1. C. Celiac disease is caused by an intolerance to gluten, which is a protein found in wheat, oats, barley and rye, All the foods in option 3 contain gluten. Option 1 would be eliminated if the child had a lactose intolerance, option 4 would be eliminated if the child had a fat intolerance.

2. D. The most important assessment is vital signs for hemorrhage. The nurse will also check the fundus and for lochia, but the most important is for hemorrhage because it is the most common cause of death in the first hour after delivery.

3. D. Unless the antibiotic is safe for the infant, it is best not to feed the baby, but in order to continue establishment of milk flow, the breasts must be stimulated.

4. A. Exercise, specifically dorsiflexion of the feet, prevents stasis by promoting venous valve and muscle action. Early ambulation, deep breathing and elevating the foot of the bed all increase blood flow. If DVT develops, the client will be placed on bedrest.

5. B. Alzheimer’s disease is a progressive disease that takes years until the patient is completely incapacitated. It is best to support the individuals self esteem by helping them maintain as much control of their life through independent functioning of self care and activities of daily living.

6. C. The physician should be notified immediately. A suspected Wilms’ tumor should never be palpated more than necessary because of the potential for metastasis and should be treated immediately following discovery. It is really not a nursing responsibility to assess for lymph node enlargement.

7. D. Patients with renal failure should have a diet that provides (high biologic value) proteins rich foods such as eggs, dairy products and meats. These are necessary to maintain a positive nitrogen balance. Foods high in calories are also necessary, and sodium intake should be limited. Foods high in Potassium should be AVOIDED due to decreased ability of the kidney(s) to filter and excrete Potassium.

8. B. The function of the lens is that of accommodation, the focusing of near objects on the retina by the lens; therefore, only the remaining lens will function in this capacity, depending on whether a cataract is present.

9. A. Although abstinence is still the best protection against spread of the HIV virus, the use of a latex condom with a H20 soluble lubricant is the most effective means. All other choices given have no proven validity against the spread of the HIV Virus.

10. B. If the bladder is full, it will push the uterus up out of the pelvis above the umbilicus. The uterus will not contract sufficiently, which could lead to increased bleeding.

11. B. Children with cardiac disease have lowered resistance to upper respiratory infections and should avoid any circumstances that may expose them to even mild infections. Option 1 is unrealistic and option 3 would not put the child at risk since allergies are not contagious, option 4 is wrong because children with cardiac conditions do receive routine immunizations.

12. D. Elevation of the legs promotes circulation and prevents venous stasis and more clot formation. Nursing measures aim at preventing further thrombi from forming and the already present thrombus from detaching. Elastic hose (2) are necessary when the client is up walking again. Placing a pillow under the limb (1) could cause a bend at the groin, with resulting decreased circulation. The client must be kept on bedrest until the danger of emboli passes (4 to 7 days).

13. A. One of the more common problems following Gastric surgery is Dumping Syndrome. Dietary management is the key to reduce or prevent this potential problem from developing. The diet should contain moderate amounts of fat, as well as below in carbohydrates, especially small molecular carbohydrates such as sucrose and glucose. These dietary modifications will result in decreased hypertonicity of the intestinal contents, and prevent osmotic pull of extracellular fluid into the intestinal area, lessening the possibility for Dumping Syndrome to develop.

14. B. While regulating or even touching an IV is definitely not within the scope of behaviors that an NA can legally perform (1), both teaching and clarification of duties is needed in this situation. Before accusing the NA, a nonpunitive environment should be created so teaching of both the LVN and NA can occur, and this action will not happen again. Unless too much medication was given, an incident report does not need to be filled out (2). Confronting the team members in a staff meeting (3) would not be following good management principles.

15. D. Following Total Gastrectomy the production of Intrinsic Factor is permanently destroyed. This is necessary (Intrinsic Factor) for the absorption of Vitamin B12 from the GI tract. As a result patients MUST receive Vitamin B12 by parenteral route throughout life, or a condition known as Pernicious Anemia will develop, and can prove to be fatal. Regular IM injections on a monthly basis of 100-200ug is the usual therapeutic dose.

a. Whole milk, ice cream and cheese
b. Rice, corn and soybeans
c. Bread, oatmeal and pretzels
d. Beef, liver and veal

2. Following delivery of a normal newborn, the nurse will assess the mother every 15 minutes for the first hour. The most important assessment is for

a. Placental fragments.
b. Presence of lochia.
c. Condition of the fundus.
d. Hemorrhage.

3. A breast feeding mother develops mastitis in the left breast and is put on an antibiotic for seven days. She asks the nurse if she can continue breast feeding. The nurse’s best answer would be:

a. “Only breast feed from the right breast.”
b. “Do not breast feed or stimulate the breasts until the infection is resolved.”
c. “Continue breast feeding, this is not a contraindication.”
d. “Pump the breasts and discard the milk until the infection resolves.“

4. The nurse is assigned a client at risk for developing deep vein thrombosis (DVT) following a total knee replacement. The most effective measure to prevent this complication is

a. An exercise schedule of dorsiflexion of the feet.
b. Maintaining a flat bed from the waist down.
c. Instruction in shallow breathing techniques.
d. Maintaining the client on bedrest.

5. An elderly man is admitted to the Geriatric Unit for his forgetfulness and severe behavioral changes. He is diagnosed with Alzheimer’s Disease. Which of the following should be the primary goal of nursing intervention?

a. Keep him away from problems of daily living
b. Keep his capacity for self care activities to the optimum
c. Keep him isolated
d. Keep all available resources to increase his dependency

6. While bathing a 1 year old, the nurse feels a large mass in the abdominal area and notices that his diaper is soiled with pinkish-tinged urine. The initial nursing action is to

a. Gently palpate the abdominal mass to determine if it is a Wilms’ tumor.
b. Continue the assessment by observing his behavior indicating pain on palpation.
c. Immediately notify the physician.
d. Assess if the tumor has spread to the lymph nodes.

7. Which of the following is an INCORRECT statement regarding diet therapy for a patient in renal failure?

a. Limit dietary protein
b. Provide a diet high in carbohydrates
c. Limit Sodium (NA) intake
d. Provide a diet high in Potassium rich food

8. Instructions given to clients following cataract surgery include the information that

a. Contact lenses will be fitted before discharge from the hospital.
b. They must use only one eye at a time to prevent double vision.
c. They will be able to judge distances without difficulty.
d. The eye patch will be removed in 3 to 4 days, and the eye may be used without difficulty.

9. In teaching High School students about health practices that promote the prevention of spread of the HIV virus, the nurse should include which of the following:

a. Use a latex condom and water soluble lubricant during intercourse
b. Abstain from intercourse if the female is menstruating
c. Following oral intercourse, use an over-the-counter mouthwash so to destroy the HIV virus
d. Shower immediately with an antibacterial soap after intercourse, so to destroy the HIV virus

10. Following delivery of a healthy baby, the nurse completes a postpartum assessment of the new mother. Which of the following symptoms would be indicative of a full bladder?

a. Pulse 52 beats/min.
b. Fundus 2F above umbilicus.
c. Increased uterine contractions.
d. Decreased lochia.

11. The parents of a child with Tetralogy of Fallot have been given discharge instructions. Which of the following situations would the parents be instructed to avoid?

a. All infant contact with persons outside the home
b. Infant contact with persons who have mild colds
c. Infant contact with persons who have severe allergies
d. Routine immunizations

12. A nursing measure to prevent the complication of deep vein thrombophlebitis following surgery would include

a. Wearing elastic hose at all times.
b. Having the client sit up TID.
c. Placing pillows under the affected limb
d. Elevating the foot of the bed.

13. Following Gastric Resection, patients are prone to developing Dumping Syndrome. Which of the following types of dietary intake by the patient would be MOST helpful to either reduce or prevent this syndrome from developing?

a. Moderate fat, low carbohydrate
b. High fat, high carbohydrate
c. Low fat, low carbohydrate
d. Moderate fat, high carbohydrate

14. The RN observes the nursing assistant (NA) regulating the IV of an oncology client receiving morphine sulfate for pain. An LVN on the RN’s team is responsible for the client and has assigned the client to the NA. The RN’s intervention is to

a. Immediately inform the charge nurse and fill out an incident report.
b. Ask the LVN and the NA to meet with the RN to discuss the responsibility -parameters each of them has.
c. Inform the LVN so that he/she intervenes to instruct the NA that this -action is not within the realm of responsibility of an NA.
d. Call a staff meeting and confront the LVN and the NA.

15. Following Total Gastrectomy patients will require vitamin replacement. Of the following, which vitamin is ESSENTIAL and MUST be given throughout life:

a. Vitamin C
b. Vitamin B6
c. Vitamin D
d. Vitamin B12

ANSWERS & RATIONALE

1. B. The elevated creatinine level suggests impaired renal function. Assessing intake and output will provide data related to renal function. The other assessments are not indicative of renal function.

2. D. Hyperextension brings the pharynx into alignment with the trachea and allows the scope to be inserted without trauma.

3. B. Palpating pulses distal to the insertion site is important to evaluate for thrombophlebitis and vessel occlusion. They should be bilateral and strong.

4. A. Urinary tract infections in the elderly often present as urinary incontinence that develops suddenly. Renal failure (1) and fluid volume excess (3) typically are characterized by oliguria. Dementia (4) develops slowly and is manifested by disordered thinking and behavior.

5. D. The most important safety measure is to tape a hemostat nearby to use in case of an air leak. Chest tubes should be checked periodically, but not necessarily every 2 hours (2). The client should be in semi-Fowler’s position to increase lung expansion.

6. C. There is an increased incidence of hemorrhaging with the external cannula. Hemorrhage results from the cannula becoming disconnected. One advantage of the external cannula is that it is painless to use. Surgery is required to establish the internal fistula and it should be allowed to heal for several weeks before being utilized.

7. A. The rope/pulley and weight system is arranged so that fracture fragments are in the desired approximate position for healing. The client’s position should always rest in line with the traction pull. The line of pull must never be interfered with by changing the position of a pulley and extension bar.

8. A. Russell’s traction is a type of skin traction that incorporates a sling under the knee that is connected by a rope to an overhead bar pulley. It is frequently used to treat femoral shaft fractures in the adolescent.

9. D. Increased pulse and pallor are symptoms associated with shock. A compromised venous return may occur if there is a mediastinal shift as a result of excessive fluid removal. Usually no more than 1 L of fluid is removed at one time to prevent this from occurring.

10. B. The collection bag must be able to fill easily; therefore, it needs to be distended. The bag must be vented with a filter so that urine can be drained from the chamber. The tube must not be allowed to coil or become kinked above the level of the bladder. The collection bag is positioned below the level of the bladder to allow for continuous urine drainage and prevent urine backflow into the bladder. In order to prevent reflux of urine, the tubing must be of sufficient length, usually 5 feet.

11. B. Because more weight can be applied with skeletal traction, it can be used to reduce fractures and maintain alignment. It is not used commonly in the elderly because of prolonged immobilization. It is not preferred for children because some displacement of fracture fragments is desirable to prevent growth disturbance. Frequently, clients have more mobility than they do with skin traction, because balanced suspension is often incorporated with skeletal traction.

12. C. Diabetes insipidus is an antidiuretic deficiency and may occur following brain surgery or head injury. It also occurs in young adults resulting from damage to the posterior lobe of the pituitary gland. Severe polyuria occurs when there is an inability to concentrate urine. These are not symptoms of types 1 and 2 diabetes (2, 3) or Addison’s disease (4) (which is adrenocorticol hypofunction).

13. D. Preventing cerebral trauma during the convulsion is a priority activity. Placing some form of padding under the head will protect the skull and brain from injury. Inserting a mouth gag (1) and restraining the limbs (3) are unsafe interventions. The nurse would not leave a seizing person to go and obtain equipment (4).

14. D. The respiratory system can become occluded if the balloon slips and moves up the esophagus, putting pressure on the trachea. This would result in respiratory distress and should be assessed frequently. Scissors should be kept at the bedside to cut the tube if distress occurs. This is a safety intervention.

15. A. Putting pressure over the vessels in the neck may be lifesaving because a severe blood loss can occur rapidly, leading to shock and death. The surgeon would be notified as soon as possible.

a. Pupillary reflex.
b. Intake and output.
c. Capillary refill.
d. Temperature.

2. A client requires that a bronchoscopy procedure be done. Due to his physical condition, he will be awake during the procedure. As part of the pretest teaching, the nurse will instruct him that before the scope insertion, his neck will be positioned so that it is

a. In an extended position.
b. In a neutral position.
c. In a flexed position.
d. Hyperextended.

3. To evaluate a client’s condition following cardiac catheterization, the nurse will palpate the pulse

a. At the insertion site.
b. Distal to the catheter insertion.
c. Above the catheter insertion.
d. In all extremities.

4. A 76-year-old woman who has been in good health develops urinary incontinence over a period of several days and is admitted to the hospital for a diagnostic workup. The nurse would assess the client for other indicators of

a. Urinary tract infection.
b. Dementia.
c. Renal failure.
d. Fluid volume excess.

5. The nurse is assigned to care for a 20 year old who has just had chest tubes inserted. An important nursing action is to

a. Check the chest tubes every 2 hours for air leaks.
b. Keep the client flat to avoid leaks in the tubing.
c. Coil the tubes carefully to prevent kinking, which could result in an air leak.
d. Place a hemostat nearby in case of an air leak.

6. A client is on dialysis treatments three times per week. The nurse explains that the main advantage of using an internal arteriovenous fistula rather than an external arteriovenous cannula for dialysis is

a. It is easier to access the blood flow with the internal fistula than through the external cannula.
b. The internal fistula can be utilized immediately after insertion.
c. There is less risk of hemorrhage from the internal fistula.
d. Accessing the internal fistula is less uncomfortable for the client.

7. When evaluating all forms of traction, the nurse knows that the direction of pull is controlled by the

a. Rope/pulley system.
b. Amount of weight.
c. Client’s position.
d. Point of friction.

8. Russell’s traction is easily recognized because it incorporates a

a. Sling under the knee.
b. Pearson attachment.
c. Pelvic girdle.
d. Cervical halter.

9. Immediately following a thoracentesis, which clinical manifestations indicate that a complication has occurred and the physician should be notified?

a. Hypotension and hypothermia.
b. Serosanguineous drainage from the puncture site.
c. Increased temperature and blood pressure.
d. Increased pulse and pallor.

10. A 60-year-old male client’s physician schedules a prostatectomy and orders a straight urinary drainage system to be inserted preoperatively. For the system to be effective, the nurse would

a. Coil the tubing above the level of the bladder.
b. Check that the collection bag is vented and distensible.
c. Position the collection bag above the level of the bladder.
d. Determine that the tubing is less than 3 feet in length.

11. Which of the following statements is true of skeletal traction?

a. Neurovascular complications are less apt to occur than with skin traction.
b. Fractures can be reduced because more weight can be used than with skin traction.
c. The client has less mobility than he does with skin traction.
d. It is preferred for children because fracture fragment alignment is so important.

12. Following brain surgery, the client suddenly exhibits polyuria and begins voiding 15 to 20 L/day. Specific gravity for the urine is 1.006. The nurse will recognize these symptoms as the possible development of

a. Diabetes, type I.
b. Addison’s disease.
c. Diabetes, insipidus.
d. Diabetes, type II.

13. The nurse enters the room of a client who is in the clonic phase of a tonic-clonic seizure. The initial nursing action should be to

a. Insert a padded mouth gag.
b. Gently restrain the limbs.
c. Obtain equipment for orotracheal suctioning.
d. Place some padding under the head.

14. A client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to

a. Check that the balloon is deflated on a regular basis.
b. Monitor IV fluids for the shift.
c. Check that a hemostat is at the bedside.
d. Regularly assess respiratory status.

15. Hemorrhage is a major complication following oral surgery and radical neck dissection. If this condition occurs, the most immediate nursing intervention would be to

a. Put pressure over the common carotid and jugular vessels in the neck.
b. Notify the surgeon immediately.
c. Treat the client for shock.
d. Immediately put the client in high-Fowler’s position.

Answers and Rationale for NCLEX RN Review of Reduction of Risk Potential

We would like to inform you that our Computer Adaptive Test for NCLEX is already available. This can be seen on on http://www.nclexonline.com.

What’s inside?

Lot’s of SATA (select all that apply) questions, True or False and Multiple choice questions that varies with each level of difficulty. Expect to answer at least 200+ questions per simulator when you start.

On this first version of our NCLEX-CAT, there are two (2) ways to pass.

How you will pass?

1. The 95% certainty rule. Program will stop if the computer determines with 95% certainty that your answers are correct. You will immediately get the results together with the answers and rationale.
2. If you achieve the passing rate set on the program for the full 265 questions. (for NCLEX-RN)

How you will fail?

1. Timer is set to have a full 6 hours of exam (for NCLEX-RN). No pause. No breaks. If you consume all the time, the probability of you being failed is very high.
2. If you didn’t meet the passing rate on the simulator’s program.
3. The 95% rule. If the program knows that most of your answers are wrong, then it will discontinue the exam and provide you with the results.

Take the Test Today!

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

NCLEX Sample Tests

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

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

1. Answer A. Advance directives are signed, witnessed documents that provide specific instructions for treatment if a client can’t give those instructions personally when required. Depending on the client’s wishes, they may or may not include DNR orders.

2. Answer B. When taking a medication order over the telephone, standard practice requires verbal verification of the order and the physician’s written signature within 24 hours. The nurse practice act doesn’t prohibit taking medication orders over the telephone

3. Answer C. The donor and recipient must have compatible blood and tissue types. They should be fairly close in size and age. When a living donor is considered, it’s preferable to have a relative donate the organ. Need is important but it can’t be the critical factor if a compatible donor isn’t available.

4. Answer A. The primary physician in charge of a client’s care must write an order for the restraint within 8 hours. In an emergency, a client who is a threat to himself or others may be restrained without an order. Voluntary clients have the right to leave against medical advice. A minor is treated the same as an adult regarding restraints.

5. Answer C. Although all of the options are desirable, knowledge of self is the basis for building a strong, therapeutic nurse-client relationship. Being aware of and understanding personal feelings and behavior are prerequisites for understanding and helping clients.

6. Answer B. When a nurse attempts to influence a family’s decision with her own opinions and values, the situation becomes one of overinvolvement on the nurse’s part and a nontherapeutic relationship. When a nurse keeps communication channels open, works with family members to decrease their dependence on health care providers, and instructs family members so they can accomplish tasks independently, she has developed an appropriate therapeutic relationship.

7. Answer B. The nurse should determine the specific concerns of the client’s wife. Jumping to conclusions regarding the client’s need for a nursing home or other care placement options would be inappropriate. The nurse must tailor care to the client and family, focusing on their needs.

8. Answer C. When a nurse discovers substandard practice by another nurse, it’s always appropriate to address the situation before conveying the information to a manager or supervisor. Informing the nurse-supervisor first doesn’t promote goodwill between nurses and can affect nursing care.

9. Answer B. The nurse violated confidentiality by informing the officer that the client wasn’t in treatment. Even with law enforcement agents, the nurse must be a client advocate and protect the client’s confidentiality. Information can be legally withheld when a court order isn’t in place.

10. Answer D. Discharge planning should begin when a client is first admitted to the facility. Initially, discharge planning requires collecting information about the client’s home environment, support systems, functional abilities, and finances.

11. Answer C. Many clients are discharged from acute care settings so quickly that they don’t receive complete instructions. Therefore, the first priority is to arrange for colostomy care. The American Cancer Society often sponsors support groups, which are helpful when the person is ready, but contacting this organization doesn’t take precedence over ensuring proper colostomy care. Requesting Meals on Wheels and asking for an occupational therapy evaluation are important but can occur later in rehabilitation.

12. Answer C. Client-care quality should always be the first consideration when proposing a change in care provision. Institutional resources, standards of practice, and nursing recruitment will all influence the decision but none as much as client-care quality should.

13. Answer D. Nursing interventions are classified as independent, interdependent, or dependent. Altering the drug schedule to coincide with the client’s daily routine represents an independent intervention, whereas consulting with the physician and pharmacist to change a client’s medication because of adverse reactions represents an interdependent intervention. Administering an already-prescribed drug on time is a dependent intervention. An intradependent nursing intervention doesn’t exist.

14. Answer A. The nurse has failed to respond immediately to the safety and privacy of a vulnerable client. Negligence is defined as an omission to do something a reasonable person would do. This nurse’s behavior is anything but sensitive, caring, or compassionate. Organization isn’t addressed in this situation.

15. Answer B. The client’s bill of rights addresses the client’s rights to information, informed consent, timely responses to requests for services, and treatment refusal. It’s a legal document and serves as a guideline for decision making by the nurse. Standards of nursing practice, the nurse practice act, and the code for nurses contain nursing practice parameters and primarily describe use of the nursing process in providing care.

16. Answer B. The Bill of Rights for Psychiatric Clients includes the right for clients to access their medical records unless doing so would be detrimental to their health. To determine if information might to be detrimental to the client, the primary care provider should be informed of the client’s request. The client doesn’t need an attorney to view her chart. She also doesn’t need to wait until after discharge to view it.

17. Answer C. An occupational therapist helps physically disabled clients adapt to physical limitations and is most qualified to help a child with cerebral palsy eat and perform other activities of daily living. A registered dietitian manages and plans for the nutritional needs of children with cerebral palsy but isn’t trained in modifying or fitting utensils with assistive devices. A physical therapist is trained to help a child with cerebral palsy gain function and prevent further disability but not to assist the child in performing activities of daily living. A nursing assistant can help a child eat; however, the nursing assistant isn’t trained in modifying utensils.

18. Answer C. In Maslow’s hierarchy of needs, pain relief is on the first layer. Activity (option B) is on the second layer. Safety (option D) is on the third layer. Love and belonging (option A) are on the fourth layer.

19. Answer C. It’s discriminatory and punitive for the nurse-manager to alter the staff nurse’s schedule. The remark is inappropriate and unprofessional, and the nurse-manager should receive counseling. The physician could choose to ignore the comment, but any provider who hears of discrimination should deal with it. If the matter can be resolved locally, reporting the nurse-manager to the labor relations board should be avoided. Institutional documentation should exist for such matters. It’s inappropriate for the physician to inform the staff nurse about what was said. Such action could create difficult relations on the unit and, thereby, affect nursing care.

20. Answer A. Physicians have an ethical and legal right to refuse to care for any client in a nonemergency situation when standard medical care isn’t acceptable to the client. It isn’t the responsibility of the surgeon to find an alternate. Jehovah’s Witnesses don’t believe in any kind of transfusion, homologous or autologous. Informing the client that her decision can shorten her life is inappropriate in that the statement may be inaccurate and it ignores the client’s right of autonomy.

21. Answer B. The usual or most prevalent reason for lack of productivity in a group of competent nurses is inadequate communication or a situation where the nurses have unexpressed feelings and emotions. Although the other answers could be contributing to the problematic situation, they’re less likely to be the cause.

22. Answer C. Theoretical models of nursing provide the foundation for all nursing knowledge. They also direct nursing practice based on the concepts of health, person, environment, and nursing. Scientific breakthroughs, technological advances, and medical practices may affect nursing but aren’t frameworks for nursing education and practice.

23. Answer B. After the final cast has been removed, foot and ankle exercises may be necessary to improve range of motion. A physical therapist should work with the child. A physical therapist is trained to help clients restore function and mobility, which will prevent further disability.

24. Answer D. Documentation should include data that the nurse obtains using only observations that are heard, seen, smelled, or felt. The nurse should record findings or observations precisely and accurately. Documentation of a leg ulcer should include its exact size and location. Documenting observed client behaviors or conversations is appropriate, but drawing conclusions about a client’s feelings is not. Stating that the client had a good day doesn’t provide precise enough information to be useful.

25. Answer A. Critical pathways are defined as a provision of care in a case management system. The pathways provide outcome-based guidelines for goal achievement within a designated length of stay. Critical pathways are to be used by the treatment team, not just by the physician. Pathways are designated lengths of stay, not therapies.

Know more tips on how to pass the nclex exam in one strike!

More NCLEX Questions coming up…

2.    Nurse Calvin receives a medication order over the telephone. How should the nurse handle this situation?
a.    Tell the physician that the nurse practice act prohibits taking medication orders over the telephone
b.    Verify the order by repeating it over the phone
c.    Request that a second physician repeat the order to the nurse over the telephone
d.    Insist that the physician sign the medication order within 1 hour

3.    A client who agreed to become an organ donor is pronounced dead. What is the most important factor in selecting a transplant recipient?
a.    Blood relationship
b.    Sex and size
c.    Compatible blood and tissue types
d.    Need

4.    Emergency restraints or seclusion may be implemented without a physician’s order under which of the following conditions?
a.    When a written order will be obtained from the primary physician within 8 hours
b.    Never
c.    If a voluntary client wants to leave against medical advice
d.    When a minor child is out of control

5.    The basis for building a strong therapeutic nurse-client relationship begins with the nurse’s:
a.    sincere desire to help others
b.    acceptance of others
c.    self-awareness and understanding
d.    sound knowledge of psychiatric nursing

6.    Nurse Carl is concerned about another nurse’s relationship with the members of a family and their ill preschooler. Which of the following behaviors would be most worrisome and should be brought to the attention of the nurse-manager?
a.    The nurse keeps communication channels open among herself, the family, physicians, and other health care providers.
b.    The nurse attempts to influence the family’s decisions by presenting her own thoughts and opinions.
c.    The nurse works with the family members to find ways to decrease their dependence on health care providers.
d.    The nurse has developed teaching skills to instruct the family members so they can accomplish tasks independently.

7.    A man found wandering in a local park is unable to state who or where he is or where he lives. He is brought to the emergency department, where his identification is eventually discovered. The client’s wife states that he was diagnosed with Alzheimer’s disease 3 years ago and has had increasing memory loss. She tells the nurse she is worried about how she’ll continue to care for him. Which response by the nurse would be most helpful?
a.    Because of the nature of your husband’s disease, you should start looking into nursing homes for him
b.    What aspect of caring for your husband is causing you the greatest concern?
c.    You may benefit from a support group called Mates of Alzheimer’s Disease Clients
d.    Do you have any children or friends who could give you a break from his care every now and then?

8.    Nurse Carrol works on a general medical-surgical unit where nurses work on 12-client pods. Each pod is staffed by two registered nurses. When one of the nurses leaves the unit for any reason, the remaining nurse cares for all 12 clients. If she needs help, she can call the agency’s in-house resource nurse. One evening when a coworker nurse left the unit, the remaining nurse, who was making rounds on the departed nurse’s clients, found medications left at bedsides and a client with a blood-draw tourniquet remaining on his arm. In addressing the problems, the nurse should:
a.    inform the nurse-supervisor right away
b.    correct the problems and submit a written report
c.    speak to the coworker when she returns to the unit
d.    ask for a meeting with the coworker and a manager

9.    Nurse Carter at a substance abuse center answers the phone. A probation officer asks if a client is in treatment. The nurse responds, “No, the client you’re looking for isn’t here.” Which of the following statements best describes the nurse’s response?
a.    Correct because she didn’t give out information about the client
b.    A violation of confidentiality because she informed the officer that the client wasn’t there
c.    A breech of the principle of veracity because the nurse is misleading the officer
d.    Illegal because she’s withholding information from law enforcement agents

10.    Nurse Carey is caring for a client with hyperemesis gravidarum who will need close monitoring at home. When should the nurse begin discharge planning?
a.    On the day of discharge
b.    When the client expresses readiness to learn
c.    When the client’s vomiting has stopped
d.    On admission to the facility

11.    A client is being discharged after undergoing abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care?
a.    Notifying the American Cancer Society of the client’s diagnosis
b.    Requesting Meals On Wheels to provide adequate nutritional intake
c.    Referring the client to a home health nurse for follow-up visits to provide colostomy care
d.    Asking an occupational therapist to evaluate the client at home

12.    In planning a presentation that advocates a decrease in the client-to-nurse ratio from 8:1 to 6:1, a nurse should emphasize its effect on:
a.    institutional resources
b.    standards of practice
c.    client-care quality
d.    nursing recruitment

13.    A client requests his medication at 9 p.m. instead of 10 p.m. so that he can go to sleep earlier. Which type of nursing intervention is required?
a.    Intradependent
b.    Interdependent
c.    Dependent
d.    Independent

14.    A family member visiting on an acute care psychiatric unit approaches the nurse’s station and reports that an elderly client is walking in the hall without her clothing. Nurse Casper doesn’t assist the client and suggests that the family member inform the nurse assigned to that client. Which of the following terms describes the nurse’s action?
a.    Negligent
b.    Sensitive
c.    Compassionate
d.    Organized

15.    The client’s rights to information, informed consent, and treatment refusal are addressed in the:
a.    standards of nursing practice
b.    client’s bill of rights
c.    nurse practice act
d.    code for nurses

16.    An agitated client demands to see her chart so she can read what has been written about her. Which of the following statements is nurse Cedric best response to the client?
a.    I’m sorry the chart is the property of the facility. We don’t permit clients to read them
b.    You have the right to see your chart. Please discuss this with your primary care provider
c.    You may see your chart after you’re discharged
d.    Please discuss this matter with your attorney

17.    Nurse Chadwick is caring for a school-age child with cerebral palsy. The child has difficulty eating using regular utensils and requires a lot of assistance. Which of the following referrals is most appropriate?
a.    Registered dietitian
b.    Physical therapist
c.    Occupational therapist
d.    Nursing assistant

18.    When prioritizing a client’s plan of care based on Maslow’s hierarchy of needs, nurse Charles first priority would be:
a.    allowing the family to see a newly admitted client
b.    ambulating the client in the hallway
c.    administering pain medication
d.    placing wrist restraints on the client

19.    Nurse Chester manages a unit that has four full-time vacant positions, and nurses volunteer to work extra shifts to cover the staffing shortages. One of the staff nurses hasn’t volunteered and states, “Forty hours a week of nursing is all I can manage to do. I won’t volunteer for overtime.” The nurse-manager says to an attending physician on the unit, “I’ll adjust her schedule to make her wish she’d volunteered.” The physician to whom she commented should:
a.    choose to ignore the comment because it isn’t the physician’s domain
b.    report the nurse-manager to the labor relations board
c.    ensure that the nurse-manager receives counseling about her comment
d.    tell the staff nurse what the manager said about her

20.    A client with mitral valve prolapse is advised to have elective mitral valve replacement. Because the client is a Jehovah’s Witness, she declares in her advance directive that no blood products are to be administered. As a result, the consulting cardiac surgeon refuses to care for the client. It would be most appropriate for nurse Christian who’s caring for the client to:
a.    realize the surgeon has the right to refuse to care for the client
b.    advise the surgeon to arrange for an alternate cardiac surgeon
c.    tell the client that she can donate her own blood for the procedure
d.    inform the client that her decision could shorten her life

21.    A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and nonproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is:
a.    unhappiness about the change in leadership
b.    unexpressed feelings and emotions among the staff
c.    fatigue from overwork and understaffing
d.    failure to incorporate staff in decision making

22.    Which of the following options serves as a framework for nursing education and clinical practice?
a.    Scientific breakthroughs
b.    Technological advances
c.    Theoretical models
d.    Medical practices

23.    Nurse Chrisopher is caring for an infant with congenital clubfoot. After the final cast has been removed, which member of the health care team will most likely help the infant with leg and ankle exercises and provide his parents with a home exercise regimen?
a.    Occupational therapist
b.    Physical therapist
c.    Recreational therapist
d.    Speech therapist

24.    Which statement reflects appropriate documentation in the medical record of a hospitalized client?
a.    Small pressure ulcer noted on left leg
b.    Client seems to be mad at the physician
c.    Client had a good day
d.    Client’s skin is moist and cool

25.    Critical pathways of care refer to:
a.    a plan of care that provides outcome-based guidelines with a designated length of stay
b.    a plan of care designed for physicians to prescribe medications
c.    a design of treatment that includes approved therapies
d.    a technique in therapy to care for the client holistically

Answers and Rationale

More nclex review to follow.

1.    Answer 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.

2.    Answer 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.

3.    Answer 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.

4.    Answer 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.

5.    Answer 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.

6.    Answer 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.

7.    Answer D. Potassium chloride administered intravenously must always be diluted in IV fluid and infused via a pump or controller. The usual concentration of IV potassium chloride is 20 to 40 mEq/L. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. Dilution in normal saline is recommended, but dextrose solution is avoided because this type of solution increases intracellular potassium shifting. The IV bag containing the potassium chloride is always gently agitated before hanging. The IV site is monitored closely because potassium chloride is irritating to the veins and the risk of phlebitis exists. The nurse monitors urinary output during administration and contacts the physician if the urinary output is less than 30 mL/hr.

8.    Answer D. A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing’s syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

9.    Answer D. A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Electrocardiographic changes include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves.

10.    Answer B. Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with renal failure or hyperaldosteronism are at risk for hypernatremia.

11.    Answer C. Hyperactive bowel sounds indicate hyponatremia. Options A, B, and D are signs of hypernatremia. In hyponatremia, increased urinary output and decreased specific gravity of the urine would be noted. Dry skin occurs in deficient fluid volume.

12.    Answer A. The normal serum calcium level is 8.6 to 10.0 mg/dL. A client with a serum calcium level of 4.0 mg/dL is experiencing hypocalcemia. The excessive ingestion of vitamin D and hyperparathyroidism are causative factors associated with hypercalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia.

13.    Answer A. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau’s or Chvostek’s sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

14.    Answer C. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. A shortened ST segment and a widened T wave occur with hypercalcemia. Prominent U waves occur with hypokalemia.

15.    Answer C. The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0 mg/dL indicates hypomagnesemia. In hypomagnesemia, the nurse would note tall T waves and a depressed ST segment. Options 2 and 4 would be noted in a client experiencing hypermagnesemia. Prominent U waves occur with hypokalemia.

16.    Answer A. The normal serum phosphorus level is 2.7 to 4.5 mg/dL. The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide–based or magnesium-based antacids. Malnutrition is associated with alcoholism. Hypoparathyroidism, tumor lysis syndrome, and renal insufficiency are causative factors of hyperphosphatemia.

17.    Answer D. Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3–   to increase. Symptoms experienced by the client would include hypoventilation and tachycardia.

18.    Answer C. The normal serum amylase level is 25 to 151 units/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value.

19.    Answer B. The normal blood urea nitrogen level is 8 to 25 mg/dL. Values such as those in options C and D reflect continued dehydration. Option A reflects a lower than normal value, which may occur with fluid volume overload, among other conditions.

20.    Answer C. Troponin is a regulatory protein found in striated muscle. The troponins function together in the contractile apparatus for striated muscle in skeletal muscle and in the myocardium. Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. A troponin T value that is higher than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction. A normal troponin I level is lower than 0.6 ng/mL.

21.    Answer C. The normal serum creatinine level for adults is 0.6 to 1.3 mg/dL. The client with a mild degree of renal insufficiency would have a slightly elevated level. A creatinine level of 0.2 mg/dL is low, and a level of 0.5 mg/dL is just below normal. A creatinine level of 3.5 mg/dL may be associated with acute or chronic renal failure.

22.    Answer B. The normal prothrombin time (PT) is 9.6 to 11.8 seconds (male adult) or 9.5 to 11.3 seconds (female adult). A therapeutic PT level is 1.5 to 2.0 times higher than the normal level. Because the value of 35 seconds is high (and perhaps near the critical range), the nurse should anticipate that the client would not receive further doses at this time.

23.    Answer D. The normal activated partial thromboplastin time (aPTT) varies between 20 and 36 seconds, depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 times normal. Thus, the client’s aPTT is within the therapeutic range, and the dose should remain unchanged.

24.    Answer C. The normal serum lipase level is 10 to 140 units/L. The client who is recovering from acute pancreatitis usually has elevated lipase levels for about 10 days after the onset of symptoms. This makes lipase a valuable test in monitoring the client’s pancreatic function because serum amylase levels usually return to normal 3 days after the onset of symptoms. Option C is the only option that contains a value just below the upper limit of normal.

25.    Answer C. The normal hemoglobin level for an adult female client is 12 to 15 g/dL. Iron deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level as a result of the body’s need for more oxygen-carrying capacity.

More nclex practice coming up…

2.    Nurse Lorena 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.    Decrease hematocrit
c.    Increased blood pressure
d.    Decrease central venous pressure (CVP)

3.    Nurse George 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

4.    Nurse Levy 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 expect 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)

5.    Nurse Faye is preparing to care for a client with a potassium deficit. The nurse reviews 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

6.    Nurse Jessica 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

7.    Tanya, a nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium?
a.    Obtaining a cotrolled IV infusion pump
b.    Monitoring urine output during administration
c.    Diluting in appropriate amount of normal saline
d.    Preparing the medication for bolus administration

8.    Nurse Kim caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level og 5.5 mEq/L on one client’s laboratory report. The nurse understands that which client is at highest risk for the development of a potassium value at this level?
a.    The client with colitis
b.    The client with Cushing’s syndrome
c.    The client who has been overusing laxatives
d.    The client who has sustained a traumatic burn

9.    Nurse Nerissa reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4 mEq/L. which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value?
a.    ST depression
b.    Inverted T wave
c.    Prominent U wave
d.    Tall peaked T waves

10.    Nurse Noemi caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client’s laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level?
a.    The client with renal failure
b.    The client who is taking diuretics
c.    The client with hyperaldosteronism
d.    The client who is taking corticosteroids

11.    Nurse Princess is caring for a client with acute congestive heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscles weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia were present?
a.    Dry skin
b.    Decrease urinary output
c.    Hyperactive bowel sounds
d.    Increased specific gravity of the urine

12.    Nurse Andrew is reviewing a client’s laboratory report and notes that the serum calcium level is 4.0 mg/dL. The nurse understands that which condition most likely caused this serum calcium level?
a.    Prolonged bed rest
b.    Renal insufficiency
c.    Hyperparathyroidism
d.    Excessive ingestion of vitamin D

13.    Nurse Editha is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client?
a.    Twitching
b.    Negative Trousseau’s sign
c.    Hypoactive bowel sounds
d.    Hypoactive deep tendon reflexes

14.    Nurse Sally caring for a client with hypocalcemia would expect to note which of the following changes on the electrocardiogram?
a.    Widened T wave
b.    Prominent U wave
c.    Prolonged QT interval
d.    Shortened ST segment

15.    Nurse Sam caring for a client with severe malnutrition reviews the laboratory results and notes a magnesium level of 1.0 mg/dL. Which electrocardiographic changes would the nurse expects to note based on the magnesium level?
a.    Prominent U waves
b.    Prolonged PR interval
c.    Depressed ST segment
d.    Widened QRS complexes

16.    Nurse Danny reviews a client’s laboratory report and notes that the client’s serum phosphorus level is 2.0 mg/dL. Which condition most likely caused this serum phosphorus level?
a.    Alcoholism
b.    Renal insufficiency
c.    Hypoparathyroidism
d.    Tumor lysis syndrome

17.    A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rete of 6 breaths/min. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/min. Arterial blood gases are drawn and nurse Gio reviews the results, expecting to note which of the following?
a.    A decreased pH and an increased CO2
b.    An increased pH and a decreased CO2
c.    A decreased pH and a decreased HCO3
d.    An increased pH with an increased HCO3

18.    Nurse Venus is assigned to a 40-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicating a laboratory report that indicates a serum amylase level of:
a.    45 units/L
b.    100 units/L
c.    300 units/L
d.    500 units/L

19.    A client has been admitted to the hospital for urinary tract infection and dehydration. Nurse Veronica determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to:
a.    3 mg/dL
b.    15 mg/dL
c.    29 mg/dL
d.    35 mg/dL

20.    A maleclient arrives in the emergency room complaining of chest pain that began 4 hours ago. A troponin T blood specimen is obtained, and the results indicate a level of 0.6 ng/mL. Nurse Celeste interprets that this result indicates a:
a.    Normal level
b.    Low value that indicates possible gastritis
c.    Level that indicates a myocardial infraction
d.    Level that indicates the presence of possible angina

21.    An adult client has had laboratory work done as part of a routine physical examination. Nurse Amy interprets that the client may have a mild degree of renal insufficiency if which of the following serum creatinine levels is noted?
a.    0.2 mg/dL
b.    0.5 mg/dL
c.    1.9 mg/dL
d.    3.5 mg/dl

22.    A female client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium (Coumadin) has a prothrombin time of 35 seconds. Based on the prothrombin time, nurse Daniel anticipates which of the following orders?
a.    Adding a dose of heparin sodium
b.    Holding the next dose of warfarin
c.    Increasing the next dose of warfarin
d.    Administering the next dose of warfarin

23.    A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client’s activated partial thromboplastin (aPTT) time is 65 seconds. Nurse Jessie anticipates that which action is needed?
a.    Discontinuing the heparin infusion
b.    Increasing the rate of the heparin infusion
c.    Decreasing the rate of the heparin infusion
d.    Leaving the rate of the heparin infusion as is

24.    An adult client was diagnosed with acute pancreatitis 9 days ago. The nurse interprets that the client is recovering from this episode if the serum lipase level decreases to which of the following values, which is just below the upper limit of normal?
a.    20 units/L
b.    80 units/L
c.    135 units/L
d.    350 units/L

25.    An adult female has a hemoglobin level of 10.8 g/dL. Nurse Gemma interprets that this result is most likely caused by which of the following conditions noted in the client’s history?
a.    Dehydration
b.    Heart failure
c.    Iron deficiency anemia
d.    Chronic obstructive pulmonary disease

Answers and Rationale

More nclex questions and tips on how to pass nclex coming very soon…