NCLEX Practice Questions Thursday, June 3, 2010 1. A patient tells you that her urine is starting to look discolored.

If you believe this change is due to medication, which of the following patient's medication does not cause urine discoloration? A. Sulfasalazine B. Levodopa C. Phenolphthalein D. Aspirin 2. You are responsible for reviewing the nursing unit's refrigerator. If you found the following drug in the refrigerator it should be removed from the refrigerator's contents? A. Corgard B. Humulin (injection) C. Urokinase D. Epogen (injection) 3. A 34 year old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb? A. IgA B. IgD C. IgE D. IgG 4. A second year nursing student has just suffered a needlestick while working with a patient that is positive for AIDS. Which of the following is the most important action that nursing student should take? A. Immediately see a social worker B. Start prophylactic AZT treatment C. Start prophylactic Pentamide treatment D. Seek counseling 5. A thirty five year old male has been an insulindependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect? A. Atherosclerosis B. Diabetic nephropathy C. Autonomic neuropathy D. Somatic neuropathy 6. You are taking the history of a 14 year old girl who has a (BMI) of 18. The girl reports inability to eat, induced vomiting and severe constipation. Which of the following would you most likely suspect? A. Multiple sclerosis B. Anorexia nervosa C. Bulimia D. Systemic sclerosis 7. A 24 year old female is admitted to the ER for confusion. This patient has a history of a myeloma diagnosis, constipation, intense abdominal pain, and

polyuria. Which of the following would you most likely suspect? A. Diverticulosis B. Hypercalcaemia C. Hypocalcaemia D. Irritable bowel syndrome 8. Rho gam is most often used to treat____ mothers that have a ____ infant. A. RH positive, RH positive B. RH positive, RH negative C. RH negative, RH positive D. RH negative, RH negative 9. A new mother has some questions about (PKU). Which of the following statements made by a nurse is not correct regarding PKU? A. A Guthrie test can check the necessary lab values. B. The urine has a high concentration of phenylpyruvic acid C. Mental deficits are often present with PKU. D. The effects of PKU are reversible. 10. A patient has taken an overdose of aspirin. Which of the following should a nurse most closely monitor for during acute management of this patient? A. Onset of pulmonary edema B. Metabolic alkalosis C. Respiratory alkalosis D. Parkinson's disease type symptoms 11. A fifty-year-old blind and deaf patient has been admitted to your floor. As the charge nurse your primary responsibility for this patient is? A. Let others know about the patient's deficits B. Communicate with your supervisor your concerns about the patient's deficits. C. Continuously update the patient on the social environment. D. Provide a secure environment for the patient. 12. A patient is getting discharged from a SNF facility. The patient has a history of severe COPD and PVD. The patient is primarily concerned about their ability to breath easily. Which of the following would be the best instruction for this patient? A. Deep breathing techniques to increase O2 levels. B. Cough regularly and deeply to clear airway passages. C. Cough following bronchodilator utilization D. Decrease CO2 levels by increase oxygen take output during meals. 13. A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present? A. Slow pulse rate B. Weight gain C. Decreased systolic pressure D. Irregular WBC lab values 14. A mother has recently been informed that her child has Down's syndrome. You will be assigned to care for

the child at shift change. Which of the following characteristics is not associated with Down's syndrome? A. Simian crease B. Brachycephaly C. Oily skin D. Hypotonicity 15. A patient has recently experienced a (MI) within the last 4 hours. Which of the following medications would most like be administered? A. Streptokinase B. Atropine C. Acetaminophen D. Coumadin 16. A patient asks a nurse, My doctor recommended I increase my intake of folic acid. What type of foods contain folic acids? A. Green vegetables and liver B. Yellow vegetables and red meat C. Carrots D. Milk 17. A nurse is putting together a presentation on meningitis. Which of the following microorganisms has noted been linked to meningitis in humans? A. S. pneumonia B. H. influenza C. N. meningitis D. Cl. difficile 18. A nurse is administering blood to a patient who has a low hemoglobin count. The patient asks how long to RBC's last in my body? The correct response is. A. The life span of RBC is 45 days. B. The life span of RBC is 60 days. C. The life span of RBC is 90 days. D. The life span of RBC is 120 days. 19. A 65 year old man has been admitted to the hospital for spinal stenosis surgery. When does the discharge training and planning begin for this patient? A. Following surgery B. Upon admit C. Within 48 hours of discharge D. Preoperative discussion 20. A child is 5 years old and has been recently admitted into the hospital. According to Erickson which of the following stages is the child in? A. Trust vs. mistrust B. Initiative vs. guilt C. Autonomy vs. shame D. Intimacy vs. isolation 21. A toddler is 16 months old and has been recently admitted into the hospital. According to Erickson which of the following stages is the toddler in? A. Trust vs. mistrust B. Initiative vs. guilt

C. Autonomy vs. shame D. Intimacy vs. isolation 22. A young adult is 20 years old and has been recently admitted into the hospital. According to Erickson which of the following stages is the adult in? A. Trust vs. mistrust B. Initiative vs. guilt C. Autonomy vs. shame D. Intimacy vs. isolation 23. A nurse is making rounds taking vital signs. Which of the following vital signs is abnormal? A. 11 year old male 90 b.p.m, 22 resp/min., 100/70 mm Hg B. 13 year old female 105 b.p.m., 22 resp/min., 105/60 mm Hg C. 5 year old male- 102 b.p.m, 24 resp/min., 90/65 mm Hg D. 6 year old female- 100 b.p.m., 26 resp/min., 90/70mm Hg 24. When you are taking a patient's history, she tells you she has been depressed and is dealing with an anxiety disorder. Which of the following medications would the patient most likely be taking? A. Elavil B. Calcitonin C. Pergolide D. Verapamil 25. Which of the following conditions would a nurse not administer erythromycin? A. Campylobacterial infection B. Legionnaire's disease C. Pneumonia D. Multiple Sclerosis Answer Key 1. D 2. A 3. D 4. B 5. C 6. B 7. B 8. C 9. D 10. D 11. D 12. C 13. B 14. C 15. A 16. A 17. D 18. D 19. B 20. B 21. A 22. D 23. B 24. A 25. D

NCLEX Review Questions January 8, 2010 1. A female client with schizophrenia has been unresponsive to antipsychotic. The physician ordered Clozapine therapy to the client. The nurse informed the client that blood test will be done every week while receiving this drug. The client asks the nurse why blood test is needed. Which of the following is the most appropriate nursing response? A) Weekly blood test are necessary to determine safe dosage and to monitor the effect of the medication on the blood. B) Your physician will want to know how well you are progressing with the medication therapy. C) Everyone taking Clozapine has to go through the same procedure because it is required by the drug company. D) Weekly blood tests are done so that you can receive another weeks supply of the medication. 2. A 78-year-old does not want to eat lunch and complains that the food that is serve does not taste good. Consistent with knowledge about age-related changes to taste, the nurse may find that the client is more willing to eat. A) Greasy foods B) Sour foods C) Sweet foods D) Salty foods. 3. A client is admitted in the hospital. The client tells the nurse that she eats excessively when she is angry and then vomits so that she wont gain a lot of weight. The nurse suspects that the client is Bulimic. Which of the following nursing diagnostic categories would be most appropriate for this client? A) Generalized Anxiety B) Imbalanced Nutrition: More than body requirements C) Disabled Family Coping D) Ineffective Coping 4. The nurse is conducting health teaching about STD in the community health clinic. Which of the following health teaching about women who acquire gonorrhea should be included? A) Gonorrhea is usually a mild disease for women. B) Women are more reluctant than men to seek medical treatment. C) Gonorrhea is not easily transmitted to women who are menopausal. D) Women with gonorrhea are usually asymptomatic. 5. The nurse is preparing a discharge plan to a female client with peptic ulcer for the dietary modification she will need to follow at home. Which of the following statements indicates that the client understands the instruction of the nurse? A) I should not drink alcohol and caffeine. B) I should eat a bland, soft diet. C) It is important to eat six small meals a day. D) I should drink several glasses of milk a day. 6. A client has disabling attacks of vertigo. The nurse suspects that the client has Menieres disease. The nurse is aware that the diet of the client must be modified. Which of the following is the best diet for the client? A) High protein B) Low Carbohydrates C) Low Sodium D) Low Fat 7. Which of the following is the most common surgical procedure for chronic otitis media? A) Myringotomy B) Ossiculoplasty C) Mastoidectomy D) Tympanoplasty 8. A community health nurse is teaching smoking cessation program to a group of healthy adult smokers. What type of prevention activity is this? A) Primary B) Secondary C) Tertiary D) None of the above 9. A female client with breast cancer is currently receiving radiation therapy for treatment. The client is complaining of

apathy, hard to concentrate on something, and feeling tired despite of having time to rest and more sleep. These complains suggest symptoms of: A) Hypocalcemia B) radiation pneumonitis C) advanced breast cancer D) fatigue 10. Which of the following statements best describes the concept of autonomy? A) Health care team makes health and treatment decision B) The nurse provides the client with the facts and then allows the client to reach an unassisted decision. C) The professional staff of physician defines the clients best interest D) The nurse respects a clients choice not to know particular information. 11. The nurse is removing the clients staples from an abdominal when the client cough continuously and the incision splits open exposing the intestines. Which of the following is the immediate nursing action of the nurse? A) Call the surgeon to come to the clients room immediately B) Have all visitors and family member leave the room C) Press the emergency alarm to call the resuscitation team D) Cover the abdominal organs with sterile dressing moistened with sterile normal saline. 12. A client who had a cholecystectomy is transferred to the nursing unit. The nurse is assigned to monitor the vital signs of the client. How often should the post operative clients temperature be assessed during the first 24 hours after surgery? A) every 2 hours B) every 4 hours C) every 6 hours D) every 8 hours 13. The nurse manager is alarmed to the increase in the medication errors with IV antibiotics in the past month. The best action to resolve this issue is to discuss the problem with each nurse involved and : A) Report the incidents to the hospital lawyer B) Document It on their evaluation C) Report them to the supervisor D) Ask them to attend inservice training for administration of IV medication. 14. A client diagnosed with Paranoid Schizophrenia is receiving Haloperidol (Haldol), Benztropine (Congentin), Quetiapine (Seroquel) and Buspirone (Buspan). After 4 days of taking these medications, the client complains of blurred vision. Which of the following medication would the nurse suspects as the cause of this side effect? A) Benztropine (Congentine) B) Buspirone (Buspan) C) Haloperidol (Haldol) D) Quetiapine (Seroquel) 15. A nurse working in an alcohol rehabilitation program is providing a discharge instruction to a client. Which of the following would the nurse emphasize in the discharge plan as a priority? A) Follow-up care B) Supportive friends C) A list of goals D) Family forgiveness 16. A nurse is conducting a health teaching in the community health center to a group of female clients about contraceptive options. The nurse tells the clients that the intra uterine device (IUD) is a good contraceptive option for women who: A) have had a history of ectopic pregnancy B) desire short-term contraceptives C) are in monogamous relationship D) have a history of STDs 17. Which of the following signs and symptoms would indicate that a client has benign prostatic hypertrophy (BPH)? A) Hematuria B) Flank pain C) Impotence D) Difficulty starting the urinary stream 18. A male client who crashed his motorcycle is now

admitted to the emergency department. The client suffered tibial fracture that required casting. The physician prescribed Methocarbamol (Robaxin) to the client. Which of the following would the nurse identify as the drugs primary effect? A) Reduction in itching B) Decrease in nervousness C) Killing of microorganisms D) Relief of muscle spasms 19. The physician prescribed Ergotamine tartrate (Gynergen) for a client with migraine headaches. The client asks the nurse why she has migraine headaches. What is the nurses best response? A) Migraine headaches are believed to be caused by sustained contraction of muscles around the scalp and face. B) Migraine headaches are believed to be caused by the dilation of the cranial arteries. C) Migraine headaches are believed to be caused by irritations and inflammation of the openings of the sinuses. D) Migraine headaches are believed to be caused by temporary decrease in intracranial pressure. 20. A male client is receiving chemotherapy for lung cancer. He asks the nurse how the drug will work. Which of the following is the correct response of the nurse? A) Chemotherapy affects all rapidly dividing cells. B) Structure of the DNA is altered. C) Chemotherapy encourages cancer cells to divide. D) Cancer cells have susceptible drug toxins. 21. A 60-year-old client and his family receive the initial diagnosis of colon cancer. Which of the following demonstrate the nurse as the client advocate? A) The nurse will document the clients desire to try an alternative therapy. B) The nurse will provide the information about standard therapies. C) The nurse will allow the client to make health care choices on her own but will assist in ensuring the client is fully informed when making those decisions. D) The nurse will document the clients treatment choices and provide information about alternative therapies. 22. A client will be receiving general anesthesia. The nurse reviews the laboratory result of the client and found out that the serum potassium level is 5.8 mEq/L. What should be the nurses initial response? A) Send the client to surgery B) Notify the anesthesiologist C) Call the surgeon D) Send the client to surgery 23. A primiparous client who is beginning to breastfeed her neonates asks the nurse what contraception method she and her husband should use until she has her 6-week post partum examination. Which of the following would be most appropriate suggestion? A) Oral contraceptives B) Condom with spermicide C) Cervical cap D) Rhythm method 24. A mother who brings her 4-moth-old infant to the health clinic for check up thinks that her infant is developing slowly. When assessing the infants development, the infant should demonstrate which of the following characteristics? A) Sitting up with support B) Reaching for a toy C) Saying mama or dada D) Finger-to-thumb grasping 25. The nurse is instructing the unlicensed assistant on how to care for a client with chest tubes that are connected to water seal drainage. Which of the following instruction would be appropriate for the nurse to give the unlicensed assistant? A) Mark the time and amount of drainage collected in the container B) Raise the collection apparatus to the height of the bed to measure the fluid level. C) Milk the test tubes every 4 hours D) Attach the chest tubes to bed linen to avoid tension of the tubing 26. After the first three dose of Paroxetine (Paxil) 20 mg, the client complains that the medication upsets his stomach.

Which of the following instructions would the nurse give to the client? A) Take the medication with 4 ounces of orange juice. B) Take the medication an hour before breakfast. C) Take the medication at bedtime. D) Take the medication with some foods. 27. An unmarried pregnant teenager is scheduled for an abortion. The nurse is assigned to be the circulating nurse in the procedure. In countries like Philippines, it is not legal to perform this procedure. In this case, if the nurse participate in the procedure the nurse serves as the: A) Principal B) Accomplice C) Accessories D) Witness of the procedure done 28. A mother seeks an advice to the nurse on how to stop her 4-year-old son in sucking his thumb. Which of the following is the appropriate suggestion of the nurse? A) Put the child in time-out every time the mother observes thumb sucking. B) Apply a special medicine that tastes terrible on the thumb. C) Remind the child every time the mother sees the thumb in his mouth. D) Get the child agree to stop the thumb sucking. 29. A Mexican mother brings her 2-month-old son to the emergency department with high fever and possible sepsis. The physician ordered lumbar puncture to the client. The mother tells the nurse that she is not going to sign the informed consent form unless her husband gives permission to the procedure. The nurse understands that: A) This behavior is unusual for Mexican cultural norms B) This needs to be reported to the social worker. C) The Mexican is considered the head of the family and makes the major decision. D) This needs to be reported to the Childrens Protective Services. 30. The nurse manager assigned a nurse to perform care on the clients Hickman catheter according to hospital policy. After 24 hours the client complains of pain in the site. The nurse found out that the client develops an infection and is considering litigation. The nurses practice is: A) tort B) respondeat superior C) malpractice D) negligent ANSWERS & RATIONALE: 1. A = the client needs specific information about the effects of the drug, specifically its effect on the blood. The statement about weekly blood tests to determine safe dosage and monitoring for effects on the blood gives the client specific information to ensure follow up with the required protocol for Clorazil therapy. Lack of accurate knowledge can lead to noncompliance with necessary follow-up procedures and noncompliance with medication. C = the older adults taste buds retain their sensitivity to carbohydrates. In addition, carbohydrates. Tend to be food items that are easy to chew. Older adults lose their sensitivity to sour and salty foods. Older adults may find greasy foods harder to digest and therefore may avoid them; however, preference for greasy foods is not related to changes in taste associated with age. D = because the client eats excessively whenever she is upset. The best nursing diagnosis is effective coping. There are no data on the family to support Disabled Family Coping. The clients bingering and purging behavior occurs in response to her difficulty with coping. If the client were only overeating and not purging then Imbalanced Nutrition: More than body requirements would be an appropriate diagnosis. The client does not report nervousness and tension that would lead to a nursing diagnosis of Generalized Anxiety.

2.

3.

4.

5.

6.

7.

8. 9. 10.

11.

12.

13.

14. 15.

16.

17.

18.

D = Many women who acquire gonorrhea are asymptomatic or experience mild symptoms that are easily ignored. They are not necessarily more reluctant than men to seek medical treatment, but they are more likely not to realize they have been affected with a disease. Gonorrhea is easily transmitted to all women and can result in serious consequences such as pelvic inflammatory disease and infertility. A = caffeinated beverages and alcohol should be avoided because they stimulate gastric acid production and irritate gastric mucosa. The client should avoid foods that cause discomfort; however, there is no need to follow a soft, bland diet. Eating six small meals daily is no longer a common treatment for peptic ulcer disease. Milk in large quantities is not recommended because it actually stimulates further production of gastric acids. C = A low sodium diet is frequently an effective mechanism for reducing the frequency and severity of the disease episodes. About three-quarters of clients with Menieres disease respond to treatment with a low salt diet. D =Tympanoplasty involves surgical reconstruction as the tympanic membrane and is done to re-establish middle ear function, close perforation, prevent recurrent infections. A = primary cancer prevention targets healthy individuals and includes steps to avoid factors that might lead to the development of diseases. D = Fatigue is a common complaint of individuals receiving medication therapy. B = It is appropriate and ethical to respect the clients truly autonomous choice not to know particular information. The clients best interests should be determined by the client after he or she receives all the necessary information and in conjunction with other people of the clients choice, including family, physicians and other healthcare personnel D = When a wound eviscerates, the nurse should cover the open area with sterile dressing moistened with sterile normal saline and then cover it with a dry dressing. The surgeon should then be notified to take the client back to the operating room to close the incision under general anesthesia. B = The clients body temperature should be assessed every 4 hour during the first 24 hour because the client is still at risk for hypothermia or malignant hyperthermia. The client does not be checked every 2 hour unless indicated by an abnormal finding. D = Identification of causes of medication errors requires inservice education to inform the staff of strategies to decrease these errors. Errors are frequently the result of systemic problems that can be identified and rectified through problem-solving technique and changes in procedures. A = Benztropine (Congentine) frequently causes the side effects of blurred vision. A = A follow-up care is essential to present relapse. The recovery has just begun when the treatment program ends. The first few months after program completion can be difficult and dangerous for the chemically dependent client. The nurse is responsible for discharge plans that include arrangements for counseling, self help group meetings and other forms of after care. C = IUD is suitable for client who desire long-term contraceptive use and are in a monogamous relationships. Because of the increased risk of spread of infection with an IUD if an STD occurs, the device is not appropriate for women with multiple partners or history of STDs. D = the symptoms of BPH are related to obstruction as a result of an enlarged prostate. Difficulty in starting the urinary stream is a common symptom, along with dribbling, hesitancy and urinary retention. D = Methocarbamol (Robaxin) is a muscle relaxant and acts primarily to relieve muscle spasms.

19. B = Migraine headaches are believed to be caused by a vascular disturbance involving branches of the carotid artery where vasoconstriction of blood vessels apparently occurs first. 20. A = There are many mechanisms of action for chemotherapeutic agents, but most affect the rapidly dividing cells-both cancerous and noncancerous. Cancer cells are characterized by rapid cell division. Chemotherapy slows cell division. 21. C = Advocacy role of the nurse implies that the nurse will ensure that the clients wishes are being respected and that she is making informed decisions. 22. B = the nurse should notify the anesthesiologist because a serum potassium level of 5.8 mEq/L places the client at risk for dysrhythmias when under general anesthesia. 23. B = If not contraindicated for moral, cultural or religious reasons, a condom with spermicide is often recommended for contraception after delivery until the clients 6-weeks post partum examination. This method has no effect on the neonate who is breastfeeding. 24. A = typically, a 4-month-old infant should be able to sit with support from a person holding the infant lightly in the area of the hips or lower chest. 25. A = It is appropriate for an unlicensed assistant to mark the time of measurement and fluid level in the collection container. 26. D = Nausea and gastrointestinal upset is a common but usually temporary side effects of Paroxetine (Paxil). Therefore, the nurse would instruct the client to take the medication with food to minimize nausea and stomach upset. 27. B = the nurse serves as the accomplice because she participate or cooperate through another act essential to the consummation of the crime. 28. D = A 4-year-old is old enough to be able to cooperate and stop the behavior. Therefore, the first step is to obtain the childs cooperation. 29. C = In the traditional Mexican household, the man is the head of the family and makes the major decisions. Efforts should be made to reach the father as soon as possible to acquire his permission. 30. B = Respondeat superior is Latin for the master is responsible for the acts of his servants. The nurse, as an employee of the hospital, was acting according to the established policy of the hospital. Because the nurse followed hospital policy, it is unlikely that this incident involved malpractice, negligence or tort law.

General NCLEX Questions - 43 questions With Rationale. Monday, September 24, 2007

a. Cause cardiac arrest b. Cause hypotension c. Produce mild bradycardia d. Be very toxic even in small doses Answer: a Rationale: Kidney disease interferes with metabolism and excretion of Quinidine, resulting in higher drug concentrations in the body. Quinidine can depress myocardial excitability enough to cause cardiac arrest. 6. A client is about to be discharged on the drug bishydroxycoumarin (Dicumarol). Of the principles below, which one is the most important to teach the client before discharge? a. He should be sure to take the medication before meals b. He should shave with an electric razor c. If he misses a dose, he should double the dose at the next scheduled time d. It is the responsibility of the physician to do the teaching for this medication Answer: b Rationale: Dicumarol is an anticoagulant drug and one of the dangers involved is bleeding. Using a safety razor can lead to bleeding through cuts. The drug should be given at the same time daily but not related to meals. Due to danger of bleeding, missed doses should not be made up. 7. A cyanotic client with an unknown diagnosis is admitted to the emergency room. In relation to oxygen, the first nursing action would be to a. Wait until the client's lab work is done b. Not administer oxygen unless ordered by the physician c. Administer oxygen at 2 liters flow per minute d. Administer oxygen at 10 liters flow per minute and check the client's nail beds Answer: c Rationale: Administer oxygen at 2 liters per minute and no more, for if the client is emphysemic and receives too high a level of oxygen, he will develop CO2 narcosis and the respiratory system will cease to function 8. A client with a diagnosis of gout will be taking colchicine and allopurinol bid to prevent recurrence. The most common early sign of colchicine toxicity that the nurse will assess for is a. Blurred vision b. Anorexia c. Diarrhea d. Fever Answer: c Rationale: Diarrhea is by far the most common early sign of colchicine toxicity. When given in the acute phase of gout, the dose of colchicine is usually 0.6 mg (PO) q hr (not to exceed 10 tablets) until pain is relieved or gastrointestinal symptoms ensue. 9. A client has chronic dermatitis involving the neck, face and antecubital creases. She has a strong family history of varied allergy disorders. This type of dermatitis is probably best described as

1. After the lungs, the kidneys work to maintain body pH. The best explanation of how the kidneys accomplish regulation of pH is that they a. Secrete hydrogen ions and sodium. b. Secrete ammonia. c. Exchange hydrogen and sodium in the kidney tubules. d. Decrease sodium ions, hold on to hydrogen ions, and then secrete sodium bicarbonate. Answer: d Rationale: By decreasing NA+ ions, holding onto hydrogen ions, and secreting sodium bicarbonate, the kidneys can regulate pH. Therefore, this is the most complete answer, and while this buffer system is the slowest, it can completely compensate for acid-base imbalance. 2. (skip) 3. The nurse explains to a client who has just received the diagnosis of Noninsulin-Dependent Diabetes Mellitus (NIDDM) that sulfonylureas, one group of oral hypoglycemic agents, act by a. Stimulating the pancreas to produce or release insulin b. Making the insulin that is produced more available for use c. Lowering the blood sugar by facilitating the uptake and utilization of glucose d. Altering both fat and protein metabolism Answer: a Rationale: Sulfonylurea drugs, Orinase for example, lowers the blood sugar by stimulating the beta cells of the pancreas to synthesize and release insulin. 4. Myasthenic crisis and cholinergic crisis are the major complications of myasthenia gravis. Which of the following is essential nursing knowledge when caring for a client in crisis? a. Weakness and paralysis of the muscles for swallowing and breathing occur in either crisis b. Cholinergic drugs should be administered to prevent further complications associated with the crisis c. The clinical condition of the client usually improves after several days of treatment d. Loss of body function creates high levels of anxiety and fear Answer: a Rationale: The client cannot handle his own secretions, and respiratory arrest may be imminent. Atropine may be administered to prevent crisis. Anticholinergic drugs are administered to increase the levels of acetylcholine at the myoneural junction. Cholinergic drugs mimic the actions of the parasympathetic nervous system and would not be used. 5. A 54-year-old client was put in Quinidine (a drug that decreases myocardial excitability) to prevent atrial fibrillation. He also has kidney disease. The nurse is aware that this drug, when given to a client with kidney disease, may

decrease in the PaO2 below 60 mmHg. a. Contact dermatitis b. Atopic dermatitis c. Eczema d. Dermatitis medicamentosa Answer: b Rationale: Atopic dermatitis is chronic, pruritic and allergic in nature. Typically it has a longer course than contact dermatitis and is aggravated by commercial face or body lotions, emotional stress, and, in some instances, particular foods. 10. Skip 11. Skip 12. The nurse would expect to find an improvement in which of the blood values as a result of dialysis treatment? a. High serum creatinine levels b. Low hemoglobin c. Hypocalcemia d. Hypokalemia Answer: a Rationale: High creatinine levels will be decreased. Anemia is a result of decreased production of erythropoietin by the kidney and is not affected by hemodialysis. Hyperkalemia and high base bicarbonate levels are present in renal failure clients. 13. A 24-year-old client is admitted to the hospital following an automobile accident. She was brought in unconscious with the following vital signs: BP 130/76, P 100, R 16, T 98F. The nurse observes bleeding from the client's nose. Which of the following interventions will assist in determining the presence of cerebrospinal fluid? a. Obtain a culture of the specimen using sterile swabs and send to the laboratory b. Allow the drainage to drip on a sterile gauze and observe for a halo or ring around the blood c. Suction the nose gently with a bulb syringe and send specimen to the laboratory d. Insert sterile packing into the nares and remove in 24 hours Answer: b Rationale: The halo or "bull's eye" sign seen when drainage from the nose or ear of a head-injured client is collected on a sterile gauze is indicative of CSF in the drainage. The collection of a culture specimen using any type of swab or suction would be contraindicated because brain tissue may be inadvertently removed at the same time or other tissue damage may result. 14. A 24-year-old male is admitted with a possible head injury. His arterial blood gases show that his pH is less than 7.3, his PaCO2 is elevated above 60 mmHg, and his PaO2 is less than 45 mmHg. Evaluating this ABG panel, the nurse would conclude that a. Edema has resulted from a low pH state b. Acidosis has caused vasoconstriction of cerebral arterioles c. Cerebral edema has resulted from a low oxygen state d. Cerebral blood flow has decreased Answer: c Rationale: Hypoxic states may cause cerebral edema. Hypoxia also causes cerebral vasodilatation particularly in response to a Answer: d Rationale: Laceration, a more severe consequence of closed head injury, occurs as the brain tissue moves across the uneven base of the skull in a contusion. Contusion causes cerebral dysfunction which results in bruising of the brain. A concussion causes transient loss of consciousness, retrograde amnesia, and is generally reversible. 17. A client with tuberculosis is given the drug pyrazinamide (Pyrazinamide). Which one of the following diagnostic tests would be inaccurate if the client is receiving the drug? a. Liver function test b. Gall bladder studies c. Thyroid function studies d. Blood glucose Answer: a Rationale: Liver function tests can be elevated in clients taking pyrazinamide. This drug is used when primary and secondary antitubercular drugs are not effective. Urate levels may be increased and there is a chemical interference with urine ketone levels if these tests are done while the client is on the drug. 18. Which one of the following conditions could lead to an inaccurate pulse oximetry reading if the sensor is attached to the client's ear? a. Artificial nails b. Vasodilation c. Hypothermia d. Movement of the head Answer: c Rationale: Hypothermia or fever may lead to an inaccurate reading. Artificial nails may distort a reading if a finger probe is used. Vasoconstriction can cause an inaccurate reading of oxygen saturation. Arterial saturations have a close correlation with the reading from the pulse oximeter as long as the arterial saturation is above 70 percent. 19. While on a camping trip, a friend sustains a snake bite from a poisonous snake. The most effective initial intervention would be to a. Place a restrictive band above the snake bite b. Elevate the bite area above the level of the heart c. Position the client in a supine position d. Immobilize the limb Answer: a Rationale: A restrictive band 2 to 4 inches above the snake 15. Skip 16. A client is admitted following an automobile accident in which he sustained a contusion. The nurse knows that the significance of a contusion is a. That it is reversible b. Amnesia will occur c. Loss of consciousness may be transient d. Laceration of the brain may occur

bite is most effective in containing the venom and minimizing lymphatic and superficial venous return. Elevation of the limb or immobilization would not be effective interventions. 20. There is a physician's order to irrigate a client's bladder. Which one of the following nursing measures will ensure patency? a. Use a solution of sterile water for the irrigation b. Apply a small amount of pressure to push the mucus out of the catheter tip if the tube is not patent c. Carefully insert about 100 mL of aqueous Zephiran into the bladder, allow it to remain for 10 hour, and then siphon it out d. Irrigate with 20mL's of normal saline to establish patency Answer: d Rationale: Normal saline is the fluid of choice for irrigation. It is never advisable to force fluids into a tubing to check for patency. Sterile water and aqueous Zephiran will affect the pH of the bladder as well as cause irritation. 21. A female client has orders for an oral cholecystogram. Prior to the test, the nursing intervention would be to a. Provide a high fat diet for dinner, then NPO b. Explain that diarrhea may result from the dye tablets c. Administer the dye tablets following a regular diet for dinner d. Administer enemas until clear Answer: b Rationale: Diarrhea is a very common response to the dye tablets. A dinner of tea and toast is usually given to the client. Each dye tablet is given at 5 minute intervals, usually with 1 glass of water following each tablet. The number of tablets prescribed will vary, because it is based on the weight of the client. 22. The physician has just completed a liver biopsy. Immediately following the procedure, the nurse will position the client a. On his right side to promote hemostasis b. In Fowler's position to facilitate ventilation c. Supine to maintain blood pressure d. In Sims' position to prevent aspiration Answer: a Rationale: Placing the client on his right side will allow pressure to be placed on the puncture site, thus promoting hemostasis and preventing hemorrhage. The other positions will not be effective in achieving these goals. 23. When a client has peptic ulcer disease, the nurse would expect a priority intervention to be a. Assisting in inserting a Miller-Abbott tube b. Assisting in inserting an arterial pressure line c. Inserting a nasogastric tube d. Inserting an IV Answer: c Rationale: An NG tube insertion is the most appropriate intervention because it will determine the presence of active gastrointestinal bleeding. A MillerAbbott tube is a weighted, mercury-filled ballooned tube used to resolve bowel obstructions. There is no evidence of shock

or fluid overload in the client; therefore, an arterial line is not appropriate at this time and an IV is optional. 24. Skip 25. In preparation for discharge of a client with arterial insufficiency and Raynaud's disease, client teaching instructions should include a. Walking several times each day as a part of an exercise routine b. Keeping the heat up so that the environment is warm c. Wearing TED hose during the day d. Using hydrotherapy for increasing oxygenation Answer: b Rationale: The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will also be useful in preventing vasoconstriction, but TED hose would not be therapeutic. Walking will most likely increase pain. 26. When a client asks the nurse why the physician says he "thinks" he has tuberculosis, the nurse explains to him that diagnosis of tuberculosis can take several weeks to confirm. Which of the following statements supports this answer? a. A positive reaction to a tuberculosis skin test indicates that the client has active tuberculosis, even if one negative sputum is obtained b. A positive sputum culture takes at least 3 weeks, due to the slow reproduction of the bacillus c. Because small lesions are hard to detect on chest x-rays, xrays usually need to be repeated during several consecutive weeks d. A client with a positive smear will have to have a positive culture to confirm the diagnosis Answer: b Rationale: Answer b is correct because the culture takes 3 weeks to grow. Usually even very small lesions can be seen on x-rays due to the natural contrast of the air in the lungs; therefore, chest x-rays do not need to be repeated frequently (c). Clients may have positive smears but negative cultures if they have been on medication (d). A positive skin test indicates the person only has been infected with tuberculosis but may not necessarily have active disease (a). 27. The nurse is counseling a client with the diagnosis of glaucoma. She explains that if left untreated, this condition leads to a. Blindness b. Myopia c. Retrolental fibroplasia d. Uveitis Answer: a Rationale: The increase in intraocular pressure causes atrophy of the retinal ganglion cells and the optic nerve, and leads eventually to blindness. 28. A nursing assessment for initial signs of hypoglycemia will include a. Pallor, blurred vision, weakness, behavioral changes

b. Frequent urination, flushed face, pleural friction rub c. Abdominal pain, diminished deep tendon reflexes, double vision d. Weakness, lassitude, irregular pulse, dilated pupils

a. Check that a hemostat is at the bedside b. Monitor IV fluids for the shift c. Regularly assess respiratory status d. Check that the balloon is deflated on a regular basis Answer: c Rationale: 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. 33. A 55-year-old client with sever epigastric pain due to acute pancreatitis has been admitted to the hospital. The client's activity at this time should be a. Ambulation as desired b. Bedrest in supine position c. Up ad lib and right side-lying position in bed d. Bedrest in Fowler's position Answer: d Rationale: The pain of pancreatitis is made worse by walking and supine positioning. The client is more comfortable sitting up and leaning forward. 34. Of the following blood gas values, the one the nurse would expect to see in the client with acute renal failure is a. pH 7.49, HCO3 24, PCO2 46 b. pH 7.49, HCO3 14, PCO2 30 c. pH 7.26, HCO3 24, PCO2 46 d. pH 7.26, HCO3 14, PCO2 30 Answer: d Rationale: The client with acute renal failure would be expected to have metabolic acidosis (low HCO3) resulting in acid blood pH (acidemia) and respiratory alkalosis (lowered PCO2) as a compensating mechanism. Normal values are pH 7.35 to 7.45; HCO3 23 to 27 mEg; and PCO2 35 to 45 mmHg. 35. A client in acute renal failure receives an IV infusion of 10% dextrose in water with 20 units of regular insulin. The nurse understands that the rationale for this therapy is to a. Correct the hyperglycemia that occurs with acute renal failure b. Facilitate the intracellular movement of potassium c. Provide calories to prevent tissue catabolism and azotemia d. Force potassium into the cells to prevent arrhythmias Answer: b Rationale: Dextrose with insulin helps move potassium into cells and is immediate management therapy for hyperkalemia due to acute renal failure. An exchange resin may also be employed. This type of infusion is often administered before cardiac surgery to stabilize irritable cells and prevent arrhythmias; in this case KC1 is also added to the infusion. 36. Skip

Answer: a Rationale: Weakness, fainting, blurred vision, pallor and perspiration are all common symptoms when there is too much insulin or too little food - hypoglycemia. The signs and symptoms in answers (b) and (c) are indicative of hyperglycemia. 29. The physician has ordered a 24-hour urine specimen. After explaining the procedure to the client, the nurse collects the first specimen. This specimen is then a. Discarded, then the collection begins b. Saved as part of the 24-hour collection c. Tested, then discarded d. Placed in a separate container and later added to the collection Answer: a Rationale: The first specimen is discarded because it is considered "old urine" or urine that was in the bladder before the test began. After the first discarded specimen, urine is collected for 24 hours. 30. Following an accident, a client is admitted with a head injury and concurrent cervical spine injury. The physician will use Crutchfield tongs. The purpose of these tongs is to a. Hypoextend the vertebral column b. Hyperextend the vertebral column c. Decompress the spinal nerves d. Allow the client to sit up and move without twisting his spine Answer: b Rationale: The purpose of the tongs is to decompress the vertebral column through hyperextending it. Both (a) and (c) are incorrect because they might cause further damage. (d) is incorrect because the client cannot sit up with the tongs in place; only the head of the bed can be elevated. 31. The most appropriate nursing intervention for a client requiring a finger probe pulse oximeter is to a. Apply the sensor probe over a finger and cover lightly with gauze to prevent skin breakdown b. Set alarms on the oximeter to at least 100 percent c. Identify if the client has had a recent diagnostic test using intravenous dye d. Remove the sensor between oxygen saturation readings Answer: c Rationale: Clients may experience inaccurate readings if dye has been used for a diagnostic test. Dyes use colors that tint the blood which leads to inaccurate readings. 32. 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

37. Skip 38. A client has had a cystectomy and ureteroileostomy (ileal conduit). The nurse observes this client for

complications in the postoperative period. Which of the following symptoms indicates an unexpected outcome and requires priority care? a. Edema of the stoma b. Mucus in the drainage appliance c. Redness of the stoma d. Feces in the drainage appliance Answer: d Rationale: The ileal conduit procedure incorporates implantation of the ureters into a portion of the ileum which has been resected from its anatomical position and now functions as a reservoir or conduit for urine. The proximal and distal ileal borders can be resumed. Feces should not be draining from the conduit. Edema and a red color of the stoma are expected outcomes in the immediate postoperative period, as is mucus from the stoma. 39. A nursing care plan for a client with a suprapubic cystostomy would include a. Placing a urinal bag around the tube insertion to collect the urine b. Clamping the tube and allowing the client to void through the urinary meatus before removing the tube c. Catheter irrigations every 4 hours to prevent formation of urinary stones d. Limiting fluid intake to 1500 mL per day Answer: b Rationale: Allowing the client to void naturally will be done prior to removal of the catheter to ensure adequate emptying of the bladder. Irrigations are not recommended, as they increase the chances of the client developing a urinary tract infection. Any time a client has an indwelling catheter in place, fluids should be encouraged (unless contraindicated) to prevent stone formation. 40. For a client who has ataxia, which of the following tests would be performed to assess the ability to ambulate? a. Kernig's b. Romberg's c. Riley-Day's d. Hoffmann's Answer: b Rationale: Romberg's test is the ability to maintain an upright position without swaying when standing with feet close together and eyes closed. Kernig's sign, a reflex contraction, is pain in the hamstring muscle when attempting to extend the leg after flexing the thigh. 41. A client admitted to a surgical unit for possible bleeding in the cerebrum has vital signs taken every hour to monitor to neurological status. Which of the following neurological checks will give the nurse the best information about the extent of bleeding? a. Pupillary checks b. Spinal tap c. Deep tendon reflexes d. Evaluation of extrapyramidal motor system Answer: a

Rationale: Pupillary checks reflect function of the third cranial nerve, which stretches as it becomes displaced by blood, tumor, etc. 42. Assessing for immediate postoperative complications, the nurse knows that a complication likely to occur following unresolved atelectasis is a. Hemorrhage b. Infection c. Pneumonia d. Pulmonary embolism Answer: c Rationale: Pneumonia is a major complication of unresolved atelectasis and must be treated along with vigorous treatment for atelectasis. Hemorrhage and infection are not related to this condition. Pulmonary embolism could result from deep vein thrombosis. 43. A young client is in the hospital with his left leg in Buck's traction. The team leader asks the nurse to place a footplate on the affected side at the bottom of the bed. The purpose of this action is to a. Anchor the traction b. Prevent footdrop c. Keep the client from sliding down in bed d. Prevent pressure areas on the foot Answer: b Rationale: The purpose of the footplate is to prevent footdrop while the client is immobilized in traction. This will not anchor the traction, keep the client from sliding down in bed, or prevent pressure areas. SOURCE: http://wwwunix.oit.umass.edu/~helene/Nclexfinal.htm