NCLEX Questions Flashcards
(37 cards)
The nurse is caring for a patient who is admitted to the hospital for acute renal failure. She notices a U wave on the ECG. The nurse should check for which of the following conditions in the patient’s laboratory values?
A. Hyperkalemia
[26%]
B. Hypokalemia
[58%]
C. Hypernatremia
[9%]
D. Hyponatremia
[7%]
Choice B is correct.
U waves on the ECG are associated with hypokalemia. Other ECG manifestations would also include large, flat T waves, ST depression, or prolonged QT intervals.
The nurse is caring for a patient with schizophrenia. The nurse should anticipate a prescription for which medication?
A. Lithium
[26%]
B. Bupropion
[7%]
C. Sertraline
[15%]
D. Risperidone
[51%]
Choice D is correct. Schizophrenia is treated with antipsychotic medications. Typical (or first-generation) antipsychotic drugs include haloperidol, fluphenazine, and chlorpromazine. Atypical (second generation) antipsychotic medications include quetiapine, ziprasidone, and risperidone.
Additional information: Schizophrenia is a psychotic disorder characterized by positive (hallucinations) and negative symptoms (lack of motivation). Most cases of schizophrenia have an onset in adolescence. Acute stabilization and maintenance treatment is accomplished by prescribed antipsychotic medications such as risperidone, haloperidol, or fluphenazine.
A patient is scheduled to undergo a CT scan with intravenous contrast dye. All of the nursing actions are appropriate concerning patient safety, except:
A. Encourage fluids when the patient returns from the scan.
[21%]
B. Confirm that the consent form is signed.
[19%]
C. Raise the side rails of the patient’s stretcher during transport.
[11%]
D. Cancel the CT scan if the patient reports a shellfish allergy.
Choice D is correct. It is inappropriate to cancel the CT scan if the patient has a history of shellfish allergy. Previously, it was felt that allergy to shellfish/seafood (because they contain iodine) and allergy to topical iodinated products conferred cross-allergy with iodine-containing contrast dyes. In fact, iodine is found ubiquitously in the form of thyroid hormones, and there is no such thing as an allergy to systemic iodine. Minor skin reactions to topical iodine do not confer cross-allergy to IV contrast dyes. There is no evidence to support this notion, and therefore, current guidelines do not suggest treatment plan modification based on a history of shellfish or seafood allergy alone.
According to the American College of Radiology (ACR) Manual on contrast media, there is no evidence to support the continuation of this old practice of inquiring specifically into a patient’s history of “allergy” to seafood, especially shellfish.
Before IV contrast administration, prescreening must include questioning the patient regarding prior reactions to contrast dye or any allergies to any medications/substances. Any allergy (not specifically, shellfish) may increase the risk of having an IV contrast dye reaction. If there is a history of severe allergies or prior reaction to contrast dye, such patients may be premedicated with diphenhydramine and steroids
The nurse is caring for a patient in the emergency department who has just received a head injury following a car accident. After a hyphema has been noted, which position should the nurse encourage this patient to be in?
A. Supine
[17%]
B. Semi-Fowler’s
[58%]
C. Lateral on the affected side
[4%]
D. Lateral on the unaffected side
[21%]
Choice B is correct. Semi Fowler’s position is the most appropriate position after a hyphema, or blood in the anterior chamber has been diagnosed. This position works with gravity to keep blood accumulation away from the optical center of the cornea.
The nurse is working with a child who has a learning disability. The child is ten years old and has trouble reading and interpreting words, letters, and symbols. What is the most likely diagnosis?
A. Phonologic processing deficit
[19%]
B. Dyslexia
[61%]
C. Tourette’s syndrome
[5%]
D. Apraxia
Choice B is correct. Dyslexia is defined as a disorder that involves trouble reading and interpreting words, letters, and symbols. It does not affect general intelligence, but children may need special assistance at school when learning to read. They may not understand at their appropriate grade level, depending on the severity of the disorder.
A client who completes an informed consent is asserting and using their basic right to:
A. Beneficence
[13%]
B. Nonmaleficence
[5%]
C. Self-determination
[60%]
D. Have choices
Choice C is correct. A client who completes an informed consent is asserting and using their fundamental right to self-determination. Self-determination is defined as the intrinsic right of all people, including healthcare consumers, to make their own autonomous decisions about accepting or rejecting care or treatments, as is done with informed consent.
The client in a psychiatric clinic tells the nurse, “I want to kill my wife. The moment I see her, I am going to kill her.” What should be the nurse’s next action?
A. Respect the client’s right to privacy and confidentiality.
[0%]
B. Document the client’s statements.
[3%]
C. Notify the client’s psychiatrist of the comments.
[44%]
D. Explore the client’s feelings about his wife
Choice C is correct. Mental health staff must report suicidal/homicidal ideation (SI/HI) and alert identifiable third parties of threats made by a person, even if these threats were discussed in a private therapy session.
Your client was admitted to your medical-surgical unit for acute renal failure. The client is expressing and demonstrating mild restlessness and asks a lot of questions about their diagnosis and treatment. This client is most likely affected with:
A. Hypokalemia
[5%]
B. Hyperkalemia
[16%]
C. Mild anxiety
[49%]
D. Moderate anxiety
Choice C is correct. This client affected with acute renal failure who is experiencing mild restlessness and asking a lot of questions about their diagnosis and treatment is most likely experiencing normal mild anxiety.
The nurse is discussing the use of medications to prevent organ rejection with the health care provider. Which of the following medicines is not used to avoid organ rejection?
A. Oxybutynin chloride
[49%]
B. Prednisone
[21%]
C. Tacrolimus
[16%]
D. Cyclosporine
Choice A is correct. Oxybutynin chloride is an anti-cholinergic medication often used for overactive bladder. This medication is not used to prevent organ rejection.
The nurse is caring for an infant who presents with a congenital abnormality where their abdominal contents come through the umbilicus while remaining in the peritoneal sac. The nurse knows the infant will be diagnosed with which of the following?
A. Intussusception
[12%]
B. Gastroschisis
[14%]
C. Omphalocele
[63%]
D. Hirschsprung’s disease
Choice C is correct. This infant has an omphalocele. An omphalocele is a congenital abnormality where the abdominal contents come through the umbilicus while remaining in the peritoneal sac.
A G1P0 client in the first trimester of pregnancy informs the clinic nurse that she has replaced coffee with hot tea at breakfast. Her hemoglobin level was 10 g/dL today. She tells the nurse that she is taking her iron supplements twice daily. Which response by the nurse would be most appropriate?
A. “You’re off to a great start! Tea has much less caffeine than coffee.”
[8%]
B. “A great addition to your cup of tea would be a little lemon. It’s going to help you absorb your iron pill better.”
[54%]
C. “Right now your iron levels are low. Please eliminate all caffeine.”
[36%]
D. “That’s alright. Drinking coffee or tea won’t affect the fetus.”
Choice B is correct. Tannins are polyphenolic compounds found in plants, wood, leaves, fruits, and tea. The tannin that is present in tea decreases the absorption of iron. But adding lemon juice, which is high in vitamin C, seems to cancel the inhibitory effect of tannins on iron absorption.
The senior nurse is evaluating a newly registered nurse who is assisting a 40-year-old status-post left knee replacement surgery to ambulate using a cane. Which action by the new nurse would warrant additional instructions from the senior nurse?
A. The nurse stands at the client’s left side during ambulation.
[8%]
B. The nurse instructs the client to move the cane at the same time with the left leg.
[25%]
C. The nurse instructs the client to hold the cane with his left hand.
[52%]
D. The nurse instructs the client to hold the cane 4 -6 inches from his foot.
[14%]
Choice C is correct. This is an inaccurate action of the nurse (therefore, the correct answer to the question) and requires further instruction from the senior nurse. The client should be instructed to hold the cane with his right hand (the hand on the unaffected side) when moving.
A patient recovering from tuberculosis is wondering when they will no longer be contagious. Which of the following diagnostic tests will confirm with the most certainty that this patient is no longer infectious?
A. Mantoux test
[11%]
B. Five negative blood cultures
[8%]
C. One negative sputum culture
[30%]
D. One negative blood test and a negative chest x-ray
Choice D is correct. The most accurate way to confirm that a patient is no longer at risk of spreading tuberculosis is one negative blood test and a negative chest x-ray.
The ER nurse assesses a patient for tactile fremitus. Which would be the correct way to assess for this abnormal finding?
A. Percuss the apices in the supraclavicular areas.
[8%]
B. Instruct the patient to breathe deeply while auscultating both sides of the lungs.
[14%]
C. Ask the patient to say “ninety-nine” while palpating the chest.
[58%]
D. Place the hands along the anterolateral wall with thumbs pointing toward the xiphoid process.
Choice C is correct. Tactile (vocal) fremitus describes the vibrations that can be palpated through the chest wall during speech. To assess for tactile fremitus, the nurse would place hands over the lung apices in the supraclavicular areas and palpate from one side to the other while the patient repeats “ninety-nine” to compare vibrations. If vibrations are uneven, it may indicate pneumothorax, inflamed lung tissue, or fluid build-up.
The nurse receives laboratory results for several clients under her care. Which client result would the nurse report to the physician immediately?
A. An elevated amylase result on a client diagnosed with acute pancreatitis.
[8%]
B. An elevated WBC count on a client with a septic leg wound.
[11%]
C. A urinalysis showing many bacteria for a client receiving chemotherapy.
[56%]
D. A serum glucose of 235 mg/dl in a client with type 1 diabetes mellitus
Choice C is correct. Chemotherapy places the client at an increased risk for infection by disrupting mucosal barriers and by suppressing the immune system. A urinalysis result of many bacteria would indicate to the nurse that there is an ongoing urinary tract infection in the client, and this would warrant her to notify the physician immediately to start antibiotic therapy.
The nurse is preparing a presentation regarding the safe disposal of hazardous materials in the hospital. Which would be appropriate to include?
A. If a wound culture is negative for infection, dressings can be discarded directly into the patient’s trash can.
[3%]
B. Sharps containers should be placed in every room at eye level.
[50%]
C. Disposable equipment used in isolation precaution rooms should be placed into a biohazard receptacle upon discharge.
[38%]
D. When biohazard bags are full, they should be removed and placed in the soiled utility room.
Choice B is correct. Sharps containers should be available in every room and should be kept at eye level to prevent over-filling of the container, which can result in accidental sticks.
Which of the following foods is contraindicated when the client is taking a monoamine oxidase inhibitor (MAO) for depression?
A. Calves’ liver
[55%]
B. Citrus fruits
[18%]
C. Milk
[17%]
D. Kale
Choice A is correct. Calves’ liver is contraindicated when the client is taking a monoamine oxidase inhibitor (MAO) for depression. Other foods that are contraindicated when the client is taking a monoamine oxidase inhibitor (MAO) for depression include bananas, raisins, cheeses, sour cream, yogurt, beer, red wines, and Italian green beans.
A nurse has received orders to administer a RhoGAM injection IM to a postpartum patient. Which situation is NOT a contraindication for administration of this injection?
A. Administration to a patient who has a history of a systemic allergic reaction to preparations containing human immunoglobulins.
[6%]
B. Administration of the injection within 72 hours after delivery.
[59%]
C. Administration to an Rh-positive female patient.
[23%]
D. Administration to a patient with an elevated temperature.
Choice B is correct. The injection should be given within 72 hours after birth. RhoGAM is administered intramuscularly within 72 hours after birth to prevent sensitization to the Rh factor in an Rh-negative woman with an infant who is Rh-positive. This injection will prevent hemolytic disease in subsequent pregnancies. Each vial of RhoGAM is cross-matched to a specific woman. The nurse must do all appropriate checks for patient identification to avoid an error in administration.
Upon noticing fetal bradycardia, the labor and delivery nurse performs a vaginal examination on her client in labor. She discovers a pulsatile mass. What is the initial action of the nurse?
A. Prepare for a Cesarean section.
[22%]
B. Tell the client not to push when contractions arrive.
[19%]
C. Escort the father out of the room.
[1%]
D. Place the client in Trendelenburg position.
Choice D is correct. Cord prolapse is a condition where the umbilical cord descends before or with the fetal presenting part. It should be suspected when there is a non-reassuring fetal heart rate tracing and absent membranes. A digital vaginal exam or external inspection will help the nurse confirm the suspicion of cord prolapse. The diagnosis is confirmed by palpating a pulsatile mass in the vaginal vault.
In this condition, the presenting fetal part puts pressure on the prolapsed cord, compromising the fetal blood supply. Additionally, fetal blood flow is further compromised by umbilical vasospasm that occurs due to exposure to a cold atmosphere. Compromise of fetal blood supply results in fetal hypoxia and a non-reassuring fetal heart rate pattern (fetal bradycardia or recurrent, variable decelerations). The Trendelenburg position makes use of gravity to pull the embryo back into the uterus, relieving pressure off the umbilical cord from the presenting part.
Cord prolapse is an obstetric emergency. The nurse should suspect it if fetal bradycardia or variable decelerations occur especially, immediately after the rupture of membranes. The nurse should:
Call for help
Avoid handling the cord, since it can cause further vasospasm and worsen outcomes.
Manually lift the presenting part off the cord by vaginal digital exam. Do not push the cord back.
Place the client in the left-lateral, Trendelenburg position, with head down and a pillow placed under the left hip.
Prepare for immediate delivery (usually via emergency Cesarean section).
If delivery is not immediately available and fetal decelerations persist, consider tocolysis (i.e. terbutaline) while awaiting the Cesarean section. Tocolytics relax the uterus, stop contractions, and therefore, relieve some pressure off the cord.
The nurse is caring for a 5-year-old client whose family is of Orthodox Jewish faith. The mother requests that the client remains kosher while in the hospital. Which of the following actions while assisting the child with lunch would best respect the mother’s request?
A. Finding metal utensils instead of plastic
[16%]
B. Placing the food on plastic plates instead of paper
[5%]
C. Helping the child unwrap the plastic utensils from their packaging
[6%]
D. Allowing the child and his mother to unwrap the eating utensils
Choice D is correct. It is appropriate to allow the child and the mother to unwrap the eating utensils. This is the only action listed that allows the child and the mother to remain kosher as requested.
A patient is started on a daily amount of phenytoin 200 mg PO in two divided doses. Which of the following instructions from the nurse is incorrect?
A. “You will need annual labs to determine the medication level in your body.”
[63%]
B. “Remember to never skip a dose of this medication.”
[3%]
C. “You need to increase your intake of vitamin D while taking this medication.”
[27%]
D. “Maintain good oral hygiene and visit your dentist regularly.”
Choice A is correct. Proper instruction includes telling the client that, initially, more frequent labs need to be drawn, NOT annual labs. Phenytoin acts by desensitizing sodium channels in the CNS. It may cause dysrhythmias, such as bradycardia, severe hypotension, and hyperglycemia. Toxicity can be avoided by careful monitoring. Weekly monitoring of phenytoin levels should be done until therapeutic levels are reached. After reaching therapeutic levels, most physicians request levels to be checked at least every three months.
A client is receiving allopurinol and asks what they should know about taking this medicine. The nurse would be most correct in stating which of the following?
A. “Facial swelling is expected in the first few days of therapy.”
[11%]
B. “Drink at least 3000 mL of water per day.”
[79%]
C. “Do not eat while taking this medication.”
[5%]
D. “This medication begins working immediately.”
Choice B is correct. Allopurinol is prescribed to patients with gout or kidney stones and works by reducing the amount of uric acid produced by the body. Patients taking this medication should be encouraged to drink plenty of water, at least 3,000 mL per day.
The nurse is preparing the discharge of a patient with heart failure. The nurse double checks his prescription and notes that the patient has been prescribed digoxin and lasix. Which of the following laboratory tests must the patient have monitored because of the medications prescribed?
A. Stool for occult blood
[1%]
B. Serum electrolytes
[92%]
C. Urinalysis
[5%]
D. Glycosylated hemoglobin
Choice B is correct. When taken together, digoxin and lasix increase renal perfusion leading to potassium loss. The patient should be instructed to monitor his serum electrolyte levels, notably his serum potassium.
The patient is receiving a blood transfusion and develops chills and vomiting. The nurse assesses the patient and finds a temperature of 103.2 degrees F and blood pressure of 100/64 mmHg. Which action should the nurse take first?
A. Call the physician to report the adverse reaction.
[1%]
B. Obtain STAT blood cultures.
[1%]
C. Discontinue the transfusion.
[98%]
D. Administer vasopressors.
Choice C is correct. This patient is showing signs of a sepsis reaction: rapid onset of chills, high fever, vomiting, and hypotension. The blood transfusion should be stopped immediately to avoid further complications. The IV line should be kept patent with only 0.9% saline solution. The other answers may be appropriate, but this is the nurse’s first priority.
