1. C. Nitrates act primarily to relax coronary smooth muscle and produce vasodilation. They can cause hypotension, which makes the client dizzy and weak. Nitrates are taken at the first sign of chest pain and before activities that might induce chest pain. Sublingual nitroglycerin is taken every 5 minutes for three doses. If the pain persists, the client should seek medical assistance immediately. Nitrates must be stored in a dark place in a closed container. Sunlight causes the medication to lose its effectiveness. Alcohol is prohibited because nitrates may enhance the effects of the alcohol.

2. B. Amniotomy increases the risk of umbilical cord prolapse, which would impair the fetal blood supply and tissue perfusion. Because the fetus’s life depends on the oxygen carried by that blood, maintaining fetal tissue perfusion takes priority over goals related to increased knowledge, infection prevention, and pain relief.

3. B. Cirrhosis causes muscle wasting, a decrease in chest and axillary hair, testicular atrophy, and an increased bleeding tendency.

4. D. Pancuronium, a nondepolarizing blocking agent, is used for muscle relaxation and paralysis. It assists mechanical ventilation by promoting endotracheal intubation and paralyzing the client so that the mechanical ventilator can do its work. Fighting the ventilator is a sign that the client needs another pancuronium dose. The nurse should administer 0.01 to 0.02 mg/kg I.V. every 20 to 60 minutes. Movement of the legs, fingers, or lips has no effect on the ventilator and therefore isn’t used to determine the need for another dose.

5. C. A vesicle is a circumscribed skin elevation filled with serous fluid. A flat, nonpalpable, colored spot is a macule. A solid, elevated, circumscribed lesion is a papule. An elevated, pus-filled, circumscribed lesion is a pustule.

6. B. Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree angle. As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a client has positive hepatojugular reflux.

7. C. As a centrally acting antitussive, codeine suppresses the cough reflex by directly affecting the sensitivity of the cough center in the medulla to incoming stimuli. Because codeine is a narcotic, it can cause dependence.

8. D. A neonate with HIV infection typically has hepatosplenomegaly, a distinctive facial dysmorphism, interstitial pneumonia, recurrent infections, behavioral deviations, and neurologic abnormalities. The other options aren’t typical findings in neonates with HIV infection.

9.C. In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing — not chest breathing — increases lung expansion.

10. B. As antidepressants take effect, individuals suffering from depression may begin to feel energetic enough to mobilize a suicide plan. Option A is incorrect because Elavil is an antidepressant, not an antipsychotic. The client shouldn’t be discharged until the risk of suicide has diminished. The elevated mood is a response to the antidepressant, not a split personality.

11. A. To sustain them until active erythropoiesis begins, neonates have Hb concentrations higher than those of older children. The normal value of Hb for neonates is 18 to 27 g/dl. Disease as well as such nonpathologic conditions as age, sex, altitude, and the degree of fluid retention or dehydration can affect Hb values. The values for a 3-month-old, a 3-year-old, and a 10-year-old are correct as stated above.

12. B. In osteoporosis, bones lose calcium and phosphate salts, becoming porous, brittle, and abnormally vulnerable to fracture. Sodium and potassium aren’t involved in the development of osteoporosis.

13. B. Neonates of heroin-addicted mothers are physically dependent on the drug and experience withdrawal when the drug is no longer supplied. Signs of heroin withdrawal include irritability, poor sucking, and restlessness. Lethargy isn’t associated with neonatal heroin addiction. A flattened nose, small eyes, and thin lips are seen in infants with fetal alcohol syndrome. Heroin use during pregnancy hasn’t been linked to specific congenital anomalies.

14. B. Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Decreasing the rate of the feeding and the concentration of the formula should decrease the client’s discomfort. Feedings are normally given at room temperature to minimize abdominal cramping. To prevent aspiration during feeding, the head of the client’s bed should be elevated at least 30 degrees. Also, to prevent bacterial growth, feeding containers should be routinely changed every 8 to 12 hours.

15. D. Complementary (alternative) therapies include a wide variety of treatment modalities that are used in addition to conventional therapy to treat a disease or illness. Educating the client about therapies that he or she uses or is interested in using is the nurse’s role.

16. B. Although herbal substances may have some beneficial effects, not all herbs are safe to use. Clients who are being treated with conventional medication therapy should be advised to avoid herbal substances with similar pharmacological effects because the combination may lead to an excessive reaction or to unknown interaction effects. Therefore, the nurse would advise the client to discuss the use of the herbal substance with the physician.

17. D. Black cohosh produces estrogen-like effects. Zinc stimulates the immune system and is used for its antiviral properties. Echinacea stimulates the immune system and ginger is used for nausea and vomiting.

18. A. The client’s fall should be treated as private information and shared on a “need to know” basis. Communication regarding the event should involve only those participating in the client’s care. An incident report is a problem-solving document; however, its completion is not documented in the nurse’s notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is desired. After a client’s fall, the nurse must frequently reassess the client, because potential complications do not always appear immediately after the fall.

19. A. Sensible losses are those of which the person is aware, such as through wound drainage, gastrointestinal tract losses, and urination. Insensible losses may occur without the person’s awareness. Insensible losses occur daily through the skin and the lungs.

20. A. Causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with congestive heart failure or decreased kidney function, or a client receiving frequent wound irrigations, is at risk for excess fluid volume.

21. D. Assessment findings in a client with a deficient fluid volume include increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. The normal CVP is between 4 and 11 cm H2O. A client with dehydration has a low CVP.

22. B.The causes of excess fluid volume include decreased kidney function, congestive heart failure, the use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for deficient fluid volume.

23. C. Assessment findings associated with excess fluid volume include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure and a bounding pulse, an elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and a decreased hematocrit.

24. B. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with renal failure or Addison’s disease and the client taking a potassium-sparing diuretic are at risk for hyperkalemia.

25. A. A serum potassium level lower than 3.5 mEq/L indicates hypokalemia. Potassium deficit is a common electrolyte imbalance and is potentially life threatening. Electrocardiographic changes include inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not a characteristic of hypokalemia.

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2.    After an amniotomy, nurse Sally is aware that the client goal should take the highest priority?
a.    The client will express increased knowledge about amniotomy
b.    The client will maintain adequate fetal tissue perfusion
c.    The client will display no signs of infection
d.    The client will report relief of pain

3.    A client is admitted with suspected cirrhosis. During assessment, nurse Lennie is most likely to detect:
a.    an increase in chest hair
b.    muscle wasting
c.    testicular hypertrophy
d.    an increased clotting tendency

4.    A male client on mechanical ventilation is receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V. as needed. Which assessment finding indicates that the client needs another pancuronium dose?
a.    Leg movement
b.    Finger movement
c.    Lip movement
d.    Fighting the ventilator

5.    When inspecting a client’s skin, nurse Kate finds a vesicle on the client’s arm. Which description applies to a vesicle?
a.    Flat, nonpalpable, and colored
b.    Solid, elevated, and circumscribed
c.    Circumscribed, elevated, and filled with serous fluid
d.    Elevated, pus-filled, and circumscribed

6.    Nurse Jinky is assessing a client with heart failure. To assess hepatojugular reflux, the nurse should:
a.    elevate the client’s head to 90 degrees
b.    press the right upper abdomen
c.    press the left upper abdomen
d.    lie the client flat in bed

7.    A male client with lung cancer has developed an intractable, nonproductive cough that is unrelieved by nonnarcotic antitussive agents. Dr. Rodriguez prescribes codeine, 10 mg P.O. every 4 hours. Which statement accurately describes codeine?
a.    It’s a centrally acting antitussive and doesn’t cause dependence
b.    It’s a peripherally acting antitussive and doesn’t cause dependence
c.    It’s a centrally acting antitussive and can cause dependence
d.    It’s a peripherally acting antitussive and can cause dependence

8.    A client with human immunodeficiency virus (HIV) infection delivers a neonate. When assessing the neonate, nurse Edwin is most likely to detect:
a.    skin vesicles
b.    limb dysmorphism
c.    conjunctivitis
d.    hepatosplenomegaly

9.    Nurse Ronald is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?
a.    Make inhalation longer than exhalation
b.    Exhale through an open mouth
c.    Use diaphragmatic breathing
d.    Use chest breathing

10.    Nurse Maureen notices that a depressed client taking amitriptyline (Elavil) for 2 weeks has become very outgoing, cheerful, and talkative. The nurse suspects that the client:
a.    is responding to the antipsychotic
b.    may be experiencing increased energy and is at an increased risk for suicide
c.    is ready to be discharged from treatment
d.    is experiencing a split personality

11.    When caring for children who are sick, who have sustained traumas, or who are suffering from nutritional inadequacies, nurse Yvette should know the correct hemoglobin (Hb) values for children. Which of the following ranges would be inaccurate?
a.    Neonates: 10.6 to 16.5 g/dl
b.    3 months: 10.6 to 16.5 g/dl
c.    3 years: 9.4 to 15.5 g/dl
d.    10 years: 10.7 to 15.5 g/dl

12.    A female client is diagnosed with osteoporosis. Which electrolytes are involved in the development of this disorder?
a.    Calcium and sodium
b.    Calcium and phosphorous
c.    Phosphorous and potassium
d.    Potassium and sodium

13.    A client who used heroin during her pregnancy delivers a neonate. When assessing the neonate, nurse Diana expects to find:
a.    lethargy 2 days after birth
b.    irritability and poor sucking
c.    a flattened nose, small eyes, and thin lips
d.    congenital defects such as limb anomalies

14.    A male adult client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?
a.    Give the feedings at room temperature
b.    Decrease the rate of feedings and the concentration of the formula
c.    Place the client in semi-Fowler’s position while feeding
d.    Change the feeding container every 12 hours

15.     The role of nurse Hans regarding complementary and alternative medicine (CAM) should include:
a.    Recommending herbal remedies that the client should use
b.    Educating the client about “good” versus “bad” therapies
c.    Discouraging the client from using any alternative therapies
d.    Educating the client about therapies that he or she is using or is interested in using

16.    An antihypertensive medication has been prescribed for a client with hypertension. The client tells nurse Michelle that she would like to take an herbal substance to help lower her blood pressure. The nurse should take which appropriate action?
a.    Tell the client that herbal substances are not safe and should never be used.
b.    Advise the client to discuss the use of an herbal substance with the physician
c.    Teach the client how to take her blood pressure so that it can be monitored closely.
d.    Tell the client that id she takes the herbal substance she will need to have her blood pressure checked frequently.

17.    Nurse Jonathan understands that which of the following statements regarding herbal therapies is true?
a.    Zinc is used for insomnia
b.    Ginger is used to improve memory
c.    Echinacea is used for erectile dysfunction
d.    Black cohosh produces estrogen-like effects.

18.    Nurse Angel has just assisted a client back to bed after a fall. The nurse and physician have assessed the client, and have determined that the client is not injured. After completing the incident report, the nurse should take which action next?
a.    Reassess the client
b.    Conduct a staff meeting to describe the fall
c.    Document in the nurse’s notes that an incident report was completed
d.    Contact the nursing supervisor to update information regarding the fall

19.    Nurse Michael is reading a physician’s progress notes in the client’s record and reads that the physician has documented “insensible fluid loss of approximately 800mL daily.” The nurse understands that this type of fluid loss can occur through:
a.    The skin
b.    Urinary output
c.    Wound drainage
d.    The gastrointestinal tract

20.    Nurse Deric is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for deficient fluid volume?
a.    A client with a colostomy
b.    A client with congestive heart failure
c.    A client with decreased kidney function
d.    A client receiving frequent wound irrigations

21.    Nurse Dominique caring for a client who has been receiving intravenous diuretics suspects that the client is experiencing a deficient fluid volume. Which assessment finding would the nurse note in a client with this condition?
a.    Lung congestion
b.    Decreased hematocrit
c.    Increased blood pressure
d.    Decreased central venous pressure (CVP)

22.    Nurse Joy is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for excess fluid volume?
a.    The client taking diuretics
b.    The client with renal failure
c.    The client with an ileostomy
d.    The client who requires gastrointestinal suctioning

23.    Nurse Stephanie is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expects to note in this client if excess fluid volume is present?
a.    Weight loss
b.    Flat neck and hand veins
c.    An increase in blood pressure
d.    A decreased central venous pressure (CVP)

24.    Nurse Rivette is preparing to care for a client with a potassium deficit. The nurse reviews the client’s record and determines that the client was at risk for developing the potassium deficit because the client:
a.    Has renal failure
b.    Requires nasogastric suction
c.    Has a history of Addison’s disease
d.    Is taking a potassium-sparing diuretic

25.    Nurse Louie reviews a client’s electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. which of the following would the nurse note on the electrocardiogram as a result of the laboratory value?
a.    U waves
b.    Absent P waves
c.    Elevated T waves
d.    Elevated ST segment

Answers and Rationale

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Answers and Rationale

More NCLEX Sample Questions

Passing the NCLEX made easy

1.    Answer B. When the urethra is ruptured, a hematoma or collection of blood separates the two sections of urethra. This may feel like a boggy mass on rectal examination. Because of the rupture and hematoma, the prostate becomes high riding. A palpable prostate gland usually indicates a nonurethral injury. Absent sphincter tone would refer to a spinal cord injury. The presence of blood would probably correlate with GI bleeding or a colon injury.

2.    Answer B. To maintain effective drainage, the client should keep the drainage bag below the bladder; this allows the urine to flow by gravity from the bladder to the drainage bag. The client shouldn’t lay the drainage bag on the floor because it could become grossly contaminated. The client shouldn’t clamp the catheter drainage tubing because this impedes the flow of urine. To promote drainage, the client may loop the drainage tubing above — not below — its point of entry into the drainage bag.

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

4.    Answer B. If the pouch faceplate doesn’t fit the stoma properly, the skin around the stoma will be exposed to continuous urine flow from the stoma, causing excoriation and red, weeping, and painful skin. A lubricant shouldn’t be used because it would prevent the pouch from adhering to the skin. When properly applied, a skin barrier prevents skin excoriation. Stoma dilation isn’t performed with an ileal conduit, although it may be done with a colostomy if ordered.

5.    Answer C. Pyelonephritis is diagnosed by the presence of leukocytosis, hematuria, pyuria, and bacteriuria. The client exhibits fever, chills, and flank pain. Because there is often a septic picture, the WBC count is more likely to be high rather than low, as indicated in option D. Ketonuria indicates a diabetic state.

6.    Answer B. Because CRF causes loss of renal function, the client with this disorder retains fluid. Hemodialysis removes this fluid, causing weight loss. Hematuria is unlikely to follow hemodialysis because the client with CRF usually forms little or no urine. Hemodialysis doesn’t increase urine output because it doesn’t correct the loss of kidney function, which severely decreases urine production in this disorder. By removing fluids, hemodialysis decreases rather than increases the blood pressure.

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

8.    Answer B. Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal. Urine specific gravity normally ranges from 1.002 to 1.035, making this client’s value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, its color ranging from pale yellow to deep amber.

9.    Answer A. The renal clearance test determines the kidneys’ ability to remove a substance from the plasma in 1 minute. It doesn’t measure the kidneys’ ability to remove a substance over a longer period.

10.    Answer C. After renal angiography involving a femoral puncture site, the nurse should check the client’s pedal pulses frequently to detect reduced circulation to the feet caused by vascular injury. The nurse also should monitor vital signs for evidence of internal hemorrhage and should observe the puncture site frequently for fresh bleeding. The client should be kept on bed rest for several hours so the puncture site can seal completely. Keeping the client’s knee bent is unnecessary. By the time the client returns to the short-procedure unit, manual pressure over the puncture site is no longer needed because a pressure dressing is in place. The nurse shouldn’t remove this dressing for several hours — and only if instructed to do so.

11.    Answer A. A client with CRF is at risk for fluid imbalance — dehydration if the kidneys fail to concentrate urine, or fluid retention if the kidneys fail to produce urine. Electrolyte imbalances associated with this disorder result from the kidneys’ inability to excrete phosphorus; such imbalances may lead to hyperphosphatemia with reciprocal hypocalcemia. CRF may cause metabolic acidosis, not metabolic alkalosis, secondary to inability of the kidneys to excrete hydrogen ions.

12.    Answer D. An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia occurs during peritoneal dialysis because of the high glucose content of the dialysate; it’s readily treatable with sliding-scale insulin. A potassium level of 3.5 mEq/L can be treated by adding potassium to the dialysate solution. An HCT of 35% is lower than normal. However, in this client, the value isn’t abnormally low because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack of erythropoietin.

13.    Answer C. During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and I.V. fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesn’t take precedence over fluid limitation. Controlling pain isn’t important because ARF rarely causes pain.

14.    Answer D. Cardiac glycosides such as digoxin should be withheld before hemodialysis. Hypokalemia is one of the electrolyte shifts that occur during dialysis, and a hypokalemic client is at risk for arrhythmias secondary to digitalis toxicity. Phosphate binders and insulin can be administered because they aren’t removed from the blood by dialysis. Some antibiotics are removed by dialysis and should be administered after the procedure to ensure their therapeutic effects. The nurse should check a formulary to determine whether a particular antibiotic should be administered before or after dialysis.

15.    Answer B. Gonorrhea must be reported to the public health department. Chlamydia, genital herpes, and human papillomavirus infection aren’t reportable diseases.

16.    Answer C. Co-trimoxazole is a sulfonamide antibiotic used to treat urinary tract infections. Therefore, absence of bacteria on urine culture indicates that the drug has achieved its desired effect. Although flank pain may decrease as the infection resolves, this isn’t a reliable indicator of the drug’s effectiveness. Co-trimoxazole doesn’t affect urine output or the RBC count.

17.    Answer D. Phenazopyridine may be prescribed in conjunction with an antibiotic for painful bladder infections to promote comfort. Because of its local anesthetic action on the urinary mucosa, phenazopyridine specifically relieves bladder pain. Nitrofurantoin is a urinary antiseptic with no analgesic properties. While ibuprofen and acetaminophen with codeine are analgesics, they don’t exert a direct effect on the urinary mucosa.

18.    Answer A. When preparing for continuous bladder irrigation, a triple-lumen indwelling urinary catheter is inserted. The three lumens provide for balloon inflation and continuous inflow and outflow of irrigation solution.

19.    Answer B. Normally, fluid intake is approximately equal to the urine output. Any other relationship signals an abnormality. For example, fluid intake that is double the urine output indicates fluid retention; fluid intake that is half the urine output indicates dehydration. Normally, fluid intake isn’t inversely proportional to the urine output.

20.    Answer C. Mumps is the most significant childhood infectious disease affecting male fertility. Chickenpox, measles, and scarlet fever don’t affect male fertility.

21.    Answer A. The most common site of renal calculi formation is the kidney. Calculi may travel down the urinary tract with or without causing damage and may lodge anywhere along the tract or may stay within the kidney. The ureter, bladder, and urethra are less common sites of renal calculi formation.

22.    Answer A. Dialysis equilibrium syndrome causes confusion, a decreasing level of consciousness, headache, and seizures. These findings, which may last several days, probably result from a relative excess of interstitial or intracellular solutes caused by rapid solute removal from the blood. The resultant organ swelling interferes with normal physiologic functions. To prevent this syndrome, many dialysis centers keep first-time sessions short and use a reduced blood flow rate. Acute bone pain and confusion are associated with aluminum intoxication, another potential complication of dialysis. Weakness, tingling, and cardiac arrhythmias suggest hyperkalemia, which is associated with renal failure. Hypotension, tachycardia, and tachypnea signal hemorrhage, another dialysis complication.

23.    Answer B. For an uncomplicated UTI, norfloxacin therapy usually lasts 7 to 10 days. Taking the drug for less than 7 days wouldn’t eradicate such an infection. Taking it for more than 10 days isn’t necessary. Only a client with a complicated UTI must take norfloxacin for 10 to 21 days.

24.    Answer C. The client should report the presence of foul-smelling or cloudy urine. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sandlike debris is normal due to residual stone products. Hematuria is common after lithotripsy.

25.    Answer D. The guidelines for initiating bladder retraining include assessing the client’s intake patterns, voiding patterns, and reasons for each accidental voiding. Lowering the client’s fluid intake won’t reduce or prevent incontinence. The client should actually be encouraged to drink 1.5 to 2 L of water per day. A voiding schedule should be established after assessment.

more nclex review

2.    When a female client with an indwelling urinary (Foley) catheter insists on walking to the hospital lobby to visit with family members, nurse Rose teaches how to do this without compromising the catheter. Which client action indicates an accurate understanding of this information?
a.    The client sets the drainage bag on the floor while sitting down.
b.    The client keeps the drainage bag below the bladder at all times.
c.    The client clamps the catheter drainage tubing while visiting with the family.
d.    The client loops the drainage tubing below its point of entry into the drainage bag.

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

4.    A male client with bladder cancer has had the bladder removed and an ileal conduit created for urine diversion. While changing this client’s pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What should nurse Katrina conclude?
a.    The skin wasn’t lubricated before the pouch was applied.
b.    The pouch faceplate doesn’t fit the stoma.
c.    A skin barrier was applied properly.
d.    Stoma dilation wasn’t performed.

5.    The nurse is aware that the following laboratory values supports a diagnosis of pyelonephritis?
a.    Myoglobinuria
b.    Ketonuria
c.    Pyuria
d.    Low white blood cell (WBC) count

6.    A female client with chronic renal failure (CRF) is receiving a hemodialysis treatment. After hemodialysis, nurse Sarah knows that the client is most likely to experience:
a.    hematuria.
b.    weight loss.
c.    increased urine output.
d.    increased blood pressure.

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

8.    Nurse Agnes is reviewing the report of a client’s routine urinalysis. Which value should the nurse consider abnormal?
a.    Specific gravity of 1.03
b.    Urine pH of 3.0
c.    Absence of protein
d.    Absence of glucose

9.    A male client is scheduled for a renal clearance test. Nurse Maureen should explain that this test is done to assess the kidneys’ ability to remove a substance from the plasma in:
a.    1 minute.
b.    30 minutes.
c.    1 hour.
d.    24 hours.

10.    A male client in the short-procedure unit is recovering from renal angiography in which a femoral puncture site was used. When providing postprocedure care, the nurse should:
a.    keep the client’s knee on the affected side bent for 6 hours.
b.    apply pressure to the puncture site for 30 minutes.
c.    check the client’s pedal pulses frequently.
d.    remove the dressing on the puncture site after vital signs stabilize.

11.    A female client is admitted for treatment of chronic renal failure (CRF). Nurse Juliet knows that this disorder increases the client’s risk of:
a.    water and sodium retention secondary to a severe decrease in the glomerular filtration rate.
b.    a decreased serum phosphate level secondary to kidney failure.
c.    an increased serum calcium level secondary to kidney failure.
d.    metabolic alkalosis secondary to retention of hydrogen ions.

12.    Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a female client’s uremia. Which finding signals a significant problem during this procedure?
a.    Potassium level of 3.5 mEq/L
b.    Hematocrit (HCT) of 35%
c.    Blood glucose level of 200 mg/dl
d.    White blood cell (WBC) count of 20,000/mm3

13.    For a male client in the oliguric phase of acute renal failure (ARF), which nursing intervention is most important?
a.    Encouraging coughing and deep breathing
b.    Promoting carbohydrate intake
c.    Limiting fluid intake
d.    Providing pain-relief measures

14.    A female client requires hemodialysis. Which of the following drugs should be withheld before this procedure?
a.    Phosphate binders
b.    Insulin
c.    Antibiotics
d.    Cardiac glycosides

15.    A client comes to the outpatient department complaining of vaginal discharge, dysuria, and genital irritation. Suspecting a sexually transmitted disease (STD), Dr. Smith orders diagnostic tests of the vaginal discharge. Which STD must be reported to the public health department?
a.    Chlamydia
b.    Gonorrhea
c.    Genital herpes
d.    Human papillomavirus infection

16.    A male client with acute pyelonephritis receives a prescription for co-trimoxazole (Septra) P.O. twice daily for 10 days. Which finding best demonstrates that the client has followed the prescribed regimen?
a.    Urine output increases to 2,000 ml/day.
b.    Flank and abdominal discomfort decrease.
c.    Bacteria are absent on urine culture.
d.    The red blood cell (RBC) count is normal.

17.    A 26-year-old female client seeks care for a possible infection. Her symptoms include burning on urination and frequent, urgent voiding of small amounts of urine. She’s placed on trimethoprim-sulfamethoxazole (Bactrim) to treat possible infection. Another medication is prescribed to decrease the pain and frequency. Which of the following is the most likely medication prescribed?
a.    nitrofurantoin (Macrodantin)
b.    ibuprofen (Motrin)
c.    acetaminophen with codeine
d.    phenazopyridine (Pyridium)

18.    A triple-lumen indwelling urinary catheter is inserted for continuous bladder irrigation following a transurethral resection of the prostate. In addition to balloon inflation, the nurse is aware that the functions of the three lumens include:
a.    Continuous inflow and outflow of irrigation solution.
b.    Intermittent inflow and continuous outflow of irrigation solution.
c.    Continuous inflow and intermittent outflow of irrigation solution.
d.    Intermittent flow of irrigation solution and prevention of hemorrhage.

19.    Nurse Claudine is reviewing a client’s fluid intake and output record. Fluid intake and urine output should relate in which way?
a.    Fluid intake should be double the urine output.
b.    Fluid intake should be approximately equal to the urine output.
c.    Fluid intake should be half the urine output.
d.    Fluid intake should be inversely proportional to the urine output.

20.    After trying to conceive for a year, a couple consults an infertility specialist. When obtaining a history from the husband, nurse Jenny inquires about childhood infectious diseases. Which childhood infectious disease most significantly affects male fertility?
a.    Chickenpox
b.    Measles
c.    Mumps
d.    Scarlet fever

21.    A male client comes to the emergency department complaining of sudden onset of sharp, severe pain in the lumbar region, which radiates around the side and toward the bladder. The client also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The physician tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site?
a.    Kidney
b.    Ureter
c.    Bladder
d.    Urethra

22.    A female client with acute renal failure is undergoing dialysis for the first time. The nurse in charge monitors the client closely for dialysis equilibrium syndrome, a complication that is most common during the first few dialysis sessions. Typically, dialysis equilibrium syndrome causes:
a.    confusion, headache, and seizures.
b.    acute bone pain and confusion.
c.    weakness, tingling, and cardiac arrhythmias.
d.    hypotension, tachycardia, and tachypnea.

23.    Dr. Marquez prescribes norfloxacin (Noroxin), 400 mg P.O. twice daily, for a client with a urinary tract infection (UTI). The client asks the nurse how long to continue taking the drug. For an uncomplicated UTI, the usual duration of norfloxacin therapy is:
a.    3 to 5 days.
b.    7 to 10 days.
c.    12 to 14 days.
d.    10 to 21 days.

24.    Nurse Joy is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra–high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to:
a.    limit oral fluid intake for 1 to 2 weeks.
b.    report the presence of fine, sandlike particles through the nephrostomy tube.
c.    notify the physician about cloudy or foul-smelling urine.
d.    report bright pink urine within 24 hours after the procedure.

25.    A client is frustrated and embarrassed by urinary incontinence. Which of the following measures should nurse Bea include in a bladder retraining program?
a.    Establishing a predetermined fluid intake pattern for the client
b.    Encouraging the client to increase the time between voidings
c.    Restricting fluid intake to reduce the need to void
d.    Assessing present elimination patterns

Answers and Rationale

Pass the NCLEX

1. The nurse is performing her admission assessment of a patient. When grading arterial pulses, a 1+ pulse indicates:
   1. Above normal perfusion.
   2. Absent perfusion.
   3. Normal perfusion.
   4. Diminished perfusion.
2. Murmurs that indicate heart disease are often accompanied by other symptoms such as:
   1. Dyspnea on exertion.
   2. Subcutaneous emphysema.
   3. Thoracic petechiae.
   4. Periorbital edema.
3. Which pregnancy-related physiologic change would place the patient with a history of cardiac disease at the greatest risk of developing severe cardiac problems?
   1. Decrease heart rate
   2. Decreased cardiac output
   3. Increased plasma volume
   4. Increased blood pressure
4. The priority nursing diagnosis for the patient with cardiomyopathy is:
   1. Anxiety related to risk of declining health status.
   2. Ineffective individual coping related to fear of debilitating illness
   3. Fluid volume excess related to altered compensatory mechanisms.
   4. Decreased cardiac output related to reduced myocardial contractility.
5. A patient with thrombophlebitis reached her expected outcomes of care. Her affected leg appears pink and warm. Her pedal pulse is palpable and there is no edema present. Which step in the nursing process is described above?
   1. Planning
   2. Implementation
   3. Analysis
   4. Evaluation
6. An elderly patient may have sustained a basilar skull fracture after slipping and falling on an icy sidewalk. The nurse knows that basilar skull factures:
   1. Are the least significant type of skull fracture.
   2. May have cause cerebrospinal fluid (CSF) leaks from the nose or ears.
   3. Have no characteristic findings.
   4. Are always surgically repaired.
7. Which of the following types of drugs might be given to control increased intracranial pressure (ICP)?
   1. Barbiturates
   2. Carbonic anhydrase inhibitors
   3. Anticholinergics
   4. Histamine receptor blockers
8. The nurse is teaching family members of a patient with a concussion about the early signs of increased intracranial pressure (ICP). Which of the following would she cite as an early sign of increased ICP?
   1. Decreased systolic blood pressure
   2. Headache and vomiting
   3. Inability to wake the patient with noxious stimuli
   4. Dilated pupils that don’t react to light
9. Jessie James is diagnosed with retinal detachment. Which intervention is the most important for this patient?
   1. Admitting him to the hospital on strict bed rest
   2. Patching both of his eyes
   3. Referring him to an ophthalmologist
   4. Preparing him for surgery
10. Dr. Bruce Owen, a chemist, sustained a chemical burn to one eye. Which intervention takes priority for a patient with a chemical burn of the eye?
    1. Patch the affected eye and call the ophthalmologist.
    2. Administer a cycloplegic agent to reduce ciliary spasm.
    3. Immediately instill a tropical anesthetic, then irrigate the eye with saline solution.
    4. Administer antibiotics to reduce the risk of infection
11. The nurse is assessing a patient and notes a Brudzinski’s sign and Kernig’s sign. These are two classic signs of which of the following disorders?
    1. Cerebrovascular accident (CVA)
    2. Meningitis
    3. Seizure disorder
    4. Parkinson’s disease
12. A patient is admitted to the hospital for a brain biopsy. The nurse knows that the most common type of primary brain tumor is:
    1. Meningioma.
    2. Angioma.
    3. Hemangioblastoma.
    4. Glioma.
13. The nurse should instruct the patient with Parkinson’s disease to avoid which of the following?
    1. Walking in an indoor shopping mall
    2. Sitting on the deck on a cool summer evening
    3. Walking to the car on a cold winter day
    4. Sitting on the beach in the sun on a summer day
14. Gary Jordan suffered a cerebrovascular accident that left her unable to comprehend speech and unable to speak. This type of aphasia is known as:
    1. Receptive aphasia
    2. Expressive aphasia
    3. Global aphasia
    4. Conduction aphasia
15. Kelly Smith complains that her headaches are occurring more frequently despite medications. Patients with a history of headaches should be taught to avoid:
    1. Freshly prepared meats.
    2. Citrus fruits.
    3. Skim milk
    4. Chocolate
16. Immediately following cerebral aneurysm rupture, the patient usually complains of:
    1. Photophobia
    2. Explosive headache
    3. Seizures
    4. Hemiparesis
17. Which of the following is a cause of embolic brain injury?
    1. Persistent hypertension
    2. Subarachnoid hemorrhage
    3. Atrial fibrillation
    4. Skull fracture
18. Although Ms. Priestly has a spinal cord injury, she can still have sexual intercourse. Discharge teaching should make her aware that:
    1. She must remove indwelling urinary catheter prior to intercourse.
    2. She can no longer achieve orgasm.
    3. Positioning may be awkward.
    4. She can still get pregnant.
19. Ivy Hopkins, age 25, suffered a cervical fracture requiring immobilization with halo traction. When caring for the patient in halo traction, the nurse must:
    1. Keep a wrench taped to the halo vest for quick removal if cardiopulmonary resuscitation is necessary.
    2. Remove the brace once a day to allow the patient to rest.
    3. Encourage the patient to use a pillow under the ring.
    4. Remove the brace so that the patient can shower.
20. The nurse asks a patient’s husband if he understands why his wife is receiving nimodipine (Nimotop), since she suffered a cerebral aneurysm rupture. Which response by the husband indicates that he understands the drug’s use?
    1. “Nimodipine replaces calcium.”
    2. “Nimodipine promotes growth of blood vessels in the brain.”
    3. “Nimodipine reduces the brain’s demand for oxygen.”
    4. “Nimodipine reduces vasospasm in the brain.”
21. Many men who suffer spinal injuries continue to be sexually active. The teaching plan for a man with a spinal cord injury should include sexually concerns. Which of the following injuries would most likely prevent erection and ejaculation?
    1. C5
    2. C7
    3. T4
    4. S4
22. Cathy Bates, age 36, is a homemaker who frequently forgets to take her carbamazepine (Tegretol). As a result, she has been experiencing seizures. How can the nurse best help the patient remember to take her medication?
    1. Tell her take her medication at bedtime.
    2. Instruct her to take her medication after one of her favorite television shows.
    3. Explain that she should take her medication with breakfast.
    4. Tell her to buy an alarm watch to remind her.
23. Richard Barnes was diagnosed with pneumococcal meningitis. What response by the patient indicates that he understands the precautions necessary with this diagnosis?
    1. “I’m so depressed because I can’t have any visitors for a week.”
    2. “Thank goodness, I’ll only be in isolation for 24 hours.”
    3. “The nurse told me that my urine and stool are also sources of meningitis bacteria.”
    4. “The doctor is a good friend of mine and won’t keep me in isolation.”
24. An early symptom associated with amyotrophic lateral sclerosis (ALS) includes:
    1. Fatigue while talking
    2. Change in mental status
    3. Numbness of the hands and feet
    4. Spontaneous fractures
25. When caring for a patient with esophageal varices, the nurse knows that bleeding in this disorder usually stems from:
    1. Esophageal perforation
    2. Pulmonary hypertension
    3. Portal hypertension
    4. Peptic ulcers
26. Tiffany Black is diagnosed with type A hepatitis. What special precautions should the nurse take when caring for this patient?
    1. Put on a mask and gown before entering the patient’s room.
    2. Wear gloves and a gown when removing the patient’s bedpan.
    3. Prevent the droplet spread of the organism.
    4. Use caution when bringing food to the patient.
27. Discharge instructions for a patient who has been operated on for colorectal cancer include irrigating the colostomy. The nurse knows her teaching is effective when the patient states he’ll contact the doctor if:
    1. He experiences abdominal cramping while the irrigant is infusing
    2. He has difficulty inserting the irrigation tube into the stoma
    3. He expels flatus while the return is running out
    4. He’s unable to complete the procedure in 1 hour
28. The nurse explains to the patient who has an abdominal perineal resection that an indwelling urinary catheter must be kept in place for several days afterward because:
    1. It prevents urinary tract infection following surgery
    2. It prevents urine retention and resulting pressure on the perineal wound
    3. It minimizes the risk of wound contamination by the urine
    4. It determines whether the surgery caused bladder trauma
29. The first day after, surgery the nurse finds no measurable fecal drainage from a patient’s colostomy stoma. What is the most appropriate nursing intervention?
    1. Call the doctor immediately.
    2. Obtain an order to irrigate the stoma.
    3. Place the patient on bed rest and call the doctor.
    4. Continue the current plan of care.
30. If a patient’s GI tract is functioning but he’s unable to take foods by mouth, the preferred method of feeding is:
    1. Total parenteral nutrition
    2. Peripheral parenteral nutrition
    3. Enteral nutrition
    4. Oral liquid supplements
31. Which type of solution causes water to shift from the cells into the plasma?
    1. Hypertonic
    2. Hypotonic
    3. Isotonic
    4. Alkaline
32. Particles move from an area of greater osmelarity to one of lesser osmolarity through:
    1. Active transport
    2. Osmosis
    3. Diffusion
    4. Filtration
33. Which assessment finding indicates dehydration?
    1. Tenting of chest skin when pinched
    2. Rapid filling of hand veins
    3. A pulse that isn’t easily obliterated
    4. Neck vein distention
34. Which nursing intervention would most likely lead to a hypo-osmolar state?
    1. Performing nasogastric tube irrigation with normal saline solution
    2. Weighing the patient daily
    3. Administering tap water enema until the return is clear
    4. Encouraging the patient with excessive perspiration to dink broth
35. Which assessment finding would indicate an extracellular fluid volume deficit?
    1. Bradycardia
    2. A central venous pressure of 6 mm Hg
    3. Pitting edema
    4. An orthostatic blood pressure change
36. A patient with metabolic acidosis has a preexisting problem with the kidneys. Which other organ helps regulate blood pH?
    1. Liver
    2. Pancreas
    3. Lungs
    4. heart
37. The nurse considers the patient anuric if the patient;
    1. Voids during the nighttime hours
    2. Has a urine output of less than 100 ml in 24 hours
    3. Has a urine output of at least 100 ml in 2 hours
    4. Has pain and burning on urination
38. Which nursing action is appropriate to prevent infection when obtaining a sterile urine specimen from an indwelling urinary catheter?
    1. Aspirate urine from the tubing port using a sterile syringe and needle
    2. Disconnect the catheter from the tubing and obtain urine
    3. Open the drainage bag and pour out some urine
    4. Wear sterile gloves when obtaining urine
39. After undergoing a transurethral resection of the prostate to treat benign prostatic hypertrophy, a patient is retuned to the room with continuous bladder irrigation in place. One day later, the patient reports bladder pain. What should the nurse do first?
    1. Increase the I.V. flow rate
    2. Notify the doctor immediately
    3. Assess the irrigation catheter for patency and drainage
    4. Administer meperidine (Demerol) as prescribed
40. A patient comes to the hospital complaining of sudden onset of sharp, severe pain originating in the lumbar region and radiating around the side and toward the bladder. The patient also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The doctor tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site?
    1. Kidney
    2. Ureter
    3. Bladder
    4. Urethra
41. A patient comes to the hospital complaining of severe pain in the right flank, nausea, and vomiting. The doctor tentatively diagnoses right ureter-olithiasis (renal calculi). When planning this patient’s care, the nurse should assign highest priority to which nursing diagnosis?
    1. Pain
    2. Risk of infection
    3. Altered urinary elimination
    4. Altered nutrition: less than body requirements
42. The nurse is reviewing the report of a patient’s routine urinalysis. Which of the following values should the nurse consider abnormal?
    1. Specific gravity of 1.002
    2. Urine pH of 3
    3. Absence of protein
    4. Absence of glucose
43. A patient with suspected renal insufficiency is scheduled for a comprehensive diagnostic work-up. After the nurse explains the diagnostic tests, the patient asks which part of the kidney “does the work.” Which answer is correct?
    1. The glomerulus
    2. Bowman’s capsule
    3. The nephron
    4. The tubular system
44. During a shock state, the renin-angiotensin-aldosterone system exerts which of the following effects on renal function?
    1. Decreased urine output, increased reabsorption of sodium and water
    2. Decreased urine output, decreased reabsorption of sodium and water
    3. Increased urine output, increased reabsorption of sodium and water
    4. Increased urine output, decreased reabsorption of sodium and water
45. While assessing a patient who complained of lower abdominal pressure, the nurse notes a firm mass extending above the symphysis pubis. The nurse suspects:
    1. A urinary tract infection
    2. Renal calculi
    3. An enlarged kidney
    4. A distended bladder
46. Gregg Lohan, age 75, is admitted to the medical-surgical floor with weakness and left-sided chest pain. The symptoms have been present for several weeks after a viral illness. Which assessment finding is most symptomatic of pericarditis?
    1. Pericardial friction rub
    2. Bilateral crackles auscultated at the lung bases
    3. Pain unrelieved by a change in position
    4. Third heart sound (S3)
47. James King is admitted to the hospital with right-side-heart failure. When assessing him for jugular vein distention, the nurse should position him:
    1. Lying on his side with the head of the bed flat.
    2. Sitting upright.
    3. Flat on his back.
    4. Lying on his back with the head of the bed elevated 30 to 45 degrees.
48. The nurse is interviewing a slightly overweight 43-year-old man with mild emphysema and borderline hypertension. He admits to smoking a pack of cigarettes per day. When developing a teaching plan, which of the following should receive highest priority to help decrease respiratory complications?
    1. Weight reduction
    2. Decreasing salt intake
    3. Smoking cessation
    4. Decreasing caffeine intake
49. What is the ratio of chest compressions to ventilations when one rescuer performs cardiopulmonary resuscitation (CPR) on an adult?
    1. 15:1
    2. 15:2
    3. 12:1
    4. 12:2
50. When assessing a patient for fluid and electrolyte balance, the nurse is aware that the organs most important in maintaining this balance are the:
    1. Pituitary gland and pancreas
    2. Liver and gallbladder.
    3. Brain stem and heart.
    4. Lungs and kidneys.

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