thick reddened papules or plaques covered by silverywhite patches. A decrease in the severity of these skin lesions is noted as an
improvement. The presence of striae (stretch marks), palpable pulses, or lack of
ecchymosis is not related to psoriasis.
The clinic nurse notes that the primary health care provider has documented a
diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding
of the cause of this disorder, the nurse determines that this definitive diagnosis was
made by which diagnostic test?
A. Positive patch test
B. Positive culture results
C. Abnormal biopsy results
D. Wood's light examination indicative of infection - Answer- B
Rationale:
With the classic presentation of herpes zoster, the clinical examination is diagnostic.
However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster
(shingles) is caused by a reactivation of the varicella zoster virus, the virus that
causes chickenpox. A patch test is a skin test that involves the administration of an
allergen to the surface of the skin to identify specific allergies. A biopsy would
provide a cytological examination of tissue. In a Wood's light examination, the skin is
viewed under ultraviolet light to identify superficial infections of the skin.
A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious
lesion performed 1 week ago. The biopsy report indicates that the lesion is a
melanoma. The nurse understands that melanoma has which characteristics? Select
all that apply.
A. Lesion is painful to touch.
B. Lesion is highly metastatic.
C. Lesion is a nevus that has changes in color.
D. Skin under the lesion is reddened and warm to touch.
E. Lesion occurs in body areas exposed to outdoor sunlight. - Answer- B, C
Rationale:
Melanomas are pigmented malignant lesions originating in the melanin-producing
cells of the epidermis. Melanomas cause changes in a nevus (mole), including color
and borders. This skin cancer is highly metastatic, and a person's survival depends
on early diagnosis and treatment. Melanomas are not painful or accompanied by
sign of inflammation. Although sun exposure increases the risk of melanoma, lesions
may occur any place on the body, especially where birthmarks or new moles are
apparent.
When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely
expects to note which findings? Select all that apply.
A. An irregularly shaped lesion
B. A small papule with a dry, rough scale
C. A firm, nodular lesion topped with crust
D. A pearly papule with a central crater and a waxy border
E. Location in the bald spot atop the head that is exposed to outdoor sunlight -
Answer- D, E
Rationale:
Basal cell carcinoma appears as a pearly papule with a central crater and rolled
waxy border. Exposure to ultraviolet sunlight is a major risk factor. A melanoma is an
irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned
color. Actinic keratosis, a premalignant lesion, appears as a small macule or papule
with a dry, rough, adherent yellow or brown scale. Squamous cell carcinoma is a
firm, nodular lesion topped with a crust or a central area of ulceration.
A client arriving at the emergency department has experienced frostbite to the right
hand. Which finding would the nurse note on assessment of the client's hand?
A. A pink, edematous hand
B. Fiery red skin with edema in the nailbeds
C. Black fingertips surrounded by an erythematous rash
D. A white color to the skin, which is insensitive to touch - Answer- D
Rationale:
Assessment findings in frostbite include a white or blue color; the skin will be hard,
cold, and insensitive to touch. As thawing occurs, flushing of the skin, the
development of blisters or blebs, or tissue edema appears. Options 1, 2, and 3 are
incorrect.
The staff nurse reviews the nursing documentation in a client's chart and notes that
the wound care nurse has documented that the client has a stage II pressure injury
in the sacral area. Which finding would the nurse expect to note on assessment of
the client's sacral area?
A. Intact skin
B. Full-thickness skin loss
C. Exposed bone, tendon, or muscle
D. Partial-thickness skin loss of the dermis - Answer- D
Rationale:
In a stage II pressure injury, the skin is not intact. Partial-thickness skin loss of the
dermis has occurred. It presents as a shallow open ulceration with a red-pink wound
bed, without slough. It may also present as an intact or open/ruptured serum-filled
blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III.
Exposed bone, tendon, or muscle is present in stage IV.
The nurse is reviewing the laboratory results of a client diagnosed with multiple
myeloma. Which would the nurse expect to note specifically in this disorder?
A. Increased calcium level
B. Increased white blood cells
C. Decreased blood urea nitrogen level
D. Decreased number of plasma cells in the bone marrow - Answer- A
Rationale:
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