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NCLEX Review Questions (Answers and Rationale)

admin — Sat, 09 Jan 2010 06:29:06 +0000

A = the client needs specific information about the effects of the drug, specifically its effect on the blood. The statement about weekly blood tests to determine safe dosage and monitoring for effects on the blood gives the client specific information to ensure follow up with the required protocol for Clorazil therapy. Lack of accurate knowledge can lead to noncompliance with necessary follow-up procedures and noncompliance with medication.
C = the older adults’ taste buds retain their sensitivity to carbohydrates. In addition, carbohydrates. Tend to be food items that are easy to chew. Older adults lose their sensitivity to sour and salty foods. Older adults may find greasy foods harder to digest and therefore may avoid them; however, preference for greasy foods is not related to changes in taste associated with age.
D = because the client eats excessively whenever she is upset. The best nursing diagnosis is effective coping. There are no data on the family to support Disabled Family Coping. The client’s bingering and purging behavior occurs in response to her difficulty with coping. If the client were only overeating and not purging then Imbalanced Nutrition: More than body requirements would be an appropriate diagnosis. The client does not report nervousness and tension that would lead to a nursing diagnosis of Generalized Anxiety.
D = Many women who acquire gonorrhea are asymptomatic or experience mild symptoms that are easily ignored. They are not necessarily more reluctant than men to seek medical treatment, but they are more likely not to realize they have been affected with a disease. Gonorrhea is easily transmitted to all women and can result in serious consequences such as pelvic inflammatory disease and infertility.
A = caffeinated beverages and alcohol should be avoided because they stimulate gastric acid production and irritate gastric mucosa. The client should avoid foods that cause discomfort; however, there is no need to follow a soft, bland diet. Eating six small meals daily is no longer a common treatment for peptic ulcer disease. Milk in large quantities is not recommended because it actually stimulates further production of gastric acids.
C = A low sodium diet is frequently an effective mechanism for reducing the frequency and severity of the disease episodes. About three-quarters of clients with Meniere’s disease respond to treatment with a low salt diet.
D =Tympanoplasty involves surgical reconstruction as the tympanic membrane and is done to re-establish middle ear function, close perforation, prevent recurrent infections.
A = primary cancer prevention targets healthy individuals and includes steps to avoid factors that might lead to the development of diseases.
D = Fatigue is a common complaint of individuals receiving medication therapy.
B = It is appropriate and ethical to respect the client’s truly autonomous choice not to know particular information. The client’s best interests should be determined by the client after he or she receives all the necessary information and in conjunction with other people of the client’s choice, including family, physicians and other healthcare personnel
D = When a wound eviscerates, the nurse should cover the open area with sterile dressing moistened with sterile normal saline and then cover it with a dry dressing. The surgeon should then be notified to take the client back to the operating room to close the incision under general anesthesia.
B = The client’s body temperature should be assessed every 4 hour during the first 24 hour because the client is still at risk for hypothermia or malignant hyperthermia. The client does not be checked every 2 hour unless indicated by an abnormal finding.
D = Identification of causes of medication errors requires inservice education to inform the staff of strategies to decrease these errors. Errors are frequently the result of systemic problems that can be identified and rectified through problem-solving technique and changes in procedures.
A = Benztropine (Congentine) frequently causes the side effects of blurred vision.
A = A follow-up care is essential to present relapse. The recovery has just begun when the treatment program ends. The first few months after program completion can be difficult and dangerous for the chemically dependent client. The nurse is responsible for discharge plans that include arrangements for counseling, self help group meetings and other forms of after care.
C = IUD is suitable for client who desire long-term contraceptive use and are in a monogamous relationships. Because of the increased risk of spread of infection with an IUD if an STD occurs, the device is not appropriate for women with multiple partners or history of STDs.
D = the symptoms of BPH are related to obstruction as a result of an enlarged prostate. Difficulty in starting the urinary stream is a common symptom, along with dribbling, hesitancy and urinary retention.
D = Methocarbamol (Robaxin) is a muscle relaxant and acts primarily to relieve muscle spasms.
B = Migraine headaches are believed to be caused by a vascular disturbance involving branches of the carotid artery where vasoconstriction of blood vessels apparently occurs first.
A = There are many mechanisms of action for chemotherapeutic agents, but most affect the rapidly dividing cells-both cancerous and noncancerous. Cancer cells are characterized by rapid cell division. Chemotherapy slows cell division.
C = Advocacy role of the nurse implies that the nurse will ensure that the client’s wishes are being respected and that she is making informed decisions.
B = the nurse should notify the anesthesiologist because a serum potassium level of 5.8 mEq/L places the client at risk for dysrhythmias when under general anesthesia.
B = If not contraindicated for moral, cultural or religious reasons, a condom with spermicide is often recommended for contraception after delivery until the client’s 6-weeks post partum examination. This method has no effect on the neonate who is breastfeeding.
A = typically, a 4-month-old infant should be able to sit with support from a person holding the infant lightly in the area of the hips or lower chest.
A = It is appropriate for an unlicensed assistant to mark the time of measurement and fluid level in the collection container.
D = Nausea and gastrointestinal upset is a common but usually temporary side effects of Paroxetine (Paxil). Therefore, the nurse would instruct the client to take the medication with food to minimize nausea and stomach upset.
B = the nurse serves as the accomplice because she participate or cooperate through another act essential to the consummation of the crime.
D = A 4-year-old is old enough to be able to cooperate and stop the behavior. Therefore, the first step is to obtain the child’s cooperation.
C = In the traditional Mexican household, the man is the head of the family and makes the major decisions. Efforts should be made to reach the father as soon as possible to acquire his permission.
B = Respondeat superior is Latin for “the master is responsible for the acts of his servants.” The nurse, as an employee of the hospital, was acting according to the established policy of the hospital. Because the nurse followed hospital policy, it is unlikely that this incident involved malpractice, negligence or tort law.

NCLEX Review Questions

admin — Fri, 08 Jan 2010 07:37:14 +0000

1.    A female client with schizophrenia has been unresponsive to antipsychotic. The physician ordered Clozapine therapy to the client. The nurse informed the client that blood test will be done every week while receiving this drug. The client asks the nurse why blood test is needed. Which of the following is the most appropriate nursing response?
A)    “Weekly blood test are necessary to determine safe dosage and to monitor the effect of the medication on the blood.”
B)    “Your physician will want to know how well you are progressing with the medication therapy.”
C)    “Everyone taking Clozapine has to go through the same procedure because it is required by the drug company.”
D)    “Weekly blood tests are done so that you can receive another week’s supply of the medication.”
2.    A 78-year-old does not want to eat lunch and complains that the food that is serve does not taste good. Consistent with knowledge about age-related changes to taste, the nurse may find that the client is more willing to eat.
A)    Greasy foods
B)    Sour foods
C)    Sweet foods
D)    Salty foods.
3.    A client is admitted in the hospital. The client tells the nurse that she eats excessively when she is angry and then vomits so that she won’t gain a lot of weight. The nurse suspects that the client is Bulimic. Which of the following nursing diagnostic categories would be most appropriate for this client?
A)    Generalized Anxiety
B)    Imbalanced Nutrition: More than body requirements
C)    Disabled Family Coping
D)    Ineffective Coping
4.    The nurse is conducting health teaching about STD in the community health clinic. Which of the following health teaching about women who acquire gonorrhea should be included?
A)    Gonorrhea is usually a mild disease for women.
B)    Women are more reluctant than men to seek medical treatment.
C)    Gonorrhea is not easily transmitted to women who are menopausal.
D)    Women with gonorrhea are usually asymptomatic.
5.    The nurse is preparing a discharge plan to a female client with peptic ulcer for the dietary modification she will need to follow at home. Which of the following statements indicates that the client understands the instruction of the nurse?
A)    “I should not drink alcohol and caffeine.”
B)    “I should eat a bland, soft diet.”
C)    “It is important to eat six small meals a day.”
D)    “I should drink several glasses of milk a day.”
6.    A client has disabling attacks of vertigo. The nurse suspects that the client has Meniere’s disease. The nurse is aware that the diet of the client must be modified. Which of the following is the best diet for the client?
A)    High protein
B)    Low Carbohydrates
C)    Low Sodium
D)    Low Fat
7.    Which of the following is the most common surgical procedure for chronic otitis media?
A)    Myringotomy
B)    Ossiculoplasty
C)    Mastoidectomy
D)    Tympanoplasty
8.     A community health nurse is teaching smoking cessation program to a group of healthy adult smokers. What type of prevention activity is this?
A)    Primary
B)    Secondary
C)    Tertiary
D)    None of the above
9.    A female client with breast cancer is currently receiving radiation therapy for treatment. The client is complaining of apathy, hard to concentrate on something, and feeling tired despite of having time to rest and more sleep. These complains suggest symptoms of:
A)    Hypocalcemia
B)    radiation pneumonitis
C)    advanced breast cancer
D)    fatigue
10.    Which of the following statements best describes the concept of autonomy?
A)    Health care team makes health and treatment decision
B)    The nurse provides the client with the facts and then allows the client to reach an unassisted decision.
C)    The professional staff of physician defines the client’s best interest
D)    The nurse respects a client’s choice not to know particular information.
11.    The nurse is removing the client’s staples from an abdominal when the client cough continuously and the incision splits open exposing the intestines. Which of the following is the immediate nursing action of the nurse?
A)    Call the surgeon to come to the client’s room immediately
B)    Have all visitors and family member leave the room
C)    Press the emergency alarm to call the resuscitation team
D)    Cover the abdominal organs with sterile dressing moistened with sterile normal saline.
12.    A client who had a cholecystectomy is transferred to the nursing unit. The nurse is assigned to monitor the vital signs of the client. How often should the post operative client’s temperature be assessed during the first 24 hours after surgery?
A)    every 2 hours
B)    every 4 hours
C)    every 6 hours
D)    every 8 hours
13.    The nurse manager is alarmed to the increase in the medication errors with IV antibiotics in the past month. The best action to resolve this issue is to discuss the problem with each nurse involved and :
A)    Report the incidents to the hospital lawyer
B)    Document It on their evaluation
C)    Report them to the supervisor
D)    Ask them to attend inservice training for administration of IV medication.
14.    A client diagnosed with Paranoid Schizophrenia is receiving Haloperidol (Haldol), Benztropine (Congentin), Quetiapine (Seroquel) and Buspirone (Buspan). After 4 days of taking these medications, the client complains of blurred vision. Which of the following medication would the nurse suspects as the cause of this side effect?
A)    Benztropine (Congentine)
B)    Buspirone (Buspan)
C)    Haloperidol (Haldol)
D)    Quetiapine (Seroquel)
15.    A nurse working in an alcohol rehabilitation program is providing a discharge instruction to a client. Which of the following would the nurse emphasize in the discharge plan as a priority?
A)    Follow-up care
B)    Supportive friends
C)    A list of goals
D)    Family forgiveness
16.    A nurse is conducting a health teaching in the community health center to a group of female clients about contraceptive options. The nurse tells the clients that the intra uterine device (IUD) is a good contraceptive option for women who:
A)    have had a history of ectopic pregnancy
B)    desire short-term contraceptives
C)    are in monogamous relationship
D)    have a history of STDs
17.    Which of the following signs and symptoms would indicate that a client has benign prostatic hypertrophy (BPH)?
A)    Hematuria
B)    Flank pain
C)    Impotence
D)    Difficulty starting the urinary stream
18.    A male client who crashed his motorcycle is now admitted to the emergency department. The client suffered tibial fracture that required casting. The physician prescribed Methocarbamol (Robaxin) to the client. Which of the following would the nurse identify as the drug’s primary effect?
A)    Reduction in itching
B)    Decrease in nervousness
C)    Killing of microorganisms
D)    Relief of muscle spasms
19.    The physician prescribed Ergotamine tartrate (Gynergen) for a client with migraine headaches. The client asks the nurse why she has migraine headaches. What is the nurse’s best response?
A)    Migraine headaches are believed to be caused by sustained contraction of muscles around the scalp and face.
B)    Migraine headaches are believed to be caused by the dilation of the cranial arteries.
C)    Migraine headaches are believed to be caused by irritations and inflammation of the openings of the sinuses.
D)    Migraine headaches are believed to be caused by temporary decrease in intracranial pressure.
20.    A male client is receiving chemotherapy for lung cancer. He asks the nurse how the drug will work. Which of the following is the correct response of the nurse?
A)    “Chemotherapy affects all rapidly dividing cells.”
B)    “Structure of the DNA is altered.”
C)    “Chemotherapy encourages cancer cells to divide.”
D)    “Cancer cells have susceptible drug toxins.”
21.    A 60-year-old client and his family receive the initial diagnosis of colon cancer. Which of the following demonstrate the nurse as the client advocate?
A)    The nurse will document the client’s desire to try an alternative therapy.
B)    The nurse will provide the information about standard therapies.
C)    The nurse will allow the client to make health care choices on her own but will assist in ensuring the client is fully informed when making those decisions.
D)    The nurse will document the client’s treatment choices and provide information about alternative therapies.
22.    A client will be receiving general anesthesia. The nurse reviews the laboratory result of the client and found out that the serum potassium level is 5.8 mEq/L. What should be the nurse’s initial response?
A)    Send the client to surgery
B)    Notify the anesthesiologist
C)    Call the surgeon
D)    Send the client to surgery
23.    A primiparous client who is beginning to breastfeed her neonates asks the nurse what contraception method she and her husband should use until she has her 6-week post partum examination. Which of the following would be most appropriate suggestion?
A)    Oral contraceptives
B)    Condom with spermicide
C)    Cervical cap
D)    Rhythm method
24.    A mother who brings her 4-moth-old infant to the health clinic for check up thinks that her infant is developing slowly. When assessing the infant’s development, the infant should demonstrate which of the following characteristics?
A)    Sitting up with support
B)    Reaching for a toy
C)    Saying mama or dada
D)    Finger-to-thumb grasping
25.    The nurse is instructing the unlicensed assistant on how to care for a client with chest tubes that are connected to water seal drainage. Which of the following instruction would be appropriate for the nurse to give the unlicensed assistant?
A)    Mark the time and amount of drainage collected in the container
B)    Raise the collection apparatus to the height of the bed to measure the fluid level.
C)    Milk the test tubes every 4 hours
D)    Attach the chest tubes to bed linen to avoid tension of the tubing
26.    After the first three dose of Paroxetine (Paxil) 20 mg, the client complains that the medication upsets his stomach. Which of the following instructions would the nurse give to the client?
A)    “Take the medication with 4 ounces of orange juice.”
B)    “Take the medication an hour before breakfast.”
C)    “Take the medication at bedtime.”
D)    “Take the medication with some foods.
27.    An unmarried pregnant teenager is scheduled for an abortion. The nurse is assigned to be the circulating nurse in the procedure. In countries like Philippines, it is not legal to perform this procedure. In this case, if the nurse participate in the procedure the nurse serves as the:
A)    Principal
B)    Accomplice
C)    Accessories
D)    Witness of the procedure done
28.    A mother seeks an advice to the nurse on how to stop her 4-year-old son in sucking his thumb. Which of the following is the appropriate suggestion of the nurse?
A)    Put the child in “time-out” every time the mother observes thumb sucking.
B)    Apply a special medicine that tastes terrible on the thumb.
C)    Remind the child every time the mother sees the thumb in his mouth.
D)    Get the child agree to stop the thumb sucking.
29.    A Mexican mother brings her 2-month-old son to the emergency department with high fever and possible sepsis. The physician ordered lumbar puncture to the client. The mother tells the nurse that she is not going to sign the informed consent form unless her husband gives permission to the procedure. The nurse understands that:
A)    This behavior is unusual for Mexican cultural norms
B)    This needs to be reported to the social worker.
C)    The Mexican is considered the head of the family and makes the major decision.
D)    This needs to be reported to the Children’s Protective Services.
30.    The nurse manager assigned a nurse to perform care on the client’s Hickman catheter according to hospital policy. After 24 hours the client complains of pain in the site. The nurse found out that the client develops an infection and is considering litigation. The nurse’s practice is:
A)    tort
B)    respondeat superior
C)    malpractice
D)    negligent

Answers and Rationale

NCLEX Comprehensive Review Answers and Rationale

Cedric — Fri, 17 Jul 2009 02:21:02 +0000

View the questions of NCLEX Comprehensive Review

1. The correct answer is A: 45 year-old African American attorney The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising.

2. The correct answer is A: Gastric lavage PRN Removing as much of the drug as possible is the first step in treatment for this drug overdose. This is best done by gastric lavage. The next drug to give would be activated charcoal, then mucomyst and lastly the IV fluids.

3. The correct answer is B: thrombus formation Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure.

4. The correct answer is C: Manage pain The immediate goal of therapy is to alleviate the client’s pain.

5. The correct answer is D: Yearly weight gain of about 5.5 pounds per year School age children gain about 5.5 pounds each year and increase about 2 inches in height.

6. The correct answer is A: go get a blood pressure check within the next 48 to 72 hours The blood pressure reading is moderately high with the need to have it rechecked in a few days. The client states it is ‘usually much lower.’ Thus a concern exists for complications such as stroke. However immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.

7. The correct answer is A: A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home.

8. The correct answer is A: Should be taken in the morning Thyroid supplement should be taken in the morning to minimize the side effects of insomnia

9. The correct answer is D: Notify the health care provider of the child”s status These findings suggest a medical emergency and may be due to epiglottises. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction.

10. The correct answer is C: Bed wetting In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bed wetting in a school age child is readily detected by the parents.

11. The correct answer is B: Chlamydia Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.

12. The correct answer is C: An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opoid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future.

13. The correct answer is C: Avoiding very heavy meals eating large, heavy meals can pull blood away from the heart for digestion and is dangerous for the client with coronary artery disease.

14. The correct answer is C: The level of drug is 100 ml at 8 AM and is 80 ml at noon The minimal dose of 10 ml per hour which would be 40 ml given in a 4 hour period. Only 60 ml should be left at noon. The pump is not functioning when more than expected medicine is left in the container.

15. The correct answer is B: Spinal column manipulation The theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation.

16. The correct answer is A: Decrease in level of consciousness A further decrease in the level of consciousness would be indicative of a further progression of the CVA.

17. The correct answer is C: Moist, productive cough Option c is a later sign. Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.

18. The correct answer is B: Send him to the emergency room for evaluation This client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care nurses must prioritize interventions based on assessment findings that are in the client’s best interest.

19. The correct answer is D: No special orders are necessary for this examination No special preparation is necessary for this examination.

20. The correct answer is B: "When you can climb 2 flights of stairs without problems, it is generally safe." There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.

21. The correct answer is B: A teenager who got singed a singed beard while camping This client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling.

22. The correct answer is C: "I understand the need to use those new skills." Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment.

23. The correct answer is A: Verify correct placement of the tube Proper placement of the tube prevents aspiration.

24. The correct answer is C: Tall peaked T waves A tall peaked T wave is a sign of hyperkalemia. The health care provider should be notified regarding discontinuing the medication.

25. The correct answer is A: All striated muscles Rhabdomyosarcoma is the most common children”s soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word and is “myo” which typically means muscle.

26. The correct answer is D: Restore yin and yang For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang.

27. The correct answer is C: Force fluids and reassess blood pressure Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency.

28. The correct answer is B: Left heart function The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the left side of the heart. The pressure readings are inferred from pressure measurements obtained on the right side of the circulation. Right-sided heart function is assessed through the evaluation of the central venous pressures (CVP).

29. The correct answer is C: Establish an airway Establishing an airway is always the primary objective in a cardiopulmonary arrest.

30. The correct answer is A: Blood pressure 94/60 Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100; systolic B/P over 100) in order to safely administer both medications.

31. The correct answer is C: Inspiratory grunt Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant.

32. The correct answer is D: Progressive placental insufficiency The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long term effects may be related to hypoxia.

33. The correct answer is B: "I just can”t ”catch my breath” over the past few minutes and I think I am in grave danger." The nurse would be concerned about all of these comments. However the most life threatening is option B. Clients who have had hip or knee surgery are at greatest risk for development of post operative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Option C may indicate a urinary tract infection. And option D requires further investigation and is not life threatening.

34. The correct answer is D: Decreased appetite Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias.

35. The correct answer is C: Gravida 3 para 1 Gravida is the number of pregnancies and Parity is the number of pregnancies that reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).

36. The correct answer is B: Improve the client”s nutrition status The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other answers are correct, but without proper nutrition, the other interventions would be of little help.

37. The correct answer is D: Have the client empty bladder The first step in the process is to have the client void prior to administering the pre-operative medication. The other actions follow this initial step in this sequence: 4 3 1 2

38. The correct answer is A: Specific feedback is given as close to the event as possible Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if the standards are clearly understood.

39. The correct answer is B: Lead to dehydration The client must take in adequate fluids before and during exercise periods.

40. The correct answer is C: We have safety bars installed in the bathroom and have 24 hour alarms on the doors. Ensuring safety of the client with increasing memory loss is a priority of home care. Note all options are correct statements. However, safety is most important to reinforce.

NCLEX Comprehensive Review

Cedric — Fri, 17 Jul 2009 02:14:41 +0000

1. Which individual is at greatest risk for developing hypertension?

A) 45 year-old African American attorney

B) 60 year-old Asian American shop owner

C) 40 year-old Caucasian nurse

D) 55 year-old Hispanic teacher

2. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first?

A) Gastric lavage PRN

B) Acetylcysteine (mucomyst) for age per pharmacy

C) Start an IV Dextrose 5% with 0.33% normal saline to keep vein open

D) Activated charcoal per pharmacy

3. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?

A) angina at rest

B) thrombus formation

C) dizziness

D) falling blood pressure

4. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is

A) Maintain fluid and electrolyte balance

B) Control nausea

C) Manage pain

D) Prevent urinary tract infection

5. What would the nurse expect to see while assessing the growth of children during their school age years?

A) Decreasing amounts of body fat and muscle mass

B) Little change in body appearance from year to year

C) Progressive height increase of 4 inches each year

D) Yearly weight gain of about 5.5 pounds per year

6. At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states “My blood pressure is usually much lower.” The nurse should tell the client to

A) go get a blood pressure check within the next 48 to 72 hours

B) check blood pressure again in 2 months

C) see the health care provider immediately

D) visit the health care provider within 1 week for a BP check

7. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission?

A) A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago

B) A young adult with diabetes mellitus Type 2 for over 10 years and admitted with antibiotic induced diarrhea 24 hours ago

C) An elderly client with a history of hypertension, hypercholesterolemia and lupus, and was admitted with Stevens-Johnson syndrome that morning

D) An adolescent with a positive HIV test and admitted for acute cellulitus of the lower leg 48 hours ago

8. A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:

A) Should be taken in the morning

B) May decrease the client’s energy level

C) Must be stored in a dark container

D) Will decrease the client’s heart rate

9. A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first?

A) Prepare the child for x-ray of upper airways

B) Examine the child’s throat

C) Collect a sputum specimen

D) Notify the healthcare provider of the child’s status

10. In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation?

A) Polyphagia

B) Dehydration

C) Bed wetting

D) Weight loss

11. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection?

A) Trichomoniasis

B) Chlamydia

C) Staphylococcus

D) Streptococcus

12. An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?

A) A middle-aged client who says "I took too many diet pills" and "my heart feels like it is racing out of my chest."

B) A young adult who says "I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?"

C) An adolescent who has been on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 10

D) An elderly client who reports having taken a "large crack hit" 10 minutes prior to walking into the emergency room

13. When teaching a client with coronary artery disease about nutrition, the nurse should emphasize

A) Eating 3 balanced meals a day

B) Adding complex carbohydrates

C) Avoiding very heavy meals

D) Limiting sodium to 7 gms per day

14. Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain break through for morphine drip is not working?

A) The client complains of discomfort at the IV insertion site

B) The client states "I just can’t get relief from my pain."

C) The level of drug is 100 ml at 8 AM and is 80 ml at noon

D) The level of the drug is 100 ml at 8 AM and is 50 ml at noon

15. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response?

A) Electrical energy fields

B) Spinal column manipulation

C) Mind-body balance

D) Exercise of joints

16. The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention?

A) Decrease in level of consciousness

B) Loss of bladder control

C) Altered sensation to stimuli

D) Emotional ability

17. A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time?

A) Positive sweat test

B) Bulky greasy stools

C) Moist, productive cough

D) Meconium ileus

18. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should

A) Place a call to the client’s health care provider for instructions

B) Send him to the emergency room for evaluation

C) Reassure the client’s wife that the symptoms are transient

D) Instruct the client’s wife to call the doctor if his symptoms become worse

19. Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test?

A) Client must be NPO before the examination

B) Enema to be administered prior to the examination

C) Medicate client with Lasix 20 mg IV 30 minutes prior to the examination

D) No special orders are necessary for this examination

20. The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question?

A) "You need to regain your strength before attempting such exertion."

B) "When you can climb 2 flights of stairs without problems, it is generally safe.”

C) "Have a glass of wine to relax you, then you can try to have sex."

D) "If you can maintain an active walking program, you will have less risk."

21. A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?

A) A 2 month old infant with a history of rolling off the bed and has bulging fontanels with crying

B) A teenager who got a singed beard while camping

C) An elderly client with complaints of frequent liquid brown colored stools

D) A middle aged client with intermittent pain behind the right scapula

22. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child’s developmental needs?

A) "I want to protect my child from any falls."

B) "I will set limits on exploring the house."

C) "I understand the need to use those new skills."

D) "I intend to keep control over our child."

23. The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is

A) Verify correct placement of the tube

B) Check that the feeding solution matches the dietary order

C) Aspirate abdominal contents to determine the amount of last feeding remaining in stomach

D) D) Ensure that feeding solution is at room temperature

24. The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued?

A) Narrowed QRS complex

B) Shortened "PR" interval

C) Tall peaked T waves

D) Prominent "U" waves

25. A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?

A) All striated muscles

B) The cerebellum

C) The kidneys

D) The leg bones

26. The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to

A) Achieve harmony

B) Maintain a balance of energy

C) Respect life

D) Restore yin and yang

27. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to

A) Increase fluids that are high in protein

B) Restrict fluids

C) Force fluids and reassess blood pressure

D) D) Limit fluids to non-caffeine beverages

28. A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure

A) Right heart function

B) Left heart function

C) Renal tubule function

D) Carotid artery function

29. A nurse enters a client’s room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is

A) Start a peripheral IV

B) Initiate closed-chest massage

C) Establish an airway

D) Obtain the crash cart

30. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?

A) Blood pressure 94/60

B) Heart rate 76

C) Urine output 50 ml/hour

D) Respiratory rate 16

31. While assessing a 1 month-old infant, which finding should the nurse report immediately?

A) Abdominal respirations

B) Irregular breathing rate

C) Inspiratory grunt

D) Increased heart rate with crying

32. The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to

A) Excessive fetal weight

B) Low blood sugar levels

C) Depletion of subcutaneous fat

D) Progressive placental insufficiency

33. The nurse is caring for a client who had a total hip replacement 4 days ago. Which assessment requires the nurse’s immediate attention?

A) I have bad muscle spasms in my lower leg of the affected extremity.

B) "I just can’t ‘catch my breath’ over the past few minutes and I think I am in grave danger."

C) "I have to use the bedpan to pass my water at least every 1 to 2 hours."

D) "It seems that the pain medication is not working as well today."

34. A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?

A) Weight gain of 5 pounds

B) Edema of the ankles

C) Gastric irritability

D) Decreased appetite

35. A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information?

A) Gravida 4 para 2

B) Gravida 2 para 1

C) Gravida 3 para 1

D) Gravida 3 para 2

36. The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?

A) Apply dressing using sterile technique

B) Improve the client’s nutrition status

C) Initiate limb compression therapy

D) Begin proteolytic debridement

37. A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethizine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first?

A) Raise the side rails on the bed

B) Place the call bell within reach

C) Instruct the client to remain in bed

D) D) Have the client empty bladder

38. Which of these statements best describes the characteristic of an effective reward-feedback system?

A) Specific feedback is given as close to the event as possible

B) Staff are given feedback in equal amounts over time

C) Positive statements are to precede a negative statement

D) Performance goals should be higher than what is attainable

39. A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which

A) Increase the heart rate

B) Lead to dehydration

C) Are considered aerobic

D) May be competitive

40. During the evaluation of the quality of home care for a client with Alzheimer’s disease, the priority for the nurse is to reinforce which statement by a family member?

A) At least 2 full meals a day is eaten.

B) We go to a group discussion every week at our community center.

C) We have safety bars installed in the bathroom and have 24 hour alarms on the doors.

D) The medication is not a problem to have it taken 3 times a day.

Get the NCLEX Comprehensive Review Answers and Rationale

Practice Questions for NCLEX Exam with Answers 4

Cedric — Mon, 06 Jul 2009 23:51:33 +0000

A nurse if reviewing a patient’s chart and notices that the patient suffers from conjunctivitis. Which of the following microorganisms is related to this condition?
1. Yersinia pestis
2. Helicobacter pyroli
3. Vibrio cholera
4. Hemophilus aegyptius
A nurse if reviewing a patient’s chart and notices that the patient suffers from Lyme disease. Which of the following microorganisms is related to this condition?
1. Borrelia burgdorferi
2. Streptococcus pyrogens
3. Bacilus anthracis
4. Enterococcus faecalis
A fragile 87 year-old female has recently been admitted to the hospital with increased confusion and falls over last 2 weeks. She is also noted to have a mild left hemiparesis. Which of the following tests is most likely to be performed?
1. FBC (full blood count)
2. ECG (electrocardiogram)
3. Thyroid function tests
4. CT scan
A 84 year-old male has been loosing mobility and gaining weight over the last 2 months. The patient also has the heater running in his house 24 hours a day, even on warm days. Which of the following tests is most likely to be performed?
1. FBC (full blood count)
2. ECG (electrocardiogram)
3. Thyroid function tests
4. CT scan
A 20 year-old female attending college is found unconscious in her dorm room. She has a fever and a noticeable rash. She has just been admitted to the hospital. Which of the following tests is most likely to be performed first?
1. Blood sugar check
2. CT scan
3. Blood cultures
4. Arterial blood gases
A 28 year old male has been found wandering around in a confused pattern. The male is sweaty and pale. Which of the following tests is most likely to be performed first?
1. Blood sugar check
2. CT scan
3. Blood cultures
4. Arterial blood gases
A mother is inquiring about her child’s ability to potty train. Which of the following factors is the most important aspect of toilet training?
1. The age of the child
2. The child ability to understand instruction.
3. The overall mental and physical abilities of the child.
4. Frequent attempts with positive reinforcement.
A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child drank 20 minutes. Which of the following is the most important instruction the nurse can give the parent?
1. This too shall pass.
2. Take the child immediately to the ER
3. Contact the Poison Control Center quickly
4. Give the child syrup of ipecac
A nurse is administering a shot of Vitamin K to a 30 day-old infant. Which of the following target areas is the most appropriate?
1. Gluteus maximus
2. Gluteus minimus
3. Vastus lateralis
4. Vastus medialis
A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4 year-old boy who is non-verbal. This child does not have on any identification. What should the nurse do?
1. Contact the provider
2. Ask the child to write their name on paper.
3. Ask a co-worker about the identification of the child.
4. Ask the father who is in the room the child’s name.

NCLEX Practice Question Answer Keys

1. D Choice A is linked to Plague, Choice B is linked to peptic ulcers, Choice C is linked to Cholera.

2. A Choice B is linked to Rheumatic fever, Choice C is linked to Anthrax, Choice D is linked toEndocarditis.

3. D A CTscan would be performed for further investigation of the hemiparesis.

4. C Weight gain and poor temperature tolerance indicate something may be wrong with the thyroidfunction.

5. C Blood cultures would be performed to investigate the fever and rash symptoms.

6. A With a history of diabetes, the first response should be to check blood sugar levels.

7. C Age is not the greatest factor in potty training. The overall mental and physical abilities of thechild is the most important factor.

8. C The poison control center will have an exact plan of action for this child.

9. C Vastus lateralis is the most appropriate location.

10. D In this case you are able to determine the name of the child by the father’s statement. You should not withhold the medication from the child following identification.

Practice Questions for NCLEX Exam with Answers 3

Cedric — Mon, 06 Jul 2009 23:42:47 +0000

A 65 year old man has been admitted to the hospital for spinal stenosis surgery. When does the discharge training and planning begin for this patient?

Following surgery
Upon admit
Within 48 hours of discharge
Preoperative discussion

A child is 5 years old and has been recently admitted into the hospital. According to Erickson which of the following stages is the child in?

Trust vs. mistrust
Initiative vs. guilt
Autonomy vs. shame
Intimacy vs. isolation

A toddler is 16 months old and has been recently admitted into the hospital. According to Erickson which of the following stages is the toddler in?

Trust vs. mistrust
Initiative vs. guilt
Autonomy vs. shame
Intimacy vs. isolation

A young adult is 20 years old and has been recently admitted into the hospital. According to Erickson which of the following stages is the adult in?

Trust vs. mistrust
Initiative vs. guilt
Autonomy vs. shame
Intimacy vs. isolation

A nurse is making rounds taking vital signs. Which of the following vital signs is abnormal?

11 year old male – 90 b.p.m, 22 resp/min. , 100/70 mm Hg
13 year old female – 105 b.p.m., 22 resp/min., 105/60 mm Hg
5 year old male- 102 b.p.m, 24 resp/min., 90/65 mm Hg
6 year old female- 100 b.p.m., 26 resp/min., 90/70mm Hg

When you are taking a patient’s history, she tells you she has been depressed and is dealing with an anxiety disorder. Which of the following medications would the patient most likely be taking?

Elavil
Calcitonin
Pergolide
Verapamil

Which of the following conditions would a nurse not administer erythromycin?

Campylobacterial infection
Legionnaire’s disease
Pneumonia
Multiple Sclerosis

A patient’s chart indicates a history of hyperkalemia. Which of the following would you not expect to see with this patient if this condition were acute?

Decreased HR
Paresthesias
Muscle weakness of the extremities
Migranes

A patient’s chart indicates a history of ketoacidosis. Which of the following would you not expect to see with this patient if this condition were acute?

Vomiting
Extreme Thirst
C: Weight gain
D: Acetone breath smell

A patient’s chart indicates a history of meningitis. Which of the following would you not expect to see with this patient if this condition were acute?

Increased appetite
Vomiting
Fever
Poor tolerance of light

NCLEX Practice Question Answer Keys

B Discharge education begins upon admit.
B Initiative vs. guilt- 3-6 years old
A Trust vs. Mistrust- 12-18 months old
D Intimacy vs. isolation- 18-35 years old
B HR and Respirations are slightly increased. BP is down.
A Elavil is a tricyclic antidepressant.
D Erythromycin is used to treat conditions A-C.
D Answer choices A-C were symptoms of acute hyperkalemia.
C Weight loss would be expected.
A Loss of appetite would be expected.

Practice Questions for NCLEX Exam with Answers 2

Cedric — Mon, 06 Jul 2009 23:34:57 +0000

A new mother has some questions about (PKU). Which of the following statements made by a nurse is not correct regarding PKU?
1. A Guthrie test can check the necessary lab values.
2. The urine has a high concentration of phenylpyruvic acid
3. Mental deficits are often present with PKU.
4. The effects of PKU are reversible.
A patient has taken an overdose of aspirin. Which of the following should a nurse most closely monitor for during acute management of this patient?
1. Onset of pulmonary edema
2. Metabolic alkalosis
3. Respiratory alkalosis
4. Parkinson’s disease type symptoms
A fifty-year-old blind and deaf patient has been admitted to your floor. As the charge nurse your primary responsibility for this patient is?
1. Let others know about the patient’s deficits.
2. Communicate with your supervisor your patient safety concerns.
3. Continuously update the patient on the social environment.
4. Provide a secure environment for the patient.
A patient is getting discharged from a SNF facility. The patient has a history of severe COPD and PVD. The patient is primarily concerned about their ability to breath easily. Which of the following would be the best instruction for this patient?
1. Deep breathing techniques to increase O2 levels.
2. Cough regularly and deeply to clear airway passages.
3. Cough following bronchodilator utilization
4. Decrease CO2 levels by increase oxygen take output during meals.
A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present?
1. Slow pulse rate
2. Weight gain
3. Decreased systolic pressure
4. Irregular WBC lab values
A mother has recently been informed that her child has Down’s syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Down’s syndrome?
1. Simian crease
2. Brachycephaly
3. Oily skin
4. Hypotonicity
A patient has recently experienced a (MI) within the last 4 hours. Which of the following medications would most like be administered?
1. Streptokinase
2. Atropine
3. Acetaminophen
4. Coumadin
A patient asks a nurse, “My doctor recommended I increase my intake of folic acid. What type of foods contain the highest concentration of folic acids?”
1. Green vegetables and liver
2. Yellow vegetables and red meat
3. Carrots
4. Milk
A nurse is putting together a presentation on meningitis. Which of the following microorganisms has noted been linked to meningitis in humans?
1. S. pneumonia
2. H. influenza
3. N. meningitis
4. Cl. Difficile
A nurse is administering blood to a patient who has a low hemoglobin count. The patient asks how long to RBC’s last in my body? The correct response is.
1. The life span of RBC is 45 days.
2. The life span of RBC is 60 days.
3. The life span of RBC is 90 days.
4. The life span of RBC is 120 days.

NCLEX Practice Question Answer Keys

D The effects of PKU stay with the infant throughout their life.
D Aspirin overdose can lead to metabolic acidosis and cause pulmonary edema development.
D This patient’s safety is your primary concern.
C The bronchodilator will allow a more productive cough.
B Weight gain is associated with CHF and congenital heart deficits.
C The skin would be dry and not oily.
A Streptokinase is a clot busting drug and the best choice in this situation.
A Green vegetables and liver are a great source of folic acid.
D Cl. difficile has not been linked to meningitis.
D RBC’s last for 120 days in the body.

Practice Questions for NCLEX Exam with Answers

Cedric — Mon, 06 Jul 2009 23:17:08 +0000

1. A nurse is reviewing a patient’s medication during shift change. Which of the following medication would be contraindicated if the patient were pregnant? Note: More than one answer may be correct.

a. Coumadin

b. Finasteride

c. Celebrex

d. Catapress

e. Habitrol

f. Clofazimine

2. A nurse is reviewing a patient’s PMH. The history indicates photosensitive reactions to medications.Which of the following drugs has not been associated with photosensitive reactions? Note: More than one answer may be correct.

a. Cipro

b. Sulfonamide

c. Noroxin

d. Bactrim

e. Accutane

f. Nitrodur

3. A patient tells you that her urine is starting to look discolored. If you believe this change is due to medication, which of the following patient’s medication does not cause urine discoloration?

a. Sulfasalazine

b. Levodopa

c. Phenolphthalein

d. Aspirin

4. You are responsible for reviewing the nursing unit’s refrigerator. If you found the following drug in the refrigerator it should be removed from the refrigerator’s contents?

a. Corgard

b. Humulin (injection)

c. Urokinase

d. Epogen (injection)

5. A 34 year old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb?

a. IgA

b. IgD

c. IgE

d. IgG

6. A second year nursing student has just suffered a needlestick while working with a patient that is positive for AIDS. Which of the following is the most important action that nursing student should take?

a. Immediately see a social worker

b. Start prophylactic AZT treatment

c. Start prophylactic Pentamide treatment

d. Seek counseling

7. A thirty five year old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect?

a. Atherosclerosis

b. Diabetic nephropathy

c. Autonomic neuropathy

d. Somatic neuropathy

8. You are taking the history of a 14 year old girl who has a (BMI) of 18. The girl reports inability to eat, induced vomiting and severe constipation. Which of the following would you most likely suspect?

a. Multiple sclerosis

b. Anorexia nervosa

c. Bulimia

d. Systemic sclerosis

9. A 24 year old female is admitted to the ER for confusion. This patient has a history of a myeloma diagnosis, constipation, intense abdominal pain, and polyuria. Which of the following would you most likely suspect?

a. Diverticulosis

b. Hypercalcaemia

c. Hypocalcaemia

d. Irritable bowel syndrome

10. Rho gam is most often used to treat____ mothers that have a ____ infant.

a. RH positive, RH positive

b. RH positive, RH negative

c. RH negative, RH positive

d. RH negative, RH negative

NCLEX Practice Question Answer Keys

A and B are both contraindicated with pregnancy.
F All of the others have can cause photosensitivity reactions.
D All of the others can cause urine discoloration.
A Corgard could be removed from the refigerator.
D IgG is the only immunoglobulin that can cross the placental barrier.
B AZT treatment is the most critical innervention.
C Autonomic neuropathy can cause inability to urinate.
B All of the clinical signs and systems point to a condition of anorexia nervosa.
B Hypercalcaemia can cause polyuria, severe abdominal pain, and confusion.
C Rho gam prevents the production of anti-RH antibodies in the mother that has a Rh positive fetus.

Answers and Rationales for NCLEX-RN Practice Exam Part 10

Cedric — Fri, 12 Jun 2009 21:50:53 +0000

View the NCLEX-RN Practice Test Part 10

1. Answer A is correct. Rapid continuous rewarming of a frostbite primarily lessens cellular damage. It does not prevent formation of blisters. It does promote movement, but this is not the primary reason for rapid rewarming. It might increase pain for a short period of time as the feeling comes back into the extremity; therefore, answers B, C, and D are incorrect.

2. Answer D is correct. Hemodialysis works by using a dialyzing membrane to filter waste that has accumulated in the blood. It does not pass water through a dialyzing membrane nor does it eliminate plasma proteins or lower the pH, so answers A, B, and C are incorrect.

3. Answer B is correct. The client who is immune-suppressed and is exposed to measles should be treated with medications to boost his immunity to the virus. An antibiotic or antiviral will not protect the client and it is too late to place the client in isolation, so answers A, C, and D are incorrect.

4. Answer D is correct. The client with MRSA should be placed in isolation. Gloves, a gown, and a mask should be used when caring for the client and hand washing is very important. The door should remain closed, but a negative-pressure room is not necessary, so answers A and B are incorrect. MRSA is spread by contact with blood or body fluid or by touching the skin of the client. It is cultured from the nasal passages of the client, so the client should be instructed to cover his nose and mouth when he sneezes or coughs. It is not necessary for the client to wear the mask at all times; the nurse should wear the mask, so answer C is incorrect.

5. Answer B is correct. Pain related to phantom limb syndrome is due to peripheral nervous system interruption. Answer A is incorrect because phantom limb pain can last several months or indefinitely. Answer C is incorrect because it is not psychological. It is also not due to infections, as stated in answer D.

6. Answer A is correct. During a Whipple procedure the head of the pancreas, which is a part of the stomach, the jejunum, and a portion of the stomach are removed and reanastomosed. Answer B is incorrect because the proximal third of the small intestine is not removed. The entire stomach is not removed, as in answer C, and in answer D, the esophagus is not removed.

7. Answer C is correct. Pepper is not processed and contains bacteria. Answers A, B, and D are incorrect because fruits should be cooked or washed and peeled, and salt and ketchup are allowed.

8. Answer A is correct. Coumadin is an anticoagulant. One of the tests for bleeding time is a Protime. This test should be done monthly. Eating more fruits and vegetables is not necessary, and dark-green vegetables contain vitamin K, which increases clotting, so answer B is incorrect. Drinking more liquids and avoiding crowds is not necessary, so answers C and D are incorrect.

9. Answer A is correct. The client who is having a central venous catheter removed should be told to hold his breath and bear down. This prevents air from entering the line. Answers B, C, and D will not facilitate removal.

10. Answer B is correct. Clients with a history of streptococcal infections could have antibodies that render the streptokinase ineffective. There is no reason to assess the client for allergies to pineapples or bananas, there is no correlation to the use of phenytoin and streptokinase, and a history of alcohol abuse is also not a factor in the order for streptokinase; therefore, answers A, C, and D are incorrect.

11. Answer B is correct. The client who is immune-suppressed and has bone marrow suppression should be taught not to floss his teeth because platelets are decreased. Using oils and cream-based soaps is allowed, as is eating salt and using an electric razor; therefore, answers A, C, and D are incorrect.

12. Answer A is correct. The best method and safest way to change the ties of a tracheotomy is to apply the new ones before removing the old ones. Having a helper is good, but the helper might not prevent the client from coughing out the tracheotomy. Answer C is not the best way to prevent the client from coughing out the tracheotomy. Asking the doctor to suture the tracheotomy in place is not appropriate.

13. Answer D is correct. The output of 300mL is indicative of hemorrhage and should be reported immediately. Answer A does nothing to help the client. Milking the tube is done only with an order and will not help in this situation, and slowing the intravenous infusion is not correct; thus, answers B and C are incorrect.

14. Answer A is correct. The infant with tetrology of falot has five heart defects. He will be treated with digoxin to slow and strengthen the heart. Epinephrine, aminophyline, and atropine will speed the heart rate and are not used in this client; therefore, answers B, C, and D are incorrect.

15. The correct answer is marked by an X in the diagram. The Tail of Spence is located in the upper outer quadrant of the breast.

16. Answer A is correct. The toddler with a ventricular septal defect will tire easily. He will not grow normally but will not need more calories. He will be susceptible to bacterial infection, but he will be no more susceptible to viral infections than other children. Therefore, answers B, C, and D are incorrect.

17. Answer B is correct. A nonstress test determines periodic movement of the fetus. It does not determine lung maturity, show contractions, or measure neurological well-being, making answers A, C, and D incorrect.

18. Answer C is correct. The monitor indicates variable decelerations caused by cord compression. If Pitocin is infusing, the nurse should turn off the Pitocin. Instructing the client to push is incorrect because pushing could increase the decelerations and because the client is 8cm dilated, making answer A incorrect. Performing a vaginal exam should be done after turning off the Pitocin, and placing the client in a semi-Fowler’s position is not appropriate for this situation; therefore, answers B and D are incorrect.

19. Answer C is correct. The graph indicates ventricular tachycardia. The answers in A, B, and D are not noted on the ECG strip.

20. Answer B is correct. Lovenox injections should be given in the abdomen, not in the deltoid muscle. The client should not aspirate after the injection or clear the air from the syringe before injection. Therefore, answers A, C, and D are incorrect.

21. Answer B is correct. Valium is not given in the same syringe with other medications, so answer A is incorrect. These medications can be given to the same client, so answer D is incorrect. In answer C, it is not necessary to wait to inject the second medication. Valium is an antianxiety medication, and Phenergan is used as an antiemetic.

22. Answer B is correct. Voiding every 3 hours prevents stagnant urine from collecting in the bladder, where bacteria can grow. Douching is not recommended and obtaining a urinalysis monthly is not necessary, making answers A and C incorrect. The client should practice wiping from front to back after voiding and bowel movements, so answer D is incorrect.

23. Answer C is correct. Of these clients, the one who should be assigned to the care of the nursing assistant is the client with dementia. Only an RN or the physician can place the client in seclusion, so answer A is incorrect. The nurse should empty the Foley catheter of the preeclamptic client because the client is unstable, making answer B incorrect. A nurse or physical therapist should ambulate the client with a fractured hip, so answer D is incorrect.

24. Answer A is correct. The client who has recently had a thyroidectomy is at risk for tracheal edema. A padded tongue blade is used for seizures and not for the client with tracheal edema, so answer B is incorrect. If the client experiences tracheal edema, the endotracheal tube or airway will not correct the problem, so answers C and D are incorrect.

25. Answer D is correct. Histoplasmosis is a fungus carried by birds. It is not transmitted to humans by cats, dogs, or turtles. Therefore, answers A, B, and C are incorrect.

Answers and Rationales for NCLEX-RN Practice Exam Part 9

Cedric — Fri, 12 Jun 2009 21:48:06 +0000

View the NCLEX-RN Practice Test Part 9

1. Answer D is correct. Methotrexate is a folic acid antagonist. Leucovorin is the drug given for toxicity to this drug. It is not used to treat iron-deficiency anemia, create a synergistic effects, or increase the number of circulating neutrophils. Therefore, answers A, B, and C are incorrect.

2. Answer B is correct. The client who is allergic to dogs, eggs, rabbits, and chicken feathers is most likely allergic to the rubella vaccine. The client who is allergic to neomycin is also at risk. There is no danger to the client if he has an order for a TB skin test, ELISA test, or chest x-ray; thus, answers A, C, and D are incorrect.

3. Answer B is correct. Zantac (rantidine) is a histamine blocker that should be given with meals for optimal effect, not before meals. However, Tagamet (cimetidine) is a histamine blocker that can be given in one dose at bedtime. Neither of these drugs should be given before or after meals, so answers A and D are incorrect.

4. Answer C is correct. The proximal end of the double-barrel colostomy is the end toward the small intestines. This end is on the client’s right side. The distal end, as in answers A, B, and D, is on the client’s left side.

5. Answer A is correct. If the nurse checks the fundus and finds it to be displaced to the right or left, this is an indication of a full bladder. This finding is not associated with hypotension or clots, as stated in answer B. Oxytoxic drugs (Pitocin) are drugs used to contract the uterus, so answer C is incorrect. It has nothing to do with displacement of the uterus. Answer D is incorrect because displacement is associated with a full bladder, not vaginal bleeding.

6. Answer C is correct. Clients with an internal defibrillator or a pacemaker should not have an MRI because it can cause dysrhythmias in the client with a pacemaker. If the client has a need for oxygen, is claustrophobic, or is deaf, he can have an MRI, but provisions such as extension tubes for the oxygen, sedatives, or a signal system should be made to accommodate these problems. Therefore, answers A, B, and D are incorrect.

7. Answer C is correct. A 6-month-old is too old for the colorful mobile. He is too young to play with the electronic game or the 30-piece jigsaw puzzle. The best toy for this age is the cars in a plastic container, so answers A, B, and D are incorrect.

8. Answer C is correct. The client with polio has muscle weakness. Periods of rest throughout the day will conserve the client’s energy. A hot bath can cause burns; however, a warm bath would be helpful, so answer A is incorrect. Strenuous exercises are not advisable, making answer B incorrect. Visual disturbances are directly associated with polio and cannot be corrected with glasses; therefore, answer D is incorrect.

9. Answer B is correct. The client with a protoepisiotomy will need stool softeners such as docusate sodium. Suppositories are given only with an order from the doctor, Methergine is a drug used to contract the uterus, and Parlodel is an anti-Parkinsonian drug; therefore, answers A, C, and D are incorrect.

10. Answer C is correct. Total Parenteral Nutrition is a high-glucose solution. This therapy often causes the glucose levels to be elevated. Because this is a common complication, insulin might be ordered. Answers A, B, and D are incorrect. TPN is used to treat negative nitrogen balance; it will not lead to negative nitrogen balance. Total Parenteral Nutrition can be managed with oral hypoglycemic drugs, but it is difficult to do so. Total Parenteral Nutrition will not lead to further pancreatic disease.

11. Answer B is correct. The client who is 10 weeks pregnant should be assessed to determine how she feels about the pregnancy. It is too early to discuss preterm labor, too late to discuss whether she was using a method of birth control, and after the client delivers, a discussion of future children should be instituted. Thus, answers A, C, and D are incorrect.

12. Answer A is correct. The best IV fluid for correction of dehydration is normal saline because it is most like normal serum. Dextrose pulls fluid from the cell, lactated Ringer’s contains more electrolytes than the client’s serum, and dextrose with normal saline will also alter the intracellular fluid. Therefore, answers B, C, and D are incorrect.

13. Answer A is correct. A thyroid scan uses a dye, so the client should be assessed for allergies to iodine. The client will not have a bolus of fluid, will not be asleep, and will not have a urinary catheter inserted, so answers B, C, and D are incorrect.

14. Answer B is correct. RhoGam is used to prevent formation of Rh antibodies. It does not provide immunity to Rh isoenzymes, eliminate circulating Rh antibodies, or convert the Rh factor from negative to positive; thus, answers A, C, and D are incorrect.

15. Answer B is correct. A client with a fractured foot often has a short leg cast applied to stabilize the fracture. A spica cast is used to stabilize a fractured pelvis or vertebral fracture. Kirschner wires are used to stabilize small bones such as toes and the client will most likely have a cast or immobilizer, so answers A, C, and D are incorrect.

16. Answer A is correct. Iridium seeds can be expelled during urination, so the client should be taught to strain his urine and report to the doctor if any of the seeds are expelled. Increasing fluids, reporting urinary frequency, and avoiding prolonged sitting are not necessary; therefore, answers B, C, and D are incorrect.

17. Answer C is correct. Immunosuppressants are used to prevent antibody formation. Antivirals, antibiotics, and analgesics are not used to prevent antibody production, so answers A, B, and D are incorrect.

18. Answer A is correct. Before cataract removal, the client will have Mydriatic drops instilled to dilate the pupil. This will facilitate removal of the lens. Miotics constrict the pupil and are not used in cataract clients. A laser is not used to smooth and reshape the lens; the diseased lens is removed. Silicone oil is not injected in this client; thus, answers B, C, and D are incorrect.

19. Answer C is correct. Placing simple signs that indicate the location of rooms where the client sleeps, eats, and bathes will help the client be more independent. Providing mirrors and pictures is not recommended with the client who has Alzheimer’s disease because mirrors and pictures tend to cause agitation, and alternating healthcare workers confuses the client; therefore, answers A, B, and D are incorrect.

20. Answer C is correct. A Jackson-Pratt drain is a serum-collection device commonly used in abdominal surgery. A Jackson-Pratt drain will not prevent the need for dressing changes, reduce edema of the incision, or keep the common bile duct open, so answers A, B, and D are incorrect. A t-tube is used to keep the common bile duct open.

21. Answer C is correct. The infant who is 32 weeks gestation will not be able to control his head, so head lag will be present. Mongolian spots are common in African American infants, not Caucasian infants; the client at 32 weeks will have scrotal rugae or redness but will not have vernix caseosa, the cheesy appearing covering found on most full-term infants. Therefore, answers A, B, and D are incorrect.

22. Answer A is correct. Hematuria in a client with a pelvic fracture can indicate trauma to the bladder or impending bleeding disorders. It is not unusual for the client to complain of muscles spasms with multiple fractures, so answer B is incorrect. Dizziness can be associated with blood loss and is nonspecific, making answer C incorrect. Nausea, as stated in answer D, is also common in the client with multiple traumas.

23. Answer C is correct. The client’s statement "They are trying to kill me" indicates paranoid delusions. There is no data to indicate that the client is hearing voices or is intoxicated, so answers A and D are incorrect. Delusions of grandeur are fixed beliefs that the client is superior or perhaps a famous person, making answer B incorrect.

24. Answer B is correct. Because the nurse is unaware of when the bottle was opened or whether the saline is sterile, it is safest to obtain a new bottle. Answers A, C, and D are not safe practices.

25. Answer C is correct. Infants with an Apgar of 9 at 5 minutes most likely have acryocyanosis, a normal physiologic adaptation to birth. It is not related to the infant being cold, experiencing bradycardia, or being lethargic; thus, answers A, B, and D are incorrect.

Answers and Rationales for NCLEX-RN Practice Exam Part 8

Cedric — Fri, 12 Jun 2009 21:45:47 +0000

View the NCLEX-RN Practice Test Part 8

1. Answer B is correct. Barbiturates create a sedative effect. When the client stops taking barbiturates, he will experience tachycardia, diarrhea, and tachpnea. Answer A is incorrect even though depression and suicidal ideation go along with barbiturate use; it is not the priority. Muscle cramps and abdominal pain are vague symptoms that could be associated with other problems. Tachycardia is associated with stopping barbiturates, but euphoria is not.

2. Answer A is correct. If the fetal heart tones are heard in the right upper abdomen, the infant is in a breech presentation. If the infant is positioned in the right occipital anterior presentation, the FHTs will be located in the right lower quadrant, so answer B is incorrect. If the fetus is in the sacral position, the FHTs will be located in the center of the abdomen, so answer C is incorrect. If the FHTs are heard in the left lower abdomen, the infant is most likely in the left occipital transverse position, making answer D incorrect.

3. Answer D is correct. Asthma is the presence of bronchiolar spasms. This spasm can be brought on by allergies or anxiety. Answer A is incorrect because the primary physiological alteration is not inflammation. Answer B is incorrect because there is the production of abnormally viscous mucus, not a primary alteration. Answer C is incorrect because infection is not primary to asthma.

4. Answer A is correct. The client with mania is seldom sitting long enough to eat and burns many calories for energy. Answer B is incorrect because the client should be treated the same as other clients. Small meals are not a correct option for this client. Allowing her into the kitchen gives her privileges that other clients do not have and should not be allowed, so answer D is incorrect.

5. Answer B is correct. Bryant’s traction is used for fractured femurs and dislocated hips. The hips should be elevated 15° off the bed. Answer A is incorrect because the hips should not be resting on the bed. Answer C is incorrect because the hips should not be above the level of the body. Answer D is incorrect because the hips and legs should not be flat on the bed.

6. Answer B is correct. Herpes zoster is shingles. Clients with shingles should be placed in contact precautions. Wearing gloves during care will prevent transmission of the virus. Covering the lesions with a sterile gauze is not necessary, antibiotics are not prescribed for herpes zoster, and oxygen is not necessary for shingles; therefore, answers A, C, and D are incorrect.

7. Answer B is correct. A trough level should be drawn 30 minutes before the third or fourth dose. The times in answers A, C, and D are incorrect times to draw blood levels.

8. Answer B is correct. The client using a diaphragm should keep the diaphragm in a cool location. Answers A, C, and D are incorrect. She should refrain from leaving the diaphragm in longer than 8 hours, not 4 hours. She should have the diaphragm resized when she gains or loses 10 pounds or has abdominal surgery.

9. Answer C is correct. Mothers who plan to breastfeed should drink plenty of liquids, and four glasses is not enough in a 24-hour period. Wearing a support bra is a good practice for the mother who is breastfeeding as well as the mother who plans to bottle-feed, so answer A is incorrect. Expressing milk from the breast will stimulate milk production, making answer B incorrect. Allowing the water to run over the breast will also facilitate "letdown," when the milk begins to be produced; thus, answer D is incorrect.

10. Answer A is correct. The facial nerve is cranial nerve VII. If damage occurs, the client will experience facial pain. The auditory nerve is responsible for hearing loss and tinnitus, eye movement is controlled by the Trochear or C IV, and the olfactory nerve controls smell; therefore, answers B, C, and D are incorrect.

11. Answer B is correct. Clients taking Pyridium should be taught that the medication will turn the urine orange or red. It is not associated with diarrhea, mental confusion, or changes in taste; therefore, answers A, C, and D are incorrect. Pyridium can also cause a yellowish color to skin and sclera if taken in large doses.

12. Answer B is correct. Accutane is contraindicated for use by pregnant clients because it causes teratogenic effects. Calcium levels, apical pulse, and creatinine levels are not necessary; therefore, answers A, C, and D are incorrect.

13. Answer D is correct. Clients taking Acyclovir should be encouraged to drink plenty of fluids because renal impairment can occur. Limiting activity is not necessary, nor is eating a high-carbohydrate diet. Use of an incentive spirometer is not specific to clients taking Acyclovir; therefore, answers A, B, and C are incorrect.

14. Answer A is correct. Clients who are pregnant should not have an MRI because radioactive isotopes are used. However, clients with a titanium hip replacement can have an MRI, so answer B is incorrect. No antibiotics are used with this test and the client should remain still only when instructed, so answers C and D are not specific to this test.

15. Answer D is correct. Clients taking Amphotericin B should be monitored for liver, renal, and bone marrow function because this drug is toxic to the kidneys and liver, and causes bone marrow suppression. Jaundice is a sign of liver toxicity and is not specific to the use of Amphotericin B. Changes in vision are not related, and nausea is a side effect, not a sign of toxicity; nor is urinary frequency. Thus, answers A, B, and C are incorrect.

16. Answer C is correct. The client with chest pain should be seen first because this could indicate a myocardial infarction. The client in answer A has a blood glucose within normal limits. The client in answer B is maintained on blood pressure medication. The client in answer D is in no distress.

17. Answer B is correct. Pancreatic enzymes should be given with meals for optimal effects. These enzymes assist the body in digesting needed nutrients. Answers A, C, and D are incorrect methods of administering pancreatic enzymes.

18. Answer C is correct. The lens allows light to pass through the pupil and focus light on the retina. The lens does not stimulate the retina, assist with eye movement, or magnify small objects, so answers A, B, and D are incorrect.

19. Answer C is correct. Miotic eyedrops constrict the pupil and allow aqueous humor to drain out of the Canal of Schlemm. They do not anesthetize the cornea, dilate the pupil, or paralyze the muscles of the eye, making answers A, B, and D incorrect.

20. Answer A is correct. When using eyedrops, allow 5 minutes between the two medications; therefore, answer B is incorrect. These medications can be used by the same client but it is not necessary to use a cyclopegic with these medications, making answers C and D incorrect.

21. Answer B is correct. Clients with color blindness will most likely have problems distinguishing violets, blues, and green. The colors in answers A, C, and D are less commonly affected.

22. Answer D is correct. The client with a pacemaker should be taught to count and record his pulse rate. Answers A, B, and C are incorrect. Ankle edema is a sign of right-sided congestive heart failure. Although this is not normal, it is often present in clients with heart disease. If the edema is present in the hands and face, it should be reported. Checking the blood pressure daily is not necessary for these clients. The client with a pacemaker can use a microwave oven, but he should stand about 5 feet from the oven while it is operating.

23. Answer A is correct. Clients who are being retrained for bladder control should be taught to withhold fluids after about 7 p.m., or 1 The times in answers B, C, and D are too early in the day.

24. Answer D is correct. Cranberry juice is more alkaline and, when metabolized by the body, is excreted with acidic urine. Bacteria does not grow freely in acidic urine. Increasing intake of meats is not associated with urinary tract infections, so answer A is incorrect. The client does not have to avoid citrus fruits and pericare should be done, but hydrogen peroxide is drying, so answers B and C are incorrect.

25. Answer C is correct. NPH insulin peaks in 8–12 hours, so a snack should be offered at that time. NPH insulin onsets in 90–120 minutes, so answer A is incorrect. Answer B is untrue because NPH insulin is time released and does not usually cause sudden hypoglycemia. Answer D is incorrect, but the client should eat a bedtime snack.