NCLEX Practice Questions — Set 37
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiographic complexes on the screen. Which is the priority action of the nurse?
Show answer and rationale
Correct answer: B. Check the client’s status and lead placement.
Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. The remaining options are secondary to client assessment.
The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats/minute. The nurse determines that the client is experiencing which dysrhythmia?
Show answer and rationale
Correct answer: B. Ventricular tachycardia
Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 second), and typically a rate between 140 and 180 impulses/minute. The rhythm is regular.
A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia?
Show answer and rationale
Correct answer: B. It can develop into ventricular fibrillation at any time.
Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Clients frequently experience a feeling of impending doom. Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (if client is awake), or defibrillation (loss of consciousness). Ventricular tachycardia can deteriorate into ventricular fibrillation at any time.
A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item?
Show answer and rationale
Correct answer: C. Blood pressure and oxygen saturation
Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders, states of hypoxemia, or by any number of physiologicalstressors, such as infection, illness, surgery, or trauma, and by intake of caffeine, nicotine, or alcohol.
The nurse is watching the cardiac monitor, and a client’s rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret the client’s heart rhythm?
Show answer and rationale
Correct answer: D. Atrial fibrillation
Atrial fibrillation is characterized by a loss of P waves and fibrillatory waves before each QRS complex. The atria quiver, which can lead to thrombus formation.
The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the paddles on the client’s chest and before discharging them, which intervention should be done?
Show answer and rationale
Correct answer: A. Confirm that the rhythm is actually ventricular fibrillation.
Until the defibrillator is attached and charged, the client is resuscitated by using cardiopulmonary resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for any loose connections. A nitroglycerin patch, if present, is removed. The client does not have to be intubated to be defibrillated. The machine is not set to the synchronous mode because there is no underlying rhythm with which to synchronize. Amiodarone may be given subsequently but is not required before defibrillation.
A client in ventricular fibrillation is about to be defibrillated. A nurse knows that to convert this rhythm effectively, the monophasic defibrillator machine should be set at which energy level (in joules, J) for the first delivery?
Show answer and rationale
Correct answer: B. 360 J
The energy level used for all defibrillation attempts with a monophasic defibrillator is 360 joules.
The nurse would evaluate that defibrillation of a client was most successful if which observation was made?
Show answer and rationale
Correct answer: B. Arousable, sinus rhythm, BP 116/72 mm Hg
After defibrillation, the client requires continuous monitoring of electrocardiographic rhythm, hemodynamic status, and neurologicalstatus. Respiratory and metabolic acidosis develop during ventricular fibrillation because of lack of respiration and cardiac output. These can cause cerebral and cardiopulmonary complications. Arousable status, adequate blood pressure, and a sinus rhythm indicate successful response to defibrillation.
The nurse is evaluating a client’s response to cardioversion. Which observation would be of highest priority to the nurse?
Show answer and rationale
Correct answer: B. Status of airway
Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administration, assessment of vitalsigns and level of consciousness, and dysrhythmia detection.
A client’s electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 second, the QRS complex measures 0.08 second, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm?
Show answer and rationale
Correct answer: B. Sinus tachycardia
Sinus tachycardia has the characteristics of normalsinus rhythm, including a regular PP interval and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats/minute.
The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client’s neurovascular status?
Show answer and rationale
Correct answer: D. The neurovascular status is normal because of increased blood flow through the leg.
An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. The remaining options are incorrect interpretations.
The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was unsuccessful?
Show answer and rationale
Correct answer: C. Rising central venous pressure
Following pericardiocentesis, a rise in blood pressure and a fall in central venous pressure are expected. The client usually expresses immediate relief. Heart sounds are no longer muffled or distant.
The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous infusion at a rate of 150 mL/hour, unchanged for the last 10 hours. The client’s urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL most recent). The client’s blood urea nitrogen level is 35 mg/dL and the serum creatinine level is 1.8 mg/dL, measured this morning. Which nursing action is the priority?
Show answer and rationale
Correct answer: A. Call the health care provider (HCP).
Following abdominal aortic aneurysm resection or repair, the nurse monitors the client for signs of acute kidney injury. Acute kidney injury can occur because often much blood is lost during the surgery and, depending on the aneurysm location, the renal arteries may be hypoperfused for a short period during surgery. The IV should have already been on a pump. Urine output lower than 30 mL/hour is reported to the HCP.
A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often at rest in the absence of precipitating factors. How would the nurse best describe this type of anginal pain?
Show answer and rationale
Correct answer: A. Variant angina
Variant angina, or Prinzmetal’s angina, is prolonged and severe and occurs at the same time each day, most often at rest. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction.
The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client’s rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How should the nurse correctly interpret this rhythm?
Show answer and rationale
Correct answer: D. Ventricular fibrillation
Ventricular fibrillation is characterized by irregular chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles.
A client who is receiving digoxin (Lanoxin) daily has a serum potassium level of 3 mEq/L and is complaining of anorexia. The health care provider prescribes determination of the serum digoxin level to rule out digoxin toxicity. The nurse checks the results, knowing that which value is the therapeutic serum level (range) for digoxin?
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Correct answer: A. 0.5 to 2 ng/mL
Therapeutic levels for digoxin range from 0.5 to 2 ng/mL.
The nurse is monitoring a client who is taking propranolol (Inderal LA). Which assessment data indicates a potential serious complication associated with this medication?
Show answer and rationale
Correct answer: A. The development of audible expiratory wheezes
Audible expiratory wheezes may indicate a serious adverse reaction, bronchospasm. ?-Blockers may induce this reaction, particularly in clients with chronic obstructive pulmonary disease or asthma. Normal decreases in blood pressure and heart rate are expected. Insomnia is a frequent mild side effect and should be monitored.
A client is diagnosed with an ST-segment elevation myocardial infarction (STEMI) and is receiving tissue plasminogen activator, alteplase (Activase, tPA). Which action is a priority nursing intervention?
Show answer and rationale
Correct answer: B. Monitor for signs of bleeding.
Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication of any type of thrombolytic medication. The client is monitored for bleeding. Monitoring for renal failure and monitoring the client’s psychosocialstatus are important but are not the most critical interventions. Heparin may be administered after thrombolytic therapy, but the question is not asking about follow-up medications.
The nurse is planning to administer hydrochlorothiazide to a client. The nurse understands that which is a concern related to the administration of this medication?
Show answer and rationale
Correct answer: D. Hypokalemia, hyperglycemia, sulfa allergy
Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia.
The nurse is monitoring a client who is taking digoxin (Lanoxin) for adverse effects. Which findings are characteristic of digoxin toxicity? Select all that apply.
Show answer and rationale
Correct answer: B. Diarrhea
Digoxin (Lanoxin) is a cardiac glycoside. The risk of toxicity can occur with the use of this medication. Toxicity can lead to life-threatening events and the nurse needs to monitor the client closely for signs of toxicity. Early signs of toxicity include gastrointestinal manifestations such as anorexia, nausea, vomiting, and diarrhea. Subsequent manifestations include headache; visual disturbances such as diplopia, blurred vision, yellow-green halos, and photophobia; drowsiness; fatigue; and weakness. Cardiac rhythm abnormalities can also occur. The nurse also monitors the digoxin level. Therapeutic levels for digoxin range from 0.5 to 2 ng/mL.
Prior to administering a client’s daily dose of digoxin, the nurse reviews the client’s laboratory data and notes the following results: serum calcium, 9.8 mg/dL; serum magnesium, 1.2 mg/dL; serum potassium, 4.1 mEq/L; serum creatinine, 0.9 mg/dL. Which result should alert the nurse that the client is at risk for digoxin toxicity?
Show answer and rationale
Correct answer: D. Serum magnesium level
An increased risk of toxicity exists in clients with hypercalcemia, hypokalemia, hypomagnesemia, hypothyroidism, and impaired renal function. The calcium, creatinine, and potassium levels are all within normal limits. The normal range for magnesium is 1.6 to 2.6 mg/dL and the results in the correct option are reflective of hypomagnesemia.
A client being treated for heart failure is administered intravenous bumetanide. Which outcome indicates the medication has achieved the expected effect?
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Correct answer: D. Urine output increases from 10 mL/hour to greater than 50 mL hourly
Bumetanide is a diuretic and expected outcomes include increased urine output, decreased crackles, and decreased weight.
Intravenous heparin therapy is prescribed for a client. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit?
Show answer and rationale
Correct answer: B. Protamine sulfate
The antidote to heparin is protamine sulfate; it should be readily available for use if excessive bleeding or hemorrhage should occur. Vitamin K is an antidote for warfarin sodium. Potassium chloride is administered for a potassium deficit. Aminocaproic acid is the antidote for thrombolytic therapy.
A client receiving thrombolytic therapy with a continuous infusion of alteplase (Activase) suddenly becomes extremely anxious and complains of itching. The nurse hears stridor and notes generalized urticaria and hypotension. Which nursing action is the priority?
Show answer and rationale
Correct answer: C. Stop the infusion and call the health care provider (HCP).
The client is experiencing an anaphylactic reaction. Therefore, the priority action is to stop the infusion and notify the HCP. The client may be treated with epinephrine, antihistamines, and corticosteroids as prescribed.
The nurse should report which assessment finding to the health care provider (HCP) before initiating thrombolytic therapy in a client with pulmonary embolism?
Show answer and rationale
Correct answer: A. Blood pressure of 198/110 mm Hg
Thrombolytic therapy is contraindicated in a number of preexisting conditions in which there is a risk of uncontrolled bleeding, similar to the case in anticoagulant therapy. Thrombolytic therapy also is contraindicated in severe uncontrolled hypertension because of the risk of cerebral hemorrhage. Therefore the nurse would report the results of the blood pressure to the HCP before initiating therapy.
A client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious and the nurse suspects air embolism. What is the priority nursing action?
Show answer and rationale
Correct answer: B. Discontinue dialysis and notify the health care provider (HCP).
If the client experiences air embolus during hemodialysis, the nurse should terminate dialysis immediately, notify the HCP, and administer oxygen as needed.
A client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of which condition?
Show answer and rationale
Correct answer: D. Trauma to the bladder or abdomen
Bladder trauma or injury should be considered or suspected in the client with low abdominal pain and hematuria. Glomerulonephritis and pyelonephritis would be accompanied by fever and are thus not applicable to the client described in this question. Renal cancer would not cause pain that is felt in the low abdomen; rather, the pain would be in the flank area.
A client is admitted to the emergency department following a motor vehicle accident. The client was wearing a lap seat belt when the accident occurred and now the client has hematuria and lower abdominal pain. To assess further whether the pain is caused by bladder trauma, the nurse should ask the client if the pain is referred to which area?
Show answer and rationale
Correct answer: C. Shoulder
Bladder trauma or injury is characterized by lower abdominal pain that may radiate to one of the shoulders due to phrenic nerve irritation. Bladder injury pain does not radiate to the umbilicus, costovertebral angle, or hip.
A client is admitted to the emergency department following a fall from a horse and the health care provider (HCP) prescribes insertion of a Foley catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take which action?
Show answer and rationale
Correct answer: B. Notify the HCP.
The presence of blood at the urinary meatus may indicate urethral trauma or disruption. The nurse notifies the HCP, knowing that the client should not be catheterized until the cause of the bleeding is determined by diagnostic testing.
The nurse is assessing the patency of a client’s left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent?
Show answer and rationale
Correct answer: B. Palpation of a thrill over the fistula
The nurse assesses the patency of the fistula by palpating for the presence of a thrill or auscultating for a bruit. The presence of a thrill and bruit indicate patency of the fistula. Although the presence of a radial pulse in the left wrist and capillary refillshorter than 3 seconds in the nail beds of the fingers on the left hand are normal findings, they do not assess fistula patency.
A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder?
Show answer and rationale
Correct answer: D. Dysuria and penile discharge
Urethritis in the male client often results from chlamydial infection and is characterized by dysuria, which is accompanied by a clear to mucopurulent discharge. Because this disorder often coexists with gonorrhea, diagnostic tests are done for both and include culture and rapid assays.
The nurse is assessing a client with epididymitis. The nurse anticipates which findings on physical examination?
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Correct answer: C. Fever, nausea, vomiting, and painful scrotal edema
Typicalsigns and symptoms of epididymitis include scrotal pain and edema, which often are accompanied by fever, nausea and vomiting, and chills. Epididymitis most often is caused by infection, although sometimes it can be caused by trauma. Epididymitis needs to be distinguished correctly from testicular torsion.
A client complains of fever, perineal pain, and urinary urgency, frequency, and dysuria. To assess whether the client’s problem is related to bacterial prostatitis, the nurse reviews the results of the prostate examination for which characteristic of this disorder?
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Correct answer: C. Tender, indurated prostate gland that is warm to the touch
The client with bacterial prostatitis has a swollen and tender prostate gland that is also warm to the touch, firm, and indurated. Systemic symptoms include fever with chills, perineal and low back pain, and signs of urinary tract infection, which often accompany the disorder.
A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess the client for which manifestations of this complication?
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Correct answer: C. Pallor, diminished pulse, and pain in the left hand
Stealsyndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and a diminished pulse distal to the fistula. The client also complains of pain distal to the fistula, caused by tissue ischemia. Warmth and redness probably would characterize a problem with infection.
The nurse is reviewing a client’s record and notes that the health care provider has documented that the client has a renal function disorder. On review of the laboratory results, the nurse most likely would expect to note which finding?
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Correct answer: D. Elevated creatinine level
Measuring the creatinine level is a frequently used laboratory test to determine renal function. The creatinine level increases when at least 50% of renal function is lost. A decreased hemoglobin level and red blood cell count may be noted if bleeding from the urinary tract occurs or if erythropoietic function by the kidney is impaired. An increased white blood cell count is most likely to be noted in renal disease.
A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client’s temperature is 100.2� F. Which nursing action is most appropriate?
Show answer and rationale
Correct answer: C. Continue to monitor vital signs.
The client may have an elevated temperature following dialysis because the dialysis machine warms the blood slightly. Therefore it is not necessary to notify the health care provider. If the temperature is elevated excessively and remains elevated, sepsis would be suspected and a blood sample would be obtained as prescribed for culture and sensitivity determinations. Encouraging fluids is an unsafe action for a client with chronic kidney disease. Since an elevated temperature is expected following dialysis, monitoring the site for infection is unnecessary.
The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the most appropriate nursing action?
Show answer and rationale
Correct answer: A. Notify the health care provider (HCP).
Disequilibrium syndrome may be caused by the rapid decreases in the blood urea nitrogen level during hemodialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs/symptoms of disequilibrium syndrome and appropriate treatments with anticonvulsive medications and barbiturates may be necessary to prevent a life-threatening situation. The HCP must be notified.
A client newly diagnosed with chronic kidney disease has just been started on peritoneal dialysis. During the infusion of the dialysate, the client complains of abdominal pain. Which action by the nurse is most appropriate?
Show answer and rationale
Correct answer: D. Explain that the pain will subside after the first few exchanges.
Pain during the inflow of dialysate is common during the first few exchanges because of peritoneal irritation; however, the pain usually disappears after 1 to 2 weeks of treatment. The infusion amount should not be decreased, and the infusion should not be slowed or stopped.
The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication?
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Correct answer: C. Hyperglycemia
An extended dwell time increases the risk of hyperglycemia in the client with diabetes mellitus as a result of absorption of glucose from the dialysate and electrolyte changes. Diabetic clients may require extra insulin when receiving peritoneal dialysis.
A week after kidney transplantation, a client develops a temperature of 101� F, the blood pressure is elevated, and the kidney is tender. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse suspects which complication?
Show answer and rationale
Correct answer: B. Acute rejection
Acute rejection most often occurs in the first 2 weeks after transplantation. Clinical manifestations include fever, malaise, elevated white blood cell count, acute hypertension, graft tenderness, and manifestations of deteriorating renal function. Chronic rejection occurs gradually over a period of months to years. Although kidney infection or obstruction can occur, the symptoms presented in the question do not relate specifically to these disorders.
The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations?
Show answer and rationale
Correct answer: D. Headache, deteriorating level of consciousness, and twitching
Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing increased intracranial pressure and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates.
A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which medication?
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Correct answer: D. Decongestants
In the client with benign prostatic hyperplasia, episodes of urinary retention can be triggered by certain medications, such as decongestants, anticholinergics, and antidepressants. The client should be questioned about the use of these medications if the client has urinary retention. Retention also can be precipitated by other factors, such as alcoholic beverages, infection, bed rest, and becoming chilled.
Nitrofurantoin (Macrodantin) is prescribed for a client with a urinary tract infection. The client contacts the nurse and reports a cough, chills, fever, and difficulty breathing. The nurse should make which interpretation about the client’s complaints?
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Correct answer: D. The client is experiencing a pulmonary reaction requiring cessation of the medication.
Nitrofurantoin can induce two kinds of pulmonary reactions: acute and subacute. Acute reactions, which are most common, manifest with dyspnea, chest pain, chills, fever, cough, and alveolar infiltrates. These symptoms resolve 2 to 4 days after discontinuing the medication. Acute pulmonary responses are thought to be hypersensitivity reactions. Subacute reactions are rare and occur during prolonged treatment. Symptoms (e.g., dyspnea, cough, malaise) usually regress over weeks to months following nitrofurantoin withdrawal. However, in some clients, permanent lung damage may occur. The remaining options are incorrect interpretations.
The nurse is providing discharge instructions to a client receiving sulfamethoxazole. Which instruction should be included in the list?
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Correct answer: A. Maintain a high fluid intake.
Each dose of sulfamethoxazole should be administered with a full glass of water, and the client should maintain a high fluid intake. The medication is more soluble in alkaline urine. The client should not be instructed to taper or discontinue the dose. Some forms of sulfamethoxazole cause urine to turn dark brown or red. This does not indicate the need to notify the HCP.
Trimethoprim-sulfamethoxazole (TMP-SMZ; Bactrim) is prescribed for a client. The nurse should instruct the client to report which symptom if it develops during the course of this medication therapy?
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Correct answer: A. Sore throat
Clients taking trimethoprim (TMP)-sulfamethoxazole (SMZ) should be informed about early signs/symptoms of blood disorders that can occur from this medication. These include sore throat, fever, and pallor, and the client should be instructed to notify the health care provider (HCP) if these occur. The other options do not require HCP notification.
Phenazopyridine (Pyridium) is prescribed for a client for symptomatic relief of pain resulting from a lower urinary tract infection. The nurse should provide the client with which information regarding this medication?
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Correct answer: D. A reddish orange discoloration of the urine may occur.
The nurse should instruct the client that a reddish-orange discoloration of urine may occur. The nurse also should instruct the client that this discoloration can stain fabric. The medication should be taken after meals to reduce the possibility of gastrointestinal upset. A headache is an occasionalside effect of the medication and does not warrant discontinuation of the medication.
Bethanechol chloride (Urecholine) is prescribed for a client with urinary retention. Which disorder would be a contraindication to the administration of this medication?
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Correct answer: D. Urinary strictures
Bethanechol chloride (Urecholine) can be hazardous to clients with urinary tract obstruction or weakness of the bladder wall. The medication has the ability to contract the bladder and thereby increase pressure within the urinary tract. Elevation of pressure within the urinary tract could rupture the bladder in clients with these conditions.
The nurse, who is administering bethanechol chloride (Urecholine), is monitoring for cholinergic overdose associated with the medication. The nurse should check the client for which sign of overdose?
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Correct answer: B. Bradycardia
Cholinergic overdose of bethanechol chloride produces manifestations of excessive muscarinic stimulation such as salivation, sweating, involuntary urination and defecation, bradycardia, and severe hypotension. Treatment includes supportive measures and the administration of atropine sulfate subcutaneously or intravenously.
Oxybutynin chloride (Ditropan XL) is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication?
Show answer and rationale
Correct answer: C. Restlessness
Toxicity (overdosage) of oxybutynin produces central nervous system excitation, such as nervousness, restlessness, hallucinations, and irritability. Other signs of toxicity include hypotension or hypertension, confusion, tachycardia, flushed or red face, and signs of respiratory depression. Drowsiness is a frequent side effect of the medication but does not indicate overdosage.
Following kidney transplantation, cyclosporine (Sandimmune) is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication?
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Correct answer: C. Elevated blood urea nitrogen level
Nephrotoxicity can occur from the use of cyclosporine (Sandimmune). Nephrotoxicity is evaluated by monitoring for elevated blood urea nitrogen and serum creatinine levels. Cyclosporine does not depress the bone marrow.
Tacrolimus (Prograf) is prescribed for a client. Which disorder, if noted in the client’s record, would indicate that the medication needs to be administered with caution?
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Correct answer: B. Pancreatitis
Tacrolimus (Prograf) is used with caution in immunosuppressed clients and in clients with renal, hepatic, or pancreatic function impairment. Tacrolimus is contraindicated in clients with hypersensitivity to this medication or hypersensitivity to cyclosporine.
The nurse receives a call from a client concerned about eliminating browncolored urine after taking nitrofurantoin (Furadantin) for a urinary tract infection. The nurse should make which appropriate response?
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Correct answer: D. "Continue taking the medication because the urine is discolored from the medication."
Nitrofurantoin (Furadantin) imparts a harmless brown color to the urine and the medication should not be discontinued until the prescribed dose is completed. Magnesium hydroxide (Maalox) will not affect urine color. In addition, antacids should be avoided because they interfere with medication effectiveness.
A client with chronic kidney disease is receiving epoetin alfa (Epogen). Which laboratory result would indicate a therapeutic effect of the medication?
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Correct answer: B. Hematocrit of 32%
Epoetin alfa is used to reverse anemia associated with chronic kidney disease. Therapeutic effect is seen when the hematocrit is between 30% and 33%.
A client with a urinary tract infection is receiving ciprofloxacin (Cipro) by the intravenous (IV) route. The nurse appropriately administers the medication by performing which action?
Show answer and rationale
Correct answer: D. Infusing slowly over 60 minutes.
Ciprofloxacin (Cipro) is prescribed for treatment of mild, moderate, severe, and complicated infections of the urinary tract, lower respiratory tract, and skin and skin structure. A single dose is administered slowly over 60 minutes to minimize discomfort and vein irritation. Other solutions infusing at the same site need to be temporarily discontinued while the ciprofloxacin is infusing.
During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action?
Show answer and rationale
Correct answer: D. Call the health care provider (HCP).
Severe pain or pain accompanied by nausea following a cataract extraction is an indicator of increased intraocular pressure and should be reported to the HCP immediately. Options 2, 3, and 4 are inappropriate actions.
The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care?
Show answer and rationale
Correct answer: C. Eye medications will need to be administered for life.
The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his or her life.
A client arrives in the emergency department following an automobile crash. The client’s forehead hit the steering wheel and a hyphema is diagnosed. The nurse should place the client in which position?
Show answer and rationale
Correct answer: D. A semi-Fowler’s position
A hyphema is the presence of blood in the anterior chamber. Hyphema is produced when a force is sufficient to break the integrity of the blood vessels in the eye and can be caused by direct injury, such as a penetrating injury from a BB or pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bed rest in a semi-Fowler’s position to assist gravity in keeping the hyphema away from the optical center of the cornea.
The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention should be initiated immediately?
Show answer and rationale
Correct answer: A. Apply ice to the affected eye.
Treatment for a contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by an HCP and receive a thorough eye examination to rule out the presence of other eye injuries.
A client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action?
Show answer and rationale
Correct answer: B. Perform visual acuity tests.
If the eye injury is the result of a penetrating object, the object may be noted protruding from the eye. This object must never be removed except by the ophthalmologist because it may be holding ocular structures in place. Application of an eye patch or irrigation of the eye may disrupt the foreign body and cause further tearing of the cornea.
The nurse is caring for a client following enucleation and notes the presence of bright red drainage on the dressing. Which nursing action is most appropriate?
Show answer and rationale
Correct answer: B. Notify the health care provider (HCP).
If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the HCP, because this indicates hemorrhage.
A woman was working in her garden. She accidentally sprayed insecticide into her right eye. She calls the emergency department, frantic and screaming for help. The nurse should instruct the woman to take which immediate action?
Show answer and rationale
Correct answer: A. Irrigate the eyes with water.
In this type of accident, the client is instructed to irrigate the eyes immediately with running water for at least 20 minutes, or until the emergency medicalservice personnel arrive. In the emergency department, the cleansing agent of choice is usually normalsaline. Calling the HCP and going to the emergency department delays necessary intervention. Hydrogen peroxide is never placed in the eyes.
Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the test results documented in the client’s chart, knowing that which is the range for normal intraocular pressure?
Show answer and rationale
Correct answer: D. 10 to 21 mm Hg
Tonometry is a method of measuring intraocular fluid pressure, using a calibrated instrument that indents or flattens the corneal apex. Pressures between 10 and 21 mm Hg are considered within the normal range.
The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery?
Show answer and rationale
Correct answer: D. Cranial nerve VII, facial nerve
An acoustic neuroma (or vestibular schwannoma) is a unilateral benign tumor that occurs where the vestibulocochlear or acoustic nerve (cranial nerve VIII) enters the internal auditory canal. It is important that an early diagnosis be made because the tumor can compress the trigeminal and facial nerves and arteries within the internal auditory canal. Treatment for acoustic neuroma is surgical removal via a craniotomy. Assessment of the trigeminal and facial nerves is important. Extreme care is taken to preserve remaining hearing and preserve the function of the facial nerve. Acoustic neuromas rarely recur following surgical removal.
The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client’s chart. The nurse understands that which describes this condition?
Show answer and rationale
Correct answer: C. A sensorineural hearing loss that occurs with aging
Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradualsensorineural loss caused by nerve degeneration in the inner ear or auditory nerve.
The clinic nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test?
Show answer and rationale
Correct answer: D. The right eye is tested, followed by the left eye, and then both eyes are tested.
Visual acuity is assessed in one eye at a time, and then in both eyes together, with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes are then tested together. Visual acuity is measured with or without corrective lenses and the client stands at a distance of 20 feet from the chart.
A client’s vision is tested with a Snellen chart. The results of the tests are documented as 20/60. How should the nurse interpret this finding?
Show answer and rationale
Correct answer: B. The client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet.
Vision that is 20/20 is normal-that is, the client is able to read from 20 feet what a person with normal vision can read from 20 feet. A client with a visual acuity of 20/60 can only read at a distance of 20 feet what a person with normal vision can read at 60 feet.
Betaxolol hydrochloride eyedrops have been prescribed for a client with glaucoma. Which nursing action is most appropriate related to monitoring for side/adverse effects of this medication?
Show answer and rationale
Correct answer: C. Monitoring blood pressure
Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are side/adverse effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia.
The nurse is preparing to administer eyedrops. Which interventions should the nurse take to administer the drops? Select all that apply.
Show answer and rationale
Correct answer: A. Pull the lower lid down against the cheek bone.
To administer eye medications, the nurse should wash hands and put gloves on. The client is instructed to tilt the head backward, open the eyes, and look up. The nurse pulls the lower lid down against the cheekbone and holds the bottle like a pencil with the tip downward. Holding the bottle, the nurse gently rests the wrist of the hand on the client’s cheek and squeezes the bottle gently to allow the drop to fall into the conjunctivalsac. The client is instructed to close the eyes gently and not to squeeze the eyes shut to prevent the loss of medication.
The nurse prepares a client for an ear irrigation as prescribed by the health care provider. Which action should the nurse take when performing the procedure?
Show answer and rationale
Correct answer: D. Warm the irrigating solution to 98.6� F.
Before ear irrigation, the nurse should inspect the tympanic membrane to ensure that it is intact. The irrigating solution should be warmed to 98.6 � F because a solution temperature that is not close to the client’s body temperature will cause ear injury, nausea, and vertigo. The affected side should be down following the irrigation to assist in drainage of the fluid. When irrigating, a direct and slow steady stream of irrigation solution is directed toward the wall of the canal, not toward the eardrum. The client is positioned sitting, facing forward with the head in a natural position; if the ear is faced upward, the nurse would not be able to visualize the canal.
Which medication, if prescribed for the client with glaucoma, should the nurse question?
Show answer and rationale
Correct answer: D. Atropine sulfate (Isopto Atropine)
The correct option is a mydriatic and cycloplegic (also anticholinergic) medication, and its use is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye.
A miotic medication has been prescribed for the client with glaucoma and the client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client?
Show answer and rationale
Correct answer: B. "The medication causes the pupil to constrict and will lower the pressure in the eye."
Miotics cause pupillary constriction and are used to treat glaucoma. They lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork.
A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication would the nurse identify as the cause of the client’s complaint?
Show answer and rationale
Correct answer: D. Acetylsalicylic acid (aspirin)
Aspirin is contraindicated for gastrointestinal bleeding and is potentially ototoxic. The client should be advised to notify the prescribing health care provider so the medication can be discontinued and/or a substitute that is less toxic to the ear can be taken instead.
In preparation for cataract surgery, the nurse is to administer cyclopentolate (Cyclogyl) eyedrops. The nurse understands that which characterizes the medication action?
Show answer and rationale
Correct answer: B. Dilates the pupil of the operative eye
Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication. Cyclopentolate is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis.
The nurse is assessing the motor function of an unconscious client. The nurse should plan to use which technique to test the client’s peripheral response to pain?
Show answer and rationale
Correct answer: A. Nail bed pressure
Motor testing in the unconscious client can be done only by testing response to painfulstimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising?
Show answer and rationale
Correct answer: C. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
A change in vitalsigns may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.
A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?
Show answer and rationale
Correct answer: A. Exhaling during repositioning
Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva’s maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed, opens the glottis, which prevents intrathoracic pressure from rising.
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should avoid which measure to minimize the risk of occurrence?
Show answer and rationale
Correct answer: C. Limiting bladder catheterization to once every 12 hours
The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and Foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painfulstimuli. The nurse administers care to minimize risk in these areas.
The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists?
Show answer and rationale
Correct answer: C. Flaccid paralysis
Resolution of spinalshock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder. Test-Taking Strategy: Recall that spinalshock is characterized by the loss of movement of skeletal muscles, loss of bowel or bladder wall function, and depressed reflex action. Return of any of these indicates that spinalshock is
The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client?
Show answer and rationale
Correct answer: D. "We need to remind him to turn his head to scan the lost visual field."
Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.
The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully?
Show answer and rationale
Correct answer: A. Consistently uses adaptive equipment in dressing self
Clients are evaluated as coping successfully with lifestyle changes after a brain attack (stroke) if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions.
The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective?
Show answer and rationale
Correct answer: C. Taking medications on time to maintain therapeutic blood levels
Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotionalstress.
The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further education if the client makes which statement?
Show answer and rationale
Correct answer: B. "I’ll try to eat my food either very warm or very cold."
Facial pain can be minimized by using cotton pads to wash the face and using room temperature water. The client should chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temperature. If toothbrushing triggers pain, an oral rinse after meals may be helpful instead.
A client with Guillain-Barr� syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness?
Show answer and rationale
Correct answer: C. Providing information, giving positive feedback, and encouraging relaxation
The client with Guillain-Barr� syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client’s condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.
A client has a neurological deficit involving the limbic system. Which assessment finding is specific to this type of deficit?
Show answer and rationale
Correct answer: B. Affect is flat, with periods of emotional lability
The limbic system is responsible for feelings (affect) and emotions. Calculation ability and knowledge of current events relate to function of the frontal lobe. The cerebral hemispheres, with specific regional functions, control orientation. Recall of recent events is controlled by the hippocampus.
The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client’s safety? Select all that apply.
Show answer and rationale
Correct answer: A. Having intravenous equipment ready for insertion of an intravenous catheter
Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if anticonvulsant medications must be administered. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client’s teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.
The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery?
Show answer and rationale
Correct answer: C. A positive Brudzinski sign
Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinskisign, and positive Kernig sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig’s sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski’s sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficits.
The nurse has completed discharge instructions for a client with application of a halo device. Which action indicates that the client needs further clarification of the instructions?
Show answer and rationale
Correct answer: C. Drives only during the daytime.
The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powder or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client cannot drive at all because the device impairs the range of vision.
The nurse is caring for a client in the emergency department who has been diagnosed with Bell’s palsy. The client has been taking acetaminophen (Tylenol), and acetaminophen overdose is suspected. Which antidote should the nurse anticipate to be prescribed?
Show answer and rationale
Correct answer: B. Acetylcysteine (Mucomyst)
The antidote for acetaminophen is acetylcysteine (Mucomyst). The normal therapeutic serum level of acetaminophen is 10 to 20 mcg/mL. A toxic level is higher than 50 mcg/mL, and levels higher than 200 mcg/mL could indicate hepatotoxicity. Auranofin (Ridaura) is a gold preparation used to treat rheumatoid arthritis. Pentostatin (Nipent) and fludarabine (Fludara) are antineoplastic agents.
Meperidine hydrochloride (Demerol) has been prescribed for a client to treat pain. Which are side/adverse effects of this medication? Select all that apply.
Show answer and rationale
Correct answer: B. Tremors
Meperidine hydrochloride is an opioid analgesic. Side/adverse effects include respiratory depression, drowsiness, hypotension, constipation, urinary retention, nausea, vomiting, and tremors.
A client is taking the prescribed dose of phenytoin (Dilantin) to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL. Which finding would be expected as a result of this laboratory result?
Show answer and rationale
Correct answer: C. Slurred speech
The therapeutic phenytoin level is 10 to 20 mcg/mL. At a level higher than 20 mcg/mL, involuntary movements of the eyeballs (nystagmus) occur. At a level higher than 30 mcg/mL, ataxia and slurred speech occur.
The client arrives at the emergency department complaining of back spasms. The client states, "I have been taking two to three aspirin every 4 hours for the last week, and it hasn’t helped my back." Since aspirin intoxication is suspected, the nurse should assess the client for which manifestation?
Show answer and rationale
Correct answer: B. Tinnitus
Mild intoxication with acetylsalicylic acid (aspirin) is called salicylism and is experienced commonly when the daily dosage is higher than 4 g. Tinnitus (ringing in the ears) is the most frequent effect noted with intoxication. Hyperventilation may occur because salicylate stimulates the respiratory center. Fever may result, because salicylate interferes with the metabolic pathways coupling oxygen consumption and heat production.
A client with myasthenia gravis has become increasingly weaker. The health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis?
Show answer and rationale
Correct answer: C. A temporary worsening of the condition
An edrophonium injection makes the client in cholinergic crisis temporarily worse. An improvement in the weakness indicates myasthenia crisis. Muscle spasms are not associated with this test.
A client with trigeminal neuralgia tells the nurse that acetaminophen (Tylenol) is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication?
Show answer and rationale
Correct answer: A. Direct bilirubin level of 2 mg/dL
In adults, overdose of acetaminophen causes liver damage. The correct option is an indicator of liver function and is the only option that indicates an abnormal laboratory value. The normal direct bilirubin level is 0 to 0.3 mg/dL. The normalsodium level is 135 to 145 mEq/L. The normal prothrombin time is 10 to 13 seconds. The normal platelet count is 150,000 to 400,000 cells/mm 3 .
The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder?
Show answer and rationale
Correct answer: D. A sedentary 65-year-old woman who smokes cigarettes
Risk factors for osteoporosis include female gender, being postmenopausal, advanced age, a lowcalcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of corticosteroids, anticonvulsants, and/or furosemide (Lasix) also increases the risk.
The nurse is one of several persons who witnessed a vehicle hit a pedestrian at fairly low speed on a small street. The victim is dazed and tries to get up. The leg appears fractured. Which intervention should the nurse take?
Show answer and rationale
Correct answer: A. Stay with the victim and encourage the person to remain still.
With a suspected fracture, the victim is not moved unless it is dangerous to remain in that spot. The nurse should remain with the victim and have someone else call for emergency help. A fracture is not reduced at the scene. Before the victim is moved, the site of fracture is immobilized to prevent further injury.
The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding?
Show answer and rationale
Correct answer: D. Serous drainage
A small amount of serous oozing is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported to the health care provider.
A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain?
Show answer and rationale
Correct answer: D. Impaired tissue perfusion
Most pain associated with fractures can be minimized with rest, elevation, application of cold, and administration of analgesics. Pain that is not relieved by these measures should be reported to the health care provider because pain unrelieved by medications and other measures may indicate neurovascular compromise. Because this is a new closed fracture and cast, infection would not have had time to set in. Intense pain after casting is normally not associated with anxiety or the recent occurrence of the injury. Treatment following the fracture should assist in relieving the pain associated with the injury.
A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds knowing that which would most likely result from this improper crutch measurement?
Show answer and rationale
Correct answer: A. Injury to the brachial plexus nerves
Crutches are measured so that the tops are two to three fingerwidths from the axillae. This ensures that the client’s axillae are not resting on the crutch or bearing the weight of the crutch, which could result in injury to the nerves of the brachial plexus.
The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus?
Show answer and rationale
Correct answer: C. Clear mentation
An altered mentalstate is an early indication of fat emboli; therefore, clear mentation is a good indicator that a fat embolus is resolving. Eupnea, not minimal dyspnea, is a normalsign. Arterial oxygen levels should be 80 to 100 mm Hg. Oxygen saturation should be higher than 95%.
A client with diabetes mellitus has had a right below-knee amputation. Given the client’s history of diabetes mellitus, which should the nurse specifically observe in the postoperative period?
Show answer and rationale
Correct answer: A. Separation of the wound edges
Clients with diabetes mellitus are more prone to wound infection and delayed wound healing because of the disease. Postoperative edema of the residual limb and hemorrhage are complications in the immediate postoperative period that apply to any client with an amputation. Slight redness of the incision is considered normal, as long as it is dry and intact.
What to do with your score
Score the set, then spend longer on the review than you did on the questions. For every item you missed, decide which of three things went wrong: you did not know the fact, you misread what the item was asking, or you knew the fact and still chose second-best. Those need three different fixes — content review, slower reading, and priority-framework practice — and lumping them together is why question banks stop working for people.
Read the rationale on the items you got right as well. Arriving at the correct option for the wrong reason is common, and it does not survive a harder version of the same question.
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