NCLEX Practice Questions — Set 50
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
The client is admitted with left lower leg pain, a positive Homans’ sign, and a temperature of 100.4�F (38�C). The nurse should assess the client further for signs of:
Show answer and rationale
Correct answer: D. Deep vein thrombosis (DVT) in the left leg.
The client demonstrates classic symptoms of DVT, and the nurse should continue to assess the client. Signs and symptoms of an aortic aneurysm include abdominal pain and a pulsating abdominal mass. Clients with drug abuse demonstrate confusion and decreased levels of consciousness. Claudication is an intermittent pain in the leg.
A client is admitted with a diagnosis of thrombophlebitis and deep vein thrombosis of the right leg. A loading dose of heparin has been given in the emergency room, and IV heparin will be continued for the next several days. The nurse should develop a plan of care for this client that will involve:
Show answer and rationale
Correct answer: B. Monitoring the client’s activated partial thromboplastin time (aPTT) and International Normalized Ratio (INR).
Heparin dosage is usually determined by the physician based on the client’s aPTT and INR laboratory values. Therefore, the nurse monitors these values to prevent complications. Administering aspirin when the client is on heparin is contraindicated. Green leafy vegetables are high in vitamin K and therefore are not recommended for clients receiving heparin. Monitoring of the client’s PT is done when the client is receiving warfarin sodium (Coumadin).
In order to prevent deep vein thrombosis (DVT) following abdominal surgery, the nurse should:
Show answer and rationale
Correct answer: B. Use pneumatic compression stockings.
The use of pneumatic compression stockings is an intervention used to prevent DVT. Other strategies include early ambulation, leg exercises if the client is confined to bed, adequate fluid intake, and administering anticoagulant medication as prescribed. Deep breathing would be encouraged postoperatively, but it does not prevent DVT.
The nurse interviews a 22-year-old female client who is scheduled for abdominal surgery the following week. The client is obese and uses estrogen-based oral contraceptives. This client is at high risk for development of:
Show answer and rationale
Correct answer: C. Thrombophlebitis.
The data suggest an increased risk of thrombophlebitis. The risk factors in this situation include abdominal surgery, obesity, and use of estrogen-based oral contraceptives. Risk factors for atherosclerosis include genetics, older age, and a high-cholesterol diet. Risk factors for diabetes include genetics and obesity. Risk factors for vasospastic disorders include cold climate, age (16 to 40), and immunologic disorders.
The nurse observes that an older female has small-to-moderate, distended, and tortuous veins running along the inner aspect of her lower legs. The nurse should:
Show answer and rationale
Correct answer: A. Encourage the client to avoid standing in one position for long periods of time.
The client has varicose veins, which are evident by the tortuous, distended veins where blood has pooled. To prevent pooling of the blood, the client should not stand in one place for long periods of time. It is not necessary to use compression devices, but the client could wear support hose if she stands for long periods of time. The client can consider cosmetic surgery to remove the distended veins, but there is no indication that the client should contact the physician at this point in time. The nurse can inspect the client’s feet, but the client is not at risk for ulcers at this time.
Which of the following clients is at risk for varicose veins?
Show answer and rationale
Correct answer: D. A client who has had thrombophlebitis.
Secondary varicosities can result from previous thrombophlebitis of the deep femoral veins, with subsequent valvular incompetence. Cerebrovascular accident, anemia, and transient ischemic attacks are not associated with an increased risk of varicose veins.
A client weighs 300 lb (136 kg) and has a history of deep vein thrombosis and thrombophlebitis. When reviewing a teaching plan with this client, the nurse determines that the client has understood the nurse’s instructions when the client states a willingness to:
Show answer and rationale
Correct answer: C. Lose weight.
The client is at risk for development of varicose veins. Therefore, prevention is key in the treatment plan. Maintaining ideal body weight is the goal. In order to achieve this, the client should consume a balanced diet and participate in a regular exercise program. Depending on the individual, leg lifts may or may not be an appropriate activity. Performing leg lifts provides muscular activity and should be done more often than every 4 hours. Wearing support hose is helpful. However, the client should not use rubber bands to hold the stockings up.
Which instructions should the nurse include when developing a teaching plan for a client being discharged from the hospital on anticoagulant therapy after having deep vein thrombosis (DVT)?
Show answer and rationale
Correct answer: A. All of the above
Clients with resolving DVT being sent home on anticoagulant therapy need instructions about assessing and preventing bleeding episodes and preventing a recurrence of DVT. Blood in the urine (hematuria) is often one of the first symptoms of anticoagulant overdose. Fresh blood in the urine is red; however, blood in the urine may also be a dark smoky color. Daily ambulation is an excellent activity to keep the venous blood circulating and thus to prevent blood clots from forming in the lower extremities. Garlic and ginger increase the bleeding time and should not be used when a client is on anticoagulant therapy. Clients who have had previous DVTs should avoid activities that cause stagnation and pooling of venous blood. Prolonged sitting coupled with change of air pressure without foot or leg exercises or ambulation in the cabin are activities that prevent venous return. Instructing the client about prevention measures is important because clients with DVT are at high risk for pulmonary emboli (PE), which can be fatal. The client can be taught risk factors for DVT and PE. In addition, recommendations for prevention of these events also are standard protocol in practice and should be shared with the client for home care purposes. Older adults should be monitored closely for bleeding because the skin becomes thinner and the capillaries become more fragile with the aging process.
A client is admitted to the emergency department with severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. The primary goal at this time is to:
Show answer and rationale
Correct answer: C. Prepare the client for emergency surgery.
The primary goal is to prepare the client for emergency surgery. The goal would be to prevent rupture of the aneurysm and potential death. Circulation is maintained, unless the aneurysm ruptures. When the client is prepared for surgery, the nurse should place the client in a recumbent position to promote circulation, teach the client about postoperative breathing exercises, and administer pain medication if prescribed.
Before surgery for a known aortic aneurysm, the client’s pulse pressure begins to widen, suggesting increased aortic valvular insufficiency. If the branches of the aortic arch are involved, the nurse should assess the client for:
Show answer and rationale
Correct answer: D. Loss of consciousness.
If the aortic arch is involved, there will be a decrease in the blood flow to the cerebrum. Therefore, loss of consciousness will be observed. A sudden loss of consciousness is a primary symptom of rupture and no blood flow to the brain. Anxiety is not a sign of aortic valvular insufficiency. The end result of decreased cerebral blood flow is loss of consciousness, not headache or disorientation.
A client has sudden, severe pain in the back and chest, accompanied by shortness of breath. The client describes the pain as a "tearing" sensation. The physician suspects the client is experiencing a dissecting aortic aneurysm. The emergency supply cart is brought into the room because one complication of a dissecting aneurysm is:
Show answer and rationale
Correct answer: B. Cardiac tamponade.
Cardiac tamponade is a life-threatening complication of a dissecting thoracic aneurysm. The sudden, painful "tearing" sensation is typically associated with the sudden release of blood, and the client may experience cardiac arrest. Stroke, pulmonary edema, and myocardial infarction are not common complications of a dissecting aneurysm.
Which of the following increases the risk of having a large abdominal aortic aneurysm rupture?
Show answer and rationale
Correct answer: B. High blood pressure.
In the preoperative phase, the goal is to prevent rupture. The client is placed in a semi-Fowler’s position and in a quiet environment. The systolic blood pressure is maintained at the lowest level the client can tolerate. Anemia, dehydration, and hyperglycemia do not put the client at risk for rupture.
A client is discharged after an aortic aneurysm repair with a synthetic graft to replace part of the aorta. The nurse should instruct the client to notify the physician before having:
Show answer and rationale
Correct answer: D. Major dental work.
The client with a synthetic graft may need to be treated with prophylactic antibiotics before undergoing major dental work. This reduces the danger of systemic infection caused by bacteria from the oral cavity. Venous access for drawing blood, IV line insertion, and x-rays do not contribute to the risk of infection.
A client with deep vein thrombosis has been receiving warfarin (Coumadin) for 2 months. The client reports bleeding gums, increased bruising, and dark stools. These symptoms indicate that the medication:
Show answer and rationale
Correct answer: A. Needs to be decreased.
symptoms suggest that the client is receiving too much Coumadin. Coumadin hinders the hepatic synthesis of vitamin K-dependent clotting factors and prolongs the clotting time. Because many factors influence the effectiveness of Coumadin, the dosage is monitored closely. Signs and symptoms of blood loss include bleeding gums, petechiae, bruises, dark stools, and dark urine.
The nurse is assessing the deep tendon reflexes of the client with hypomagnesemia. Which method is used to elicit the biceps reflex?
Show answer and rationale
Correct answer: C. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
The answer can only be A because the other methods elicit different reflexes. Answer B elicits the triceps reflex, answer C elicits the patella reflex, and answer D elicits the radial nerve
Which observation in the newborn of a mother who is alcohol dependent would require immediate nursing intervention?
Show answer and rationale
Correct answer: C. Jitteriness
Jitteriness is a sign of seizure in the neonate. Answers A, B, and D are incorrect because crying, wakefulness, and yawning are expected in the newborn
Which information obtained from the visit to a client with hemophilia would cause the most concern? The client:
Show answer and rationale
Correct answer: B. Likes to play football
The client with hemophilia is likely to experience bleeding episodes if he participates in contact sports. Drinking several carbonated drinks per day, as in answer B, has no bearing on the hemophiliac’s condition. Having two sisters with sickle cell, as in answer C, is not information that would cause concern. Taking acetaminophen for pain, as in answer D, is an accepted practice and does not cause concern.
Immediately following the removal of a chest tube, the nurse would:
Show answer and rationale
Correct answer: A. Cover the insertion site with a Vaseline gauze
When a chest tube is removed, the hole should be immediately covered with a Vaseline gauze to prevent air from rushing into the chest and causing the lung to collapse. The doctor, not the nurse, will order a chest x-ray; therefore, answer A is incorrect. Taking the BP in answer B is good but is not the priority action. Practice Exam 2 and Rationales 123 Answer D is incorrect because the Valsalva maneuver is done during removal of the tube, not afterward
Which would be an expected finding during injection of dye with a cardiac catheterization?
Show answer and rationale
Correct answer: D. Warmth in the extremity
It is normal for the client to have a warm sensation when dye is injected. Answer A is incorrect because the client should not have a cold extremity.This indicates peripheral vascular disease. Answer C is incorrect because extreme chest pain can be related to a myocardial infarction. The pain is not normal. Answer D is incorrect because itching is a sign of an allergic reaction. Also, the itching will most likely be on the chest and skin folds. 124 Chapter 2
The nurse is making rounds. Which client should be seen first?
Show answer and rationale
Correct answer: A. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone intravenously
The client with multiple sclerosis should receive priority because of the IV cortisone treatment. This client is at highest risk for complications. The clients in answers A and B are more stable and are not the priority. The client with MRSA (methicillin-resistant staphylococcus aureus) is being treated with antibiotics, but there is no data to indicate that the nurse should see this client first, so answer C is incorrect
A 2-year-old toddler is seen in the pediatrician’s office. During physical assessment, the nurse would anticipate the need for which intervention?
Show answer and rationale
Correct answer: D. Ask the parent/guardian to stay with the child during the examination
There is no reason to tell the parents to leave because this might cause the child to become more agitated, making answer A incorrect. Removing his toys may also cause him to fret and make the examination more difficult, so answer B is incorrect. Answer D is incorrect because telling him that the behavior is inappropriate will not help because the child is too young to understand
The nurse is caring for a gravida 1 admitted in labor. Which finding would suggest the need for an internal fetal monitor?
Show answer and rationale
Correct answer: C. The fetal heart tones are difficult to assess using the external toco monitor.
There are only a few reasons to apply an internal monitor: if the fetus is in distress or if the fetal heart tones cannot be assessed using the external monitor. Answer A is incorrect because cervical dilation is not a reason to apply an internal monitor. Answer C is incorrect because the fact that the fetus is at 0 station is not a reason to apply an internal monitor. Answer D is also incorrect because noting contractions every 3 minutes is not a reason to apply an internal monitor. It is not necessary for a scalp electrode placement, as long as the membranes are still intact
A client is admitted for an MRI (magnetic resonance imaging). The nurse should question the client regarding:
Show answer and rationale
Correct answer: D. A titanium hip replacement
The client will be asked to remain still during portions of the exam. If the client has difficulty hearing, accommodations for the inability to follow instructions will need to be made. Answer B is incorrect because clients with a titanium joint replacement can have an MRI (magnetic resonance imaging). Answer C is incorrect because the client will not have ntibiotics administered in preparation for the exam. Answer D is incorrect because the client will not need to move his feet during the exam
The client with colorblindness will most likely have problems distinguishing which of the following colors?
Show answer and rationale
Correct answer: C. Violet
Clients with colorblindness will most likely have problems distinguishing violets, blues, and greens. The other colors are less commonly affected, so answers A, C, and D are incorrect.
The physician has ordered a CAT (computerized axial tomography) scan for a client with a possible cerebral aneurysm. Which information is most important to the nurse who is preparing the client for the CAT scan? The client:
Show answer and rationale
Correct answer: D. Is allergic to oysters
Answer C is correct because a history of allergies to oysters may indicate a potential allergy to the dye used in the contrast medium. Answer A is incorrect because the client can have a CAT scan if she is having her menses. Answer B is incorrect because a history of claustrophobia is not related to having a CAT scan. Answer D is incorrect because a client with sensory hearing loss can have a CAT scan
The client has an order for Demerol (meperidine) and Phenergan (promethazine) to be given together. The nurse is aware that the purpose of this order is:
Show answer and rationale
Correct answer: D. For its synergistic effect
Demerol and Phenergan are given for their synergistic effect.Synergistic means that one drug increases the effectiveness of the other. Demerol is a narcotic analgesic, and Phenergan is an antianxiety, antiemetic medication. Answer B is incorrect because they are not given for the agonist effect; an agonist is a medication that works with chemicals or substances in the blood, such as hormones. Answer C is incorrect because they are not given together to cause extrapyramidal effects.Answer D is incorrect because antagonists work against one another.
A client with an above-the-knee amputation is being taught methods to prevent hip-flexion deformities. Which instruction should be given to the client?
Show answer and rationale
Correct answer: C. "Lie prone every 4 hours during the day for 30 minutes."
To prevent hip-flexion deformities, the client should be instructed to lie prone every 4 hours for 30 minutes during the day. This will force the leg to extend to 0 and prevent the contracture. Answer A, C, and D are incorrect because lying on his back or side, or flat will not help.
A client hospitalized with severe depression and suicidal ideation refuses to talk with the nurse. The nurse recognizes that the suicidal client has difficulty:
Show answer and rationale
Correct answer: B. Expressing anger toward others
The suicidal client has difficulty expressing anger toward others. The depressed suicidal client frequently expresses feelings of low self-worth, feelings of remorse and guilt, and a dependence on others; therefore, answers A, B, and C are incorrect.
A client receiving HydroDIURIL (hydrochlorothiazide) is instructed to increase her dietary intake of potassium. The best snack for the client requiring increased potassium is:
Show answer and rationale
Correct answer: B. Banana
Answers A, B, and C are incorrect because they contain lower amounts of potassium. (Note that the banana contains 450mg K+, the orange contains235mg K+, the pear contains 208mg K+, and the apple contains 165mg K+.)
A client hospitalized with chronic dyspepsia is diagnosed with gastric cancer. Which of the following is associated with an increased incidence of gastric cancer?
Show answer and rationale
Correct answer: A. Luncheon meats
Luncheon meats contain preservatives such as nitrites that have been linked to gastric cancer. Answers A, B, and C have not been found to increase the risk of gastric cancer; therefore, they are incorrect
A client is sent to the psychiatric unit for forensic evaluation after he is accused of arson. His tentative diagnosis is antisocial personality disorder. In reviewing the client’s record, the nurse could expect to find:
Show answer and rationale
Correct answer: A. A history of cruelty to animals
A history of cruelty to people and animals, truancy, setting fires, and lack of guilt or remorse are associated with a diagnosis of conduct disorder in children, which becomes a diagnosis of antisocial personality disorder in adults. Answer A is incorrect because the client with antisocial personality disorder does not hold consistent employment. Answer B is incorrect because the IQ is usually higher than average. Answer D is incorrect because of a lack of guilt or remorse for wrongdoing.
The licensed vocational nurse may not assume the primary care for a client:
Show answer and rationale
Correct answer: B. With a venous access device
The licensed vocational nurse may not assume primary care of the client with a central venous access device. The licensed vocational nurse may care for the client in labor, the client post-operative client, and the client with bipolar disorder
The physician has ordered dressings with mafenide acetate (Sulfamylon) cream for a client with full-thickness burns of the hands and arms. Before dressing changes, the nurse should give priority to:
Show answer and rationale
Correct answer: D. Administering pain medication
Sulfamylon (mafenide acetate) produces a painful sensation when applied to the burn wound; therefore, the client should receive pain medicationbefore dressing changes. Answers B, C, and D do not pertain to dressing changes for the client with burns, so they are incorrect.
The nurse is teaching a group of parents about gross motor development of the toddler. Which behavior is an example of the normal gross motor skill of a toddler?
Show answer and rationale
Correct answer: D. She can pull a toy behind her.
According to the Denver Developmental Screening Test, the child can pull a toy behind her by age 2 years. Answers B, C, and D are not accomplished until ages 4-5 years; therefore, they are incorrect.
A client hospitalized with a fractured mandible is to be discharged.Which piece of equipment should be kept on the client with a fractured mandible?
Show answer and rationale
Correct answer: C. Wire cutters
The client with a fractured mandible should keep a pair of wire cutters with him at all times to release the device in case of choking or aspiration. Answer B is incorrect because the wires would prevent insertion of an oral airway. Answer C is incorrect because it would be of no use in releasing the wires. Answer D is incorrect because it would be used only as a last resort in case of airway obstruction.
The nurse is to administer digoxin (Lanoxin) elixir to a 6-monthold with a congenital heart defect. The nurse auscultates an apical pulse rate of 100. The nurse should:
Show answer and rationale
Correct answer: C. Record the heart rate and administer the medication
The infant’s apical heart rate is within the accepted range for administering the medication. Answers A, C, and D are incorrect because the apical heart rate is suitable for giving the medication.Practice Exam 3 and Rationales 191
A mother of a 3-year-old hospitalized with lead poisoning asks the nurse to explain the treatment for her daughter. The nurse’s explanation is based on the knowledge that lead poisoning is treated with:
Show answer and rationale
Correct answer: D. Chelating agents
Chelating agents are used to treat the client with poisonings from heavy metals such as lead and iron. Answers A and D are used to remove noncorrosive poisons; therefore, they are incorrect. Answer C prevents vomiting; therefore,it is an incorrect response.
An 18-month-old is scheduled for a cleft palate repair. The usual type of restraints for the child with a cleft palate repair are:
Show answer and rationale
Correct answer: B. Elbow restraints
The least restrictive restraint for the infant with cleft lip and cleft palate repair is elbow restraints. Answers B, C, and D are more restrictive and unnecessary; therefore, they are incorrect.
Which of the following is a common complaint of the client with end-stage renal failure?
Show answer and rationale
Correct answer: B. Itching
Pruritis or itching is caused by the presence of uric acid crystals on the skin, which is common in the client with end-stage renal failure. Answers A, C, and D are not associated with end-stage renal failure.
Which of the following medication orders needs further clarification?
Show answer and rationale
Correct answer: B. Coumadin (warfarin sodium) 10mg PO
There is no specified time or frequency for the ordered medication. Answers A, B, and D contain specified time and frequency, therefore they do not require further clarification.
An 8-year-old admitted with an upper-respiratory infection has an order for O2 saturation via pulse oximeter. To ensure an accurate reading, the nurse should:
Show answer and rationale
Correct answer: D. Place the probe on the child’s finger
he pulse oximeter should be placed on the child’s finger or earlobe because blood flow to these areas is most accessible for measuring oxygen concentration.Answer A is incorrect because the probe cannot be secured to the abdomen. Answer B is incorrect because it should be recalibrated before application.Answer C is incorrect because a reading is obtained within seconds, not minutes.
The client scheduled for electroconvulsive therapy tells the nurse, "I’m so afraid. What will happen to me during the treatment?" Which of the following statements is most therapeutic for the nurse to make?
Show answer and rationale
Correct answer: C. "You will be given medicine to relax you during the treatment."
The client will receive medication that relaxes skeletal muscles and produces mild sedation. Answers B and D are incorrect because such statements increase the client’s anxiety level. Nausea and headache are not associated with ECT; therefore, answer C is incorrect
Which of the following snacks would be suitable for the child with gluten-induced enteropathy?
Show answer and rationale
Correct answer: C. Buttered popcorn
The client with gluten-induced enteropathy experiences symptoms after ingesting foods containing wheat, oats, barley, or rye. Corn or millet are substituted in the diet. Answers A, C, and D are incorrect because they contain foods that worsen the client’s condition.
A client with schizophrenia is receiving chlorpromazine (Thorazine) 400mg twice a day. An adverse side effect of the medication is:
Show answer and rationale
Correct answer: A. Elevated temperature
Neuroleptic malignant syndrome is an adverse reaction that is characterized by extreme elevations in temperature. Answers A and C are incorrect because they are expected side effects. Elevations in blood pressure are associated with reactions between foods containing tyramine and MAOI; therefore, answer D is incorrect.
An 8-year-old is admitted with drooling, muffled phonation, and a temperature of 102�F. The nurse should immediately notify the doctor because the child’s symptoms are suggestive of:
Show answer and rationale
Correct answer: D. Epiglottitis
The child’s symptoms are consistent with those of epiglottitis, an infection of the upper airway that can result in total airway obstruction. Symptoms of strep throat, laryngotracheobronchitis, and bronchiolitis are different than those presented by the client; therefore, answers A, C, and D are incorrect
Phototherapy is ordered for a newborn with physiologic jaundice. The nurse caring for the infant should:
Show answer and rationale
Correct answer: C. Offer the baby sterile water between feedings of formula
Providing additional fluids will help the newborn eliminate excess bilirubin in the stool and urine. Answer B is incorrect because oils and lotions should not be used with phototherapy. Physiologic jaundice is not associated with infection; therefore, answers C and D are incorrect.
A teen hospitalized with anorexia nervosa is now permitted to leave her room and eat in the dining room. Which of the following nursing interventions should be included in the client’s plan of care?
Show answer and rationale
Correct answer: D. Having a staff member remain with her for 1 hour after she eats
Having a staff member remain with the client for 1 hour after meals will help prevent self-induced vomiting. Answer A is incorrect because the client will weigh more after meals, which can undermine treatment. Answer C is incorrect because the client will need a balanced diet and excess protein might not be well tolerated at first. Answer D is incorrect because it treats the client as a child rather than as an adult.
According to Erickson’s stage of growth and development, the developmental task associated with middle childhood is:
Show answer and rationale
Correct answer: A. Industry
According to Erikson’s Psychosocial Developmental Theory, the developmental task of middle childhood is industry versus inferiority. Answer A is incorrect because it is the developmental task of infancy. Answer B is incorrect because it is the developmental task of the school-age child. Answer C is incorrect because it is not one of Erikson’s developmental stages.
The nurse should observe for side effects associated with the use of bronchodilators. A common side effect of bronchodilators is:
Show answer and rationale
Correct answer: A. Nausea
A side effect of bronchodilators is nausea. Answers A and C are not associated with bronchodilators; therefore, they are incorrect. Answer D is incorrect because hypotension is a sign of toxicity, not a side effect. Practice Exam 3 and Rationales 193
The 5-minute Apgar of a baby delivered by C-section is recorded as 9. The most likely reason for this score is:
Show answer and rationale
Correct answer: B. Cyanosis of the hands and feet
Although cyanosis of the hands and feet is common in the newborn, it accounts for an Apgar score of less than 10. Answer B suggests cooling, which is not scored by the Apgar. Answer B is incorrect because conjunctival hemorrhages are not associated with the Apgar. Answer D is incorrect because it is within normal range as measured by the Apgar.
A client with a bowel resection and anastamosis returns to his room with an NG tube attached to intermittent suction. Which of the following observations indicates that the nasogastric suction is working properly?
Show answer and rationale
Correct answer: A. The client’s abdomen is soft.
Nasogastric suction decompresses the stomach and leaves the abdomen soft and nondistended. Answer B is incorrect because it does not relate to the effectiveness of the NG suction. Answer C is incorrect because it relates to peristalsis, not the effectiveness of the NG suction. Answer D is incorrect because it relates to wound healing, not the effectiveness of the NG suction.
Which of the following symptoms is associated with exacerbation of multiple sclerosis?
Show answer and rationale
Correct answer: D. Diplopia
The most common sign associated with exacerbation of multiple sclerosis is double vision. Answers A, B, and D are not associated with a diagnosis of multiple sclerosis; therefore, they are incorrect.
Which of the following conditions is most likely related to the development of renal calculi?
Show answer and rationale
Correct answer: C. Gout
Gout and renal calculi are the result of increased amounts of uric acid. Answer B is incorrect because it does not contribute to renal calculi. Answers C and D can result from decreased calcium levels. Renal calculi are the result of excess calcium; therefore, answers C and D are incorrect.
Which of the following meal choices is suitable for a 6-month-old infant?
Show answer and rationale
Correct answer: B. Rice cereal, apple juice, formula
Rice cereal, apple juice, and formula are suitable foods for the 6-month-old infant. Whole milk, orange juice, and eggs are not suitable for the young infant; therefore, they are incorrect
The nurse is caring for a client with detoxification from alcohol.Which medication is used in the treatment of alcohol withdrawal?
Show answer and rationale
Correct answer: C. Ativan (lorazepam)
Benzodiazepines are ordered for the client in alcohol withdrawal to prevent delirium tremens. Answer A is incorrect because it is a medication used in aversive therapy to maintain sobriety. Answer B is incorrect because it is used for the treatment of benzodiazepine overdose. Answer C is incorrect because it is the treatment for opiate withdrawal.
A client with insulin-dependent diabetes takes 20 units of NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at:
Show answer and rationale
Correct answer: B. 3 p.m.
The client taking NPH insulin should have a snack midafternoon to prevent hypoglycemia. Answers A and B are incorrect because the times are too early for symptoms of hypoglycemia. Answer D is incorrect because the time is too late and the client would be in severe hypoglycemia.
The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnoses should receive priority?
Show answer and rationale
Correct answer: D. Alteration in mobility
The client with a detached retina will have limitations in mobility before and after surgery. Answer A is incorrect because a detached retina produces no pain or discomfort. Answers C and D do not apply to the client with a detached retina; therefore, they are incorrect
The primary purpose for using a CPM machine for the client with a total knee repair is to help:
Show answer and rationale
Correct answer: A. Promote flexion of the artificial joint
The primary purpose for the continuous passive-motion machine is to promote flexion of the artificial joint. The device should be placed at the foot of the client’s bed. Answers A, C, and D do not describe the purpose of the CPM machine; therefore, they are incorrect
A factory worker is brought to the nurse’s office after a metal fragment enters his right eye. The nurse should:
Show answer and rationale
Correct answer: C. Cover both eyes and transport the client to the ER
The nurse should cover both of the client’s eyes and transport him immediately to the ER or the doctor’s office. Answers A, B, and D are incorrect because they increase the risk of further damage to the eye
A client is admitted with burns of the right arm, chest, and head. According to the Rule of Nines, the percent of burn injury is:
Show answer and rationale
Correct answer: A. 0.27
Burn injury of the arm (9%), chest (9%), and head (9%) accounts for burns covering 27% of the total body surface area. Answers A, C, and D are incorrect percentages
A client who was admitted with chest pain and shortness of breath has a standing order for oxygen via mask. Standing orders for oxygen mean that the nurse can apply oxygen at:
Show answer and rationale
Correct answer: D. 6L per minute
With standing orders, the nurse can administer oxygen at 6L per minute via mask. Answer A is incorrect because the amount is too low to help the client with chest pain and shortness of breath. Answers C and D have oxygen levels requiring a doctor’s order.
The physician has ordered aspirin therapy for a client with severe rheumatoid arthritis. A sign of acute aspirin toxicity is:
Show answer and rationale
Correct answer: A. Tinnitus
Tinnitus is a sign of aspirin toxicity. Answers A, B, and D are not related to aspirin toxicity; therefore, they are incorrect
A client is admitted to the emergency room with symptoms of delirium tremens. After admitting the client to a private room, the priority nursing intervention is to:
Show answer and rationale
Correct answer: C. Provide seizure precautions
The client with delirium tremens has an increased risk for seizures; therefore, the nurse should provide seizure precautions. Answer A is not a priority in the client’s care; therefore, it is incorrect. Answer C is incorrect because the client should be kept in a dimly lit, not dark, room. Answer D is incorrect because thiamine and multivitamins are given to prevent ernicke’s encephalopathy, not delirium tremens.
A newborn has been diagnosed with exstrophy of the bladder. The nurse should position the newborn:
Show answer and rationale
Correct answer: D. On either side
Placing the newborn in a side-lying position helps the urine to drain from the exposed bladder. Answer A is incorrect because it would position the child on the exposed bladder. Answers B and D are incorrect choices because they would allow the urine to pool
The mother of a 3-month-old with esophageal reflux asks the nurse what she can do to lessen the baby’s reflux. The nurse should tell the mother to:
Show answer and rationale
Correct answer: C. Burp the baby frequently throughout the feeding
Burping the baby frequently throughout the feeding will help prevent gastric distention that contributes to esophageal reflux. Answers A and B are incorrect because they allow air to collect in the baby’s stomach, which contributes to reflux. Answer C is incorrect because the baby should be placed side-lying with the head elevated, to prevent aspiration. 206 Chapter 3
A child is hospitalized with a fractured femur involving the epiphysis. Epiphyseal fractures are serious because:
Show answer and rationale
Correct answer: C. Normal bone growth is affected.
Growth plates located in the epiphysis can be damaged by epiphyseal fractures. Answers A, C, and D are untrue statements; therefore, they are incorrect.
Before administering a nasogastric feeding to a client hospitalized following a CVA, the nurse aspirates 40mL of residual. The nurse should:
Show answer and rationale
Correct answer: A. Replace the aspirate and administer the feeding
The nurse should replace the aspirate and administer the feeding because the amount aspirated was less than 50mL. Answers B and C are incorrect choices because the aspirate should not be discarded. Answer D is incorrect because the feeding should not be withheld.
A client has an order for Dilantin (phenytoin) .2g orally twice a day. The medication is available in 100mg capsules. For the morning medication, the nurse should administer:
Show answer and rationale
Correct answer: A. 2 capsules
The nurse should administer two capsules. Answers A, C, and D contain inaccurate amounts; therefore, they are incorrect.
A client with acute pancreatitis has requested pain medication. Which pain medication is indicated for the client with acute pancreatitis?
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Correct answer: A. Demerol (meperidine)
To prevent spasms of the sphincter of Oddi, the client with acute pancreatitis should receive non-opiate analgesics for pain. Answer B is incorrect because the client with acute pancreatitis might be prone to bleed; therefore, Toradol is not a drug of choice for pain control. Morphine and codeine, opiate analgesics, are contraindicated for the client with acute pancreatitis; therefore, answers C and D are incorrect.
A client with a hiatal hernia has been taking magnesium hydroxide for relief of heartburn. Overuse of magnesium-based antacids can cause the client to have:
Show answer and rationale
Correct answer: C. Diarrhea
Overuse of magnesium-containing antacids results in diarrhea. Antacids containing calcium and aluminum cause constipation; therefore, answer A is incorrect. Answers B and C are not associated with the use of magnesium antacids; therefore, they are incorrect.
When performing a newborn assessment, the nurse measures the circumference of the neonate’s head and chest. Which assessment finding is expected in the normal newborn?
Show answer and rationale
Correct answer: B. The head is 2cm larger than the chest.
The head circumference of the normal newborn is approximately 33 cm, while the chest circumference is 31cm. Answer A is incorrect because the head and chest are not the same circumference. Answer C is incorrect because the head is larger in circumference than the chest. Answer D is incorrect because the difference in head circumference and chest circumference is too great.
The mother of a child with hemophilia asks the nurse which overthe- counter medication is suitable for her child’s joint discomfort. The nurse should tell the mother to purchase:
Show answer and rationale
Correct answer: D. Tylenol (acetaminophen)
The nurse should recommend acetaminophen for the child’s joint discomfort because it will have no effect on the bleeding time. Answers A, C, and D are all nonsteroidal anti-inflammatory medications that can prolong bleeding time; therefore, they are not suitable for the child with hemophilia.
The nurse is caring for a newborn with hypospadias. Which statement describes hypospadias?
Show answer and rationale
Correct answer: B. The urinary meatus is located on the underside of the penis rather than the tip.
Hypospadias results when the urinary meatus is located on the underside of the penis rather than the tip. Answer B is incorrect because it refers to ureteral reflux. Answer C is incorrect because it refers to epispadias. Answer D is incorrect because it refers to exstrophy of the bladder.
The recommended time for daily administration of Tagamet (cimetidine) is:
Show answer and rationale
Correct answer: C. At bedtime
Tagamet (cimetidine) should be administered in one dose at bedtime. Answers A, B, and C have incorrect times for dosing.
Which statement best describes the difference between the pain of angina and the pain of myocardial infarction?
Show answer and rationale
Correct answer: A. Pain associated with angina is relieved by rest.
Pain associated with angina is relieved by rest. Answer B is incorrect because it is not a true statement. Answer C is incorrect because pain associated with angina can be referred to the jaw, the left arm, and the back. Answer D is incorrect because pain from a myocardial infarction can be referred to areas other than the left arm
The nurse is developing a bowel-retraining plan for a client with multiple sclerosis. Which measure is likely to be least helpful to the client:
Show answer and rationale
Correct answer: B. Limiting fluid intake to 1000mL per day
It would not be helpful to limit the fluid intake of a client during bowel retraining. Answers B, C, and D would help the client; therefore, they are incorrect answers.
The nurse is caring for a client who is unconscious following a fall. Which comment by the nurse will help the client become reoriented when he regains consciousness?
Show answer and rationale
Correct answer: B. "You were in an accident that hurt your head. You are in the hospital."
Telling the client what happened and where he is helps with reorientation. Answer A does not explain what happened to the client; therefore, it is incorrect. Answer B is not helpful because the client regaining consciousness will not know where he is; therefore, the answer is incorrect. The nurse should not offer false reassurances, such as "everything will be alright"; therefore, answer C is incorrect.
Following a generalized seizure, the nurse can expect the client to:
Show answer and rationale
Correct answer: D. Be drowsy and prone to sleep
Following a generalized seizure, the client frequently experiences drowsiness and postictal sleep. Answer A is incorrect because the client is able to move the extremities. Answer C is incorrect because the client can remember events before the seizure. Answer D is incorrect because the blood pressure is elevated. 208 Chapter 3
The nurse is assessing an infant with Hirschsprung’s disease. The nurse can expect the infant to:
Show answer and rationale
Correct answer: D. Have infrequent bowel movements
The infant with Hirschsprung’s disease will have infrequent bowel movements. Answers A, C, and D do not apply to the condition; therefore, they are incorrect.
The physician has ordered an external monitor for a laboring client. If the fetus is in the left occipital posterior (LOP) position, the nurse knows that the ultrasound transducer will be located:
Show answer and rationale
Correct answer: D. Over the fetal back
n the left occipital posterior position, the heart sounds will be heard loudest through the fetal back. Answers A, B, and D are incorrect locations.
A client develops tremors while withdrawing from alcohol. Which medication is routinely administered to lessen physiological effects of alcohol withdrawal?
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Correct answer: C. Klonopin (clonazepam)
Benzodiazepines such as Ativan (lorazepam) and Klonopin (clonazepam) are given to the client withdrawing from alcohol. Answer A is incorrect because methodone is given to the client withdrawing from opiates. Answer C is incorrect Because disufiram is used in aversive therapy for alcohol addiction.
A client with Type II diabetes has an order for regular insulin 10 units SC each morning. The client’s breakfast should be served within:
Show answer and rationale
Correct answer: D. 30 minutes
The client’s breakfast should be served within 30 minutes to coincide with the onset of the client’s regular insulin
A 10-year-old has an order for Demerol (meperidine) 35mg IM for pain. The medication is available as Demerol 50mg per mL. How much should the nurse administer?
Show answer and rationale
Correct answer: C. 7mL
The nurse should administer .07mL of the medication. Answers A, B, and D are incorrect because the dosage is incorrect.
Which antibiotic is contraindicated for the treatment of infections in infants and young children?
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Correct answer: C. Tetracyn (tetracycline)
Tetracycline is contraindicated for use in infants and young children because it stains the teeth and arrests bone development. Answers B, C, and D are incorrect because they can be used to treat infections in infants and children.
A nurse is assessing a client hospitalized with peptic ulcer disease. Which finding should be reported to the charge nurse immediately?
Show answer and rationale
Correct answer: C. BP 82/60, pulse 120
Decreased blood pressure and increased pulse rate are signs of bleeding. Answers B, C, and D are within normal limits; therefore, they are incorrect.
An elderly client asks the nurse how often he will need to receive immunizations against pneumonia. The nurse should tell the client that she will need an immunization against pneumonia:
Show answer and rationale
Correct answer: B. Every 5 years
Immunization against pneumonia is recommended every 5 years for persons over age 65, as well as for those with a chronic illness. Answers A and B are incorrect because the client still has immunity from the vaccine. Answer D is incorrect because the client should have received the booster immunization much sooner.
A client with gallstones in the gall bladder is scheduled for lithotripsy. For the procedure, the client will be placed:
Show answer and rationale
Correct answer: C. In a prone position
because it is the position used for lithotripsy for the client with gallstones in the gall bladder. Answer B is incorrect because it is the position used for lithotripsy for the client with gallstones in the common bile duct. Answers C and D are incorrect because side-lying and recumbent positions do not allow the maximum effect of therapy.
A client with rheumatoid arthritis is being treated with daily steroid medication. Which food should the client avoid?
Show answer and rationale
Correct answer: D. Raw oysters
Persons receiving steroids should eat only cooked or processed foods. Raw oysters carry hepatitis A as well as E. coli. Answers B, C, and D are all suitable foods for the client taking steroid medication; therefore, they are incorrect.256 Chapter 4
The nurse is caring for a 3-year-old in a wet hip spica cast made from plaster of Paris. When turning the 3-year-old with a wet cast, the nurse should:
Show answer and rationale
Correct answer: B. Use the palms of the hands
The nurse should handle the cast using the palms of the hands, to prevent indentations in the cast. Answer A is incorrect because grasping the cast with the hands will produce indentations that cause pressure points. Answers B and D are incorrect choices because assistive slings and lifting devices would frighten the 3-year-old and are not needed
The nurse is caring for an infant with atopic dermatitis. An important part of the infant’s care will be:
Show answer and rationale
Correct answer: A. Trimming the fingernails
The infant’s fingernails should be kept short to prevent scratching the skin. Keeping the infant warm will increase itching; therefore, answer A is incorrect. Soap should not be used because it dries the skin; therefore, answer C is incorrect. Peroxide is damaging to the tissues; therefore, answer D is incorrect. Practice Exam 4 and Rationales 259
A nurse finds her neighbor lying unconscious in the doorway of her bathroom. After determining that the victim is unresponsive, the nurse should:
Show answer and rationale
Correct answer: D. Call for help
According to the American Heart Association, the nurse should call for help before instituting CPR. Answer A is incorrect because the nurse would first call for help. The nurse would not start cardiac compressions before evaluating the client’s carotid pulse. Answer B is incorrect because the nurse would first call for help. The nurse would not administer rescue breathing until she established that the client was not breathing on her own. Answer C is incorrect because the nurse would open the airway after calling for help.
The nurse is assessing a client following a subtotal thyroidectomy. Part of the assessment is asking the client to state her name. The primary reason for asking the client to state her name is to check for:
Show answer and rationale
Correct answer: A. Laryngeal nerve damage
Hoarseness and weak voice are signs of laryngeal nerve damage. These would be evident when the client states her name. Answer A is incorrect because it is not assessed by having the client state her name. The nurse would check the client’s dressing and check behind the neck for signs of post-operative bleeding. Answer B is incorrect because it is not assessed by having the client state her name. Signs of decreased calcium include tingling around the mouth and muscle twitching. Answer C is incorrect because it is not assessed by having the client state her name. Signs of laryngeal stridor include harsh, high-pitched respirations.
A client is admitted for treatment of essential hypertension. Essential hypertension exists when the client maintains a blood pressure reading at or above:
Show answer and rationale
Correct answer: B. 140/90
Essential hypertension is defined as maintenance of a blood pressure reading at or above 140/90. Answers B, C, and D are incorrect because the blood pressures are lower than 140/90.
The nurse is applying karaya powder to the skin surrounding the client’s ilestomy. The purpose of the karaya powder is to:
Show answer and rationale
Correct answer: C. Help form a seal that will protect the skin
Karaya powder is applied to help form a seal that will protect the skin from the liquid stool. Answer A is incorrect because karaya powder will not Practice Exam 4 and Rationales 261 prevent the formation of odor. Answer C is incorrect because karaya powder will not prevent the loss of electrolytes from the ileostomy. Answer D is incorrect because karaya powder will not increase the time between bag evaluations
The nurse is caring for a 9-month-old with suspected celiac disease. Which diet is appropriate?
Show answer and rationale
Correct answer: B. Breast milk and rice cereal
The appropriate diet for the 9-month-old with suspected celiac disease is breast milk and rice cereal. Answer A is incorrect because the 9-month-old is too young to have whole milk, and oats contain gluten, which is associated with celiac disease. Both mixed cereal and barley cereal contain gluten, which is associated with celiac disease; therefore, answers B and C are incorrect.
Which lab finding would the nurse expect to find in the client with diverticulitis?
Show answer and rationale
Correct answer: A. Elevated white cell count
An elevated white cell count is expected in inflammatory conditions such as diverticulitis. Answers A, B, and D are not associated with inflammation; therefore, they are incorrect.
A gravida two para one has just delivered a full-term infant. Which finding indicates separation of the placenta?
Show answer and rationale
Correct answer: A. Increased length of the cord
Increased length of the cord is a sign that the placenta has separated. Answers A, C, and D are not associated with separation of the placenta; therefore, they are incorrect.
The physician has ordered a daily dose of Tagamet (cimetidine) for a client with gastric ulcers. The nurse should administer the medication:
Show answer and rationale
Correct answer: D. At bedtime
It is recommended that a daily dose of cimetadine be given at bedtime. Answers A, B, and D are inaccurate times; therefore, they are incorrect
A client admitted for treatment of a duodenal ulcer complains of sudden sharp midepigastric pain. Further assessment reveals that the client has a rigid, boardlike abdomen. The nurse recognizes that the client’s symptoms most likely indicate:
Show answer and rationale
Correct answer: C. Ulcer perforation
Perforation of a duodenal ulcer is characterized by sudden sharp midepigastric pain caused by the emptying of duodenal contents into the peritoneum. The abdomen is tender, rigid, and boardlike. Answer B is not associated with the client’s sudden onset of symptoms; therefore, it is incorrect. Answer C is incorrect because the client would complain of heartburn or reflux. Answer D is incorrect because the client would have increased abdominal distention, visible peristaltic waves, and high-pitched bowel sounds.
Which snack is best for the child following a tonsillectomy?
Show answer and rationale
Correct answer: D. Banana popsicle
The banana popsicle is best for the child following a tonsillectomy because it is cold and the yellow color does not allow it to be confused with any bleeding that the child might have. Answer B is incorrect because milk products form a film on the operative area and thicken saliva. Answer C is incorrect because fruit punch contains fruit juices that might cause a burning sensation in the throat following a tonsillectomy. Answer D is incorrect because the carbonation from cola causes a burning sensation in the throat following a tonsillectomy.
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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