NCLEX STUDY

Question 1

The nurse is preparing a patient for an 8:00 AM outpatient electroconvulsive (ECT) treatment. Which of the following questions is the MOST important for the nurse to ask?

1. “Did you have anything to eat or drink before you came in today?”
2. “Have you had any headaches since your last treatment?”
3. “Who came with you to the hospital today?”
4. “Have you had much memory loss since you began your treatments?”

Answer 1

(1) correct–client given general anesthesia for ECT; NPO after midnight
(2) not relevant to ECT
(3) not most important
(4) memory loss is an expected outcome

Question 2

A 36-year-old man has a flaccid bladder following a spinal cord injury. The nurse is teaching the client about dietary changes. Which of the following beverages, if selected by the client, would indicate to the nurse that teaching was effective?

1. Lemonade.
2. Prune juice.
3. Milk.
4. Orange juice.

Answer 2

(1) promotes alkaline urine, should also avoid citrus juices, excessive amounts of milk, carbonated beverages
(2) correct–promotes acidic urine, minimizes risk of urinary tract infection and stone formation, also use cranberry, tomato juice, bouillon
(3) excessive amounts of milk promotes alkaline urine
(4) promotes alkaline urine, should also avoid citrus juices, excessive amounts of milk and carbonated beverages

Question 3

The nurse is caring for a client with a long history of alcohol and drug dependence. It would be MOST important for the nurse to include which of the following as a part of his discharge planning?

1. Referral to a social service agency for assistance with housing.
2. Referral to an aftercare center in the community.
3. Participation in Alcoholics Anonymous (AA) meetings with a sponsor.
4. A prescription for an antidepressant medication.

Answer 3

(1) may be of some help, but will not directly provide support necessary to maintain sobriety
(2) may be of some help, but will not directly provide support necessary to maintain sobriety
(3) correct–self-help groups have greatest success rate as a sustained support system in the community
(4) unnecessary

Question 4

A client has come to the clinic for a hepatitis B vaccine and asks if he has to be re-vaccinated after his first injection. Which of the following responses by the nurse is BEST?

1. “A booster shot is required yearly.”
2. “Additional injections are given at one and six months.”
3. “Repeat doses are given at two and four months.”
4. “Revaccination is not required.”

Answer 4

(1) yearly doses are given for flu shots, not for hepatitis B vaccine
(2) correct–hepatitis B vaccine is repeated at one and six months
(3) schedule for infant immunizations for OPV and DPT
(4) inaccurate

Question 5

The nurse is planning care for a 56-year-old man who returned from surgery for a bowel resection with an IV of 0.9% NaCl infusing at 100 cc/h into his left wrist. Which of the following actions, if performed by the nurse, is BEST?

1. Change the IV tubing each time a new IV solution is hung.
2. Cleanse the IV site with an alcohol swab using long strokes.
3. Limit manipulation of the cannula at the IV insertion site.
4. Adjust the drop rate to keep the total volume of IV fluids on schedule.

Answer 5

(1) unnecessary, changed every 48–72 hrs
(2) should move swab in a circular motion outward
(3) correct–will prevent dislodgment of needle
(4) should give IV at rate ordered by physician, don’t play “catch-up” with fluids

Question 6

The nurse notes that one of the staff members caring for clients has a watery discharge from the right eye and the eye appears red. Which of the following actions, if taken by the nurse, is BEST?

1. Send the staff member home.
2. Assess the staff member’s compliance with standard precautions.
3. Assign the staff member only to clients with chronic diseases.
4. Re-assign the staff member to clean the supply closet.

Answer 6

(1) correct–extreme tearing, redness, foreign body sensation are symptoms of viral conjunctivitis,
highly contagious; infected employees cannot work until symptoms have resolved in 3–7 days
(2) restrict from patient contact and the patient’s environment
(3) restrict from patient contact and the patient’s environment
(4) cannot work

Question 7

. The nursing staff is planning to use behavior modification techniques for an elderly woman who constantly screams. Which of the following nursing assessments is necessary to establish a successful program?

1. Monitor the client’s ability to complete her activities of daily living (ADL).
2. Assess the client’s levels of pain and correlate it with her response to analgesia.
3. Observe the client’s behavior at regular intervals to obtain baseline information related to her screaming.
4. Ask the client why she is screaming and document it on her nursing assessment record.

Answer 7

(1) important because activities of daily living can contribute to the targeted behavior of screaming; assessing only the area of ADLs does not provide comprehensive data for developing a behavior management program
(2) important because activities of pain can contribute to the targeted behavior of screaming; assessing only the area of pain does not provide comprehensive data for developing a behavior management program
(3) correct–to design an effective behavior modification program, accurate baseline data must first be collected about the target behavior in relation to frequency, amount, time, and precipitating factors
(4) client may be unable to state why she is screaming; asking “why” questions is nontherapeutic

Question 8

The nurse observes a student nurse checking the placement of a nasogastric (NG) tube. Which of the following actions, if performed by the student nurse, would require an intervention by the nurse?

1. Places the end of the NG tube in a cup of water and watches for bubble formation.
2. Checks the pH of the contents aspirated from the NG tube.
3. Positions a stethoscope on the upper abdomen and listens as air is introduced into the NG tube.
4. Uses a large barreled syringe to aspirate for stomach contents.

Answer 8

(1) correct–not considered acceptable procedure
(2) gastric contents are acidic
(3) “swoosh” of air indicates proper placement
(4) acceptable action

Question 9

While scheduling the administration of bromocriptine (Parlodel), which nursing action has the HIGHEST priority?

1. The medication should be taken once a day for six weeks.
2. The medication should be taken with orange juice.
3. The medication should be taken in the morning and at bedtime.
4. The medication should be taken with meals.

Answer 9

(1) is taken twice a day for two to three weeks
(2) unnecessary
(3) will cause GI upset unless taken with meals
(4) correct–will decrease GI upset

Question 10

A brace is ordered for a young teen with scoliosis. The nurse knows that teaching has been effective if the client makes which of the following statements?

1. “I will have my parents put bed-boards on my bed.”
2. “I should decrease my caloric intake.”
3. “I should only take tub baths.”
4. “I can remove the brace for one hour a day.”

Answer 10

(1) bed-boards maintain proper vertebral alignment, but can’t correct lateral curvature of scoliosis
(2) diet should be high-calorie due to age of child and growth requirements; diet doesn’t affect curvature of the spine
(3) either tub bathing or a shower is permitted
(4) correct–should be worn at all times, except when bathing

Question 11

The nurse in a long-term care facility is reviewing the nurse’s notes in a client’s chart. The nurse would be MOST concerned by which of the following entries?

1. “Foley catheter draining clear urine and the pH is 6.5.”
2. “The client’s skin is blanched over the scapular areas.”
3. “Vital signs are within normal limits.”
4. “The client drinks three glasses of orange juice every day.”

Answer 11

(1) appropriate charting of normal urine
(2) correct–blanching or hyperemia that does not disappear in a short time is a warning sign of pressure ulcers
(3) although the charting is not objective, blanching of the skin takes priority because it indicates a problem
(4) appropriate charting

Question 12

The nurse is caring for clients in the outpatient clinic. The nurse returns to the desk and finds four phone messages. Which of the following messages should the nurse return FIRST?

1. A client with cold symptoms has an oral temperature of 103°F (39.4°C).
2. A client with stage II decubitus ulcer reports that the dressing has come off.
3. A client is nauseated and has vomited 6 times in the previous 24 hours.
4. A client is complaining of leg pain after walking half a mile.

Answer 12

(1) elevated temperature indicates infection; determine the underlying cause, encourage fluids
(2) stable client
(3) correct–assess amount, character, symptoms of fluid volume deficit
(4) stable client, complaint indicates intermittent claudication

Question 13

A client has a bovine graft inserted into the left arm for hemodialysis. During the immediate postoperative period, which of the following actions, if performed by the nurse, is BEST?

1. Restart the IV above the level of the graft.
2. Take blood pressures only on the right arm.
3. Elevate the left arm above the level of the heart.
4. Check the radial pulse on the left arm q4h.

Answer 13

(1) IVs should not be started in the grafted arm
(2) correct–BP should always be taken on the opposite arm from the graft
(3) unnecessary
(4) would not prevent complications, but would identify complications

Question 14

The nurse assesses a prolonged deceleration of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. The priority nursing intervention would be to

1. discontinue the infusion.
2. turn client to the left side.
3. change the fluids to LR.
4. increase the IV flow rate.

Answer 14

(1) correct–will decrease contractions and thus possibly remove uterine pressure to the fetus,
which is possibly cause of deceleration
(2) may help the deceleration, but is not a priority
(3) will have no influence on the fetal heart rate
(4) will have no influence on the fetal heart rate

Question 15

The nurse is caring for a patient recovering from abdominal surgery. While ambulating, the patient complains to the nurse that she has a dull ache in her left leg. The nurse should

1. place the patient on bedrest and elevate the foot of the bed six inches.
2. ask the patient to remain in bed and place a pillow under the knee to elevate her left leg.
3. ambulate the patient as directed to prevent complications of bedrest.
4. obtain thigh-high compression or elastic stockings and continue ambulating the patient.

Answer 15

(1) correct–promotes venous return and decreases venous pressure relieving pain and edema
(2) would obstruct venous flow increasing chance for thrombus formation
(3) would cause pressure fluctuations in venous system; could cause emboli, should be on bedrest 5–7 days
(4) used to prevent deep vein thrombosis, should be on bedrest initially

Question 16

A middle-aged female client begins outpatient therapy sessions with a psychiatric clinical nurse specialist for management of a phobic disorder. Which of the following nursing interventions should be an initial approach in symptom reduction?

1. Referral for psychopharmacologic intervention.
2. Group psychotherapy.
3. Systematic desensitization.
4. Biofeedback.

Answer 16

(1) reasonable treatment options as the nurse obtains further information
(2) reasonable treatment options as the nurse obtains further information
(3) correct–phobic disorders are learned responses; learned responses can be unlearned
through certain techniques, such as behavioral modification; systematic desensitization is a
form of behavior modification; is a strategy used in conjunction with deep muscle relaxation
to decrease the extreme response to anxiety-producing situations as they are gradually
exposed; then exposure is increased; goal is to eradicate the phobic response by replacing it
with the relaxation response
(4) is usually more useful for reducing stress associated with physiologically based disorders

Question 17

The nurse is caring for a client with Cushing’s syndrome. Which of the following nursing actions
would be of HIGHEST priority?
1. Implement measures to prevent skin breakdown.
2. Plan measures to prevent infections.
3. Teach the client signs and symptoms of hyperglycemia.
4. Instigate measures to prevent fluid overload.

Answer 17

(1) clients are susceptible to skin breakdown and infections
(2) clients are susceptible to skin breakdown and infections
(3) impaired glucose tolerance often leads to hyperglycemia, but is not highest priority
(4) correct–respirations are the first priority; clients with Cushing’s syndrome are prone to fluid
overload and CHF due to sodium and water retention

Question 18

The nurse is assessing a client with a diagnosis of detached retina. Which of the following
observations would support this diagnosis?
1. Loss of acuity in the peripheral visual field.
2. Increased lacrimation, blurred vision.
3. Conjunctivitis, dilated pupils bilaterally.
4. Photophobia, loss of a portion of the visual field.

Answer 18

(1) loss of peripheral vision occurs with glaucoma; loss of acuity occurs with cataracts
(2) occurs with ocular infections
(3) has no correlation with detached retina
(4) correct–bright flashes of light and client stating that portion of visual field is dark are classic
symptoms

Question 19

19. The physician orders indomethacin (Indocin) 25 mg PO bid for a 34-year-old woman. It would be
    most important for the nurse to make which of the following statements?
20. “Take this medication with food.”
21. “Take this medication one hour before meals.”
22. “Take this medication one hour after meals.”
23. “Take this medication with orange juice.”

Answer 19

(1) correct–reduces GI upset
(2) risk of GI upset
(3) should be given with food
(4) risk of GI upset

Question 20

20. A child comes to the school nurse with a honey-colored crusted lesion below her right nostril.
    Which of the following actions should the nurse take FIRST?
21. Remove the scab.
22. Apply a wet cloth to the lesion.
23. Notify the child’s parents.
24. Contact the health department.

Answer 20

(1) notify parents first; loosen scab with Burrow’s solution compress; gently remove, topical
ointment
(2) notify parents first, use compress made of Burrow’s solution
(3) correct–describes impetigo, highly infectious superficial bacterial infection; notify parents so
they can contact the physician
(4) unnecessary to report impetigo to the health department

Question 21

21. Which of the following nursing actions should be the priority for an infant admitted with a positive
stool culture for Salmonella?
1. Change the diet to clear liquids.
2. Initiate intravenous fluids.
3. Maintain contact precautions.
4. Apply cloth diapers.

Answer 21

(1) may be appropriate, but is not a priority over answer choice #3, which will prevent
transmission
(2) may be appropriate but is not a priority over answer choice #3, which will prevent
transmission
(3) correct–prevents transmission of this bacterium to other individuals
(4) may be appropriate, but is not a priority over answer choice #3, which will prevent
transmission

Question 22

22. A client admitted four days ago for treatment of alcohol dependence is now displaying the
    following symptoms: slurred speech, ataxia, uncoordinated movements, and headache. Which of
    the following nursing actions should be taken FIRST?
23. Observe the client for eight hours to collect additional data.
24. Perform a complete physical assessment.
25. Collect a urine specimen for a drug screen.
26. Encourage the client to talk about whatever is bothering him.

Answer 22

(1) will not provide the data that a physical assessment would; may be a medical emergency
requiring an immediate intervention
(2) correct–best way to identify possible physical complications of alcohol dependence is
through a complete physical assessment
(3) should be done after the physical assessment is completed
(4) inaccurate because the symptoms are most likely caused by physical and not psychological
stressors

Question 23

23. The nurse would identify which of the following clients as being at the highest risk for developing
    a pulmonary embolus?
24. A 19-year-old four days postpartum with an obstetrical history of placenta previa.
25. An obese 40-year-old man with multiple pelvic fractures from an auto accident two days ago.
26. A 65-year-old woman who had a fractured hip repaired 10 days ago and who is in physical
    therapy daily.
27. A 22-year-old leukemic client with a platelet count of 120,000/mm3 and a hemoglobin level of
    9.0 g

Answer 23

(1) at high risk for shock and bleeding complications
(2) correct–obesity, immobility, and pooling of blood in the pelvic cavity contribute to
development of pulmonary emboli
(3) client does not have a high risk for pulmonary emboli
(4) at high risk for shock and bleeding complications

Question 24

24. The nurse is supervising a student nurse administer a tube feeding to a client via a Levin tube.
    Which of the following actions, if performed by the student nurse, indicates a proper
    understanding of the correct procedure?
25. The Levin tube remains unclamped for 30 minutes after the feeding.
26. Sterile equipment is used to administer the feeding.
27. The amount of the feeding is varied according to the patient’s tolerance.
28. The tube feeding is given at room temperature.

Answer 24

(1) clamping tube between feedings prevents introduction of air and loss of liquid
(2) clean, not sterile, supplies are required
(3) physician will order amount of feedings, usually begin with a small amount and increases 50-
100 cc until nutritional requirements met
(4) correct–minimizes intestinal cramping

Question 25

25. The nurse is caring for a client with deep vein thrombosis (thrombophlebitis) of the left leg. Which of the following would be an appropriate nursing goal for this client? 1. Decrease inflammatory response in the affected extremity and prevent embolus formation. 2. Increase peripheral circulation and oxygenation of the affected extremity. 3. Prepare the client and family for anticipated vascular surgery on the affected extremity. 4. Prevent hypoxia associated with the development of a pulmonary embolus.

Answer 25

(1) correct–important to prevent the complication of pulmonary embolism in clients at high risk (2) relates to arterial disease (3) surgery is not anticipated for this client (4) preventing embolism is the first priority

Question 26

26. The nurse is called to the room of a patient four days after abdominal surgery. The patient had been coughing and said he “felt something give.” The nurse observes that the edges of the incision have separated, and a small loop of the bowel protrudes through the incision. The nurse should position the patient 1. with the head of the bed elevated 30°. 2. with the foot of the bed tilted and the head of the bed down. 3. with the head of the bed elevated 15°. 4. with the head of the bed elevated 90°.

Answer 26

(1) semi-Fowler’s, too high, would put pressure on abdominal area (2) Trendelenberg position, would impede respiratory excursion (3) correct–low Fowler’s, reduces stress on suture line, may be placed supine with hips and knees bent (4) high Fowler’s, too high, would put pressure on abdominal area

Question 27

27. On a home health visit, an elderly client states, “This neighborhood has really gone down. I feel like a prisoner in my own home with all the trouble out there.” Which of the following nursing responses by the nurse is BEST? 1. “Have you and your neighbors formed a neighborhood watch?” 2. “It must be very difficult for you to live in this neighborhood.” 3. “I see a lot of police cars, so you should be pretty safe.” 4. “Tell me what has happened to make you feel that you are not safe.”

Answer 27

(1) jumps ahead to solutions without adequately defining the problem (2) empathetic response, but does not obtain more information from the client or encourage the client to continue (3) false reassurance (4) correct–assessing the basis for client’s fears and encouraging client to talk about them is the first positive step

Question 28

28. An intravenous pyelogram (IVP) is ordered for a client who is scheduled to have his left kidney removed because of hypertension and renal disease. Which of the following nursing actions has the highest priority the evening prior to the IVP? 1. Administer a cathartic enema to cleanse the bowel. 2. Obtain information about client allergies. 3. Instruct the client to be NPO after midnight. 4. Teach the client that x-rays will be taken at multiple intervals.

Answer 28

(1) implementation, contains correct information, but is not a priority (2) correct–assessment, clients sensitive to iodine can develop anaphylaxis; client should be asked specifically about allergies to iodine; iodine is present in the radiopaque material that is injected IV (3) implementation, contains correct information, but is not a priority (4) implementation, test may be canceled if the client is allergic to iodine

Question 29

29. The nurse cares for an 8 lb, 8 oz newborn boy. The infant’s history indicates that his mother was given magnesium sulfate IV 4 g in 250 ml D5W several hours before delivery. The nurse would be MOST concerned if which of the following was observed? 1. Temperature 97.6°F (36.5°C). 2. Apical pulse 140 bpm. 3. Respirations 18. 4. BP 80/50.

Answer 29

(1) normal temp 98.6°F (37°C), magnesium sulfate does not affect temperature (2) normal pulse 120–140, magnesium sulfate does not affect cardiac system of infant (3) correct–magnesium sulfate can cause slowing of respirations and hyporeflexia; normal respirations 30–60/min (4) normal BP 60/40–80/50, magnesium sulfate does not affect BP

Question 30

30. The nurse is assisting a 58-year-old woman from the bed to the chair for the first time after a right total hip replacement. It is MOST important for the nurse to take which of the following actions? 1. Assist the patient to stand on her right leg and pivot to a low soft chair, keeping her hips straight. 2. Assist the patient to stand on her left leg and pivot to a straight-backed chair, flexing her hips slightly. 3. Ask the patient to bear weight equally on both legs, bend at the waist, and sit in a low soft chair. 4. Assist the patient to stand on both legs and take a few steps to a straight-backed chair.

Answer 30

(1) should not bear weight on affected side, dislocation may occur (2) correct–prevents dislocation (3) no weight bearing on affected leg, dislocation may occur (4) no weight bearing on affected leg, dislocation may occur

Question 31

31. At approximately 6 PM, the nurse begins to open the nurses’ notes for the evening shift. The last entry is noted for 1 PM, and there is no signature. The MOST appropriate nursing response is to 1. leave approximately three or four lines for the day nurse to enter the day information and sign the chart. 2. review with the client the activities after 1 PM, and enter what are determined to be the activities after 1 PM. 3. begin charting on the next line below the last entry, and make a note for the day nurse to make a late entry to complete the chart. 4. do not enter anything until the day nurse has been notified of the problem and returns to the unit to complete charting.

Answer 31

(1) blank lines should never be left in the nurses’ notes (2) nurse should chart only the care that s/he has administered (3) correct–day nurse can make a “late entry” to add any additional information (4) unnecessary

Question 32

32. A client is started on doxepin hydrochloride (Sinequan) 75 mg PO tid. The nurse should recommend a change in the client’s therapy if which of the following occurs? 1. The client refuses to speak and sits quietly in the room. 2. The client becomes excitable and develops tremors. 3. The client refuses to eat breakfast. 4. The client sleeps 18 hours a day.

Answer 32

(1) not relevant to this medication (2) correct–doxepin HCL (Sinequan) is an antidepressant; signs of overdosage include excitability and tremors (3) not relevant to this medication (4) not relevant to this medication

Question 33

33. Which of the following guidelines is appropriate for the nurse to give a mother concerning the developmental stage of her seven-year-old daughter? 1. The child’s periods of shyness are to be expected. 2. Nightmares are not characteristic of this age and should be investigated. 3. The child should be encouraged to care for her younger sister. 4. Punishment may be necessary for acts of independence.

Answer 33

(1) correct–normal for developmental stage, beginning to show independence from parents (2) nightmares are frequently experienced at this age (3) should be encouraged to be independent, not responsible for sibling, inappropriate for this age group (4) should allow child to be increasingly independent without punishment

Question 34

A client is scheduled for a cardiac catheterization, and the nurse teaches him about the procedure. What statements, if made by the client, would indicate to the nurse that he understands the teaching? 1. “I’m going to feel cold during the procedure.” 2. “I can get up and walk to the bathroom immediately after the procedure.” 3. “The nurse will be checking my foot pulses after the procedure.” 4. “I won’t be able to eat for 24 hours before the procedure.”

Answer 34

(1) may feel burning sensation when dye injected (2) on bedrest 8–12 h after procedure with pressure dressing applied over catheter insertion site (3) correct–peripheral pulses checked every 15 min for 1 h, then every 30 min for 2 h, then every 4 h (4) NPO midnight prior to procedure

Question 35

A client had an aortic aneurysm resection two days ago. A complete blood count reveals a decreased red blood cell count. The nursing assessment is MOST likely to reveal which of the following? 1. Fatigue, pallor, and exertional dyspnea. 2. Nausea, vomiting, and diarrhea. 3. Vertigo, dizziness, and shortness of breath. 4. Malaise, flushing, and tachycardia.

Answer 35

(1) correct–these “constitutional symptoms” are characteristic of most types of anemia and are predominantly the result of tissue hypoxia secondary to inadequate red blood cells (2) are not as indicative of the loss of red blood cells (3) are not as indicative of the loss of red blood cells (4) are not as indicative of the loss of red blood cells

Question 36

The physician orders meperidine (Demerol) 50 mg IM every 3–4 h PRN for pain for a client. The client asks the nurse for the medication at bedtime. Prior to administering the pain medication, the nurse should 1. take measures to determine if the pain is psychological. 2. check to see if the man has a history of addiction. 3. try several other comfort and pain relief measures. 4. learn the location, character, and intensity of the pain.

Answer 36

(1) should assess patient first (2) not highest priority, should assess patient first (3) need to assess before implementing action (4) correct–assessment first step in nursing process

Question 37

The nurse is assessing a pregnant client with problems of mitral stenosis and congestive heart failure (CHF). Which of the following in the client’s history would have a direct correlation with her current problem? 1. History of rheumatic fever four years ago. 2. Presence of ventricular septal defect as an infant. 3. Heart disease in both the maternal and the paternal families. 4. Persistent ear infections and mastoiditis as a child.

Answer 37

(1) correct–most common cause of mitral valve problems is a history of rheumatic fever with a subsequent complication of carditis, which affects the valve (2) does not contribute to mitral valve disease (3) does not contribute to mitral valve disease (4) does not contribute to mitral valve disease

Question 38

The nurse is preparing a 56-year-old woman for a paracentesis. It is MOST important for the nurse to take which of the following actions? 1. Keep the woman NPO 12 hours before the procedure. 2. Have the woman void just before the procedure. 3. Initiate a bowel preparation program 24 hours before the procedure. 4. Place the woman supine during the procedure.

Answer 38

(1) does not need to be NPO (2) correct–prevents puncture of bladder (3) bowel preparation unnecessary (4) would make it more difficult to drain fluid, patient should be positioned sitting upright at side of bed with feet supported

Question 39

The nurse is caring for a client in the ICU. Hemodynamic monitoring is accomplished via a Swan- Ganz catheter. The nurse is aware that this type of monitoring will provide which of the following information? 1. Measures the circulatory volume in the coronary arteries. 2. Indirectly measures the pressure in the ventricles. 3. Analyzes the adequacy of pulmonary circulation. 4. Directly measures the adequacy of CO2 exchange.

Answer 39

(1) not a function of this catheter, and does not reflect hemodynamic monitoring (2) correct–CVP readings measure the pressure in the right ventricle, the Swan-Ganz catheter measures the pulmonary artery wedge pressure, which is an indirect reading of the pressure in the left ventricle (3) not a function of this catheter, and does not reflect hemodynamic monitoring (4) not a function of this catheter, and does not reflect hemodynamic monitoring

Question 40

A client is admitted with a diagnosis of trigeminal neuralgia (tic douloureux) involving the maxillary branch of the affected nerve. When performing client teaching, it is MOST important for the nurse to include which of the following instructions? 1. Report an increase in blurred vision. 2. Eat soft, warm foods. 3. Change positions slowly. 4. Chew food on the affected side.

Answer 40

(1) unnecessary, does not occur with this condition (2) correct–intense facial pain experienced along nerve tract is characteristic of this condition; nursing care should be directed toward preventing stimuli to the area and decreasing pain (3) intervention for Ménière’s disease (4) chewing food on unaffected side less likely to trigger an attack

Question 41

An abdominal wound irrigation with a normal saline solution is ordered for a client. To perform this procedure, the nurse should 1. warm the irrigating solution to 110°F (43.3°C). 2. establish a sterile field that includes the irrigating equipment. 3. direct the irrigating solution at the outer edges of the wound, then the center of the wound. 4. aspirate the irrigating fluid with a syringe to prevent accumulation in the wound.

Answer 41

(1) too warm, should be room temperature or 90–95°F (32.2–35°C) (2) correct–requires strict aseptic technique (3) may cause new microorganisms to be flushed into wound (4) fluid should drain by gravity

Question 42

The lab reports a lecithin/sphingomyelin (L/S) ratio of 3:1 for a client who has been on bedrest 48 hours in an unsuccessful attempt to arrest premature labor at 33-weeks gestation. Based on this result, the nurse would anticipate 1. administration of ritodrine hydrochloride (Yutopar). 2. initiation of an oxytocin (Pitocin) drip. 3. delivery of the infant by cesarean section. 4. continuation of bedrest until otherwise indicated.

Answer 42

(1) no longer necessary as the results indicate sufficient lung maturity for safe delivery (2) although the lungs are mature enough for safe delivery, client would either be allowed to progress naturally to a vaginal delivery or sectioned, but not induced (3) correct–because the lungs are adequately mature, there is no need to attempt to postpone labor; delivery by cesarean section is generally preferred for preterm infants (4) is no longer necessary with adequately mature lungs

Question 43

The nurse is caring for clients in the hospital. Which of the following nursing activities BEST promotes rest for an elderly hospitalized client? 1. Place a clock at the bedside. 2. Restrict visitors so that the client is alone during the evening. 3. Tell the client how to call for help if needed. 4. Postpone explanation of further tests that the client will need.

Answer 43

(1) does not promote rest (2) does not promote rest (3) correct–elderly client who feels isolated and unable to obtain help if needed cannot rest properly (4) elderly client will rest better if s/he understands what is going on with his/her health care Preparation for the Nursing Licensure Examination

Question 44

The nurse has just received report from the previous shift. Which of the following clients should the nurse see FIRST? 1. A client with chronic renal failure complaining of swollen fingers and ankle edema. 2. A client one-day postoperative after abdominal surgery who has dried blood on the abdominal dressing. 3. A client with type I diabetes mellitus who states, “I have this quivering feeling in my abdomen.” 4. A client on high doses of antibiotics for a resistant infection who complains of diarrhea.

Answer 44

(1) Indicates peripheral edema, treatment includes fluid and sodium restrictions (2) stable client (3) correct–indicates hypoglycemia; symptoms include tachycardia, cold and clammy skin, weakness and pallor; check blood sugar, offer milk (4) common sequelae of antibiotic therapy, monitor fluid and electrolytes, check for skin breakdown

Question 45

A 57-year-old man admitted with metastatic cancer has been receiving chemotherapy for 3 months. His lab values include: RBC 3.8 million/mm3, WBC 2,000/mm3, Hgb 9.3 g/dL, platelets 50,000/mm3. Which of the following nursing diagnoses is MOST appropriate for this patient? 1. Decreased cardiac output. 2. Ineffective thermoregulation. 3. Risk for injury. 4. Ineffective airway clearance.

Answer 45

(1) will increase due to decreased oxygenation caused by anemia; normal RBC male: 4.3–5.9 million/mm3, female: 3.5–5.5 million/mm3; decreased with anemia, causes heart rate and respirations to increase; normal WBC 4,500–11,000/mm3; decreased (leukopenia) causes susceptibility to infection; normal Hgb: male 13.5–17.5 g/dL, female 12–16 g/dL; decreased with anemia (2) no change in temperature (3) correct–due to low platelet count, normal platelets 150,000–400,000/mm3, decrease causes problems with blood clotting (4) no information about airway problems

Question 46

A young client with a postoperative abdominal abscess had a drain inserted. Which of the following assessments by the nurse is BEST? 1. Amount of the drainage. 2. Character of the drainage. 3. Consistency of the drainage. 4. Amount of suction on the drainage system.

Answer 46

(1) lower priority (2) correct–with this complication, the character of the drainage, purulent or otherwise, is a major priority to note and report (3) lower priority (4) unnecessary

Question 47

In caring for an elderly client with a depressed affect, which of the following nursing actions would be MOST appropriate to help the client to complete activities of daily living? 1. Medicate the client before the activities begin. 2. Develop a written schedule of activities, allowing extra time. 3. Assist the client with grooming activities so it doesn’t take as long. 4. Provide frequent forceful direction to keep the client focused.

Answer 47

(1) will not increase the client’s independence and may interfere with the client’s self-esteem (2) correct–written schedule with built-in extra time will allow client to understand what is expected and will allow him to participate at a slower pace (3) will not increase the client’s independence, allow extra time for care (4) will not increase the client’s independence and may interfere with the client’s self-esteem

Question 48

A patient is returned to his room following an appendectomy. The nurse notices a large amount of serosanguineous drainage on the dressing. It is MOST important for the nurse to obtain an answer to which of the following questions? 1. “Were there any intraoperative complications?” 2. “Has the dressing been changed?” 3. “Why didn’t the recovery room nurse report any drainage?” 4. “Was a tissue drain placed during surgery?”

Answer 48

(1) doesn’t indicate understanding that drainage may be normal after this surgery (2) first dressing usually changed by physician (3) doesn’t indicate understanding that drainage may be normal after this surgery (4) correct–drain is frequently placed during surgery to prevent accumulation in wound, dressing should be reinforced

Question 49

The nurse is caring for a client in her third trimester of pregnancy. The nurse is MOST concerned by which of the following assessments? 1. The client complains of epigastric pain. 2. The client complains of shortness of breath. 3. The client states she has increased rectal pressure. 4. The client has gained of 33 pounds during her pregnancy.

Answer 49

(1) correct–is usually indicative of an impending convulsion (2) expected observation (3) expected observation (4) is important to address, but is not as high a priority as answer choice #1

Question 50

A middle-aged adult is seen in the emergency room for complaints of severe right-flank pain. The client is twenty pounds overweight, lives a sedentary lifestyle, and was treated for renal calculi four years ago. Which of the following actions, if performed by the nurse, is MOST important? 1. Ensure that the client has nothing to eat or drink. 2. Obtain a “clean-catch” urine specimen for analysis. 3. Provide warm packs to relieve discomfort. 4. Measure and strain the client’s urine.

Answer 50

(1) should force fluids to 3,000/day to assist client pass stone (2) not most important, used to identify infection (3) not most important, analgesics given to reduce discomfort (4) correct–will document passage of stone and allow composition to be analyzed

Question 51

The nurse is supervising a student nurse teach a client about a newly prescribed medication. Which of the following actions, if observed by the nurse, would require an intervention? 1. The student nurse glances at his/her watch when instructing the client. 2. The student nurse uses culturally appropriate language and teaching materials. 3. The student nurse begins instructions to the client discussing information that concerns the client. 4. The student nurse chooses a time for teaching when there are no visitors.

Answer 51

(1) correct–lack of attending behaviors are always a barrier to learning (2) appropriate teaching strategy (3) appropriate teaching strategy (4) appropriate teaching strategy

Question 52

Prior to a cesarean section delivery, a 24-year-old woman is treated for abruptio placentae. The nurse is caring for the woman during the postpartum period. Which of the following symptoms would be suggestive of disseminated intravascular coagulation (DIC)? 1. The client’s vital signs are: BP 90/58, temperature 101°F (38.3°C), pulse 112, respirations 18. 2. The client’s laboratory results are: Hgb 13 g/dL, Hct 40%, WBC 7,000/mm3. 3. The client is nauseated, lethargic, and has vomited three times. 4. There is oozing blood from the venipuncture site and abdominal incision.

Answer 52

(1) may indicate hemorrhage or sepsis (2) results normal, DIC would be reflected in clotting studies (PT, PTT) (3) nonspecific, could be related to anesthesia or pain medication (4) correct–DIC is acquired clotting disorder from overstimulation, prolonged oozing from sites of minor trauma first symptom

Question 53

A four-week-old infant with symptoms of pyloric stenosis is brought to the outpatient clinic by his mother. Which of the following statements would the nurse expect the mother to make about her son’s symptoms? 1. “My son’s bowel movements have turned black and sticky.” 2. “I really have to encourage my son to suck the bottle.” 3. “My son is fussy and seems hungry all the time.” 4. “My son spits up green liquid after feeding.”

Answer 53

(1) not expected with pyloric stenosis, suggestive of blood in stool (2) sucking problems not expected with pyloric stenosis (3) correct– becomes lethargic, dehydrated, and malnourished (4) would expect emesis to contain milk or formula, should not be bile-colored

Question 54

The physician prescribes cimetidine (Tagamet) 300 mg PO qid for a 75-year-old man. The nurse instructs the client about the medication. Which of the following statements, if made by the client, would indicate that further teaching is needed? 1. “I’ll take this pill with meals and before bed.” 2. “I may experience mild diarrhea for a while.” 3. “My stools may change color while I’m on this medication.” 4. “I should call my doctor if I get an acne-like rash.”

Answer 54

(1) taking with meals ensures consistent therapeutic effect (2) common side effect, usually subsides (3) correct–no change in stool color (4) side effect seen with medication

Question 55

A teenager comes to the clinic complaining of fatigue, a sore throat, and flu-like symptoms for the previous two weeks. Physical exam reveals enlarged lymph nodes and temperature of 100.3°F (37.9°C). Which of the following statements by the nurse is BEST? 1. “Cover your mouth and nose when you sneeze or cough.” 2. “Eat in a separate room away from your family.” 3. “Don’t share your drinking glass or silverware with anybody.” 4. “Stay in your room until all of your symptoms are gone.”

Answer 55

(1) mononucleosis is spread by direct contact (2) no reason to be isolated (3) correct–symptoms indicate mononucleosis, spread by direct contact; advise family to avoid contact with cups and silverware for about 3 months (4) clients with mononucleosis are not isolated

Question 56

. Which of the following strategies would be MOST therapeutic as the nurse tries to analyze a bulimic client’s eating habits and the circumstances that precipitate the client’s eating problems? 1. Observe family communication patterns at a “monitored mealtime.” 2. Distract the client at mealtime. 3. Assign the client a food/feelings/thoughts/actions journal. 4. Assign the client to write a “lifeline” in relation to eating behaviors.

Answer 56

(1) assessment, should be done after a food/feelings/actions journal (2) implementation, should be done after a food/feelings/actions journal (3) correct–implementation, nurse is trying to analyze and understand what triggers the client’s binging and purging activities, so therapeutic nursing intervention of assigning a thought/feelings/actions (T/F/A) journal relating to client’s eating behaviors will be most helpful to the nurse and therapeutic to the client; after this information is gained and reviewed, collaboration by the nurse and client on other strategies such as delay and distraction techniques, stress reduction, and developing a “lifeline” in relation to eating behaviors will further benefit the client (4) implementation, should be done after a food/feelings/actions journal

Question 57

A 20-year-old primipara attends a class for women who plan to breastfeed. To prepare for breastfeeding, the nurse should encourage the women to 1. apply moisturizer to their breasts every day after bathing. 2. expose their breasts to air every day for 20 minutes. 3. wash their breasts with water and rub with a towel every day. 4. massage their breasts to increase circulation twice daily.

Answer 57

(1) use of creams not recommended, could cause breast tissues to become tender, sebaceous glands keep skin pliable (2) doesn’t prepare breasts for feeding (3) correct–prepares nipples for stretching action of sucking during breastfeeding, soap avoided to prevent drying (4) could cause breast tissues to become tender

Question 58

A 45-year-old client with newly diagnosed IDDM (insulin-dependent diabetes mellitus) is being seen by the home health nurse. The physician has placed him on a 1,800-calorie ADA diet, ordered the client to self-administer 15 units of NPH insulin each day before breakfast, and check his blood sugar qid. When the nurse visits the client at 5 PM, the nurse discovers that the client has not eaten since noon and has just returned from jogging. The client’s vital signs are: BP 110/80, pulse 120, respirations 18, temperature 98.2°F (36.8°C).When the client obtains his blood sugar reading, the nurse would expect it to be 1. 250 mg/dL. 2. 160 mg/dL. 3. 90 mg/dL. 4. 50 mg/dL.

Answer 58

(1) hyperglycemia symptoms are hot dry skin, rapid, deep respirations (Kussmaul), lethargic, polyuria, polydipsia, polyphagia, glycosuria, nausea and vomiting (2) NPH insulin is intermediate-acting, onset 3–4 hours, peak 8–16 hours, duration 18–26 hours (3) normal blood sugar 70–110 mg/dL (4) correct–hypoglycemia symptoms are cool, clammy skin, diaphoresis, nervousness, weakness, hunger, confusion, headache, slurred speech, coma

Question 59

The mother of an eight-month-old infant prepares to take her child home after treatment for bacterial meningitis. The mother confides to the nurse that she is afraid that her child will have brain damage as a result of his illness. Which of the following is the BEST response by the nurse? 1. “Trust your doctors. They are excellent pediatricians and will know what to look for.” 2. “There is a 20% incidence of residual brain damage after this type of illness, but the odds are in your favor.” 3. “It is an unlikely possibility, but if your child doesn’t develop normally, your pediatrician will help you with any problems.” 4. “You feel guilty about your son’s illness, and that’s understandable.You will feel better after you get home.”

Answer 59

(1) nontherapeutic, diminishes person’s concerns and feelings (2) nontherapeutic to discuss statistics with patients, wrong emphasis for discussion (3) correct–if treated early, good prognosis; may be complications and long-term effects (seizure disorders, hydrocephalus, impaired intelligence, visual and hearing defects), therapeutic response (4) nontherapeutic, interprets person’s feelings

Question 60

The nurse is preparing a client for a herniorrhaphy. It would be MOST important for the nurse to complete which of the following one hour prior to surgery? 1. Administer an enema. 2. Confirm that the consent form has been signed. 3. Perform a preoperative shave and scrub. 4. Evaluate for food or medication allergies.

Answer 60

(1) should be done earlier than one hour before surgery (2) correct–surgical consent should be rechecked prior to going to surgery (3) should be done earlier than one hour before surgery (4) assessment, should be done earlier than one hour before surgery

Question 61

The nurse is caring for an 11-year-old girl being treated for a fractured right femur with balanced suspension traction with a Thomas splint and Pearson attachment. When the nurse checks the patient, the nurse finds the weights on the floor, and the girl’s feet touching the foot of the bed. The nurse should 1. release the traction weights and reposition the patient in bed. 2. pull on the traction weights while two nurse’s aides pull the girl up in bed. 3. steady the traction and have the girl bend her left leg and push up in bed. 4. assess the patient’s right leg for proper position and alignment.

Answer 61

(1) release of weights would change pull of traction, weight should never be released (2) pulling on traction weights would alter proper pull on fracture (3) correct–permits patient to reposition self and reestablish pull of traction weights (4) would not reestablish proper pull of traction

Question 62

The nurse is making rounds on the postpartum unit. The nurse notes that a client’s uterus is relaxed. The nurse should 1. put the infant to the woman’s breast. 2. encourage the woman to drink warm oral fluids. 3. check the woman’s pulse and respirations. 4. continue to monitor the firmness of the uterus

Answer 62

(1) correct–implementation, causes natural surge of oxytocin that results in contraction of uterus (2) implementation, has no effect on contraction of uterus (3) assessment, not best action, situation does not suggest that patient is in shock (4) assessment, needs manual massage or release of natural oxytocin to contract uterus

Question 63

A client with Addison’s disease is admitted with pneumonia. The nurse suggests salted broth for lunch. The appropriateness of this decision is based on which of the following statements about Addison’s disease? 1. The client requires increased sodium intake to prevent hypotension. 2. A decrease in sodium intake may lead to seizures. 3. Steroid replacement causes rapid loss of sodium. 4. Sodium intake should be increased during periods of stress.

Answer 63

(1) not as important as answer choice #4 (2) not a correct statement for this condition (3) steroid replacement increases sodium retention (4) correct–with decrease in aldosterone, there is an increased excretion of sodium; sodium intake should be increased

Question 64

The nurse is performing screening at the local senior citizens facility. The nurse would be MOST concerned if which of the following was observed? 1. A 69-year-old man has a slightly elevated systolic blood pressure. 2. The nurse has difficulty palpating an apical pulse on a 74-year-old woman. 3. The nurse auscultates an S3 ventricular gallop on a 78-year-old woman. 4. An 81-year-old man has a temperature of 98.2°F (36.7°C).

Answer 64

(1) usual finding for the older adult (2) usual finding for the older adult (3) correct–ventricular gallop is the earliest sign of CHF (4) may be normal in all age groups

Question 65

The nurse is aware that which of the following statements made by a client indicates a correct understanding of patient-controlled analgesia (PCA)? 1. “If I start feeling drowsy, I should notify the nurse.” 2. “This button will give me enough to kill the pain whenever I want it.” 3. “If I start itching, I need to call you.” 4. “This medicine will make me feel no pain.”

Answer 65

(1) may feel sleepy due to medication (2) preset dose administered with preset lock-out times (3) correct–itching is a common side effect of narcotics used in PCA pain management (4) indicates a need for further teaching or clarification

Question 66

``` A client taking trifluoperazine (Stelazine) should be instructed to notify the nurse immediately if he experiences which of the following? 1. Dry mouth and nasal stuffiness. 2. Increased sensitivity to heat. 3. Difficulty urinating. 4. Weight gain and constipation. ```

Answer 66

(1) possible side effect of antipsychotic medications, but client can be instructed on measures to take at home to resolve this problem (2) possible side effect of antipsychotic medications, but client can be instructed on measures to take at home to resolve this problem (3) correct–is an anticholinergic reaction that may become a severe health problem unless treated (4) possible side effect of antipsychotic medications, but client can be instructed on measures to take at home to resolve this problem