1.      Answer D is correct. Protamine sulfate is given to counteract the effects of enoxaprin as well as heparin. Calcium gluconate is given to counteract the effects of magnesium sulfate; therefore, answer A is incorrect. Answer B is incorrect because aquamephyton is given to counteract the effects of sodium warfarin. Answer C is incorrect because methargine is given to increase uterine contractions following delivery.

2.      Answer A is correct. Participating in reality orientation is the most appropriate activity for the client who is confused. Answers B, C, and D are incorrect because they are not suitable activities for a client who is confused.

3.      Answer B is correct. The nurse should recommend acetaminophen for the child’s joint discomfort because it will have no effect on the bleeding time. Answers A, C, and D are all nonsteroidal anti-inflammatory medications that can prolong bleeding time; therefore, they are not suitable for the child with hemophilia.

4.      Answer D is correct. Applying a paste of baking soda and water soothes the itching and helps to dry the vesicles. The use of baby powder is not recommended for either children; therefore, answer A is incorrect. Answers B and C are incorrect because hydrogen peroxide and saline will not relieve the itching and will prevent the vesicles from crusting.

5.      Answer A is correct. The infant with hypospadias has altered patterns of urinary elimination caused by the location of the urinary meatus on the dorsum, or underside, of the penis. Answer B is incorrect because it refers to ureteral reflux. Answer C is incorrect because it refers to epispadias. Answer D is incorrect because it refers to exstrophy of the bladder.

6.      Answer D is correct. Zantac (ranitidine) should be administered in one dose at bedtime or with meals. Answers A, B, and C have incorrect times for dosing.

7.      Answer A is correct. Pain associated with angina is relieved by rest. Answer B is incorrect because it is not a true statement. Answer C is incorrect because pain associated with angina can be referred to the jaw, the left arm, and the back. Answer D is incorrect because pain from a myocardial infarction can be referred to areas other than the left arm.

8.      Answer A is correct. It would not be helpful to limit the fluid intake of a client during bowel retraining. Answers B, C, and D would help the client; therefore, they are incorrect answers.

9.      Answer B is correct. The client with Meniere’s disease should limit the intake of foods that contain sodium. Answers A, C, and D have no relationship to the symptoms of Meniere’s disease; therefore, they are incorrect.

10.  Answer A is correct. The nurse should pay close attention to swelling in the client with preeclampsia. Facial swelling indicates that the client’s condition is worsening and blood pressure will be increased. Answer B is not related to the question; therefore, it is incorrect. Answer C is incorrect because ankle edema is expected in pregnancy. Diminished reflexes are associated with the use of magnesium sulfate, which is the treatment of preeclampsia; therefore, answer D is incorrect.

11.  Answer D is correct. Verbalizing feelings of anger and sadness to a staff member is an appropriate therapeutic goal for the client with a risk of self-directed violence. Answers A and C place the client in an isolated situation to deal with her feelings alone; therefore, they are incorrect. Answer B is incorrect because it does not allow the client to ventilate her feelings.

12.  Answer C is correct. The nurse should remove any remaining ointment before applying the medication again. Answer A is incorrect because it interferes with absorption. Answer B does not apply to the question of how to administer the medication; therefore, it is incorrect. Answer D is incorrect because the medication’s action is more immediate.

13.  Answer D is correct. Telling the client what happened and where he is helps with reorientation. Answer A does not explain what happened to the client; therefore, it is incorrect. Answer B is not helpful because the client regaining consciousness will not know where he is; therefore, the answer is incorrect. The nurse should not offer false reassurances, such as "everything will be alright"; therefore, answer C is incorrect.

14.  Answer B is correct. Following a generalized seizure, the client frequently experiences drowsiness and postictal sleep. Answer A is incorrect because the client is able to move the extremities. Answer C is incorrect because the client can remember events before the seizure. Answer D is incorrect because the blood pressure is elevated.

15.  Answer A is correct. The client with oxylate renal calculi should avoid sources of oxylate, which include strawberries, rhubarb, and spinach. Answers B, C, and D are incorrect because they are not sources of oxylate.

16.  Answer D is correct. The child with Legg-Calve Perthes disease should be prevented from bearing weight on the affected extremity until revascularization has occurred. Answer A is incorrect because it does not relate to the condition. Answers B and C are incorrect choices because the condition does not involve the muscles or the joints.

17.  Answer B is correct. The child with Hirschsprung’s disease will have a scaphoid or hollowed abdomen. Answers A, C, and D do not apply to the condition; therefore, they are incorrect.

18.  Answer B is correct. Iron supplements should be taken with a source of vitamin C to promote absorption. Answer A is incorrect because iron should not be taken with milk. Answer C is incorrect because high-fiber sources prevent the absorption of iron. Answer D is an inaccurate statement; therefore, it is incorrect.

19.  Answer A is correct. The client does not need to drastically reduce her caloric intake during pregnancy. Doing so would not provide adequate nourishment for proper development of the fetus. Answers B, C, and D indicate that the client understands the nurse’s dietary teaching regarding obesity and hypertension; therefore, they are incorrect.

20.  Answer B is correct. Confusion, disorientation, behavioral changes, and alterations in judgment are early signs of dementia. Answers A, C, and D do not relate to the question; therefore, they are incorrect.

21.  Answer C is correct. In the left occipital posterior position, the heart sounds will be heard loudest through the fetal back. Answers A, B, and D are incorrect locations.

22.  Answer B is correct. Benzodiazepines such as clonazepam and lorazepam are given to the client withdrawing from alcohol. Answer A is incorrect because methodone is given to the client withdrawing from opiates. Answer C is incorrect because naloxone is an antidote for narcotic overdose. Answer D is incorrect because disufiram is used in aversive therapy for alcohol addiction.

23.  Answer C is correct. The client’s breakfast should be served within 30 minutes to coincide with the onset of the client’s regular insulin.

24.  Answer C is correct. The nurse should administer .7mL of the medication. Answers A, B, and D are incorrect because the dosage is incorrect.

25.  Answer A is correct. Tetracycline is contraindicated for use in infants and young children because it stains the teeth and arrests bone development. Answers B, C, and D are incorrect because they can be used to treat infections in infants and children.

• NCLEX-PN Practice Exam Part 1 – Answers and Rationales
• NCLEX-PN Practice Exam Part 2 – Answers and Rationales
• NCLEX-PN Practice Exam Part 3 – Answers and Rationales
• NCLEX-PN Practice Exam Part 4 – Answers and Rationales
• NCLEX-PN Practice Exam Part 5 – Answers and Rationales
• NCLEX-PN Practice Exam Part 6 – Answers and Rationales
• NCLEX-PN Practice Exam Part 7 – Answers and Rationales

If you want to practice more questions like this, we strongly suggest to get a copy of NCLEX-PN Practice Questions and NCLEX-PN Exam Cram from informit.com.

1.      A client with a history of emboli is receiving Lovenox (enoxaparin). Which drug is given to counteract the effects of enoxaparin?

a.       Calcium gluconate

b.      Aquamephyton

c.       Methergine

d.      Protamine sulfate

2.      The nurse is formulating a plan of care for a client with a cognitive disorder. Which activity is most appropriate for the client with confusion and short attention span?

a.       Taking part in a reality-orientation group

b.      Participating in unit community goal setting

c.       Going on a field trip with a group of clients

d.      Meeting with an assertiveness training group

3.      The mother of a child with hemophilia asks the nurse which over-the-counter medication is suitable for her child’s joint discomfort. The nurse should tell the mother to purchase:

a.       Advil (ibuprofen)

b.      Tylenol (acetaminophen)

c.       Aspirin (acetylsalicytic acid)

d.      Naproxen (naprosyn)

4.      Which home remedy is suitable to relieve the itching associated with varicella?

a.       Dusting the lesions with baby powder

b.      Applying gauze saturated in hydrogen peroxide

c.       Using cool compresses of normal saline

d.      Applying a paste of baking soda and water

5.      A newborn male has been diagnosed with hypospadias with chordee. The nurse understands that the infant will have altered patterns of urination because:

a.       The urinary meatus is on the dorsum of the penis.

b.      The ureters will reflux urine into the kidneys.

c.       The urinary meatus is on the top of the penis.

d.      The bladder lies outside the abdominal cavity.

6.      The recommended time for administering Zantac (ranitidine) is:

a.       Before breakfast

b.      Midafternoon

c.       After dinner

d.      At bedtime

7.      Which statement best describes the difference between the pain of angina and the pain of myocardial infarction?

a.       Pain associated with angina is relieved by rest.

b.      Pain associated with myocardial infarction is always more severe.

c.       Pain associated with angina is confined to the chest area.

d.      Pain associated with myocardial infarction is referred to the left arm.

8.      The nurse is developing a bowel-retraining plan for a client with multiple sclerosis. Which measure is likely to be least helpful to the client:

a.       Limiting fluid intake to 1000mL per day

b.      Providing a high-roughage diet

c.       Elevating the toilet seat for easy access

d.      Establishing a regular schedule for toileting

9.      The nurse is providing dietary teaching for a client with Meniere’s disease. Which statement indicates that the client understands the role of diet in triggering her symptoms?

a.       "I can expect to see more problems with tinnitus if I eat a lot of dairy products."

b.      "I need to limit foods that taste salty or that contain a lot of sodium."

c.       "I can help control problems with vertigo if I avoid breads and cereals."

d.      "I need to eat fewer foods that are high in potassium, such as raisins and bananas."

10.  The nurse is assessing a multigravida, 36 weeks gestation for symptoms of pregnancy-induced hypertension and preeclampsia. The nurse should give priority to assessing the client for:

a.       Facial swelling

b.      Pulse deficits

c.       Ankle edema

d.      Diminished reflexes

11.  An adolescent with borderline personality is hospitalized with suicidal ideation and self-mutilation. Which goal is both therapeutic and realistic for this client?

a.       The client will remain in her room when feeling overwhelmed by sadness.

b.      The client will request medication when feeling loss of emotional control.

c.       The client will leave group activities to pace when feeling anxious.

d.      The client will seek out a staff member to verbalize feelings of anger and sadness.

12.  A client with angina has an order for nitroglycerin ointment. Before applying the medication, the nurse should:

a.       Apply the ointment to the previous application

b.      Obtain both a radial and an apical pulse

c.       Remove the previously applied ointment

d.      Tell the client he will experience pain relief in 15 minutes

13.  The nurse is caring for a client who is unconscious following a fall. Which comment by the nurse will help the client become reoriented when he regains consciousness?

a.       "I am your nurse and I will be taking care of you today."

b.      "Can you tell me your name and where you are?"

c.       "I know you are confused right now, but everything will be alright."

d.      "You were in an accident that hurt your head. You are in the hospital."

14.  Following a generalized seizure, the nurse can expect the client to:

a.       Be unable to move the extremities

b.      Be drowsy and prone to sleep

c.       Remember events before the seizure

d.      Have a drop in blood pressure

15.  A client with oxylate renal calculi should be taught to avoid eating:

a.       Strawberries

b.      Oranges

c.       Apples

d.      Pears

16.  A 6-year-old is diagnosed with Legg-Calve Perthes disease of the right femur. An important part of the child’s care includes instructing the parents:

a.       To increase the amount of dietary protein

b.      About exercises to strengthen affected muscles

c.       About relaxation exercises to minimize pain in the joints

d.      To prevent weight bearing on the affected leg

17.  The nurse is assessing an infant with Hirschsprung’s disease. The nurse can expect the infant to:

a.       Weigh less than expected for height and age

b.      Have a scaphoid-shaped abdomen

c.       Exhibit clubbing of the fingers and toes

d.      Have hyperactive deep tendon reflexes

18.  The physician has prescribed supplemental iron for a prenatal client. The nurse should tell the client to take the medication with:

a.       Milk, to prevent stomach upset

b.      Tomato juice, to increase absorption

c.       Oatmeal, to prevent constipation

d.      Water, to increase serum iron levels

19.  The nurse is teaching a client with a history of obesity and hypertension regarding dietary requirements during pregnancy. Which statement indicates that the client needs further teaching?

a.       "I need to reduce my daily intake to 1,200 calories a day."

b.      "I need to drink at least a quart of milk a day."

c.       "I shouldn’t add salt when I am cooking."

d.      "I need to eat more protein and fiber each day."

20.  An elderly client is admitted to the psychiatric unit from the nursing home. Transfer information indicates that the client has become confused and disoriented, with behavioral problems. The client will also likely show a loss of ability in:

a.       Speech

b.      Judgment

c.       Endurance

d.      Balance

21.  The physician has ordered an external monitor for a laboring client. If the fetus is in the left occipital posterior (LOP) position, the nurse knows that the ultrasound transducer will be located:

a.       Near the symphysis pubis

b.      Near the umbilicus

c.       Over the fetal back

d.      Over the fetal abdomen

22.  A client develops tremors while withdrawing from alcohol. Which medication is routinely administered to lessen physiological effects of alcohol withdrawal?

a.       Dolophine (methodone)

b.      Klonopin (clonazepam)

c.       Narcan (Naloxone)

d.      Antabuse (disulfiram)

23.  A client with Type II diabetes has an order for regular insulin 10 units SC each morning. The client’s breakfast should be served within:

a.       15 minutes

b.      20 minutes

c.       30 minutes

d.      45 minutes

24.  A 10-year-old has an order for Demerol (meperidine) 35mg IM for pain. The medication is available as Demerol 50mg per ml. How much should the nurse administer?

a.       .5mL

b.      .6mL

c.       .7mL

d.      .8mL

25.  Which antibiotic is contraindicated for the treatment of infections in infants and young children?

a.       Tetracyn (tetracycline)

b.      Amoxil (amoxicillin)

c.       Cefotan (cefotetan)

d.      E-Mycin (erythromycin)

GET ANSWERS AND RATIONALE

1.      Answer C is correct. Apricots are low in potassium; therefore, it is a suitable snack of the client on a potassium-restricted diet. Raisins, oranges, and bananas are all good sources of potassium; therefore, answers A, B, and C are incorrect.

2.      Answer B is correct. No special preparation is needed for the blood test for H. pylori. Answer A is incorrect because the client is not NPO before the test. Answer C is incorrect because it refers to preparation for the breath test. Answer D is incorrect because glucose is not administered before the test.

3.      Answer B is correct. Oral potassium supplements should be given in at least 4oz. of juice or other liquid, to prevent gastric upset and to disguise the unpleasant taste. Answers A, C, and D are incorrect because they cause gastric upset.

4.      Answer D is correct. Fresh specimens are essential for accurate diagnosis of CMV. Answer A is incorrect because cultures of urine, sputum, and oral swab are preferred. Answer B is incorrect because pregnant caregivers should not be assigned to care for clients with suspected or known infection with CMV. Answer C is incorrect because a convalescent culture is obtained 2–4 weeks after diagnosis.

5.      Answer D is correct. The client should receive pain medication 30 minutes before the application of Sulfamylon. Answer A is incorrect because it refers to silver nitrate. Answer B is incorrect because it refers to Silvadene. Answer C is incorrect because it refers to Betadine.

6.      Answer D is correct. Gingival hyperplasia is a side effect of Dilantin; therefore, the nurse should provide oral hygiene and gum care every shift. Answers A, B, and C do not apply to the medication; therefore, they are incorrect.

7.      Answer C is correct. Zofran is given before chemotherapy to prevent nausea. Answers A, B, and D are not associated with the medication; therefore, they are incorrect.

8.      Answer A is correct. When administering ear drops to a child under 3 years of age, the nurse should pull the ear down and back to straighten the ear canal. Answers B and D are incorrect positions for administering ear drops. Answer C is used for administering ear drops to an adult client.

9.      Answer C is correct. The nurse should carefully monitor the client taking Thorazine for signs of infection that can quickly become overwhelming. Answers A, B, and C are incorrect because they are expected side effects of the medication.

10.  Answer A is correct. Iron is better absorbed when taken with ascorbic acid. Orange juice is an excellent source of ascorbic acid. Answer B is incorrect because the medication should be taken with orange juice or tomato juice. Answer C is incorrect because iron should not be taken with milk because it interferes with absorption. Answer D is incorrect because apple juice does not contain high amounts of ascorbic acid.

11.  Answer B is correct. Burn injury of the arm (9%), chest (9%), and head (9%) accounts for burns covering 27% of the total body surface area. Answers A, C, and D are incorrect percentages.

12.  Answer B is correct. With standing orders, the nurse can administer oxygen at 6L per minute via mask. Answer A is incorrect because the amount is too low to help the client with chest pain and shortness of breath. Answers C and D have oxygen levels requiring a doctor’s order.

13.  Answer A is correct. Stool from the ileostomy contains digestive enzymes that can cause severe skin breakdown. Answer B contains contradictory information; therefore, it is incorrect. Answers C and D contain inaccurate statements; therefore, they are incorrect.

14.  Answer C is correct. Tinnitus is a sign of aspirin toxicity. Answers A, B, and D are not related to aspirin toxicity; therefore, they are incorrect.

15.  Answer B is correct. The client with delirium tremens has an increased risk for seizures; therefore, the nurse should provide seizure precautions. Answer A is not a priority in the client’s care; therefore, it is incorrect. Answer C is incorrect because the client should be kept in a dimly lit, not dark, room. Answer D is incorrect because thiamine and multivitamins are given to prevent Wernicke’s encephalopathy, not delirium tremens.

16.  Answer D is correct. Steak, baked potato, and tossed salad are lower in purine than the other choices. Liver, crab, and chicken are high in purine; therefore, answers A, B, and C are incorrect.

17.  Answer C is correct. Placing the newborn in a side-lying position helps the urine to drain from the exposed bladder. Answer A is incorrect because it would position the child on the exposed bladder. Answers B and D are incorrect because they would allow the urine to pool.

18.  Answer D is correct. Burping the baby frequently throughout the feeding will help prevent gastric distention that contributes to esophageal reflux. Answers A and B are incorrect because they allow air to collect in the baby’s stomach, which contributes to reflux. Answer C is incorrect because the baby should be placed side-lying with the head elevated, to prevent aspiration.

19.  Answer B is correct. Growth plates located in the epiphysis can be damaged by epiphyseal fractures. Answers A, B, and C are untrue statements; therefore, they are incorrect.

20.  Answer A is correct. The nurse should replace the aspirate and administer the feeding because the amount aspirated was less than 50mL. Answers B and C are incorrect because the aspirate should not be discarded. Answer D is incorrect because the feeding should not be withheld.

21.  Answer B is correct. The nurse should administer two capsules. Answers A, C, and D contain inaccurate amounts; therefore, they are incorrect.

22.  Answer B is correct. The normal specific gravity is 1.010 to 1. Answers A, C, and D are inaccurate statements; therefore, they are incorrect.

23.  Answer A is correct. To prevent spasms of the sphincter of Oddi, the client with pancreatitis should receive nonopiate analgesics for pain. Answer B is incorrect because the client with pancreatitis might be prone to bleed; therefore, Toradol is not a drug of choice for pain control. Morphine and codeine, opiate analgesics, are contraindicated for the client with pancreatitis; therefore, answers C and D are incorrect.

24.  Answer D is correct. Overuse of magnesium-containing antacids results in diarrhea. Antacids containing calcium and aluminum cause constipation; therefore, answer A is incorrect. Answers B and C are not associated with the use of magnesium antacids; therefore, they are incorrect.

25.  Answer B is correct. The head circumference of the normal newborn is approximately 33cm, while the chest circumference is 31cm. Answer A is incorrect because the head and chest are not the same circumference. Answer C is incorrect because the head is larger in circumference than the chest. Answer D is incorrect because the difference in head circumference and chest circumference is too great

1.      The physician has ordered a low-potassium diet for a child with acute glomerulonephritis. Which snack is suitable for the child with potassium restrictions?

a.       Raisins

b.      Oranges

c.       Apricots

d.      Bananas

2.      The physician has ordered a blood test for H. pylori. The nurse should prepare the client by:

a.       Withholding intake after midnight

b.      Telling the client that no special preparation is needed

c.       Explaining that a small dose of radioactive isotope will be used

d.      Giving an oral suspension of glucose 1 hour before the test

3.      The nurse is preparing to give an oral potassium supplement. The nurse should:

a.       Give the medication without diluting it

b.      Give the medication with 4oz. of juice

c.       Give the medication with water only

d.      Give the medication on an empty stomach

4.      The physician has ordered cultures for cytomegalovirus (CMV). Which statement is true regarding collection of cultures for cytomegalovirus?

a.       Stool cultures are preferred for definitive diagnosis.

b.      Pregnant caregivers may obtain cultures.

c.       Collection of one specimen is sufficient.

d.      Accurate diagnosis depends on fresh specimens.

5.      A pediatric client with burns to the hands and arms has dressing changes with Sulfamylon (mafenide acetate) cream. The nurse is aware that the medication:

a.       Will cause dark staining of the surrounding skin

b.      Produces a cooling sensation when applied

c.       Can alter the function of the thyroid

d.      Produces a burning sensation when applied

6.      The physician has ordered Dilantin (phenytoin) for a client with generalized seizures. When planning the client’s care, the nurse should:

a.       Maintain strict intake and output

b.      Check the pulse before giving the medication

c.       Administer the medication 30 minutes before meals

d.      Provide oral hygiene and gum care every shift

7.      A client receiving chemotherapy for breast cancer has an order for Zofran (ondansetron) 8mg PO to be given 30 minutes before induction of the chemotherapy. The purpose of the medication is to:

a.       Prevent anemia

b.      Promote relaxation

c.       Prevent nausea

d.      Increase neutrophil counts

8.      The physician has ordered cortisporin ear drops for a 2-year-old. To administer the ear drops, the nurse should:

a.       Pull the ear down and back

b.      Pull the ear straight out

c.       Pull the ear up and back

d.      Leave the ear undisturbed

9.      A client with schizophrenia has been taking Thorazine (chlorpromazine) 200mg four times a day. Which finding should be reported to the doctor immediately?

a.       The client complains of thirst

b.      The client has gained 4 pounds in the past 2 months

c.       The client complains of a sore throat

d.      The client naps throughout the day

10.  A client with iron-deficiency anemia is taking an oral iron supplement. The nurse should tell the client to take the medication with:

a.       Orange juice

b.      Water only

c.       Milk

d.      Apple juice

11.  A client is admitted with burns of the right arm, chest, and head. According to the Rule of Nines, the percent of burn injury is:

a.       18%

b.      27%

c.       36%

d.      45%

12.  A client who was admitted with chest pain and shortness of breath has a standing order for oxygen via mask. Standing orders for oxygen mean that the nurse can apply oxygen at:

a.       2L per minute

b.      6L per minute

c.       10L per minute

d.      12L per minute

13.  The nurse is caring for a client with an ileostomy. The nurse should pay careful attention to care around the stoma because:

a.       Digestive enzymes cause skin breakdown.

b.      Stools are less watery and contain more solid matter.

c.       The stoma will heal more slowly than expected.

d.      It is difficult to fit the appliance to the stoma site.

14.  The physician has ordered aspirin therapy for a client with severe rheumatoid arthritis. A sign of acute aspirin toxicity is:

a.       Anorexia

b.      Diarrhea

c.       Tinnitus

d.      Pruritis

15.  A client is admitted to the emergency room with symptoms of delirium tremens. After admitting the client to a private room, the priority nursing intervention is to:

a.       Obtain a history of his alcohol use

b.      Provide seizure precautions

c.       Keep the room cool and dark

d.      Administer thiamine and zinc

16.  The nurse is providing dietary teaching for a client with gout. Which dietary selection is suitable for the client with gout?

a.       Broiled liver, macaroni and cheese, spinach

b.      Stuffed crab, steamed rice, peas

c.       Baked chicken, pasta salad, asparagus casserole

d.      Steak, baked potato, tossed salad

17.  A newborn has been diagnosed with exstrophy of the bladder. The nurse should position the newborn:

a.       Prone

b.      Supine

c.       On either side

d.      With the head elevated

18.  The mother of a 3-month-old with esophageal reflux asks the nurse what she can do to lessen the baby’s reflux. The nurse should tell the mother to:

a.       Feed the baby only when he is hungry

b.      Burp the baby after the feeding is completed

c.       Place the baby supine with head elevated

d.      Burp the baby frequently throughout the feeding

19.  A child is hospitalized with a fractured femur involving the epiphysis. Epiphyseal fractures are serious because:

a.       Bone marrow is lost through the fracture site.

b.      Normal bone growth is affected.

c.       Blood supply to the bone is obliterated.

d.      Callus formation prevents bone healing.

20.  Before administering a nasogastric feeding to a client hospitalized following a CVA, the nurse aspirates 40mL of residual. The nurse should:

a.       Replace the aspirate and administer the feeding

b.      Discard the aspirate and withhold the feeding

c.       Discard the aspirate and begin the feeding

d.      Replace the aspirate and withhold the feeding

21.  A client has an order for Dilantin (phenytoin) .2g orally twice a day. The medication is available in 100mg capsules. For the morning medication, the nurse should administer:

a.       1 capsule

b.      2 capsules

c.       3 capsules

d.      4 capsules

22.  The LPN is reviewing the lab results of an elderly client when she notes a specific gravity of 1. The nurse recognizes that:

a.       The client has impaired renal function.

b.      The client has a normal specific gravity.

c.       The client has mild to moderate dehydration.

d.      The client has diluted urine from fluid overload.

23.  A client with pancreatitis has requested pain medication. Which pain medication is indicated for the client with pancreatitis?

a.       Demerol (meperidine)

b.      Toradol (ketorolac)

c.       Morphine (morphine sulfate)

d.      Codeine (codeine)

24.  A client with a hiatal hernia has been taking magnesium hydroxide for relief of heartburn. Overuse of magnesium-based antacids can cause the client to have:

a.       Constipation

b.      Weight gain

c.       Anorexia

d.      Diarrhea

25.  When performing a newborn assessment, the nurse measures the circumference of the neonate’s head and chest. Which assessment finding is expected in the normal newborn?

a.       The head and chest circumference are the same.

b.      The head is 2cm larger than the chest.

c.       The head is 3cm smaller than the chest.

d.      The head is 4cm larger than the chest.

GET ANSWERS AND RATIONALE

1.      The physician has ordered Stadol (butorphanol) for a post-operative client. The nurse knows that the medication is having its intended effect if the client:

a.       Is asleep 30 minutes after the injection

b.      Asks for extra servings on his meal tray

c.       Has an increased urinary output

d.      States that he is feeling less nauseated

2.      The mother of a child with cystic fibrosis tells the nurse that her child makes "snoring" sounds when breathing. The nurse is aware that many children with cystic fibrosis have:

a.       Choanal atresia

b.      Nasal polyps

c.       Septal deviations

d.      Enlarged adenoids

3.      A client is hospitalized with hepatitis A. Which of the client’s regular medications is contraindicated due to the current illness?

a.       Prilosec (omeprazole)

b.      Synthroid (levothyroxine)

c.       Premarin (conjugated estrogens)

d.      Lipitor (atorvastatin)

4.      The nurse has been teaching the role of diet in regulating blood pressure to a client with hypertension. Which meal selection indicates that the client understands his new diet?

a.       Cornflakes, whole milk, banana, and coffee

b.      Scrambled eggs, bacon, toast, and coffee

c.       Oatmeal, apple juice, dry toast, and coffee

d.      Pancakes, ham, tomato juice, and coffee

5.     An 18-month-old is being discharged following hypospadias repair. Which instruction should be included in the nurse’s discharge teaching?

a.       The child should not play on his rocking horse.

b.      Applying warm compresses to decrease pain.

c.       Diapering should be avoided for 1–2 weeks.

d.      The child will need a special diet to promote healing.

6.      An obstetrical client calls the clinic with complaints of morning sickness. The nurse should tell the client to:

a.       Keep crackers at the bedside for eating before she arises

b.      Drink a glass of whole milk before going to sleep at night

c.       Skip breakfast but eat a larger lunch and dinner

d.      Drink a glass of orange juice after adding a couple of teaspoons of sugar

7.      The nurse has taken the blood pressure of a client hospitalized with methicillin-resistant staphylococcus aureus. Which action by the nurse indicates an understanding regarding the care of clients with MRSA?

a.       The nurse leaves the stethoscope in the client’s room for future use.

b.      The nurse cleans the stethoscope with alcohol and returns it to the exam room.

c.       The nurse uses the stethoscope to assess the blood pressure of other assigned clients.

d.      The nurse cleans the stethoscope with water, dries it, and returns it to the nurse’s station.

8.      The physician has discussed the need for medication with the parents of an infant with congenital hypothyroidism. The nurse can reinforce the physician’s teaching by telling the parents that:

a.       The medication will be needed only during times of rapid growth.

b.      The medication will be needed throughout the child’s lifetime.

c.       The medication schedule can be arranged to allow for drug holidays.

d.      The medication is given one time daily every other day.

9.      A client with diabetes mellitus has a prescription for Glucotrol XL (glipizide). The client should be instructed to take the medication:

a.       At bedtime

b.      With breakfast

c.       Before lunch

d.      After dinner

10.  The nurse is caring for a client admitted with suspected myasthenia gravis. Which finding is usually associated with a diagnosis of myasthenia gravis?

a.       Visual disturbances, including diplopia

b.      Ascending paralysis and loss of motor function

c.       Cogwheel rigidity and loss of coordination

d.      Progressive weakness that is worse at the day’s end

11.  The nurse is teaching the parents of a newborn with osteogenesis imperfecta. The nurse should tell the parents:

a.       That the baby will need daily calcium supplements

b.      To lift the baby by the buttocks when diapering

c.       That the condition is a temporary one

d.      That only the bones are affected by the disease

12.  Physician’s orders for a client with acute pancreatitis include the following: strict NPO, NG tube to low intermittent suction. The nurse recognizes that these interventions will:

a.       Reduce the secretion of pancreatic enzymes

b.      Decrease the client’s need for insulin

c.       Prevent secretion of gastric acid

d.      Eliminate the need for analgesia

13.  A client with diverticulitis is admitted with nausea, vomiting, and dehydration. Which finding suggests a complication of diverticulitis?

a.       Pain in the left lower quadrant

b.      Boardlike abdomen

c.       Low-grade fever

d.      Abdominal distention

14.  The diagnostic work-up of a client hospitalized with complaints of progressive weakness and fatigue confirms a diagnosis of myasthenia gravis. The medication used to treat myasthenia gravis is:

a.       Prostigmine (neostigmine)

b.      Atropine (atropine sulfate)

c.       Didronel (etidronate)

d.      Tensilon (edrophonium)

15.  A client with AIDS complains of a weight loss of 20 pounds in the past month. Which diet is suggested for the client with AIDS?

a.       High calorie, high protein, high fat

b.      High calorie, high carbohydrate, low protein

c.       High calorie, low carbohydrate, high fat

d.      High calorie, high protein, low fat

16.  The nurse is caring for a 4-year-old with cerebral palsy. Which nursing intervention will help ready the child for rehabilitative services?

a.       Patching one of the eyes to strengthen the muscles

b.      Providing suckers and pinwheels to help strengthen tongue movement

c.       Providing musical tapes to provide auditory training

d.      Encouraging play with a video game to improve muscle coordination

17.  At the 6-week check-up, the mother asks when she can expect the baby to sleep all night. The nurse should tell the mother that most infants begin to sleep all night by age:

a.       1 month

b.      2 months

c.       3–4 months

d.      5–6 months

18.  Which of the following pediatric clients is at greatest risk for latex allergy?

a.       The child with a myelomeningocele

b.      The child with epispadias

c.       The child with coxa plana

d.      The child with rheumatic fever

19.  The nurse is teaching the mother of a child with cystic fibrosis how to do postural drainage. The nurse should tell the mother to:

a.       Use the heel of her hand during percussion

b.      Change the child’s position every 20 minutes

c.       Do percussion after the child eats and at bedtime

d.      Use cupped hands during percussion

20.  The nurse calculates the amount of an antibiotic for injection to be given to an infant. The amount of medication to be administered is 1.25mL. The nurse should:

a.       Divide the amount into two injections and administer in each vastus lateralis muscle

b.      Give the medication in one injection in the dorsogluteal muscle

c.       Divide the amount in two injections and give one in the ventrogluteal muscle and one in the vastus lateralis muscle

d.      Give the medication in one injection in the ventrogluteal muscle

21.  A client with schizophrenia is receiving depot injections of Haldol Deconate (haloperidol decanoate). The client should be told to return for his next injection in:

a.       1 week

b.      2 weeks

c.       4 weeks

d.      6 weeks

22.  A 3-year-old is immobilized in a hip spica cast. Which discharge instruction should be given to the parents?

a.       Keep the bed flat, with a small pillow beneath the cast

b.      Provide crayons and a coloring book for play activity

c.       Increase her intake of high-calorie foods for healing

d.      Tuck a disposable diaper beneath the cast at the perineal opening

23.  The nurse is caring for a client following the reimplantation of the thumb and index finger. Which finding should be reported to the physician immediately?

a.       Temperature of 100°F

b.      Coolness and discoloration of the digits

c.       Complaints of pain

d.      Difficulty moving the digits

24.  When assessing the urinary output of a client who has had extracorporeal lithotripsy, the nurse can expect to find:

a.       Cherry-red urine that gradually becomes clearer

b.      Orange-tinged urine containing particles of calculi

c.       Dark red urine that becomes cloudy in appearance

d.      Dark, smoky-colored urine with high specific gravity

25.  The physician has prescribed Cognex (tacrine) for a client with dementia. The nurse should monitor the client for adverse reactions, which include:

a.       Hypoglycemia

b.      Jaundice

c.       Urinary retention

d.      Tinnitus

GET ANSWERS AND RATIONALE

1.      Answer C is correct. Changes in breath sounds are the best indication of the need for suctioning in the client with ineffective airway clearance. Answers A, B, and D are incorrect because they can be altered by other conditions.

2.      Answer D is correct. An adverse reaction to Myambutol is change in visual acuity or color vision. Answer A is incorrect because it does not relate to the medication. Answer C is incorrect because it is an adverse reaction to Streptomycin. Answer C is incorrect because it is a side effect of Rifampin.

3.      Answer D is correct. Insufficient erythropoietin production is the primary cause of anemia in the client with chronic renal failure. Answers A, B, and C do not relate to the anemia seen in the client with chronic renal failure; therefore, they are incorrect.

4.      Answer C is correct. The contrast media used during an intravenous pyelogram contains iodine, which can result in an anaphylactic reaction. Answers A, B, and D do not relate specifically to the test; therefore, they are incorrect.

5.      Answer D is correct. Aspirin prevents the platelets from clumping together to prevent clots. Answer A is incorrect because the low-dose aspirin will not prevent headaches. Answers B and C are untrue statements; therefore, they are incorrect.

6.      Answer C is correct. The usual course of treatment requires that medication be given for 18 months to 2 years. Answers A and D are incorrect because the treatment time is too brief. Answer B is incorrect because the medication is not needed for life.

7.      Answer D is correct. At 4 months of age, the infant can roll over, which makes it vulnerable to falls from dressing tables or beds without rails. Answer A is incorrect because it does not prove a threat to safety. Answers B and C are incorrect because the 4-month-old is not capable of crawling or standing.

8.      Answer C is correct. Adverse side effects of Dilantin include agranulocytosis and aplastic anemia; therefore, the client will need frequent CBCs. Answer A is incorrect because the medication does not cause dental staining. Answer B is incorrect because the medication does not interfere with the metabolism of carbohydrates. Answer D is incorrect because the medication does not cause drowsiness.

9.      Answer A is correct. The infant with hypospadias should not be circumcised because the foreskin is used in reconstruction. Answer B and C are incorrect because reconstruction is done between 16 and 18 months of age, before toilet training. Answer D is incorrect because the infant with hypospadias should not be circumcised.

10.  Answer C is correct. Coconut oil is high in saturated fat and is not appropriate for the client on a low-cholesterol diet. Answers A, B, and D are incorrect because they are suggested for the client with elevated cholesterol levels.

11.  Answer B is correct. In stage III of Alzheimer’s disease, the client develops agnosia, or failure to recognize familiar objects. Answer A is incorrect because it appears in stage I. Answer C is incorrect because it appears in stage II. Answer D is incorrect because it appears in stage IV.

12.  Answer D is correct. The client taking steroid medication should receive an annual influenza vaccine. Answer A is incorrect because the medication should be taken with food. Answer B is incorrect because increased appetite and weight gain are expected side effects of the medication. Answer C is incorrect because wearing sunglasses will not prevent cataracts.

13.  Answer A is correct. The client with an above-the-knee amputation should be placed prone 15–30 minutes twice a day to prevent contractures. Answers B and D are incorrect because elevating the extremity after the first 24 hours will promote the development of contractures. Use of a trochanter roll will prevent rotation of the extremity but will not prevent contracture; therefore, answer D is incorrect.

14.  Answer D is correct. All 20 primary, or deciduous, teeth should be present by age 30 months. Answers A, B, and C are incorrect because the ages are wrong.

15.  Answer C is correct. The radioactive implant should be picked up with tongs and returned to the lead-lined container. Answer A is incorrect because radioactive materials are placed in lead-lined containers, not plastic ones, and are returned to the radiation department, not the lab. Answer B is incorrect because the client should not touch the implant or try to reinsert it. Answer D is incorrect because the implant should not be placed in the commode for disposal.

16.  Answer A is correct. Following a laparoscopic cholecystectomy, the client should avoid a tub bath for 48 hours. Answer B is incorrect because the stools should not be clay colored. Answer C is incorrect because pain is usually located in the shoulders. Answer D is incorrect because the client should not resume a regular diet until clear liquids have been tolerated.

17.  Answer B is correct. The client recovering from mononucleosis should avoid contact sports and other activities that could result in injury or rupture of the spleen. Answer A is incorrect because the client does not need additional fluids. Hypoglycemia is not associated with mononucleosis; therefore, answer C is incorrect. Answer D is incorrect because antibiotics are not usually indicated in the treatment of mononucleosis.

18.  Answer B is correct. Pancreatic enzyme replacement is given with each meal and each snack. Answers A, C, and D do not specify a relationship to meals; therefore, they are incorrect.

19.  Answer A is correct. Meat, eggs, and dairy products are foods high in vitamin B12. Answer B is incorrect because peanut butter, raisins, and molasses are sources rich in iron. Answer C is incorrect because broccoli, cauliflower, and cabbage are sources rich in vitamin K. Answer D is incorrect because shrimp, legumes, and bran cereals are high in magnesium.

20.  Answer A is correct. The client’s aerobic workout should be 20–30 minutes long three times a week. Answers B, C, and D exceed the recommended time for the client beginning an aerobic program; therefore, they are incorrect.

21.  Answer A is correct. A total mastectomy involves removal of the entire breast and some or all of the axillary lymph nodes. Following surgery, the client’s right arm should be elevated on pillows, to facilitate lymph drainage. Answers B, C, and D are incorrect because they would not help facilitate lymph drainage and would create increased edema in the affected extremity.

22.  Answer D is correct. Absence seizures, formerly known as petit mal seizures, are characterized by a brief lapse in consciousness accompanied by rapid eye blinking, lip smacking, and minor myoclonus of the upper extremities. Answer A refers to myoclonic seizure; therefore, it is incorrect. Answer B refers to tonic clonic, formerly known as grand mal, seizures; therefore, it is incorrect. Answer C refers to atonic seizures; therefore, it is incorrect.

23.  Answer A is correct. A side effect of antipsychotic medication is the development of Parkinsonian symptoms. Answers B and C are incorrect because they are used to reverse Parkinsonian symptoms in the client taking antipsychotic medication. Answer D is incorrect because the medication is an anticonvulsant used to stabilize mood. Parkinsonian symptoms are not associated with anticonvulsant medication.

24.  Answer B is correct. Exercises that provide light passive resistance are best for the child with rheumatoid arthritis. Answers A and C require movement of the hands and fingers that might be too painful for the child with juvenile rheumatoid arthritis; therefore, they are incorrect. Answer D is incorrect because it requires the use of larger joints affected by the disease.

25.  Answer B is correct. The client’s diabetes is well under control. Answer A is incorrect because it will lead to elevated glycosylated hemoglobin. Answer C is incorrect because the diet and insulin dose are appropriate for the client. Answer D is incorrect because the desired range for glycosylated hemoglobin in the adult client is 2.5%–5.9%

• NCLEX-PN Practice Exam Part 1 – Answers and Rationales
• NCLEX-PN Practice Exam Part 2 – Answers and Rationales
• NCLEX-PN Practice Exam Part 3 – Answers and Rationales
• NCLEX-PN Practice Exam Part 4 – Answers and Rationales

If you want to practice more questions like this, we strongly suggest to get a copy of NCLEX-PN Practice Questions and NCLEX-PN Exam Cram from informit.com.

1.      Which finding is the best indication that a client with ineffective airway clearance needs suctioning?

a.       Oxygen saturation

b.      Respiratory rate

c.       Breath sounds

d.      Arterial blood gases

2.      A client with tuberculosis has a prescription for Myambutol (ethambutol HCl). The nurse should tell the client to notify the doctor immediately if he notices:

a.       Gastric distress

b.      Changes in hearing

c.       Red discoloration of bodily fluids

d.      Changes in color vision

3.      The primary cause of anemia in a client with chronic renal failure is:

a.       Poor iron absorption

b.      Destruction of red blood cells

c.       Lack of intrinsic factor

d.      Insufficient erythropoietin

4.      Which of the following nursing interventions has the highest priority for the client scheduled for an intravenous pyelogram?

a.       Providing the client with a favorite meal for dinner

b.      Asking if the client has allergies to shellfish

c.       Encouraging fluids the evening before the test

d.      Telling the client what to expect during the test

5.      The doctor has prescribed aspirin 325mg daily for a client with transient ischemic attacks. The nurse knows that aspirin was prescribed to:

a.       Prevent headaches

b.      Boost coagulation

c.       Prevent cerebral anoxia

d.      Keep platelets from clumping together

6.      A client with tuberculosis asks the nurse how long he will have to take medication. The nurse should tell the client that:

a.       Medication is rarely needed after 2 weeks.

b.      He will need to take medication the rest of his life.

c.       The course of therapy is usually 18–24 months.

d.      He will be re-evaluated in 1 month to see if further medication is needed.

7.      Which development milestone puts the 4-month-old infant at greatest risk for injury?

a.       Switching objects from one hand to another

b.      Crawling

c.       Standing

d.      Rolling over

8.      A client taking Dilantin (phenytoin) for grand mal seizures is preparing for discharge. Which information should be included in the client’s discharge care plan?

a.       The medication can cause dental staining.

b.      The client will need to avoid a high-carbohydrate diet.

c.       The client will need a regularly scheduled CBC.

d.      The medication can cause problems with drowsiness.

9.      Assessment of a newborn male reveals that the infant has hypospadias. The nurse knows that:

a.       The infant should not be circumcised.

b.      Surgical correction will be done by 6 months of age.

c.       Surgical correction is delayed until 6 years of age.

d.      The infant should be circumcised to facilitate voiding.

10.  The nurse is providing dietary teaching for a client with elevated cholesterol levels. Which cooking oil is not suggested for the client on a low-cholesterol diet?

a.       Safflower oil

b.      Sunflower oil

c.       Coconut oil

d.      Canola oil

11.  The nurse is caring for a client with stage III Alzheimer’s disease. A characteristic of this stage is:

a.       Memory loss

b.      Failing to recognize familiar objects

c.       Wandering at night

d.      Failing to communicate

12.  The doctor has prescribed Cortone (cortisone) for a client with systemic lupus erythematosis. Which instruction should be given to the client?

a.       Take the medication 30 minutes before eating.

b.      Report changes in appetite and weight.

c.       Wear sunglasses to prevent cataracts.

d.      Schedule a time to take the influenza vaccine.

13.  The nurse is caring for a client with an above-the-knee amputation (AKA). To prevent contractures, the nurse should:

a.       Place the client in a prone position 15–30 minutes twice a day

b.      Keep the foot of the bed elevated on shock blocks

c.       Place trochanter rolls on either side of the affected leg

d.      Keep the client’s leg elevated on two pillows

14.  The mother of a 6-month-old asks when her child will have all his baby teeth. The nurse knows that most children have all their primary teeth by age:

a.       12 months

b.      18 months

c.       24 months

d.      30 months

15.  While caring for a client with cervical cancer, the nurse notes that the radioactive implant is lying in the bed. The nurse should:

a.       Place the implant in a biohazard bag and return it to the lab

b.      Give the client a pair of gloves and ask her to reinsert the implant

c.       Use tongs to pick up the implant and return it to a lead-lined container

d.      Discard the implant in the commode and double-flush

16.  The nurse is preparing to discharge a client following a laparoscopic cholecystectomy. The nurse should:

a.       Tell the client to avoid a tub bath for 48 hours

b.      Tell the client to expect clay-colored stools

c.       Tell the client that she can expect lower abdominal pain for the next week

d.      Tell the client that she can resume a regular diet in the next 24 hours

17.  A high school student returns to school following a 3-week absence due to mononucleosis. The school nurse knows it will be important for the client:

a.       To drink additional fluids throughout the day

b.      To avoid contact sports for 1–2 months

c.       To have a snack twice a day to prevent hypoglycemia

d.      To continue antibiotic therapy for 6 months

18.  A 6-year-old with cystic fibrosis has an order for Creon. The nurse knows that the medication will be given:

a.       At bedtime

b.      With meals and snacks

c.       Twice daily

d.      Daily in the morning

19.  The doctor has prescribed a diet high in vitamin B12 for a client with pernicious anemia. Which foods are highest in B12?

a.       Meat, eggs, dairy products

b.      Peanut butter, raisins, molasses

c.       Broccoli, cauliflower, cabbage

d.      Shrimp, legumes, bran cereals

20.  A client with hypertension has begun an aerobic exercise program. The nurse should tell the client that the recommended exercise regimen should begin slowly and build up to:

a.       20–30 minutes three times a week

b.      45 minutes two times a week

c.       1 hour four times a week

d.      1 hour two times a week

21.  A client with breast cancer is returned to the room following a right total mastectomy. The nurse should:

a.       Elevate the client’s right arm on pillows

b.      Place the client’s right arm in a dependent sling

c.       Keep the client’s right arm on the bed beside her

d.      Place the client’s right arm across her body

22.  A neurological consult has been ordered for a pediatric client with suspected petit mal seizures. The client with petit mal seizures can be expected to have:

a.       Short, abrupt muscle contraction

b.      Quick, bilateral severe jerking movements

c.       Abrupt loss of muscle tone

d.      A brief lapse in consciousness

23.  A client with schizoaffective disorder is exhibiting Parkinsonian symptoms. Which medication is responsible for the development of Parkinsonian symptoms?

a.       Zyprexa (olanzapine)

b.      Cogentin (benzatropine mesylate)

c.       Benadryl (diphenhydramine)

d.      Depakote (divalproex sodium)

24.  Which activity is best suited to the 12-year-old with juvenile rheumatoid arthritis?

a.       Playing video games

b.      Swimming

c.       Working crossword puzzles

d.      Playing slow-pitch softball

25.  The glycosylated hemoglobin of a 40-year-old client with diabetes mellitus is 2.5%. The nurse understands that:

a.       The client can have a higher-calorie diet.

b.      The client has good control of her diabetes.

c.       The client requires adjustment in her insulin dose.

d.      The client has poor control of her diabetes.

GET ANSWERS AND RATIONALE

1.      Answer D is correct. Respiratory stridor is a symptom of partial airway obstruction. Answers A, B, and C are expected with a tonsillectomy; therefore, they are incorrect.

2.      Answer C is correct. Pain associated with duodenal ulcers is lessened if the client eats a meal or snack. Answer A is incorrect because it makes the pain worse. Answer B refers to dumping syndrome; therefore, it is incorrect. Answer D refers to gastroesophageal reflux; therefore, it is incorrect.

3.      Answer C is correct. Foods containing rice or millet are permitted on the diet of the client with celiac disease. Answers A, B, and D are not permitted because they contain flour made from wheat, which exacerbates the symptoms of celiac disease; therefore, they are incorrect.

4.      Answer B is correct. Increased thirst and increased urination are signs of lithium toxicity. Answers B and D do not relate to the medication; therefore, they are incorrect. Answer C is an expected side effect of the medication; therefore, it is incorrect.

5.      Answer C is correct. The immunization protects the child against diphtheria, pertussis, tetanus, and H. influenza b. Answer A is incorrect because a second injection is given before 4 years of age. Answer B is not a true statement; therefore, it is incorrect. Answer D is incorrect because it is not a one-time injection, nor does it protect against measles, mumps, rubella, or varicella.

6.      Answer D is correct. The milkshake will provide needed calories and nutrients for the client with mania. Answers A and B are incorrect because they are high in sodium, which causes the client to excrete the lithium. Answer C has some nutrient value, but not as much as the milkshake.

7.      Answer A is correct. The child with intussusception has stools that contain blood and mucus, which are described as "currant jelly" stools. Answer B is a symptom of pyloric stenosis; therefore, it is incorrect. Answer C is a symptom of Hirschsprung’s; therefore, it is incorrect. Answer D is a symptom of Wilms tumor; therefore, it is incorrect.

8.      Answer D is correct. The nurse should not use water, soap, or lotion on the area marked for radiation therapy. Answer A is incorrect because it would remove the marking. Answers B and C are not necessary for the client receiving radiation; therefore, they are incorrect.

9.      Answer A is correct. Growth hormone levels generally fall rapidly after a hypophysectomy, allowing insulin levels to rise. The result is hypoglycemia. Answer B is incorrect because it traumatizes the oral mucosa. Answer C is incorrect because the client’s head should be elevated to reduce pressure on the operative site. Answer D is incorrect because it increases pressure on the operative site that can lead to a leak of cerebral spinal fluid.

10.  Answer C is correct. Precose (acarbose) is to be taken with the first bite of a meal. Answers A, B, and D are incorrect because they specify the wrong schedule for medication administration.

11.  Answer B is correct. The client going for therapy in the hyperbaric oxygen chamber requires no special skin care; therefore, washing the skin with water and patting it dry are suitable. Lotions, petroleum products, perfumes, and occlusive dressings interfere with oxygenation of the skin; therefore, answers A, C, and D are incorrect.

12.  Answer C is correct. The primary reason for the NG to is to allow for nourishment without contamination of the suture line. Answer A is not a true statement; therefore, it is incorrect. Answer B is incorrect because there is no mention of suction. Answer D is incorrect because the oral mucosa was not involved in the laryngectomy.

13.  Answer A is correct. The client with expressive aphasia has trouble forming words that are understandable. Answer B is incorrect because it describes receptive aphasia. Answer C refers to apraxia; therefore, it is incorrect. Answer D is incorrect because it refers to agnosia.

14.  Answer D is correct. Sunscreens of at least an SPF of 15 should be applied 20–30 minutes before going into the sun. Answers A, B, and C are incorrect because they do not allow sufficient time for sun protection.

15.  Answer B is correct. The combination of the two medications produces an effect greater than that of either drug used alone. Agonist effects are similar to those produced by chemicals normally present in the body; therefore, answer A is incorrect. Antagonist effects are those in which the actions of the drugs oppose one another; therefore, answer C is incorrect. Answer D is incorrect because the drugs would have a combined depressing, not excitatory, effect.

16.  Answer C is correct. The medication should be withheld and the doctor should be notified. Answers A, B, and D are incorrect because they do not provide for the client’s safety.

17.  Answer B is correct. Solid foods should be added to the diet one at a time, with 4- to 7-day intervals between new foods. The extrusion reflex fades at 3–4 months of age; therefore, answer A is incorrect. Answer C is incorrect because solids should not be added to the bottle and the use of infant feeders is discouraged. Answer D is incorrect because the first food added to the infant’s diet is rice cereal.

18.  Answer C is correct. The client’s symptoms suggest an adverse reaction to the medication known as neuroleptic malignant syndrome. Answers A, B, and D are not appropriate.

19.  Answer D is correct. The client with HIV should adhere to a low-bacteria diet by avoiding raw fruits and vegetables. Answers A, B, and C are incorrect because they are permitted in the client’s diet.

20.  Answer C is correct. The child with leukemia has low platelet counts, which contribute to spontaneous bleeding. Answers A, B, and D, common in the child with leukemia, are not life-threatening.

21.  Answer A is correct. The nurse should prevent the infant with atopic dermatitis (eczema) from scratching, which can lead to skin infections. Answer B is incorrect because fever is not associated with atopic dermatitis. Answers C and D are incorrect because they increase dryness of the skin, which worsens the symptoms of atopic dermatitis.

22.  Answer D is correct. Symptoms associated with diverticulitis are usually reported after eating popcorn, celery, raw vegetables, whole grains, and nuts. Answers A, B, and C are incorrect because they are allowed in the diet of the client with diverticulitis.

23.  Answer B is correct. The Whipple procedure is performed for cancer located in the head of the pancreas. Answers A, C, and D are not correct because of the location of the cancer.

24.  Answer C is correct. Side effects of Pulmozyme include sore throat, hoarseness, and laryngitis. Answers A, B, and C are not associated with Pulmozyme; therefore, they are incorrect.

25.  Answer B is correct. The nurse should be concerned with alleviating the client’s pain. Answers A, B, and C are not primary objectives in the care of the client receiving an opiate analgesic; therefore, they are incorrect.

1.      The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?

a.       Reluctance to swallow

b.      Drooling of blood-tinged saliva

c.       An axillary temperature of 99°F

d.      Respiratory stridor

2.      The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort lessens when he:

a.       Skips a meal

b.      Rests in recumbent position

c.       Eats a meal

d.      Sits upright after eating

3.      Which of the following meal selections is appropriate for the client with celiac disease?

a.       Toast, jam, and apple juice

b.      Peanut butter cookies and milk

c.       Rice Krispies bar and milk

d.      Cheese pizza and Kool-Aid

4.      A client with hyperthyroidism is taking lithium carbonate to inhibit thyroid hormone release. Which complaint by the client should alert the nurse to a problem with the client’s medication?

a.       The client complains of blurred vision.

b.      The client complains of increased thirst and increased urination.

c.       The client complains of increased weight gain over the past year.

d.      The client complains of ringing in the ears.

5.      A 2-month-old infant has just received her first Tetramune injection. The nurse should tell the mother that the immunization:

a.       Will need to be repeated when the child is 4 years of age

b.      Is given to determine whether the child is susceptible to pertussis

c.       Is one of a series of injections that protects against dpt and Hib

d.      Is a one-time injection that protects against MMR and varicella

6.      The nurse is caring for a client hospitalized with bipolar disorder, manic phase. Which of the following snacks would be best for the client with mania?

a.       Potato chips

b.      Diet cola

c.       Apple

d.      Milkshake

7.      A 2-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?

a.       "Currant jelly" stools

b.      Projectile vomiting

c.       "Ribbonlike" stools

d.      Palpable mass over the flank

8.      A client is being treated for cancer with linear acceleration radiation. The physician has marked the radiation site with a blue marking pen. The nurse should:

a.       Remove the unsightly markings with acetone or alcohol

b.      Cover the radiation site with loose gauze dressing

c.       Sprinkle baby powder over the radiated area

d.      Refrain from using soap or lotion on the marked area

9.      The nurse is caring for a client with acromegaly. Following a transphenoidal hypophysectomy, the nurse should:

a.       Monitor the client’s blood sugar

b.      Suction the mouth and pharynx every hour

c.       Place the client in low Trendelenburg position

d.      Encourage the client to cough

10.  A client newly diagnosed with diabetes is started on Precose (acarbose). The nurse should tell the client that the medication should be taken:

a.       1 hour before meals

b.      30 minutes after meals

c.       With the first bite of a meal

d.      Daily at bedtime

11.  A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should:

a.       Apply a lanolin-based lotion to the skin

b.      Wash the skin with water and pat dry

c.       Cover the area with a petroleum gauze

d.      Apply an occlusive dressing to the site

12.  A client with a laryngectomy returns from surgery with a nasogastric tube in place. The primary reason for placement of the nasogastric tube is to:

a.       Prevent swelling and dysphagia

b.      Decompress the stomach via suction

c.       Prevent contamination of the suture line

d.      Promote healing of the oral mucosa

13.  The chart indicates that a client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with:

a.       Speaking and writing

b.      Comprehending spoken words

c.       Carrying out purposeful motor activity

d.      Recognizing and using an object correctly

14.  A camp nurse is applying sunscreen to a group of children enrolled in swim classes. Chemical sunscreens are most effective when applied:

a.       Just before sun exposure

b.      5 minutes before sun exposure

c.       15 minutes before sun exposure

d.      30 minutes before sun exposure

15.  A post-operative client has an order for Demerol (meperidine) 75mg and Phenergan (promethazine) 25mg IM every 3–4 hours as needed for pain. The combination of the two medications produces a/an:

a.       Agonist effect

b.      Synergistic effect

c.       Antagonist effect

d.      Excitatory effect

16.  Before administering a client’s morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:

a.       Record the pulse rate and administer the medication

b.      Administer the medication and monitor the heart rate

c.       Withhold the medication and notify the doctor

d.      Withhold the medication until the heart rate increases

17.  What information should the nurse give a new mother regarding the introduction of solid foods for her infant?

a.       Solid foods should not be given until the extrusion reflex disappears, at 8–10 months of age.

b.      Solid foods should be introduced one at a time, with 4- to 7-day intervals.

c.       Solid foods can be mixed in a bottle or infant feeder to make feeding easier.

d.      Solid foods should begin with fruits and vegetables.

18.  A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:

a.       Withholding all morning medications

b.      Ordering a CBC and CPK

c.       Administering prescribed anti-Parkinsonian medication

d.      Transferring the client to a medical unit

19.  A client with human immunodeficiency syndrome has gastrointestinal symptoms, including diarrhea. The nurse should teach the client to avoid:

a.       Calcium-rich foods

b.      Canned or frozen vegetables

c.       Processed meat

d.      Raw fruits and vegetables

20.  A 4-year-old is admitted with acute leukemia. It will be most important to monitor the child for:

a.       Abdominal pain and anorexia

b.      Fatigue and bruising

c.       Bleeding and pallor

d.      Petechiae and mucosal ulcers

21.  A 5-month-old is diagnosed with atopic dermatitis. Nursing interventions will focus on:

a.       Preventing infection

b.      Administering antipyretics

c.       Keeping the skin free of moisture

d.      Limiting oral fluid intake

22.  The nurse is caring for a client with a history of diverticulitis. The client complains of abdominal pain, fever, and diarrhea. Which food was responsible for the client’s symptoms?

a.       Mashed potatoes

b.      Steamed carrots

c.       Baked fish

d.      Whole-grain cereal

23.  The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client’s cancer is located in:

a.       The tail of the pancreas

b.      The head of the pancreas

c.       The body of the pancreas

d.      The entire pancreas

24.  A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is:

a.       Weight gain

b.      Hair loss

c.       Sore throat

d.      Brittle nails

25.  The doctor has ordered Percocet (oxycodone) for a client following abdominal surgery. The primary objective of nursing care for the client receiving an opiate analgesic is to:

a.       Prevent addiction

b.      Alleviate pain

c.       Facilitate mobility

d.      Prevent nausea

GET ANSWERS AND RATIONALE

1. Answer A is correct. The major complication of SLE is lupus nephritis, which results in end-stage renal disease. SLE affects the musculoskeletal, integumentary, renal, nervous, and cardiovascular systems, but the major complication is renal involvement; therefore, answers B and D are incorrect. Answer C is incorrect because the SLE produces a "butterfly" rash, not desquamation.

2. Answer C is correct. A diet that is high in fat and refined carbohydrates increases the risk of colorectal cancer. High fat content results in an increase in fecal bile acids, which facilitate carcinogenic changes. Refined carbohydrates increase the transit time of food through the gastrointestinal tract and increase the exposure time of the intestinal mucosa to cancer-causing substances. Answers A, B, and D do not relate to the question; therefore, they are incorrect.

3. Answer B is correct. The nurse should avoid giving the infant a pacifier or bottle because sucking is not permitted. Holding the infant cradled in the arms, providing a mobile, and offering sterile water using a Breck feeder are permitted; therefore, answers A, C, and D are incorrect.

4. Answer D is correct. The client with esophageal varices can develop spontaneous bleeding from the mechanical irritation caused by taking capsules; therefore, the nurse should request the medication in a suspension. Answer A is incorrect because it does not best meet the client’s needs. Answer B is incorrect because it is not the best means of preventing bleeding. Answer C is incorrect because the medications should not be given with milk or antacids.

5. Answer A is correct. Tomatoes are a poor source of iron, although they are an excellent source of vitamin C, which increases iron absorption. Answers B, C, and D are good sources of iron; therefore, they are incorrect.

6. Answer A is correct. Periodically lying in a prone position without a pillow will help prevent the flexion of the spine that occurs with Parkinson’s disease. Answers B and C flex the spine; therefore, they are incorrect. Answer D is not realistic because of position changes during sleep; therefore, it is incorrect.

7. Answer B is correct. The client recovering from pancreatitis needs a diet that is high in calories and low in fat. Answers A, C, and D are incorrect because they can increase the client’s discomfort.

8. Answer B is correct. Dressing in layers and using extra covering will help decrease the feeling of being cold that is experienced by the client with hypothyroidism. Decreased sensation and decreased alertness are common in the client with hypothyroidism; therefore, the use of electric blankets and heating pads can result in burns, making answers A and C incorrect. Answer D is incorrect because the client with hypothyroidism has dry skin, and a hot bath morning and evening would make her condition worse.

9. Answer D is correct. A history of frequent alcohol and tobacco use is the most significant factor in the development of cancer of the larynx. Answers A, B, and C are also factors in the development of laryngeal cancer, but they are not the most significant; therefore, they are incorrect.

10. Answer B is correct. Numbness and tingling in the extremities is common in the client with pernicious anemia, but not those with other types of anemia. Answers A, C, and D are incorrect because they are symptoms of all types of anemia.

11. Answer B is correct. The client with echolalia repeats words or phrases used by others. Answer A is incorrect because it refers to clang association. Answer C is incorrect because it refers to circumstantiality. Answer D is incorrect because it refers to neologisms.

12. Answer C is correct. Holding a cup of coffee or hot chocolate helps to relieve the pain and stiffness of the hands. Answers A, B, and D do not relieve the symptoms of rheumatoid arthritis; therefore, they are incorrect.

13. Answer A is correct. The infant’s birth weight should double by 6 months of age. Answers B, C, and D are incorrect because they are greater than the expected weight gain by 6 months of age.

14. Answer C is correct. The symptoms of nontropical sprue and celiac are caused by the ingestion of gluten, which is found in wheat, oats, barley, and rye. Creamed soup and crackers contain gluten. Answers A, B, and D do not contain gluten; therefore, they are incorrect.

15. Answer A is correct. Lanoxin slows and strengthens the contraction of the heart. An increase in urinary output shows that the medication is having a desired effect by eliminating excess fluid from the body. Answer B is incorrect because the weight would decrease. Answer C might occur but is not directly related to the question; therefore, it is incorrect. Answer D is incorrect because pedal edema would decrease, not increase.

16. Answer B is correct. The toddler has gross motor skills suited to playing with a ball, which can be kicked forward or thrown overhand. Answers A and C are incorrect because they require fine motor skills. Answer D is incorrect because the toddler lacks gross motor skills for play on the swing set.

17. Answer A is correct. Antacids containing aluminum and calcium tend to cause constipation. Answer A refers to the side effects of anticholinergic medications used to treat ulcers; therefore, it is incorrect. Answer C refers to antacids containing magnesium; therefore, it is incorrect. Answer D refers to dopamine antagonists used to treat ulcers; therefore, it is incorrect.

18. Answer D is correct. The client with an abdominal aortic aneurysm frequently complains of pulsations or "feeling my heart beat" in the abdomen. Answers A and C are incorrect because they occur with rupture of the aneurysm. Answer B is incorrect because back pain is not affected by changes in position.

19. Answer A is correct. The client with acute adrenal crisis has symptoms of hypovolemia and shock; therefore, the blood pressure would be low. Answer B is incorrect because the pulse would be rapid and irregular. Answer C is incorrect because the skin would be cool and pale. Answer D is incorrect because the urinary output would be decreased.

20. Answer B is correct. Bright red bleeding with many clots indicates arterial bleeding that requires surgical intervention. Answer A is within normal limits; therefore, it is incorrect. Answer C indicates venous bleeding, which can be managed by nursing intervention; therefore, it is incorrect. Answer D does not indicate excessive need for pain management that requires the doctor’s attention; therefore, it is incorrect.

21. Answer D is correct. The child with polymigratory arthritis will exhibit swollen, painful joints. Answer B is incorrect because it describes subcutaneous nodules. Answer C is incorrect because it describes erythema marginatum. Answer A is incorrect because it describes Syndeham’s chorea.

22. Answer D is correct. The primary reason for placing a child with croup under a mist tent is to liquefy secretions and relieve laryngeal spasms. Answer A is incorrect because it does not prevent insensible water loss. Answer B is incorrect because the oxygen concentration is too high. Answer C is incorrect because the mist tent does not prevent dehydration or reduce fever.

23. Answer B is correct. Symptoms of hypothyroidism include weight gain, lethargy, slow speech, and decreased respirations. Answers A and D do not describe symptoms associated with myxedema; therefore, they are incorrect. Answer C describes symptoms associated with Graves’s disease; therefore, it is incorrect.

24. Answer D is correct. The contagious stage of varicella begins 24 hours before the onset of the rash and lasts until all the lesions are crusted. Answers A, B, and C are inaccurate regarding the time of contagion; therefore, they are incorrect.

25. Answer C is correct. Delusions of grandeur are associated with low self-esteem. Answer A is incorrect because conversion is expressed as sensory or motor deficits. Answers B and C can cause an increase in the client’s delusions but do not explain their purpose; therefore, they are incorrect.