All of our nurses have put a great amount of time, energy and effort to make this site possible. Take some time to review the NCLEX Prep tests as well as other course notes that we have put up all together. We understood the huge need and we hope that you will find all the information necessary on NCLEX online to be helpful and informative as you deal with the NCLEX Exam.

NCLEX Sample Tests

• NCLEX Prep for Maternity and New Born Care
• NCLEX Prep for Physiological Integrity
• NCLEX Prep for Physiological Integrity (ANSWERS & RATIONALE)
• NCLEX Prep for Psychosocial Integrity
• NCLEX Prep for Psychosocial Integrity (ANSWERS & RATIONALE)
• NCLEX Prep for Safe and Effective Care Environment
• NCLEX Prep for Safe and Effective Care Environment (ANSWERS & RATIONALE)
• NCLEX Prep for Safe and Effective Care Management
• NCLEX Prep for Safe and Effective Care Management (ANSWERS & RATIONALE)
• NCLEX Questions for Physiological Integrity
• NCLEX Questions for Physiological Integrity (ANSWERS & RATIONALE)
• NCLEX Review for Health Promotion and Maintenance
• NCLEX Review for Health Promotion and Maintenance (ANSWERS & RATIONALE)
• NCLEX Review for Maternity and New Born Care (ANSWERS & RATIONALE)
• NCLEX Review for Physiological Integrity
• NCLEX Review for Physiological Integrity (ANSWERS & RATIONALE)

The NCLEX Online CAT Simulator will be available somewhere in September (no exact date yet) but if you want to get updated, you can follow us on twitter.

1.    Answer: A.
Effects of estrogen:
•    Inhibits the production of FSH
•    Causes hypertrophy of the myometrium
•    Increases the quantity and pH of cervical mucus, causing it to become thin and watery and can be stretched to a distance of 10-13 cm.
Effects of Progesterone
•    Inhibits the production of LH
•    Increases endometrial tortuosity
•    Increased endometrial secretions
•    Facilitates transport of the fertilized ovum through the fallopian tubes

2.    Answer: A
Abnormalities of Menstruation
1.    Amenorrhea – absence of menstrual flow
2.    Dysmenorrhea – painful menstruation
3.    Oligomenorrhea – scanty menstruation
4.    Menorrhagia -excessive menstrual bleeding
5.    Metrorrhagia – bleeding between periods of less than 2 weeks

3.    Answer: D. Gynecoid is the “normal” female pelvis. The inlet is well rounded. This is the most ideal pelvis for childbirth.
•    Android – “male” pelvis. Inlet has a narrow, shallow posterior portion and pointed anterior portion.
•    Anthropoid – transverse diameter is narrow and anteroposterior (AP) diameter of this pelvis is larger than normal.
•    Platypelloid – inlet is oval while AP diameter of this pelvis is shallow.

4.    Answer: C.  Ischial spines are the point of reference in determining the station (relationship of the fetal presenting part to the ischial spines). When the fetal head is at the level of the ischial spines the station is zero. When it is 1 cm above the ischial spines it is -1 and if 1 cm below the ischial spines it is +1.

5.    Answer: B. The keyword here is “permanent cessation”. Thus, menopause is the correct answer. Amenorrhea is a temporary cessation of menses. Oligomenorrhea is a menstruation with scanty blood flow. Hypomenorrhea is an abnormally short duration of menstruation.

6.    Answer: C.
•    Gravida (G) – number of pregnancy
•    Term (T) – number of full-term infants born (born at 37 weeks or after)
•    Para (P) – number of preterm infants born (born before 37 weeks)
•    Abortion (A) – number of spontaneous or induced abortions (pregnancy terminated before the age of viability). Age of viability is 24 weeks.
•    Living children (L) – number of living children.
•    (Source: Maternal and Child Health Nursing by Adelle Pillitteri, 5th Ed. P.252)

Since Mrs Donna has two previous pregnancies and is presently pregnant (16 weeks), G is 3. Mark, her only child was born at 35 weeks AOG which falls under the preterm category. Thus, T is zero and P is 1. The other pregnancy was terminated at 20 weeks AOG which falls under abortion, hence A=1. Mark is her only living child, thereby, L=1.  Her GTPAL score is:
30111, G=3 T=0 P=1 A=1 L=1

7.    Answer: B. Morning sickness characterized by nausea and vomiting is only noted during the FIRST TRIMESTER of pregnancy (first 3 months). Excessive nausea and vomiting which persists more than 3 months is a condition called Hyperemesis gravidarum that requires immediate intervention to prevent starvation and dehydration. Management for hyperemesis gravidarum includes the administration of D5NSS 3L in 24 hours and complete bed rest.
Easy fatigability is a consequence of the physiologic anemia of pregnancy (physiologic meaning it is normally expected during pregnancy, thus A is incorrect). Edema of the upper extremities not the lower extremities should alert the nurse because of the possibility of toxemia, hence C is incorrect. Heartburn during pregnancy is due to the increase progesterone which decreases gastric motility causing a reversed peristaltic wave leading to regurgitation of the stomach contents through the cardiac sphincter into the esophagus, causing irritation.

8.    Answer: C. The client is in her second trimester of pregnancy (16 weeks AOG or 4 months), thus, she perceived the baby as a separate entity. Presenting denial and disbelief and sometime repression is the psychological/emotional response of a pregnant woman on her first trimester. Identifying the fetus and setting realistic plans for the child’s future is noted during the third trimester of pregnancy. It is during this time also that the woman verbalizes fear of death.

9.    Answer: A. Mrs. Donna’s gestational age is 16 weeks (4 months). During this time, the fetal heart rate is audible with a Doppler apparatus. A fetal heart beat can be detected with a Doppler apparatus starting at 12 weeks AOG. By 8 weeks AOG, fetal heartbeat can be detected with an ultrasound. A fetal heart beat is detectable with fetoscope by the 20th week AOG. (Source: Foundations of Maternal-Newborn Nursing by Murray and McKinney/Saunders 4th Ed.)

10.    Answer: A. Fetal heart starts beating at 3 weeks AOG. The heart at this time is consisting of two parallel tubes.  By 8 weeks AOG, fetal heartbeat can be detected with an ultrasound. During 12 weeks AOG, the fetal heart rate is audible with a Doppler apparatus. A fetal heart beat is detectable with fetoscope by the 20th week AOG. (Source: Foundations of Maternal-Newborn Nursing by Murray and McKinney/Saunders 4th Ed.)

11.    Answer: B. The keyword is INITIAL ACTION. The important consideration before answering the question is to take a look at the situation. SITUATION: THE WOMAN IS IN THE Emergency Room or is seeking admission.
A woman in labor seeking admission to the hospital (in the ER) and saying that her BOW has ruptured should BE PUT TO BED IMMEDIATELY and the fetal heart tones taken consequently. If a woman in the Labor Room says that her membranes have ruptured, the initial nursing action is to take the fetal heart tone.

12.    Answer: B. The nurse would expect that the client’s cervical dilatation is 4-7 cm as the contraction duration and interval is noted for clients who are in the active phase of the first stage of labor. The maximum cervical dilatation is 10 cm, thus, letter D should be eliminated first. The first stage of labor (stage of dilatation) is divided into three phases.
•    Latent phase – 0-3 cm cervical dilatation; contractions are short and mild lasting 20-40 seconds and occurring approximately every 5-10 minutes.
•    Active phase – 4-7 cm cervical dilatation; contractions grow stronger, lasting 40-60 seconds and occur at approximately every 3-5 minutes.
•    Transition phase – 8-10 cm cervical dilatation; contractions reach their peak of intensity, occurring every 2-3 minutes with a duration of 60-90 seconds.

13.    Answer: C. Station -1 means that the fetal presenting part is above the level of the ischial spines. Letter A is wrong because engagement is described as Station 0. Letter B is incorrect because the statement of nurse is describing the occurrence of engagement that is again station 0. Prior to engagement the fetus is said to be "floating" or ballottable, thus letter C is the best option. Letter D, is describing crowning which is described as Station +3 or +4.

14.    Answer: A. Multiparas are transported to the DR when the cervical dilatation is 7-8 cm because in multiparas dilatation may proceed before effacement is completed. Effacement must occur at the end of dilatation, however, before the fetus can be safely pushed through the cervical canal; otherwise, cervical tearing could result. Primiparas are transported to the DR when the cervical dilatation is 9-10 cm.

15.    Answer: D. The nurse should spread his/her fingers lightly over the fundus to monitor the uterine contractions.

16.    Answer: C. Prolactin is the hormone that produces milk in mammary glands. Uterine contractions can occur because of the interplay of the contractile enzyme adenosine triphosphate and the influence some hormones and major electrolytes which are the following:
•    Calcium
•    Sodium
•    Potassium
•    Specific contractile proteins (actin and myosin)
•    Epinephrine and norepinephrine
•    Oxytocin
•    Estrogen and progesterone
•    Prostaglandins

17.    Answer: D.
Dysfunctional Labor is caused by the ff:
•    Inappropriate use of analgesia
•    Pelvic bone contraction that has narrowed the pelvic diameter so that a client can’t pass (e.g. in a client with rickets)
•    Poor fetal position
•    Extension rather then extension of the fetal head
•    Overdistention of the uterus
•    Cervical rigidity
•    Presence of a full rectum or bladder
•    Mother becoming exhausted from labor
•    Primigravid status

18.    Answer: D. When the contractions are hypotonic, the length of labor is increased. When the cervix is dilated for a long period of time, both the uterus and fetus are at greater risk of infection. Hypotonic contractions are not exceedingly painful because of their lack of intensity. Monitoring of bleeding through evaluation of lochia is done during the postpartum period not the intrapartum period.

19.    Answer: A. Initially, the nurse should obtain an ultrasonic confirmation ruling out a CPD or cephalopelvic disproportion. Thus, A is the best answer. Oxytocin is infused after the CPD is ruled out, because if CPD is present CS will be done. Analgesic administration will further decrease the intensity of uterine contractions as its inappropriate use is one of the reasons why hypotonic contractions occur. Amniotomy (artificial rupture of membrane) may be done after oxytocin is infused to speed up the labor

20.    Answer: B. During the postpartum period, the uterus should be palpated and lochia should be assessed because contractions after birth may also be hypotonic that will result to bleeding.

21.    Answer: C. In placenta previa the bleeding that occurs is abrupt, painless, bright-red and sudden to frighten a woman. With abruption placenta, the bleeding is painful, the abdomen is rigid or board-like and the blood is dark-red or filled with clots.

22.    Answer: C. Never attempt a pelvic or rectal examination with painless bleeding late in pregnancy because any agitation of the cervix when there is placenta previa may initiate massive hemorrhage, possibly fatal to both the mother and the fetus.
The perineum should be assessed or observed or inspected for bleeding by looking over the perenial pads. An Apt or Kleihauer-Betke test (test strip procedures) can be used to detect whether the blood is of fetal or maternal origin.
23.    Answer: A. placenta previa presents bleeding without pain whilst the bleeding in abruptio placenta is painful.

24.    Answer: D. Signs of fetal distress include: tachycardia, bradycardia, fetal thrashing and meconium-stained amniotic fluid.

25.    Answer: B. Predisposing factors for abruptio placenta:
•    Advanced maternal age
•    Short-umbilical cord
•    Chronic hypertensive disease
•    PIH
•    Direct trauma
•    Vasoconstriction from cocaine or cigarette use

Here’s a quick guide on how to pass the nclex exam on first srike.

Situation: During an Anatomy and Physiology class, the lecturer discussed about the female reproductive system.

1.    Estrogen, one of the hormones regulating cyclic activities in female reproductive system is responsible for which effect?
a.    Increases the quantity and pH of cervical mucus, causing it to become thin and watery and can be stretched to a distance of 10-13 cm.
b.    Inhibits the production of LH
c.    Increases endometrial tortuosity
d.    All of the above

2.    Jessa, 17 years old, is bleeding between periods of less than two weeks. This condition is an abnormality in the menstrual cycle known as:
a.    Metrorrhagia
b.    Menorrhagia
c.    Amenorrhea
d.    Dysmenorrheal

3.    One factor of having a normal delivery is the size of the pelvis. Pelvis serves as the passageway for the passenger (fetus) during childbirth. The most ideal pelvis for childbirth is:
a.    Android
b.    Anthropoid
c.    Platypelloid
d.    Gynecoid

4.    An important landmark of the pelvis that determines the distance of the descent of the head is known as:
a.    Linea terminalis
b.    Sacrum
c.    Ischial spines
d.     Ischial tuberosities

5.    The permanent cessation of menstruation is:
a.    Amenorrhea
b.    Menopause
c.    Oligomenorrhea
d.    Hypomenorrhea

Situation: Mrs. Donna, pregnant for 16 weeks age of gestation (AOG), visits the health care facility for her prenatal check-up with her only son, Mark. During assessment the client told the nurse that previously she got pregnant twice. The first was with her only child, Mark, who was delivered at 35 weeks AOG and the other pregnancy was terminated at about 20 weeks AOG.

6.    Based on the data obtained, Mrs. Donna’s GTPAL score is:
a.     20111
b.    21111
c.    30111
d.    31111

7.    Discomforts during pregnancy are discussed by the nurse to the Mrs. Donna. Which of the following, when complained by the client would alert the nurse?
a.    Easy fatigability
b.    Nausea and vomiting
c.    Edema of the lower extremities
d.    Heartburn

8.    Psychological and emotional responses of pregnant women differ. However, general emotional response has been noted during pregnancy based on their gestational age. Mrs. Donna will most likely have which emotional response towards her pregnancy?
a.    Presents denial disbelief and sometimes repression.
b.    Has personal identification of the baby and realistic plans for future of the child.
c.    Fantasizes the appearance of the baby.
d.    Verbalizes fear of death during childbirth.

9.    The nurse assisted Mrs. Donna to a dorsal recumbent position and is about to assess the fetal heart rate (FHR). Which of the following apparatus should the nurse use in auscultating for the FHR?
a.    Doppler apparatus
b.    Fetoscope
c.    Ultrasound
d.    Stethoscope

10.    Mrs. Donna asked the nurse, when a fetal heart starts beating. The nurse correctly responded by stating:
a.    3 weeks AOG
b.    8 weeks AOG
c.    12 weeks AOG
d.    20 weeks AOG

Situation: Mrs. Dela Cruz is in labor and is brought to the emergency room with a ruptured bag of water.

11.    The nurse’s initial action once the bag of water has ruptured is:
a.     Take the fetal heart tones
b.    Put the client to the bed immediately
c.    Perform an IE
d.    Take the woman’s temperature

12.    Mrs. Dela Cruz’s has contractions growing stronger which lasts for 40-60 seconds and occur approximately every 3-5 minutes. The doctor is about to perform an IE, the nurse expects that the client’s cervical dilatation will be:
a.    0-3 cm
b.    4-7 cm
c.    8-10 cm
d.    11-13 cm

13.    The doctor informed the woman that she is on station -1. Mrs. Dela Cruz asked the nurse, what does a station -1 means, the most appropriate response of the nurse is:
a.    “It means that engagement has already occurred.”
b.    “The presenting part of your baby is at the entrance of the true pelvis or the largest diameter of the presenting part into the true pelvis.”
c.    “Your baby is still floating or “ballotable”
d.    “The presenting part of your baby is at the vulvar ring of your reproductive organ.”

14.    The history of Mrs. Dela Cruz revealed that she is a multipara. When should the nurse transport the client from the labor room to the delivery room?
a.    When the cervical dilatation is 8 cm.
b.    When the cervical dilatation is 10 cm.
c.    When the cervical dilatation is 9 cm.
d.    When the client feels the urge to push.

15.    Monitoring contractions is very important during labor. To monitor uterine contractions, what should the nurse do?
a.    Observe for the client’s facial expression to know that the contraction has started or stopped.
b.    Instruct the client take note of the duration of her contractions.
c.    Offer ice chips to the woman.
d.    Spread the fingers lightly over the fundus to monitor the contraction.

16.    Uterine contractions can occur because of the interplay of the contractile enzyme adenosine triphosphate and the influence some hormones. Which of the following least likely contributes to the occurrence of uterine contractions?
a.    Oxytocin
b.    Estrogen
c.    Prolactin
d.    All of the above

17.    Dysfunctional labor may be caused by which of the following?
a.    Excessive or too early analgesia administration
b.    Exhausted mother
c.    Overdistention of the uterus
d.    All of the above

18.    The client’s uterine contractions are hypotonic. The nurses top priority with hypotonic contractions during the intrapartal period is:
a.    Pain relief
b.    Psychological support
c.    Monitoring the lochia for possible bleeding
d.    Infection control

19.    For a woman experiencing hypotonic contractions, what should be done initially?
a.    Obtain an ultrasonic result
b.    Infusion of oxytocin
c.    Administration of analgesia
d.    Amniotomy

20.    The most important nursing consideration in a postpartal woman with a hypotonic contraction is:
a.    Assessment for infection
b.    Assessment for bleeding
c.    Assessment for FHR
d.    Assessment for woman’s coping mechanism

Situation: Bleeding during pregnancy is a serious case and should be managed immediately.

21.    Mrs. Diane is diagnosed with Placenta Previa. The main difference with the bleeding in placenta previa and abruption placenta is that placenta previa has:
a.    Painful bleeding
b.    Rigid abdomen
c.    Bright-red blood
d.    Blood filled with clots

22.    In caring for a client diagnosed with placenta previa, the nurse should avoid which of the following?
a.    Inspecting the perineum
b.    Performing a Kleihauer-Betke test
c.    Performing a pelvic examination
d.    All of the above

23.    For the nurse to distinguish that the bleeding of the patient is placenta previa or abruption placenta what should she ask the woman?
a.    Whether there was accompanying pain
b.    What she has done for bleeding
c.    Estimation of blood loss
d.    All of the above

24.    Continued bleeding may result to fetal distress. The nurse knows that the fetus is being compromised when she observed or note which of the following:
a.    Fetal tachycardia
b.    Fetal bradycardia
c.    Fetal thrashing
d.    All of the above

25.    A woman in labor is diagnosed with abruption placenta. The nurse would expect which findings in the client’s history that may contribute to the occurrence of the complication?
a.    Age of 24 years old
b.    Cigarette smoking
c.    Sleeping 8 hours per night
d.    Sitting for long period

Answers and Rationale

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View Questions

1.    Answer: C. Mantoux test is read 48-72 hours after injection.
2.    Answer: A. Mantoux tests are done intradermally.
3.    Answer: D. Mantoux test is considered positive for Mycobacterium Tubercle Bacilli if the induration is 10 mm or more. For HIV positive clients, induration of 5mm is considered positive. 
4.    Answer: C. The client is instructed to remove metals from the chest. Consent, NPO post midnight and atropine sulfate administration are not needed for this procedure.
5.    Answer: A. 

Nursing interventions before bronchogram:
•    Secure written consent
•    Check for allergies (seafoods and iodine or anesthesia)
•    NPO 6-8 hours
•    Pre-op meds: atropine sulfate and valium, topical anesthesia sprayed followed by local anesthetic into the larynx
•    Have oxygen and antispasmodic agents ready

Nursing Interventions after bronchogram
•    Side-lying position
•    NPO until cough and gag reflex returns
•    Cough and deep breathe clients
•    Low grade fever common
6.    Answer: D. After thoracentesis the client is placed or turned to the unaffected side to prevent leakage of fluid in the thoracic cavity.
7.    Answer: D. The client should be hyperventilated with 100% oxygen before and after suctioning.
8.    Answer: A. Position a conscious person who has a functional gag reflex in the semi fowler’s position with the head turned to one side for oral suctioning or with the neck hyper extended for nasal suctioning. If the client is unconscious place the patient a lateral position facing you.
9.    Answer: A. Suction bottle will have continuous suctioning while the water seal bottle will have an intermittent suctioning.
10.    Answer: D. A water seal bottle is expected to be observed for intermittent bubbling. Therefore, the nurse should only make sure that bottle is at least 2-3 feet below the chest. Checking for an air leak would be the nurse’s action if the water seal has continuous bubbling. Kinks should be check for possible obstruction if no bubbling is noted in the water seal bottle.
11.    Answer: C. In removal of the chest tube the nurse should prepare the following:
•    Petrolatum gauze
•    Suture removal kit
•    Sterile gauze
•    Adhesive tape
12.    Answer: A. As the chest tube is removed the client should be instructed to exhale deeply and do valsalva maneuver. The client is placed in a semi-fowler’s position before the chest tube is removed.
13.    Answer: B. Because the pain is felt above the eyebrows the affected sinus is the frontal sinus.
Pain assessment in sinusitis
•    Maxillary: cheek and upper teeth
•    Frontal: above eyebrows
•    Ethmoid: in and around the eyes
•    Sphenoid: behind eye, occiput, top of the head
14.    Answer: C. ASA is avoided in sinusitis as it increases the risk of developing nasal polyps.
15.    Answer: B.
Management for sinusitis:
•    Rest
•    Increase fluids
•    Hot wet packs
•    Codeine
•    Amoxicillin and other anti-infectives
•    Nasal decongestants
•    Irrigation of maxillary sinuses with warm NSS
16.    Answer: A.  After a Caldwell-Luc Operation (Radical Antrum Surgery) the following should be instructed to the client:
•    Do not chew on the affected side
•    Caution with oral hygiene to prevent trauma of incision
•    Do not wear dentures for 10 days
•    Do not blow nose for 2 weeks after the removal of the packing
•    Avoid sneezing for two weeks after surgery
17.    Answer: D. Surgery is indicated for patients with tonsillitis recurring 5-6 times a year.
18.    Answer: B. The should assess for Upper respiratory tract infection (URTI). Coughing and sneezing postoperatively due to URTI may cause bleeding.
19.    Answer: C. to promote comfort the nurse must administer acetaminophen to alleviate pain from the operation. Also, ice collar can be applied to decrease pain thus, promoting comforting. Assisting the client to the proper position after tonsillectomy (semi-fowler’s) while supporting the position with pillows is also one way to promote comfort. The only choice that does not promote comfort but monitors for hemorrhage is the assessment for frequent swallowing, thus, it is the correct answer (C).
20.    Answer: B. after tonsillectomy, the client’s stool will be black or dark for a few days due to the swallowed blood.
21.    Answer: D. Allergy (extrinsic) and inflammation (intrinsic) triggers the release of chemical mediators that causes narrowing of the airways and spasm. These mediators are:
•    Serotonin
•    Prostaglandin
•    Bradykinin
•    Histamine
•    Leukotrienes
22.    Answer: B. An overdistended and non-functional alveoli is a condition called emphysema. Atelectasis is the collapse of a part or the whole lung. Empyema is the presence of pus in the lung.
23.    Answer: A. The strategy used in this item is the “umbrella effect.” Hemothorax (blood), hydrothorax (water) and pyothirax (pus; also called empyema) are all types of pleural effusion. The three choices are under pleural effusion (umbrella effect), thus the correct answer is A.
24.    Answer: B. Diet for COPD: High calorie, high protein and low carbohydrate diet
•    High caloric diet provides source of energy.
•    High protein diet helps maintain integrity of alveolar walls.
•    Low carbohydrate diet limits carbon dioxide production (natural end product). The client with COPD has difficulty exhaling carbon dioxide.
25.    Answer: D. Benadryl (Dipenhydramine) is an antihistamine not bronchodilator.

2.    A nurse is about to perform a Mantoux test. The test is done by using which route?
a.    Intradermal
b.    Intramuscular
c.    Subcutaneous
d.    IM with the use of Z-track method

3.    A client is suspected to have an HIV. The nurse knows that in the Mantoux test result, a client is considered positive with HV if he has an induration of:
a.    More than 10 mm
b.    3mm
c.    4 mm
d.    5 mm

4.    A client is about to undergo a chest x-ray. Which of the following should the nurse do first before the procedure?
a.    Secure a written consent
b.    Instruct the client not to eat anything at the night before the procedure
c.    Instruct the client to remove metals from the chest
d.    Administer atropine sulfate and valium before the procedure

5.    Mr. Lorenzo is schedule for a bronchography. Before the procedure the nurse least likely performs which of the following?
a.    Assist the client in a side-lying position
b.    Checking for allergies
c.    Instructing the client to be on NPO for 6-8 hours
d.    Administer atropine sulfate

6.    After thoracentesis the client should be placed on which position?
a.    Affected side
b.    Unaffected side
c.    Prone position
d.    Supine position

7.    The most important action the nurse should do before and after suctioning a client is:
a.    Placing the client in a supine position
b.    Making sure that suctioning takes only 10-15 seconds
c.    Evaluating for clear breath sounds
d.    Hyperventilating the client with 100% oxygen

8.    The position of a conscious client during suctioning is:
a.    Fowler’s
b.    Supine position
c.    Side-lying
d.     Prone

9.    A client is on chest tube. A three-way bottle system is used. The nurse expects that the suction bottle will normally have which of the following characteristics.
a.    Intermittent bubbling
b.    Continuous bubbling
c.    No bubbling
d.    None of the above

10.    Before the nurse’s shift ended, the water seal bottle is observed to have an intermittent suctioning. The nurse should do which of the following?
a.    Check for an air leak
b.    Check for kinks in the tube
c.    Inform the physician immediately
d.    Make sure that the bottle is at least 2-3 feet below the level of the chest

11.    The physician is going to remove the chest tube from a client. The nurse should least likely prepare which of the following item?
a.    Sterile gauze
b.    Suture removal kit
c.    Empty bottles
d.    Adhesive tape

12.    While the chest tube is removed the nurse should instruct the patient to:
a.    Exhale deeply
b.    Inhale deeply
c.    Lie at the abdomen
d.    Hyperextend the neck

13.    A client is brought to the ER with complaints of stuffy nose, headache, persistent cough, fever and post-nasal drip. Pain is complained by the client above the eyebrows. The diagnosis is sinusitis. Which of the following sinuses is affected?
a.    Maxillary
b.    Frontal
c.    Ethmoid
d.    Sphenoid

14.    Which of the following medications is avoided in sinusitis to prevent the risk of developing nasal polyps?
a.    Codeine
b.    Amoxicillin
c.    ASA
d.    Anti-infectives

15.    Which intervention is least likely done for sinutis?
a.    Increase fluid intake
b.    Cold wet packs
c.    Hot wet packs
d.    Rest

16.    A client with sinusitis had undergone Caldwell-Luc Surgery. The nurse should instruct the client to do which of the following after the procedure?
a.    Chew on the unaffected side only.
b.    The client can wear dentures 5 days after.
c.    Sneezing should be avoided for a week after the surgery
d.    All of the above

17.    A teen ager is diagnosed to have inflamed tonsils (tonsillitis). The patient’s history reveals recurrent tonsillitis episodes for about 6 times of the same year. The most appropriate intervention for the patient is:
a.    Promoting rest
b.    Increasing fluid intake
c.    Warm saline gargle
d.    Surgery

18.    Before a tonsillectomy is performed, which of the following data is very crucial for the nurse to assess?
a.    Degree of pain
b.    URTI
c.    Drainage on the ears
d.    Respiration pattern

19.    Mark underwent a tonsillectomy procedure. To promote comfort the following interventions should be done by the nurse except:
a.    Application of ice collar
b.    Assist the client to a semi-fowler’s position with pillow support
c.    Assess for frequent swallowing of the patient
d.    Administration of acetaminophen

20.    Two days after tonsillectomy, Mark’s reported that his stool is black. Initially, the nurse should:
a.    Inform the physician
b.    Document the findings
c.    Obtain stool for analysis
d.    Check the client’s vital signs

21.    Asthma can be caused by extrinsic and intrinsic factors. Presence of these factors triggers the release of the chemical mediators which does not include:
a.    Serotonin
b.    Prostaglandin
c.    Bradykinin
d.    Adrenaline

22.    Presence of overdistended and non-functional alveoli is a condition called:
a.    Bronchitis
b.    Emphysema
c.    Empyema
d.    Atelectasis

23.    The accumulation of fluids in the pleural space is called:
a.    Pleural effusion
b.    Hemothorax
c.    Hydrothorax
d.    Pyothorax

24.     A client with COPD is instructed to follow what diet?
a.    High carbohydrate, low calorie and high protein diet
b.    High protein, high calorie and low carbohydrate diet
c.    High carbohydrate, low protein and high calorie diet
d.    High protein, high carbohydrate and high caloric diet

25.    Bronchodilators include the following apart from:
a.    Theophyline
b.    Terbutaline
c.    Metaproterenol
d.    Dipenhydramine

Answers and Rationale

More nclex questions coming up.

1.    Answer C. The three criteria for a client to be diagnosed with AIDS are the following:
•    HIV positive
•    CD4+ T-cell count below 200 cells/microliter
•    Have one or more specific conditions that include acute infection of HIV

2.    Answer D. Keyword: MOST EASILY. Rationale: HIV is MOST EASILY transmitted in blood, semen and vaginal secretions. However, it has been noted to be found in fecal materials, urine, saliva, tears and breast milk.

3.    Answer A. Keyword: BEST TIME. Rationale: To determine if a preexisting infection is present a test should be done immediately and is repeated again in 3 months time (12 weeks) to detect seroconversion as a result of the needle stick.

4.    Answer B. Keyword: FIRST. Rationale: The ELISA test is the first screening test for HIV. A Western blot test confirms a positive ELISA test. Other blood tests that support the diagnosis of HIV include CD4+ and CD8 + counts, CBC, immunoglobulin levels, p24 antigen assay, and quantitative ribonucleic acid assays.

5.    Answer B. Keyword: MAIN REASON. Rationale: HIV was identified in 1983, thus, A is incorrect. By 1988 two strains of HIV existed, HIV-1 and HIV-2. Viruses spread rapidly and mature easily but these factors don’t affect the potential for development against HIV. Mutating too easily makes it hard to create a vaccine against it.

6.    Answer C. Rationale: HIV is a retrovirus that has a ribonucleic acid dependent reverse transcriptase.

7.    Answer D.  Keyword: STIMULATING THE PRODUCTION OF RBC. Rationale: Kidneys produce and release the hormone erythropoietin that is responsible for initiating the production of RBCs in the red marrow, thus, the correct answer is D. The Red Marrow is the site of RBC production. The spleen is responsible for removing the damage RBC.

8.    Answer A. Rationale: Anemia is characterized by a decreased in the number of RBCs.

9.    Answer C. Keyword: PRECURSOR. Rationale: the precursor of RBC is the stem cells in the red marrow.

10.    Answer A. Rationale: Stem cells – erythroblast- reticulocyte – erythrocytes. Erythropoietin is the hormone that stimulates red blood cell production in the red marrow. Mature red blood cells are formed from stem cells in the bone marrow. With the presence of erythropoietin, red cell pathway starts to form proerythroblast from stem cells. At this point the cell still contains nucleus. However, as the development progresses the nucleus becomes smaller and the cytoplasm becomes basophilic due to the presence of ribosome, thus the cell is now called basophilic erythroblast. As the cell becomes older it also becomes smaller and eventually when it begins to produce hemoglobin it is now termed as polychromatic erythroblast. Later on the cytoplasm will become more eosinophilic and the cell is now called orthochromatic erythroblast, which will then extrude its nucleus as the cells slowly fill with hemoglobin before entering the circulation as reticulocytes. Reticulocytes will mature to form the anucleated red blood cells.

11.    Answer C. Keyword: TRUE. Rationale: Kidneys produce and release the hormone erythropoietin that is responsible for initiating the production of RBCs in the red marrow. Red blood cells are anucleated cells (without nucleus) and have a life span of 120 days or 4 months.

12.    Answer A. Keyword: PASSES/CROSSES THE PLACENTA. Rationale: There is only one immunoglobulin that passes or crosses that placenta, the IgG. IgG starts to cross the placenta at the first trimester of pregnancy.  However, the largest amount of IgG transfer is noted during the third trimester of pregnancy. This type of immunoglobulin provides the fetus a passive immunity to possible bacterial and viral infections. However, the passive immunity it provides is only temporary. The immunity gradually disappears at about 6 to 8 months of life. The gradual disappearance of passive immunity, leads to the gradual production of larger quantities of immunoglobulin to replace the IgG from the mother.

13.    Answer C. Keyword: FIRST IMMUNOGLOBULIN PRODUCED BY THE BODY. Rationale: IgM is the first immunoglobulin produced by the body when the neonate is distressed, has acquired an infection or is challenged. When a newborn is exposed to environmental antigens, production of IgM rapidly increases. This type of immunoglobulin provides protection from gram-negative bacteria. IgM cannot cross the placental barrier.  In cases where large amount of IgM is found in the placenta, possible exposure to infection in the utero is probable

14.    Answer B. Keyword: HEMOGLOBIN SYNTHESIS. Rationale: Dietary elements are essential for RBC production. The following are needed by the red marrow to produce erythrocytes:
•    Iron – for hemoglobin synthesis
•    Folic Acid – for DNA synthesis
•    Vitamin B12 – for DNA synthesis

15.    Answer D. Keyword: MOST AT RISK. Rationale: The elderly are most at risk for anemia often due to financial concerns affecting protein intake or poor dentition that interferes with chewing meat.

16.    Answer B. Keyword: DECREASED NUMBER OF PLATELETS. Rationale: thrombocytopenia is a decreased number of platelets. Thrombocytosis is an excess in the number of platelets. Thrombocytopathy is a platelet dysfunction. Thrombectomy is the surgical removal of a thrombus.

17.    Answer C. Rationale: TO IMPROVE PLATELET COUNT. Rationale: Corticosteroid therapy can decrease antibody production and phagocytosis of the antibody-coated platelets, retaining more functioning platelets. Methotrexate can cause thrombocytopenia. Vitamin K is used to treat an excessive anticoagulable state from warfarin overload, and ASA decreases platelet aggregation.

18.     Answer A. Keyword: B-CELLS. Rationale: B-Cells are responsible for humoral or immunoglobulin mediated immunity. T-cells are responsible for cell-mediated immunity. There is such thing as antigen-mediated immunity.

19.    Answer D. Rationale: The life span of a normal platelet is 7-10 days. However, in idiopathic thrombocytopenia the life span is reduced to 1-3 days.

20.    Answer D. Keyword: PRIMARILY. Rationale: SLE is a chronic, inflammatory, autoimmune disorder affecting primarily the connective tissues. It also affects the skin and kidneys and may affect the pulmonary, cardiac, neural and renal systems.

21.    Answer C. Keyword: NEUROLOGICAL INVOLVEMENT. Rationale: neurologic involvement may be shown by:
•    Psychosis
•    Seizures
•    Headaches

22.    Answer A. Keyword: CLASSIC SIGN. Rationale: Although all these symptoms can be signs of SLE, the classic sign is the butterfly rash over the cheeks and nose.

23.    Answer B. Keyword: SUPPORTS THE DIAGNOSIS. Rationale: lab findings for clients with SLE usually show:
•    Pancytopenia
•    Elevated ANA titer
•    Decreased serum complement levels

24.    Answer C. Keyword: AVOID. Rationale: a low-bacteria diet would be indicated. Raw fruits and vegetables are excluded in the client’s diet.

25.    Answer C. Keyword: AVERAGE LENGTH OF TIME. Rationale: epidemiologic studies show the average time from initial contact with HIV to the development of AIDS is 10 years.

by: Daisy Jane, RN

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How to pass the nclex

1.    Ms. X is diagnosed with acquired immunodeficiency syndrome (AIDS). The nurse caring for this patient is aware that for a patient to be diagnosed with HIV she should have which condition?
a.    Infection of HIV, have a CD4+ T-cell count of 500 cells/microliter, history of acute HIV infection
b.    Infection with Tuberculosis, HIV and cytomegalovirus
c.    Infection of HIV, have a CD4+ T-cell count of >200 cells/microliter, history of acute HIV infection
d.    Infection with HIV, history of HIV infection and T-cell count below 200 cells/microliter

2.    The nurse observes precaution in caring for Mr. X as HIV is most easily transmitted in:
a.    Vaginal secretions and urine
b.    Breast milk and tears
c.    Feces and saliva
d.    Blood and semen

3.    Nurse Jaja is giving an injection to Ms. X. After giving an injection, the nurse accidentally stuck her finger with the needle when the client became very agitated. To determine if the nurse became infected with HIV when is the best time to test her for HIV antibodies?
a.    Immediately and repeat the test after 12 weeks
b.    Immediately and repeat the test after 4 weeks
c.    After  a week and repeat the test in 4 months
d.    After a weeks and repeat the test in 6 months

4.    The blood test first used to identify  a response to HIV infection is:
a.    Western blot
b.    ELISA test
c.    CD4+ T-cell count
d.    CBC

5.    What is the main reason why it is difficult to develop a vaccine against HIV?
a.    HIV is still unknown to human
b.    HIV mutates easily
c.    HIV spreads rapidly throughout the body
d.    HIV matures easily

6.    Human Immunodeficiency virus belongs to which classifications?
a.    Rhabdovirus
b.    Rhinovirus
c.    Retrovirus
d.    Rotavirus

7.    Which organ is responsible for stimulating the production of red blood cells?
a.    Yellow marrow
b.    Red marrow
c.    Spleen
d.    Kidney

8.    In anemia, which of the following blood components is decreased?
a.    Erythrocytes
b.    Granulocytes
c.    Leukocytes
d.    Platelets

9.    The precursor of red blood cells is called:
a.    T cells
b.    B cells
c.    Stem cells
d.    Macrophage

10.    In erythropoiesis, the sequence of erythrocyte formation is chronologically described in which option?
a.    Stem cells, erythroblast, reticulocyte, erythrocytes
b.    Stem cells, reticulocyte, erythroblast, erythrocytes
c.    Erythroblast, stem cells, reticulocyte, erythrocytes
d.    Erythroblast, reticulocyte, stem cells, erythrocytes

11.    Which of the following is true of red blood cell?
a.    It is nucleated.
b.    It has a lifespan of 100 days
c.    It’s production and formation depends on the action of the kidney
d.    It is produced in the yellow marrow

12.    Which type of immunoglobulin passes or crosses the placenta starting at the first trimester of pregnancy?
a.    IgG
b.    IgA
c.    IgM
d.    All of these

13.    The first immunoglobulin produced by the body when the neonate is distressed, has acquired an infection or is challenged is:
a.    IgG
b.    IgA
c.    IgM
d.    All of these

14.    Which of the following is essential for the hemoglobin synthesis during RBC production?
a.    Folic Acid
b.     Iron
c.    Vitamin B12
d.    All of these

15.    The age group most at risk for developing anemia is:
a.    20-25 years old
b.    26-32 years old
c.    40-50 years old
d.    >65 years old

16.    Decreased number of platelets is called:
a.    Thrombectomy
b.    Thrombocytopenia
c.    Thrombocytopathy
d.    Thrombocytosis

17.    To improve the platelet count of a patient with an idiopathic thrombocytopenic purpura, this medication should be given:
a.    Vitamin K
b.    Methotrexate
c.    Corticosteroid
d.    Acetylsalicylic Acid

18.    B-cells are involved in which of the following types of immunity?
a.    Humoral immunity
b.    Cell-mediated immunity
c.    Antigen-mediated immunity
d.    All of these

19.    What is the life span of normal platelets?
a.    3-4 months
b.    1-2 months
c.    1-3 days
d.    7-10 days

20.    A patient is diagnosed with a systematic lupus erythematous (SLE). SLE primarily attacks which tissues?
a.    Heart
b.    Lung
c.    Nerve
d.    Connective

21.    A sign of neurologic involvement in SLE is manifested by:
a.    CVA
b.    Infection
c.    Psychosis
d.    Facial tic

22.    A classic sign of SLE is:
a.    Rashes over the cheeks and nose
b.    Weight loss
c.    Vomiting
d.    Difficulty urinating

23.    A laboratory test result that supports the diagnosis of SLE is:
a.    Leukocytosis, elevated BUN and CREA
b.    Pancytopenia, elevated antinuclear antibody (ANA) titer
c.    Thrombocytosis, elevated ESR
d.    None of these

24.    Which food should a client with leukemia avoid?
a.    Wheat bread
b.    Steak
c.    Orange
d.    All of these

25.    The average length of time from HIV infection to the development of AIDS is?
a.    Less than 3 years
b.    5-7 years
c.    10 years
d.    More than 10 years

Answers and Rationale will be posted soon…

 
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Passing the nclex exam

1.    Answer: B. Early detection of cancer is promoted by annual oral examination, monthly BSE from age 20, annual chest x-ray, yearly digital rectal examination for persons over age 40, annual Pap smear from age 40 and annual physical and blood examination. Letter B is wrong because it says Pap smear should be done yearly for sexually active women. All women should have an annual pap smear by age 40 and up whether sexually active or not.
2.    Answer: D. Halstead surgery also called radical mastectomy involves the removal of entire breast, pectoralis major and minor muscles and neck lymph nodes. It is followed by skin grafting. Removal of the entire breast, pectoralis major muscle and the axillary lymph nodes is a surgical procedure called modified radical mastectomy. Simple mastectomy is the removal of the entire breast but the pectoralis muscles and nipples remain intact.
3.    Answer: D. chemotherapy is contraindicated in cases of infection (chemotherapeutic agents are immunosuppressive), recent surgery (chemotherapeutic agent may retard the healing process), impaired renal and hepatic function (drugs are nephrotoxic and hepatotoxic), recent radiation therapy (immunosuppressive treatment), pregnancy (drugs can cause congenital defects) and bone marrow depression (chemo. Agents may aggravate the condition).
4.    Answer: A. The nurse should be corrected if she is only wearing mask and glove because gowns should also be worn in handling chemotherapeutic drugs. The vials should be vent after mixing to reduce the internal pressure. Air bubbles are expelled on wet cotton to prevent the spread of the chemotherapeutic agent particles.
5.    Answer: C.

6.    Answer: D. Unexplained sudden weight loss is a warning signal of cancer. Letter A is wrong because the sore in cancer does not heal. Nagging cough not dry cough and hoarseness of voice is a sign of cancer. Presence of lump is not limited to the breast only; it can grow elsewhere that is why letter C is wrong.
7.    Answer: B. TNM stands for tumor, node, and metastasis.
8.    Answer: B. This client needs further teaching as palpation in BSE should start at the periphery going to the center in a circular motion.
9.    Answer: C. Diarrhea not constipation is the side effect of radiation therapy.
10.    Answer: C. Radiation therapy makes the platelet count decrease. Thus, nursing responsibilities should be directed at promoting safety by avoiding episodes of hemorrhage or bleeding such as physical trauma and aspirin administration. Analgesics are given before meals to alleviate the pain caused by stomatitis. Bland diet and saline rinses every 2 hours should also be done to manage stomatitis.
11.    Answer: C. No soap should be used on the skin of the client undergoing radiation. Soap and irritants and may cause dryness of the patient’s skin. Only water should be used in washing the area.
12.    Answer A.  Metochlopramide (Metozol) – antiemetic. Succimer (Chemet) – chelating agent for lead poisoning. Anastrazole (Arimidex) – hormone regulator. Busulfan (Myleran) – alkylating agent
13.    Answer: A. The distance of at least 3 feet / 0.9 or 1 meter should be maintained when a nurse is not performing any nursing procedures.
14.    Answer: B. To promote safety to the personnel, the client will remain alone in the treatment room while the machine is in operation. The client may voice out any concern throughout the treatment because a technologist is just outside the room observing through a window or closed circuit TV. There is no residual radioactivity after radiation therapy. Safety precautions are necessary only during the time of actual irradiation. The client may resume normal activities of daily living afterwards.
15.    Answer C: Principles of Radiation protection follows the DTS system. Distance (D), Time (T) and Shielding (S). Distance – at least 3 feet should be maintained when a nurse is not performing any nursing procedures. Time – limit contact to 5 minutes each time. Shielding – use lead shield during contact with client.
16.    Answer: D. Hemorrhagic cystitis is the potentially fatal side effect of Cytoxan. Myeloma is an indication for giving this medication. Alopecia is a common side effect.
17.    Answer: D. Cytarabine syndrome includes fever, myalgia, bone pain, chest pain, rash, conjunctivitis and malaise. No diarrhea is included in this syndrome thus; letter D is the best choice.
18.    Answer: C. Steroids may be prescribed to promote relief from cytarabine syndrome. Allopurinol is given for hyperurecemia that will result from taking some chemotherapeutic agent.
19.    Answer: B. Fluorouracil (Adrucil) is an antimetabolite.
20.    Answer: B. Vincristine is a mitotic inhibitor
21.    Answer: B. Anstrazole (arimidex)- treatment of advanced breast cancer in post menopausal women following tamoxifen therapy. Estramustine (Emcyt) – palliative treatment of metastatic and progressive prostate cancer. Pclitaxel (Taxol) – treatment of ovarian cancer, breast cancer and AIDS related to Kaposi’s sarcoma. Irinotecan (Camptosar)- treatment of metastatic colon or rectal cancer after treatment with 5-FU.
22.    Answer: A. The client should prevent hot and spicy food because of the stomatitis side effect. The client should avoid people with infection but should not isolate himself in his room all the time. Fluid intake should be increased. Urine color change is normal.
23.    Answer B. Stage I – tumor size up to 2 cm. Stage II – tumor size up to 5 cm with axillary and neck lymph node involvement. Stage III – tumor size is more than 5 cm with axillary and neck lymph node involvement. Stage IV – metastasis to distant organs (liver, lungs, bone and brain).
24.    Answer A. Classic symptoms that define breast cancer includes:  Firm, nontender, nonmobile mass. Solitary, irregularly shaped mass. Adherence to muscle or skin causing dimpling effect. Involvement of the upper outer quadrant or central nipple portion. Asymmetry of the breasts. “Orange peel” skin. Retraction of nipple. Abnormal discharge from nipple.
25.    Answer: B. removal of the entire breast, pectoralis major muscle and the axillary lymph nodes is a surgical procedure called modified radical mastectomy. Simple mastectomy is the removal of the entire breast but the pectoralis muscles and nipples remain intact. Halstead surgery also called radical mastectomy involves the removal of entire breast, pectoralis major and minor muscles and neck lymph nodes. It is followed by skin grafting.

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Test Questions for Oncologic Disorders
1.    A 25 year old patient is inquiring about the methods or ways to detect cancer earlier. The nurse least likely identify this method by stating:
a.    Annual chest x-ray.
b.    Annual Pap smear for sexually active women only.
c.    Annual digital rectal examination for persons over age 40.
d.    Yearly physical and blood examination

2.    The removal of entire breast, pectoralis major and minor muscles and neck lymph nodes which is followed by skin grafting is a procedure called:
a.    Simple mastectomy
b.    Modified radical mastectomy
c.    Radiation therapy
d.    Radical mastectomy

3.    Chemotherapy is one of the therapeutic modalities for cancer. This treatment is contraindicated to which of the following conditions?
a.    Recent surgery
b.    Pregnancy
c.    Bone marrow depression
d.    All of the above

4.    The nurse is preparing Cyclophosphamide (Cytoxan). Safe handling of the drug should be implemented to protect the nurse from injury. Which of the following action by the nurse should be corrected?
a.    The nurse should wear mask and gloves.
b.    Air bubbles should be expelled on wet cotton.
c.    Label the hanging IV bottle with ANTINEOPLASTIC CHEMOTHERAPY sign.
d.    Vent vials after mixing.

5.    Neoplasm can be classified as either benign or malignant. The following are characteristics of malignant tumor apart from:
a.    Metastasis
b.    Infiltrates surrounding tissues
c.    Encapsulated
d.    Poorly differentiated cells

6.    On a clinic visit a client who has a relative with cancer, is asking about the warning signs that may relate to cancer. The nurse correctly identifies the warning signs of cancer by responding:
a.    “If a sore healing took a month or more to heal, cancer should be suspected.”
b.    “Presence of dry cough is one of the warning signs of cancer.”
c.    “A lump located only in the breast area may suggest the presence of cancer.”
d.    “Sudden weight loss of unexplained etiology can be a warning sign of cancer.”

7.    In staging and grading neoplasm TNM system is used. TNM stands for:
a.    Time, neoplasm, mode of growth
b.    Tumor, node, metastasis
c.    Tumor, neoplasm, mode of growth
d.    Time, node, metastasis

8.    Breast self examination (BSE) is one of the ways to detect breast cancer earlier. The nurse is conducting a health teaching to female clients in a clinic. During evaluation the clients are asked to state what they learned. Which of the following statement made by a client needs further teaching about BSE?
a.    “BSE is done after menstruation.”
b.    “BSE palpation is done by starting at the center going to the periphery in a circular motion.”
c.     “BSE can be done in either supine or standing position.”
d.    “BSE should start from age 20.”

9.    A client had undergone radiation therapy (external). The expected side effects include the following apart from:
a.    Hair loss
b.    Ulceration of oral mucous membranes
c.    Constipation
d.    Headache

10.    Nurse Janet is assigned in the oncology section of the hospital. Which of the following orders should the nurse question if a client is on radiation therapy?
a.    Analgesics before meals
b.    Saline rinses every 2 hours
c.    Aspirin every 4 hours
d.    Bland diet

11.    Skin reactions are common in radiation therapy. Nursing responsibilities on promoting skin integrity should be promoted apart from:
a.    Avoiding the use of  ointments, powders and lotion to the area
b.    Using soft cotton fabrics for clothing
c.    Washing the area with a mild soap and water and patting it dry not rubbing it.
d.    Avoiding direct sunshine or cold.

12.    Nausea and vomiting is an expected side effect of chemotherapeutic drug use. Which of the following drug should be administered to a client on chemotherapy to prevent nausea and vomiting?
a.    Metochlopramide (Metozol)
b.    Succimer (Chemet)
c.    Anastrazole (Arimidex)
d.    Busulfan (Myleran)

13.    Radiation protection is very important to implement when performing nursing procedures. When the nurse is not performing any nursing procedures what distance should be maintained from the client?
a.    1 feet
b.    2 feet
c.    2.5 feet
d.    3 feet

14.    The following are teaching guidelines regarding radiation therapy except:
a.    The therapy is painless
b.    To promote safety, the client is assisted by therapy personnel while the machine is in operation.
c.    The client may communicate all his concerns or needs or discomforts while the machine is operating.
d.    Safety precautions are necessary only during the time of actual irradiation.

15.    Contact of client on radiation therapy should be limited only to how many minutes to promote safety of the therapy personnel?
a.    1 minute
b.    3 minutes
c.    5 minutes
d.    10 minutes

16.    A client is taking Cyclophosphamide (Cytoxan) for the treatment of lymphoma. The nurse is very cautious in administering the medication because this drug poses the fatal side effect of:
a.    Alopecia
b.    Myeloma
c.    CNS toxicity
d.    Hemorrhagic cystitis

17.    Cytarabine (Ara-C) is an antimetabolite that can cause a common cytarabine syndrome which includes the following apart from:
a.    Fever
b.    Myalgia
c.    Chest pain
d.    Diarrhea

18.    To provide relief from the cytarabine syndrome, which drug is given?
a.    Analgesic
b.    Aspirin
c.    Steroids
d.    Allopurinol

19.    Chemotherapeutic agents have different specific classifications. The following medications are antineoplastic antibiotics except:
a.    Doxorubicin (Adriamycin)
b.    Fluorouracil (Adrucil)
c.    Mitoxantrone (Novantrone)
d.    Bleomycin (Blenoxane)

20.    Specific classification of the chemotherapeutic agent, Vincristine ((Oncovin) is:
a.    Hormone modulator
b.    Mitotic inhibitor
c.    Antineoplastic antibiotic
d.    Antimetabolite

21.    A client is diagnosed with progressive prostate cancer. The nurse expects which drug is given?
a.    Anstrazole (arimidex)
b.    Estramustine (Emcyt)
c.    Pclitaxel (Taxol)
d.    Irinotecan (Camptosar)

22.    A client taking a chemotherapeutic agent  understands the effects of therapy by stating:
a.    “I will avoid eating hot and spicy foods.”
b.    “I should stay in my room all the time.”
c.    “I should limit my fluid intake to about 500 ml per day.”
d.    “I should notify the physician immediately if a urine color change is observed.”

23.    A client is diagnosed with breast cancer. The tumor size is up to 5 cm with axillary and neck lymph node involvement. The client is in what stage of breast cancer?
a.    Stage I
b.    Stage II
c.    Stage III
d.    Stage IV

24.    The classic symptoms that define breast cancer includes the following except:
a.    “pink peel” skin
b.    Solitary, irregularly shaped mass
c.    Firm, nontender, nonmobile mass
d.    Abnormal discharge from the nipple

25.    Surgical procedure to treat breast cancer involves the removal of the entire breast, pectoralis major muscle and the axillary lymph nodes is:
a.    Simple mastectomy
b.    Modified radical mastectomy
c.    Halstead Surgery
d.    Radical mastectomy

Answers and Rationale will be posted soon…

More NCLEX Review…

Pass the NCLEX

1.    Answer B. Reports of bladder spasms and the urge to void suggest that a blood clot may be occluding the catheter. After TURP, urine normally appears red to pink, and normal saline irrigant usually is infused at a rate of 40 to 60 drops/minute or according to facility protocol. The amount of returned fluid (1,200 ml) should correspond to the amount of instilled fluid, plus the client’s urine output (1,000 ml + 200 ml), which reflects catheter patency.

2.    Answer B. When inserting a urinary catheter, facilitate insertion by asking the client to breathe deeply. Doing this will relax the urinary sphincter. Initiating a stream of urine isn’t recommended during catheter insertion. Turning to the side or holding the labia or penis won’t ease insertion, and doing so may contaminate the sterile field.

3.    Answer D. ARF, characterized by abrupt loss of kidney function, commonly causes oliguria, which is demonstrated by a urine output of 400 ml/24 hours. A serum creatinine level of 1.2 mg/dl isn’t diagnostic of ARF. A BUN level of 22 mg/dl or a temperature of 100.2° F (37.8° C) wouldn’t result from this disorder.

4.    Answer A. TURP is the most widely used procedure for prostate gland removal. Because it requires no incision, TURP is especially suitable for men with relatively minor prostatic enlargements and for those who are poor surgical risks. Suprapubic prostatectomy, retropubic prostatectomy, and transurethral laser incision of the prostate are less common procedures; they all require an incision.

5.    Answer B. Fluid depletion before excretory urography is contraindicated in clients with multiple myeloma, severe diabetes mellitus, and uric acid nephropathy — conditions that can seriously compromise renal function in fluid-depleted clients with reduced renal perfusion. If these clients must undergo excretory urography, they should be well hydrated before the test. Cystic fibrosis, gout, and myasthenia gravis don’t necessitate changes in client preparation for excretory urography.

6.    Answer A. By encouraging a daily fluid intake of at least 2 L, the nurse helps fill the client’s bladder, thereby promoting bladder retraining by stimulating the urge to void. The nurse shouldn’t give the client soda before bedtime; soda acts as a diuretic and may make the client incontinent. The nurse should take the client to the bathroom or offer the bedpan at least every 2 hours throughout the day; twice per day is insufficient. Consultation with a dietitian won’t address the problem of urinary incontinence.

7.    Answer B. Percussion over the costovertebral angle normally produces a dull, thudding sound, which is soft to moderately loud with a moderate pitch and duration. This sound occurs over less dense, mostly fluid-filled matter, such as the kidneys, liver, and spleen. In contrast, a flat sound occurs over highly dense matter such as muscle; hyperresonance occurs over the air-filled, overinflated lungs of a client with pulmonary emphysema or the lungs of a child (because of a thin chest wall); and tympany occurs over enclosed structures containing air, such as the stomach and bowel.

8.    Answer D. An elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which the nurse can detect immediately by palpating the pulse. The client’s blood pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should assess blood pressure later. The nurse also can delay assessing respirations and temperature because these aren’t affected by the serum potassium level.

9.    Answer C. Infection can occur with renal calculi from urine stasis caused by obstruction. Options A and D aren’t appropriate for this diagnosis, and retention of urine usually occurs, rather than incontinence.

10.    Answer A. As urine output decreases, the serum potassium level rises; if it rises sufficiently, hyperkalemia may occur, possibly triggering a cardiac arrhythmia. Hyperkalemia doesn’t cause paresthesia (sensations of numbness and tingling). Dehydration doesn’t occur during this oliguric phase of ARF, although typically it does arise during the diuretic phase. In a client with ARF, pruritus results from increased phosphates and isn’t associated with hyperkalemia.

11.    Answer C. Although postoperative pain is expected, the nurse should make sure that other factors, such as an obstructed irrigation catheter, aren’t the cause of the pain. After assessing catheter patency, the nurse should administer an analgesic, such as meperidine, as prescribed. Increasing the I.V. flow rate may worsen the pain. Notifying the physician isn’t necessary unless the pain is severe or unrelieved by the prescribed medication.

12.    Answer D. A nurse who discovers a nodule, swelling, or other abnormal finding during a scrotal examination should transilluminate the scrotum by darkening the room and shining a flashlight through the scrotum behind the mass. A scrotum filled with serous fluid transilluminates as a red glow; a more solid lesion, such as a hematoma or mass, doesn’t transilluminate and may appear as a dark shadow. Although the nurse should notify the physician of the abnormal finding, performing transillumination first provides additional information. The nurse can’t uncover more information about a scrotal mass by changing the client’s position and repeating the examination or by performing a rectal examination.

13.    Answer C. In a client with CRF, unrestricted intake of sodium, protein, potassium, and fluid may lead to a dangerous accumulation of electrolytes and protein metabolic products, such as amino acids and ammonia. Therefore, the client must limit intake of sodium; meat, which is high in protein; bananas, which are high in potassium; and fluid, because the failing kidneys can’t secrete adequate urine. Salt substitutes are high in potassium and should be avoided. Extra carbohydrates are needed to prevent protein catabolism.

14.    Answer B. Urinary incontinence isn’t a normal part of aging nor is it a disease. It may be caused by confusion, dehydration, fecal impaction, restricted mobility, or other causes. Certain medications, including diuretics, hypnotics, sedatives, anticholinergics, and antihypertensives, may trigger urinary incontinence. Most clients with urinary incontinence can be treated; some can be cured.

15.    Answer D. If the catheter is blocked by blood clots, it may be irrigated according to physician’s orders or facility protocol. The nurse should use sterile technique to reduce the risk of infection. Urinating around the catheter can cause painful bladder spasms. Encourage the client to drink fluids to dilute the urine and maintain urine output. The catheter remains in place for 2 to 4 days after surgery and is only removed with a physician’s order.

16.    Answer B. When receiving a sulfonamide such as co-trimoxazole, the client should drink at least eight 8-oz glasses of fluid daily to maintain a urine output of at least 1,500 ml/day. Otherwise, inadequate urine output may lead to crystalluria or tubular deposits. For maximum absorption, the client should take this drug at least 1 hour before or 2 hours after meals. No evidence indicates that antacids interfere with the effects of sulfonamides. To prevent a photosensitivity reaction, the client should avoid direct sunlight during co-trimoxazole therapy.

17.    Answer A. Generalized edema, especially of the face and periorbital area, is a classic sign of acute glomerulonephritis of sudden onset. Other classic signs and symptoms of this disorder include hematuria (not green-tinged urine), proteinuria, fever, chills, weakness, pallor, anorexia, nausea, and vomiting. The client also may have moderate to severe hypertension (not hypotension), oliguria or anuria (not polyuria), headache, reduced visual acuity, and abdominal or flank pain.

18.    Answer A. The symptoms of C. albicans include itching and a scant white discharge that has the consistency of cottage cheese. Yellow-green discharge is a sign of Trichomonas vaginalis. Gray-white discharge and a fishy odor are signs of Gardnerella vaginalis.

19.    Answer A. Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap smears are very important for early detection. Because condylomata acuminata is a virus, there is no permanent cure. Because condylomata acuminata can occur on the vulva, a condom won’t protect sexual partners. HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx.

20.    Answer A. Maintaining a closed indwelling urinary catheter system helps prevent introduction of bacteria; securing the catheter to the client’s leg also decreases the risk of infection by helping to prevent urethral trauma. To flush bacteria from the urinary tract, the nurse should encourage the client to drink at least 10 glasses of fluid daily, if possible. Douching and feminine deodorants may irritate the urinary tract and should be discouraged.

21.    Answer A. By encouraging a daily fluid intake of at least 2 L, the nurse helps fill the client’s bladder, thereby promoting bladder retraining by stimulating the urge to void. The nurse shouldn’t give the client soda before bedtime; soda acts as a diuretic and may make the client incontinent. The nurse should take the client to the bathroom or offer the bedpan at least every 2 hours throughout the day; twice per day is insufficient. Consultation with a dietitian won’t address the problem of urinary incontinence.

22.    Answer B. Most catheters have a self-sealing port for obtaining a urine specimen. Antiseptic solution is used to reduce the risk of introducing microorganisms into the catheter. Tubing shouldn’t be disconnected from the urinary catheter. Any break in the closed urine drainage system may allow the entry of microorganisms. Urine in urine drainage bags may not be fresh and may contain bacteria, giving false test results. When there is no urine in the tubing, the catheter may be clamped for no more than 30 minutes to allow urine to collect.

23.    Answer D. Symptoms of gonorrhea in men include purulent, foul-smelling drainage from the penis and painful urination. Rashes on the palms of the hands and soles of the feet are symptoms of the secondary stage of syphilis. Cauliflower-like warts on the penis are a sign of human papillomavirus. Painful red papules on the shaft of the penis may be a sign of the first stage of genital herpes.

24.    Answer A. Kayexalate is a sodium exchange resin. Thus the client will gain sodium as potassium is lost in the bowel. For the exchange to occur, Kayexalate must be in contact with the bowel for at least 30 minutes. Sorbitol in the Kayexalate enema causes diarrhea, which increases potassium loss and decreases the potential for Kayexalate retention.

25.    Answer A. Because acetaminophen is metabolized in the liver, its dosage and dosing schedule need not be adjusted for a client with ARF. In contrast, the dosages and schedules for gentamicin and ticarcillin, which are metabolized and excreted by the kidney, should be adjusted. Because cyclosporine may cause nephrotoxicity, the nurse must monitor both the dosage and blood drug level in a client receiving this drug.

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2.    Nurse Myrna is inserting a urinary catheter into a client who is extremely anxious about the procedure. The nurse can facilitate the insertion by asking the client to:
a.    initiate a stream of urine.
b.    breathe deeply.
c.    turn to the side.
d.    hold the labia or shaft of penis.

3.    A female adult client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)?
a.    Blood urea nitrogen (BUN) level of 22 mg/dl
b.    Serum creatinine level of 1.2 mg/dl
c.    Serum creatinine level of 1.2 mg/dl
d.    Urine output of 400 ml/24 hours

4.    A 55-year old client with benign prostatic hyperplasia doesn’t respond to medical treatment and is admitted to the facility for prostate gland removal. Before providing preoperative and postoperative instructions to the client, nurse Gail asks the surgeon which prostatectomy procedure will be done. What is the most widely used procedure for prostate gland removal?
a.    Transurethral resection of the prostate (TURP)
b.    Suprapubic prostatectomy
c.    Retropubic prostatectomy
d.    Transurethral laser incision of the prostate

5.    A female client with suspected renal dysfunction is scheduled for excretory urography. Nurse July reviews the history for conditions that may warrant changes in client preparation. Normally, a client should be mildly hypovolemic (fluid depleted) before excretory urography. Which history finding would call for the client to be well hydrated instead?
a.    Cystic fibrosis
b.    Multiple myeloma
c.    Gout
d.    Myasthenia gravis

6.    Nurse Kim  is caring for a client who had a cerebrovascular accident (CVA). Which nursing intervention promotes urinary continence?
a.    Encouraging intake of at least 2 L of fluid daily
b.    Giving the client a glass of soda before bedtime
c.    Taking the client to the bathroom twice per day
d.    Consulting with a dietitian

7.    When examining a female client’s genitourinary system, nurse Sally  assesses for tenderness at the costovertebral angle by placing the left hand over this area and striking it with the right fist. Normally, this percussion technique produces which sound?
a.    A flat sound
b.    A dull sound
c.    Hyperresonance
d.    Tympany

8.    A male client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should nurse Olivia assess first?
a.    Blood pressure
b.    Respirations
c.    Temperature
d.    Pulse

9.    Nurse Hazel is ware that the following is an appropriate nursing diagnosis for a client with renal calculi?
a.    Ineffective tissue perfusion
b.    Functional urinary incontinence
c.    Risk for infection
d.    Decreased cardiac output

10.    A male client develops acute renal failure (ARF) after receiving I.V. therapy with a nephrotoxic antibiotic. Because the client’s 24-hour urine output totals 240 ml, nurse Andy suspects that the client is at risk for:
a.    cardiac arrhythmia.
b.    paresthesia.
c.    dehydration.
d.    pruritus.

11.    After undergoing transurethral resection of the prostate to treat benign prostatic hyperplasia, a male client returns to the room with continuous bladder irrigation. On the first day after surgery, the client reports bladder pain. What should nurse Andrew do first?
a.    Increase the I.V. flow rate.
b.    Notify the physician immediately.
c.    Assess the irrigation catheter for patency and drainage.
d.    Administer meperidine (Demerol), 50 mg I.M., as prescribed.

12.    When performing a scrotal examination, nurse Paul finds a nodule. What should the nurse do next?
a.    Notify the physician.
b.    Change the client’s position and repeat the examination.
c.    Perform a rectal examination.
d.    Transilluminate the scrotum.

13.    A male client who has been treated for chronic renal failure (CRF) is ready for discharge. Nurse Bea should reinforce which dietary instruction?
a.    “Be sure to eat meat at every meal.”
b.    “Monitor your fruit intake, and eat plenty of bananas.”
c.    “Increase your carbohydrate intake.”
d.    “Drink plenty of fluids, and use a salt substitute.”

14.    Nurse Wayne is aware that the following statements describing urinary incontinence in the elderly is true?
a.    Urinary incontinence is a normal part of aging.
b.    Urinary incontinence isn’t a disease.
c.    Urinary incontinence in the elderly can’t be treated.
d.    Urinary incontinence is a disease.

15.    The client underwent a transurethral resection of the prostate gland 24 hours ago and is on continuous bladder irrigation. Nurse Yoly is aware that the following nursing interventions is appropriate?
a.    Tell the client to try to urinate around the catheter to remove blood clots.
b.    Restrict fluids to prevent the client’s bladder from becoming distended.
c.    Prepare to remove the catheter.
d.    Use aseptic technique when irrigating the catheter.

16.    A female client with a urinary tract infection is prescribed co-trimoxazole (trimethoprim-sulfamethoxazole). Nurse Don should provide which medication instruction?
a.    “Take the medication with food.”
b.    “Drink at least eight 8-oz glasses of fluid daily.”
c.    “Avoid taking antacids during co-trimoxazole therapy.”
d.    “Don’t be afraid to go out in the sun.”

17.    A male client is admitted for treatment of glomerulonephritis. On initial assessment, Nurse Rose detects one of the classic signs of acute glomerulonephritis of sudden onset. Such signs include:
a.    generalized edema, especially of the face and periorbital area.
b.    green-tinged urine.
c.    moderate to severe hypotension.
d.    polyuria.

18.    A client reports experiencing vulvar pruritus. Which assessment factor may indicate that the client has an infection caused by Candida albicans?
a.    Cottage cheese–like discharge
b.    Yellow-green discharge
c.    Gray-white discharge
d.    Discharge with a fishy odor

19.    A 24-year old female client has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?
a.    This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.
b.    The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days.
c.    The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse.
d.    The human papillomavirus (HPV), which causes condylomata acuminata, can’t be transmitted during oral sex.

20.    Nurse Vic is monitoring the fluid intake and output of a female client recovering from an exploratory laparotomy. Which nursing intervention would help the client avoid a urinary tract infection (UTI)?
a.    Maintaining a closed indwelling urinary catheter system and securing the catheter to the leg
b.    Limiting fluid intake to 1 L/day
c.    Encouraging the client to use a feminine deodorant after bathing
d.    Encouraging the client to douche once a day after removal of the indwelling urinary catheter

21.    Nurse Eve is caring for a client who had a cerebrovascular accident (CVA). Which nursing intervention promotes urinary continence?
a.    Encouraging intake of at least 2 L of fluid daily
b.    Giving the client a glass of soda before bedtime
c.    Taking the client to the bathroom twice per day
d.    Consulting with a dietitian

22.    A female client with an indwelling urinary catheter is suspected of having a urinary tract infection. Nurse Angel should collect a urine specimen for culture and sensitivity by:
a.    disconnecting the tubing from the urinary catheter and letting the urine flow into a sterile container.
b.    wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle.
c.    draining urine from the drainage bag into a sterile container.
d.    clamping the tubing for 60 minutes and inserting a sterile needle into the tubing above the clamp to aspirate urine.

23.    Nurse Grace is assessing a male client diagnosed with gonorrhea. Which symptom most likely prompted the client to seek medical attention?
a.    Rashes on the palms of the hands and soles of the feet
b.    Cauliflower-like warts on the penis
c.    Painful red papules on the shaft of the penis
d.    Foul-smelling discharge from the penis

24.    Nurse Ethel is planning to administer a sodium polystyrene sulfonate (Kayexalate) enema to a client with a potassium level of 5.9 mEq/L. Correct administration and the effects of this enema would include having the client:
a.    retain the enema for 30 minutes to allow for sodium exchange; afterward, the client should have diarrhea.
b.    retain the enema for 30 minutes to allow for glucose exchange; afterward, the client should have diarrhea.
c.    retain the enema for 60 minutes to allow for sodium exchange; diarrhea isn’t necessary to reduce the potassium level.
d.    retain the enema for 60 minutes to allow for glucose exchange; diarrhea isn’t necessary to reduce the potassium level.

25.    When caring for a male client with acute renal failure (ARF), Nurse Fatima expects to adjust the dosage or dosing schedule of certain drugs. Which of the following drugs would not require such adjustment?
a.    acetaminophen (Tylenol)
b.    gentamicin sulfate (Garamycin)
c.    cyclosporine (Sandimmune)
d.    ticarcillin disodium (Ticar)

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