NCLEX Practice Questions — Set 51
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 nurse is instructing a post-operative client on the use of an incentive spirometer. The nurse knows that the correct use of the incentive spirometer is directly related to:
Show answer and rationale
Correct answer: A. Increasing the client’s respiratory effort
The correct use of the incentive spirometer will increase the client’s respiratory effort and effectiveness. Answers A and B are indirectly affected by the correct use of the incentive spirometer; therefore, they are incorrect. Answer C is not affected by the use of an incentive spiromenter; therefore, it is incorrect.
The nurse is assisting the physician with the insertion of an esophageal tamponade. Before insertion, the nurse should:
Show answer and rationale
Correct answer: C. Inflate and deflate the gastric and esophageal balloons
Unless the manufacturer recommends otherwise, the nurse should inflate and deflate the gastric and esophageal balloons to make sure they are not defective. Answer B refers to the insertion of a standard nasogastric tube; therefore, it is incorrect. Answer C is incorrect because the esophageal tamponade is usually removed after 48 hours. Answer D is incorrect because the esophageal tamponade has a port for gastric suction. 262 Chapter 4
The nurse is assessing a client immediately following delivery. The nurse notes that the client’s fundus is boggy. The nurse’s next action should be to:
Show answer and rationale
Correct answer: C. Gently massage the fundus
Gently massaging the fundus immediately following delivery will help it to contract. Answer A is incorrect because the uterus would be displaced to one side if the bladder was distended. Answer B is incorrect. The nurse should first massage the fundus before notifying the doctor. Answer D is incorrect because uterine relaxation is not associated with pain.
Which breakfast selection is suitable for the client on a high-fiber diet?
Show answer and rationale
Correct answer: C. Oatmeal, grapefruit wedges, coffee, and milk
Oatmeal and grapefruit wedges are high in fiber. Answers A, C, and D are incorrect because they contain less fiber.
A male client is admitted with a tentative diagnosis of Hodgkin’s lymphoma. The client with Hodgkin’s lymphoma commonly reports:
Show answer and rationale
Correct answer: C. Finding enlarged nodes in the neck while shaving
Many clients with Hodgkin’s lymphoma report finding enlarged nodes in the neck when shaving. Answer B is associated with brain tumors; therefore, it is incorrect. Answer C is associated with leukemia; therefore, it is incorrect. Answer D is associated with renal cancer; therefore, it is incorrect.
During a well baby visit, the mother asks the nurse when the "soft spot" on the front of her baby’s head will close. The nurse should tell the mother that the anterior fontanel normally closes by the time the baby is:
Show answer and rationale
Correct answer: B. 12-18 months of age
The anterior fontanel usually closes by the time the baby is 12-18 months of age. Answers A, B and C are incorrect because the baby is too young for the anterior fontanel to be closed.
An elderly client with anemia has a positive Schilling test. The nurse knows that the client’s anemia is due to:
Show answer and rationale
Correct answer: A. Lack of intrinsic factor
A positive Schilling test indicates that the client has pernicious anemia, which is due to the lack of intrinsic factor. Answer A describes iron-deficiency anemia; therefore, it is incorrect. Answer B describes sickle cell anemia; therefore, it is incorrect. Answer D describes Cooley’s anemia; therefore, it is incorrect.
The nurse is cleaning up a blood spill that occurred during removal of a chest tube. The nurse should clean the blood spill using:
Show answer and rationale
Correct answer: C. Weak solution of bleach
According to universal precautions, blood spills should be cleaned up immediately using a weak solution of bleach (1 part bleach to 10 parts water). Answers A, C, and D are not recommended for cleaning up accidental blood spills; therefore, they are incorrect.
A 5-month-old admitted with gastroenteritis is managed with IV fluids and is to be NPO. Which nursing intervention will provide the most comfort for the 5-month-old who is NPO?
Show answer and rationale
Correct answer: B. Offering a pacifier
Providing a pacifier will provide the most comfort for the 5- month-old by providing oral gratification. Answers B, C, and D will comfort the infant, but not as much as the pacifier while he is NPO
During the admission assessment, the nurse discovers that the client has brought her medications from home. The nurse should:
Show answer and rationale
Correct answer: D. Make a list of the medications and ask a family member to take the medications home
The nurse should make a list of the medications and ask a family member to take the medications home. If no family member is available, the medication should remain locked in the medication room until the client is discharged home. Answer A is incorrect because the client might take the medication without the nurse’s knowledge, which might result in overmedication. Answer C is incorrect because over-the-counter medications and herbal supplements can interact with medications the physician might order. Answer D is incorrect because only medications supplied by the hospital pharmacy should be used while the client is hospitalized unless the physician writes an order allowing the nurse to administer medication previously purchased by the client
The nurse is caring for a client following a pneumonectomy. Which nursing intervention will help prevent an embolus?
Show answer and rationale
Correct answer: D. Ambulating the client as soon as possible
Ambulating the client as soon as possible prevents venous stasis and helps to prevent embolus formation. Answers A and C are measures to increase the effectiveness of respirations and help to prevent pneumonia; therefore, they are incorrect. Answer B is a treatment to break up an existing embolus; therefore, it is incorrect.
The physician has ordered B & O (belladonna and opium) suppositories for a client following a prostatectomy. The nurse recognizes that the medication will:
Show answer and rationale
Correct answer: D. Help relieve pain due to bladder spasms
B & O suppositories relieve pain following a prostatectomy by reducing bladder spasms. The medication does not improve urinary output, does not reduce post-operative swelling, and does not treat nausea and vomiting; therefore, answers B, C, and D are incorrect
Post-operative orders have been left for a client with an abovethe- knee amputation. The orders include wrapping the stump with an elastic bandage. The nurse knows that the primary reason for wrapping the stump with an elastic bandage is to:
Show answer and rationale
Correct answer: A. Shrink the stump
The primary reason for wrapping the stump with an elastic bandage is to shrink the stump and get it ready for application of a prosthetic device. Answer A is incorrect because the application of an elastic bandage will not decrease bleeding. Answer C is incorrect because the application of an elastic bandage will not prevent phantom pain. Application of an elastic bandage will prevent the client from seeing the area, but this is not the primary reason for its use; therefore, answer D is incorrect.
The nurse is assisting a client with a total hip replacement to a chair. Which type of chair is appropriate for the client following a total hip replacement?
Show answer and rationale
Correct answer: D. A recliner
Following a total hip replacement, the nurse should assist the client to sit in a recliner, which limits the amount of hip flexion to 60� or less. Answers B, C, and D are incorrect because they allow the hip to be flexed more than 90�, which might dislocate the hip prosthesis
The nurse at a local daycare center observes a group of preschool-age children playing. The children are playing in an unorganized fashion, with no obvious rules to the play activity. The type of play that is typical of preschool-age children is known as:
Show answer and rationale
Correct answer: B. Associative play
The typical play of preschool-age children is described as associative play. In associative play, children of the same sex play together with no obvious rules for play activity and without leaders. Answer A is incorrect because it is the typical play activity of the infant. Answer B is incorrect because it is the typical play 264 Chapter 4 activity of the toddler. Answer D is incorrect because it is the typical play activity of the school-age child.
Which of the following is not a part of routine cord care of the newborn?
Show answer and rationale
Correct answer: B. Placing a petroleum gauze on the cord
Petroleum gauze should not be applied to the cord, which separates by a process of drying. Answers B, C, and D are all parts of routine cord care; therefore, they are incorrect.
The nurse is monitoring a client admitted with an overdose of Phenobarbital (phenobarbital). The nurse should carefully observe the client for signs of:
Show answer and rationale
Correct answer: B. Decreased respirations
Phenobarbital is a central nervous system depressant that is capable of producing decreased respirations and apnea. Answer A is associated with an overdose of aspirin; therefore, it is incorrect. Answer C is incorrect because the blood pressure would be decreased. Answer D is not associated with an overdose of Phenobarbital; therefore, it is incorrect.
An elderly client is admitted with a fractured left hip. Which type of traction will be used to immobilize the client’s left extremity?
Show answer and rationale
Correct answer: A. Buck’s traction
Buck’s traction is a skin traction used for short-time immobilization of hip fractures before surgical correction. Answer A is incorrect because 90-90 traction is a skeletal traction used to immobilize fractures of the femur. Answer C is incorrect because Bryant’s traction is used only for children who weigh less than 30 pounds. Answer D is incorrect because Dunlop’s traction is used to treat fractures of the humerus.
The physician has prescribed Zoloft (sertraline) for a client who has been taking Nardil (phenelzine). The recommended length of time between discontinuing a monoamine oxidase inhibitor and beginning therapy with a selective serotonin reuptake inhibitor is:
Show answer and rationale
Correct answer: A. 14 days
Concurrent use of an SSRI and an MAO inhibitor can produce serotonin syndrome; therefore, the client should discontinue the MAO inhibitor 14 days before beginning therapy with an SSRI. Answers A, B, and C are incorrect because the time is too brief between the use of the MAO inhibitor and the beginning of therapy with an SSRI.
The nurse is observing a developmental assessment of an infant. Which of the following is an example of cephalocaudal development?
Show answer and rationale
Correct answer: C. The infant is able to raise her head before sitting.
Cephalocaudal development refers to head-to-tail (toe) development; therefore, the infant can raise her head before she can sit. Answer A is an example of simple-to-complex development; therefore, it is incorrect. Answer B is an example of proximodistal development; therefore, it is incorrect. Answer D is an example of general-to-specific development; therefore, it is incorrect.
The physician has ordered a straight catheterization for a female client. When performing a straight catheterization on a female client, the nurse should:
Show answer and rationale
Correct answer: A. Hold the catheter in place while the bladder empties
When performing a straight catheterization, the nurse should hold the catheter in place as the bladder empties to prevent it from slipping out. Answer A is incorrect because surgical, not medical, asepsis is used when performing a catheterization. Answer B is incorrect because the catheter should be inserted 2-3 inches. Answer C is incorrect because the straight catheter does not have a balloon for inflation.
Before moving a client up in bed, the nurse lowers the head of the bed. The purpose of lowering the head of the bed is:
Show answer and rationale
Correct answer: D. To avoid working against gravity as the client is moved
Moving the client up in the bed is easier with the head of the bed lowered because the nurse does not have to work against the force of gravity. Answer B is incorrect because lowering the head of the bed will not prevent wrinkles in the linen. Answer C is incorrect because lowering the head of the bed will not eliminate the need for additional help to move the client. Answer D is incorrect because lowering the head of the bed will not relieve pressure on the client’s sacrum. Practice Exam 4 and Rationales 265
The physician has ordered Dolophine (methadone) for a client withdrawing from opiates. Which finding is associated with acute methodone toxicity?
Show answer and rationale
Correct answer: C. Respiratory depression
Methodone is an opiod agonist; therefore, it is capable of producing respiratory depression
The nurse is assessing a primgravida 12 hours after a Caesarean section. The nurse notes that the client’s fundus is at the umbilicus and is firm. The nurse should:
Show answer and rationale
Correct answer: B. Chart the finding
The client’s assessment findings are within normal 12 hours after a Caesarean section; therefore, the nurse should chart the finding. Answer A is incorrect because the assessment does not reveal the presence of bladder distention. Answer B is incorrect because the assessment does not reveal uterine atony. Answer D is incorrect because the client needs to ambulate.
Which of the following observations in a 4-year-old suggests the possibility of child abuse?
Show answer and rationale
Correct answer: D. The presence of "rainbow" bruises
"Rainbow" bruises refer to bruises in various stages of healing. Although they are not conclusive proof of physical abuse, they do suggest the possibility. Answer B is incorrect because the 4-year-old might still suck the thumb when going to sleep. The victim of child abuse usually endures painful procedures with little expression of emotion; therefore, answer C is incorrect. Victims of child abuse are usually reluctant to talk to strangers; therefore, answer D is incorrect.
A client with a history of alcoholism cannot remember the events of the past week even though he has receipts from various places of business. The client’s inability to recall events is known as:
Show answer and rationale
Correct answer: A. A blackout
An alcoholic blackout refers to the inability to remember what occurred before or after a period of alcohol intake. Answer A is incorrect because it occurs after a period of heavy drinking or when the usual alcohol intake is reduced. Alcoholic hallucinosis is characterized by hallucinations. Answer B is incorrect because it refers to the headache and gastrointestinal symptoms experienced after drinking alcohol. Sunday morning paralysis refers to radial nerve palsy commonly observed when a stuporous person lies with his arm pressed over a projecting surface; therefore, answer D is incorrect.
The nurse is caring for a client with degenerative joint disease. Which finding is associated with degenerative joint disease?
Show answer and rationale
Correct answer: A. Joint pain that intensifies with activity and diminishes with rest
Degenerative joint disease (osteoarthritis) is characterized by joint pain that intensifies with activity and diminishes with rest. Answers B, C, and D are typical findings in the client with rheumatoid arthritis; therefore, they are incorrect
The physician has ordered an injection of Demerol (meperidine) for a client with pancreatitis. The nurse should:
Show answer and rationale
Correct answer: D. Hold pressure on the injection site for 3-5 minutes
The client with pancreatitis has decreased levels of vitamin K, making him more likely to have prolonged bleeding with injections; therefore, the nurse should hold pressure on the injection site for 3-5 minutes. Answer A is incorrect because the medication is not administered using the Z track method. Answer C is incorrect because the medication is not administered subcutaneously. Answer D is incorrect because alcohol, not betadine, is used to prep the skin.
The nurse is preparing a client with Addison’s disease for discharge. The nurse should explain that the client can help prevent complications by:
Show answer and rationale
Correct answer: D. Staying out of crowds
The client with Addison’s disease is treated with corticosteroid therapy that reduces the client’s immunity. The client needs to stay out of crowds to prevent complications posed by infection. Answers A and C are incorrect because the client needs additional sources of sodium and potassium in the diet. Answer B is incorrect because the client with Addison’s disease should dress in warm clothing to prevent easy chilling.
A 10-year-old received an injury to his face and mouth in a bicycle accident. Examination reveals that a permanent tooth has been evulsed. Emergency care following evulsion of a permanent tooth includes:
Show answer and rationale
Correct answer: A. Rinsing the tooth in milk before reimplantation
The evulsed tooth should be rinsed in milk, in saline solution, or under running water before reimplantation. Answer B is incorrect because it will disturb 266 Chapter 4 the adhering periodontal membrane. Answer C is incorrect because the tooth should be held by the crown, not the root. Answer D is incorrect because the child might swallow or aspirate the tooth.
The nurse is caring for a client following an exploratory laparotomy. Which of the following assessment findings requires intervention?
Show answer and rationale
Correct answer: D. The hourly urinary output of 20mL is dark amber in color.
The hourly urinary output should be maintained between 30mL and 50mL per hour. The fact that the urine is dark amber indicates that the client is not receiving adequate fluids to prevent dehydration. Answers A, C, and D do not call for any interventions; therefore, they are incorrect.
The nurse is caring for a client following a colonoscopy in which conscious sedation was used. Initial assessment of the client reveals the following: BP 128/72, temperature 97, pulse 64, respirations 14, oxygen saturation 90%, and Glascow score of 13. An IV of normal saline is infusing at 20 drops per minute. Which nursing intervention should receive priority?
Show answer and rationale
Correct answer: B. Administering oxygen per standing order
The client’s oxygen saturation is low; therefore, the nurse should give priority to administering oxygen per standing order. Answer A is incorrect because there is nothing that indicates that the client needs an analgesic. Answer C is incorrect because the client’s temperature is satisfactory. Answer D is incorrect because the Glascow score of 13 indicates that the client is not fully recovered from the effects of conscious sedation; therefore, the IV should not be discontinued.
The physician has ordered diuretic therapy and fluid restrictions for a client admitted with a stroke. The nurse knows that diuretic therapy and fluid restrictions are ordered during the acute phase of a stroke to:
Show answer and rationale
Correct answer: C. Reduce cerebral edema
Diuretic therapy and restriction of fluids are ordered during the acute phase of a stroke to reduce cerebral edema. Answer A is incorrect because the orders are not intended to reduce cardiac output. Answer B is incorrect because the measures will not prevent an embolus. Answer D is incorrect because the measures are not intended to minimize incontinence.
Which food is the best source of calcium and potassium?
Show answer and rationale
Correct answer: A. Spinach
Spinach is an excellent source of both calcium and potassium. Broccoli is a good source of calcium but not potassium; therefore, answer A is incorrect. Sweet potato and avocado are good sources of potassium but not calcium; therefore, answers B and D are incorrect.
The physician has ordered a PSA and acid phosphatase for a client admitted with complaints of dysuria. The nurse knows that a PSA and acid phosphatase are screening tests for:
Show answer and rationale
Correct answer: A. Cancer of the prostate
The PSA (prostate specific antigen) and acid phosphatase are valuable screening tests for cancer of the prostate. The PSA is not a screening test for cancers of the bladder, vas deferens, or testes; therefore, answers A, C, and D are incorrect.
The client’s morning lithium level is 1.2mEq/L. The nurse recognizes that:
Show answer and rationale
Correct answer: C. The level is within the therapeutic range.
The client’s lithium level is within the therapeutic range. Answer A is incorrect because the lithium level is not too low to be therapeutic. Answer B is incorrect because the client is not within the range of toxicity. Answer D is incorrect because eating more sodium-rich foods will reduce the lithium level.
Which emergency treatment is appropriate for the client who suddenly develops ventricular fibrillations?
Show answer and rationale
Correct answer: A. Defibrillation
The treatment for ventricular fibrillations (V-fib) is defibrillation (D-fib). Answers A, B, and D are not emergency treatments for the client who suddenly develops ventricular fibrillations.
The nurse is caring for a client following a stroke that left him with apraxia. The nurse knows that the client will:
Show answer and rationale
Correct answer: C. Be unable to perform previously learned skills
The client with apraxia is unable to recognize the purpose of familiar objects; therefore, he is unable to perform previously learned skills such as combing his hair. Answer A is incorrect because it refers to aphasia. Answer B is incorrect because it refers to dysphagia. Answer C is incorrect because it refers to ataxia.
A client with thrombophlebitis is receiving Lovenox (enoxaparin). Which method is recommended for administering Lovenox?
Show answer and rationale
Correct answer: A. Subcutaneously in the abdominal tissue
The recommended way of administering Lovenox (enoxaparin) is subcutaneously in the abdominal tissue. Answers A and B are not recommended ways of administering Lovenox (enoxaparin); therefore, they are incorrect. Answer D is incorrect because Lovenox (enoxaprin) is not available in an oral form
A client with angina is to be discharged with a prescription for nitroglycerin tablets. The client should be instructed to:
Show answer and rationale
Correct answer: A. Leave the medication in a dark-brown bottle
Nitroglycerin should be kept in a dark-brown bottle to protect it from light, which causes deterioration of the medication. Answer A is incorrect because the medication is placed beneath the tongue when needed, not taken daily. Answer C is incorrect because the medication supply should be replenished every 6 months, not every year. Answer D is incorrect because the cotton should be removed from the bottle because it absorbs the medication. 268
A client is receiving external radiation for cancer of the larynx. As a result of the treatment, the client will most likely complain of:
Show answer and rationale
Correct answer: B. Sore throat
Because of the location, the client receiving external radiation for cancer of the larynx will most likely complain of a sore throat. Generalized pruritis, dyspnea, and bone pain are not associated with external radiation for cancer of the larynx; therefore, answers A, B, and D are incorrect.
An infant with respiratory synctial virus has been started on Virazole (ribavirin). When caring for the infant receiving Virazole, the nurse should:
Show answer and rationale
Correct answer: C. Temporarily stop administration of the medication when the mist tent needs to be opened
The nurse should temporarily stop the administration of the Virazole when the mist tent needs to be opened to allow the medication particles to settle. Answer A is incorrect because contact precautions should be used even though the infant is receiving Virazole. Answer B is incorrect because contact precautions are used whether the mist tent is opened or closed. Answer D is incorrect because increasing or decreasing the rate of medication administration is not a nursing function.
A 9-month-old is admitted with a diagnosis of eczema. The nurse would expect the 9-month-old to have eczematous lesions over:
Show answer and rationale
Correct answer: A. The cheeks and extensor surfaces of arms and legs
Eczematous lesions are more common on the cheeks and extensor surfaces of the arms and legs. Answer A is incorrect because the abdomen is not a common site of eczematous lesions. Answer B is incorrect because the buttocks, abdomen, and back are not common sites of eczematous lesions. Answer C is incorrect because the back and flexor surfaces of the arms and legs are not common sites of eczematous lesions
Which one of the following factors has the greatest influence on the recovery and sobriety of a client with a chemical addiction?
Show answer and rationale
Correct answer: C. The client’s own desire to become drug-free
The client’s own desire to become drug-free has the most influence on recovery and sobriety. Answers A, B, and D are important factors, but they do not have the greatest influence on the client’s recovery; therefore, they are incorrect.
Which of the following signs is characteristic of the child with Duchenne’s muscular dystrophy?
Show answer and rationale
Correct answer: A. The use of Gower’s maneuver to rise to a standing position
The child with Duchenne’s muscular dystrophy must use Gower’s maneuver to rise to a standing position. The child puts his hands on his knees and moves the hands up the legs until he is standing. Answer B is incorrect because it refers to the child with Osgood-Schlatter disease. Answer C is incorrect because it refers to the child with lordosis. Answer D is incorrect because it refers to the child with Legg-Calve-Perthes disease
An obstetrical client is admitted in active labor. When the membranes rupture, the nurse would expect to find:
Show answer and rationale
Correct answer: A. A moderate amount of straw-colored discharge
Amniotic fluid is straw colored in appearance. Answer A is incorrect because it indicates active bleeding. Answer C is incorrect because it indicates the passage of meconium, which is associated with fetal distress. Answer D is incorrect because the discharge should be straw colored, not dark brown in appearance.
Fetal heart tones can be heard using a fetoscope as early as:
Show answer and rationale
Correct answer: A. 18 weeks gestation
Fetal heart tones can be heard using a fetoscope as early as 18 weeks gestation. Answers A, B, and C are incorrect because fetal heart tones cannot be heard using a fetoscope before 18 weeks gestation.
The nurse is teaching the pregnant client ways to prevent heartburn. The nurse should tell the client to:
Show answer and rationale
Correct answer: C. Avoid caffeinated beverages
The client can help prevent heartburn by avoiding caffeinated beverages. Answers A and C are incorrect because the client should sleep on her left side with her head elevated on several pillows. Answer B is incorrect because eating dry crackers at bedtime can increase problems with heartburn.
A child with cystic fibrosis takes pancreatic enzymes with each of his meals and between meal snacks. Which finding indicates that the prescribed amount of pancreatic replacement is adequate?
Show answer and rationale
Correct answer: C. Increased weight
Pancreatic enzyme replacement is given to facilitate the digestion of fats, proteins, and carbohydrates. Therefore, if the amount of pancreatic enzyme is adequate, the client will have an increase in weight. Answer A is incorrect because pancreatic enzyme replacement has no effect on respiratory function. Answer B is incorrect because pancreatic enzyme replacement does not decrease sodium excretion. Answer D is incorrect because pancreatic enzyme replacement does not decrease chloride excretion.
The physician has ordered a Guthrie test for a newborn. The nurse recognizes that the test is ordered to detect:
Show answer and rationale
Correct answer: C. Phenylketonuria
The Guthrie test is a screening test for newborns to detect phenylketonuria. Cystic fibrosis is confirmed by a sweat test; therefore, answer A is incorrect . Hypothyroidsim is confirmed by a T3 and T4; therefore, answer C is incorrect. Sickle cell is confirmed by the Sickledex; therefore, answer D is incorrect.
The physician has ordered a low-calorie, low-fat, low-sodium diet for a client with hypertension. Which menu selection is appropriate for the client?
Show answer and rationale
Correct answer: B. Baked chicken, apple, angel food cake, 1% milk
A meal of baked chicken, apple, angel food cake, and 1% milk is low in calories, low in fat, and low in sodium. Answer A is incorrect because blue 270 Chapter 4 cheese dressing and crackers are high in sodium. Answer B is incorrect because frankfurters are high in calories, fat, and sodium. Answer C is incorrect because taco seasoning, meat, chips, and sour cream are high in calories, fat, and sodium.
A postpartal client wants to know how the nutrient value of breast milk differs from that of cow’s milk. The nurse should tell the client that breast milk is:
Show answer and rationale
Correct answer: C. Higher in fat
Breast milk is higher in fat than cow’s milk. Answers B, C, and D are inaccurate statements regarding breast milk; therefore, they are incorrect.
The nurse is administering medication to a client with paranoid schizophrenia. The client accepts the medication but does not place it in his mouth. The nurse should:
Show answer and rationale
Correct answer: C. Tell the client to put the medicine in his mouth and swallow it with the water
The nurse should direct the client to put the medicine in his mouth and swallow it with some water. Answer A is incorrect because it is threatening to the client. Answer C is incorrect because medication administration and supervision is a responsibility of the nurse, not the nursing assistant. Answer D is incorrect because the nurse is threatening the client.
While reviewing the client’s lab report, the nurse notes that the client has a potassium level of 3.0 mEq/L. What is the best source of potassium?
Show answer and rationale
Correct answer: C. One cup of prune juice
One cup of prune juice provides 707mg of potassium. Answers A, B, and C are incorrect because they provide less potassium than prune juice. (One cup of apple juice provides 295mg of potassium, one cup of orange juice provides 496mg of potassium, and one cup of cranberry juice provides 152mg of potassium.)
A client admitted with renal calculi is experiencing severe pain in the right flank and nausea. The immediate nursing intervention is to:
Show answer and rationale
Correct answer: B. Administer pain medication as ordered
The immediate nursing intervention is the administration of pain medication. Answers B, C, and D will be done later; therefore, they are incorrect.
The physician has ordered a sterile urine specimen from a client with an in-dwelling catheter. The nurse should:
Show answer and rationale
Correct answer: B. Use a sterile syringe and needle to remove urine from the port nearest the client and place the urine into a sterile specimen cup
The urine should be removed using a sterile syringe and needle. Removing the urine from the port nearest the client ensures that the urine is more sterile. Answer A is incorrect because urine in the bag is not sterile. Answer B is incorrect because urine in the drainage tube is not sterile. Answer C is incorrect because urine in the bag is not sterile.
The nurse is admitting a newborn to the nursery. Which finding is expected in the full-term newborn?
Show answer and rationale
Correct answer: D. Presence of vernix caseosa
Vernix caseosa covers the body of the full-term infant. Absence of sucking pads, presence of the scarf sign, and the absence of solar creases are expected findings in the preterm infant; therefore, answers A, C, and D are incorrect.
Which of the following tasks is within the developmental norm for the 22-month-old child?
Show answer and rationale
Correct answer: C. Feeds herself with a spoon
The 22-month-old child can be expected to feed herself with a spoon. Answers B, C, and D are developmental tasks of the older child; therefore, they are incorrect. Practice Exam 4 and Rationales 271
A pediatric client is admitted with Munchausen’s syndrome by proxy. The nurse would expect the child to have:
Show answer and rationale
Correct answer: B. Unexplained illness
Munchausen’s syndrome by proxy is characterized by unexplained illness brought on by another person, usually the mother, for the purpose of gaining attention. Answer A refers to nursing bottle syndrome; therefore, it is incorrect. Answer C refers to oral allergy syndrome; therefore, it is incorrect. Answer D refers to Christ-Siemen’s Touraine syndrome; therefore, it is incorrect.
A nurse complains that a client is noncompliant because she prefers to take herbs prescribed by her herbalist rather than taking "real medicine." The nurse’s statement is an example of:
Show answer and rationale
Correct answer: C. Ethnocentrism
The nurse believes that her way of treating illness (real medication) is superior to the client’s way of treating illness (herbals). Answer A refers to belonging to a particular ethnic group; therefore, it is incorrect. Answers B and D are incorrect choices because the nurse’s statement did not reflect cultural sensitivity or cultural tolerance.
The nurse is checking the fetal heart rates of a client in labor. The normal range for fetal heart rates is:
Show answer and rationale
Correct answer: A. 110-160 beats per minute
The normal range for fetal heart tones is 110-160bpm. Answer A is incorrect because the heart rate is too slow. Answers C and D are incorrect choices because the heart rate is too rapid.
Which one of the following measures decreases abdominal discomfort when the post-operative client is asked to cough?
Show answer and rationale
Correct answer: A. Splinting the incision with a pillow
The client can decrease abdominal discomfort by splinting the incision with a pillow. Answers A and C are incorrect because they increase abdominal discomfort. Answer D is incorrect because it does not decrease abdominal discomfort.
The nurse is caring for a client with arteriosclerotic heart disease. The nurse recognizes that a nonmodifiable risk factor in the development of arteriosclerotic heart disease is:
Show answer and rationale
Correct answer: B. Family history
A family history of arteriosclerotic heart disease is a nonmodifiable risk factor in the development of arteriorsclerotic heart disease. Answers B, C, and D are incorrect because the risk of developing arteriosclerotic heart disease can be modified or altered by controlling hypertension, eliminating high cholesterol and high saturated fats from the diet, and enrolling in a program of regular exercise.
The physician has ordered Nardil (phenelzine), an MAO inhibitor for a client who is currently taking Paxil (paroxetine). The nurse should:
Show answer and rationale
Correct answer: D. Clarify the orders with the physician
The concurrent use of an MAO inhibitor such as Nardil and an SSRI such as Paxil is contraindicated because it can result in serotonin syndrome. Answers A and D are incorrect because the concurrent use of the medications is contraindicated. Answer C is incorrect because anti-Parkinsonian medication is used for the client with neuroleptic malignant syndrome, not serotonin syndrome.
The nurse is assessing a client who has undergone a right lobectomy. Which assessment should alert the nurse to the possibility of internal bleeding?
Show answer and rationale
Correct answer: C. Restless and shortness of breath
Signs of possible internal bleeding include restless and shortness of breath. Answer A is incorrect because the urinary output is within normal limits. Answer B is incorrect because the color and rate of chest tube drainage is within the expected range following a lobectomy. Answer D is incorrect because the pulse rate and respiratory rate would be increased with internal bleeding.
A client with congestive heart failure loses 4.1kg while hospitalized. The client’s weight loss is approximately:
Show answer and rationale
Correct answer: B. 9 pounds
A weight of 2.2 pounds is equal to 1kg; therefore, 4.1kg equals 9.02kg. Answers A, B, and C are inaccurate answers; therefore, they are incorrect. 272
A 40-year-old client with a myocardial infarction tells the nurse, "My father died with a heart attack when he was in his forties, and I guess I will, too." Which response by the nurse is most appropriate?
Show answer and rationale
Correct answer: C. "Tell me more about what you are feeling."
Asking the client to tell more about what he is feeling gives the client an opportunity to discuss his fears and apprehensions. Answer B is incorrect because it is a closed question. Answer C is incorrect because it minimizes the client’s feelings and offers false reassurances. Answer D is incorrect because it minimizes the client’s feelings.
An elderly client injured in a fall is admitted with fractures of the ribs and a closed right pneumothorax. The nurse should position the client:
Show answer and rationale
Correct answer: D. In semi-Fowler’s position tilted toward the right side
Positioning the client in semi-Fowler’s position tilted toward the right side will help to splint the fractured ribs and will allow the uninvolved left lung to fully inflate. Answers A and C are incorrect because they would make breathing more difficult. Answer D is incorrect because it would not allow the full expansion of the uninvolved lung.
A client develops cravings while withdrawing from alcohol. Which measure will best help the client maintain sobriety?
Show answer and rationale
Correct answer: D. Gaining support from other recovering alcoholics
An established means of dealing with cravings and maintaining sobriety is gaining support from other recovering alcoholics. Answers A and B are incorrect because they are punitive and will not help the client deal with his cravings. Answer D will help provide for the client’s safety during withdrawal, but it will not help the client maintain sobriety; therefore, it is incorrect.
The nurse is preparing to administer a DTP, Hib, and hepatitis B immunizations to an infant. The nurse should:
Show answer and rationale
Correct answer: A. Administer the DTP in one leg, and the Hib and the hepatitis B in the other leg
When administering the DTP, Hib, and hepatitis B vaccines, it is recommended that the DTP be administered in one leg and the Hib and hepatitis B vaccine be administered in the other leg. Answer A is incorrect ecause all the immunizations are not given in one site. No immunizations are to be given in the infant’s arm; therefore, answers C and D are incorrect
Lab results indicate that a client receiving heparin has a prolonged bleeding time. Which medication is the antidote for heparin?
Show answer and rationale
Correct answer: D. Protamine sulfate (protamine sulfate)
Protamine sulfate is the antidote for heparin overdose. Aquamephyton is the antidote for sodium warfarin overdose; therefore, answer A is incorrect. Ticlid is used to inhibit platelet aggregation and decrease the incidence of strokes; therefore, answer B is incorrect. Amicar is used in the management of hemorrhage caused by thrombolytic agents; therefore, answer D is incorrect.
A newborn of 32 weeks gestation is diagnosed with respiratory distress syndrome 3 hours after birth. An assessment finding in the newborn with respiratory distress syndrome is:
Show answer and rationale
Correct answer: D. Nasal flaring
Assessment findings in the newborn with respiratory distress syndrome include nasal flaring, grunting respirations, and retractions. Answers A, C, and D are not associated with respiratory distress syndrome; therefore, they are incorrect.
To reduce the risk of SIDS (sudden infant death syndrome), the nurse should tell parents to place the infant:
Show answer and rationale
Correct answer: D. On his back while he is sleeping
Placing the infant on his back while he is sleeping helps to reduce the risk of SIDS. Answers A, B, and D are incorrect because they have not been shown to reduce the risk of SIDS.
The physician has discharged a client with diverticulitis with a prescription for Metamucil (psyllium). When teaching the client how to prepare the medication, the nurse should tell the client to:
Show answer and rationale
Correct answer: C. Mix the medication with water and drink it immediately
Metamucil should be mixed with the recommended amount of water and drunk immediately. Answers A, C, and D are improper ways of preparing the medication; therefore, they are incorrect.
Young children living in housing that was built before the 1970s are at risk for:
Show answer and rationale
Correct answer: B. Lead poisoning
Before the mid-1970s, lead-based paint was used extensively. Children living in housing built before that time are at risk for lead poisoning. Answer B is incorrect because it is due to a lack of intrinsic factor needed for the production of red blood cells. Answer C is incorrect because it is related to the overuse of iron supplements or vitamins containing iron. Answer D is incorrect because it is related to the ingestion of grains such as oats, barley, wheat, and rye.
Which of the following findings is associated with fluid overload in the child with renal disease?
Show answer and rationale
Correct answer: A. Distention of the jugular veins and pitting edema
Distention of the jugular veins and pitting edema are findings associated with fluid overload in the child with renal disease. Answers A, C, and D are not characteristics of fluid overload; therefore, they are incorrect.
A child with beta thalassemia has developed hemosiderosis. To prevent organ damage, the child will receive chelation therapy with:
Show answer and rationale
Correct answer: A. Desferal (deferoxamine)
Desferal (deferoxamine) is the chelating agent used to treat the child with hemosiderosis. Succimer, Versenate, and EDTA are chelating agents used to treat the child with lead poisoning; therefore, answers A, B, and D are incorrect.
The nurse is caring for a client 1 week post-burn injury. The nurse should expect the client to benefit from a diet that is:
Show answer and rationale
Correct answer: B. High in protein, high in carbohydrates, and high in calories
The client recovering from a burn injury should have a diet that is high in protein, high in carbohydrates, and high in calories to meet the body’s requirements for tissue repair. Answer A is incorrect because the client needs additional carbohydrates. Answer B is incorrect because the client would benefit from increased fat. Answer D is incorrect because the client needs additional calories.
Which of the following describes a nosocomial infection?
Show answer and rationale
Correct answer: D. A client develops MRSA while hospitalized for treatment of a fractured hip.
Nosocomial infections are infections acquired in the healthcare facility. Answer B is incorrect because the infection was not acquired in the healthcare facility. Answers C and D refer to community acquired infections; therefore, they are incorrect.
The nurse is caring for a 6-year-old following revision of a ventriculoperitoneal shunt. An expected nursing intervention is:
Show answer and rationale
Correct answer: B. Daily measurement of head circumference
The nurse should measure the child’s head circumference daily to determine the effectiveness of the shunt. Answer A is incorrect because it is a medical intervention. Answer C is incorrect because the fontanels would be closed. Answer D is incorrect because it is not necessary to maintain the child in a prone position. 274
The nurse is assessing an infant with coarctation of the aorta. The nurse can expect to find:
Show answer and rationale
Correct answer: D. Diminished femoral pulses
Coarctation of the aorta is an acyanotic heart defect characterized by the presence of diminished femoral pulses and bounding radial and brachial pulses. Answers A, B, and C are incorrect because they describe the child with a cyanotic heart defect.
The primary nursing consideration when working with a newly admitted adolescent with anorexia nervosa is:
Show answer and rationale
Correct answer: B. Restoring the client’s nutritional status
The primary nursing consideration is restoring the client’s nutritional status. Answers A, B, and C are an important part of the client’s care but are not the primary nursing considerations of the newly admitted client with anorexia nervosa; therefore, they are incorrect.
The nurse is palpating the fontanels of a 2-month-old. The fontanels should feel:
Show answer and rationale
Correct answer: D. Flat and firm
The fontanels of a 2-month-old should feel flat and firm to the touch. Tense, bulging fontanels indicate increased intracranial pressure; therefore, answers A and D are incorrect. Soft, sunken fontanels indicate dehydration; therefore, answer B is incorrect.
An infant born at 25 weeks gestation was treated with prolonged oxygen therapy. Prolonged oxygen therapy places the infant at risk for:
Show answer and rationale
Correct answer: D. Retinopathy of prematurity
Retinopathy of prematurity is caused by damage to immature blood vessels in the retina, which can be the result of high levels of oxygen. Answers A, B, and C are not associated with prolonged oxygen therapy; therefore, they are incorrect.
The nurse is in the process of administering PO medications. Which of the following drugs should not be administered at the same time?
Show answer and rationale
Correct answer: A. Levofloxacin (Levaquin) and Mylanta
Administering Levofloxacin (Levaquin) and Mylanta at the same time will decrease the absorption of the fluoroquinolones. The drug combinations in answers B, C, and D are not contraindicated because the drugs in each combination do not affect one another.
The nurse caring for a client with hyperthyroidism would expect which group of clinical manifestations to be exhibited?
Show answer and rationale
Correct answer: B. Restlessness, fatigue, and weight loss
A hyperactive thyroid causes hypermetabolism and increased sympathetic nervous system activity. Weight gain occurs with hypothyroidism, making answer A incorrect. Although tachycardia occurs with hyperthyroidism, diuresis and hypokalemia do not, so answer D is incorrect. Dyspnea can occur with this disorder, but clients exhibit increased libido, making answer B incorrect.
Which medication would the nurse expect to be prescribed for a client exhibiting tetany after thyroid surgery?
Show answer and rationale
Correct answer: A. Calcium
Tetany is caused by a decrease in calcium. Answers B, C, and D are not used in the treatment plan for clients with hypocalcemia.
The nurse should assess a client who has a peptic ulcer for signs of bleeding. Which symptom would best indicate this complication?
Show answer and rationale
Correct answer: B. Melena
Melena is blood in the stools, which would occur with bleeding in the gastrointestinal tract due to a peptic ulcer. Answers B, C, and D are not specific to the GI system so are incorrect. Hematuria (blood in the urine) is not indicative of a peptic ulcer, blood from the lungs can occur as hemoptysis but is not related to this problem, and ecchymosis indicates bruising.
The nurse is preparing to administer insulin to a diabetic. Ten units regular and 35 units of NPH are ordered. Which of the following is the proper procedure for drawing up the medications?
Show answer and rationale
Correct answer: B. Inject 35 units of air into the NPH, inject 10 units of air into the regular, withdraw 10 units of regular, and then withdraw 35 units of NPH
When mixing insulins, air should be injected into both vials before drawing up the dose, and clear (Regular) insulin should be drawn up before cloudy (NPH). Answer A would require two injections, which is not necessary. Answers B and C are incorrect procedures because regular insulin, not NPH, should be drawn up first.
What does the nurse recognize as the primary reason that food and fluids are withheld from clients with pancreatitis?
Show answer and rationale
Correct answer: A. Decrease stimulation of the pancreas
Pancreatic enzyme secretion is activated by food and fluid. Therefore, keeping the client NPO will prevent the pancreas from secreting, resulting in decreased pain and damage to the pancreas. Answers A and D would produce negative outcomes and would have no relationship to why food and fluids are withheld. Because pancreatic enzymes are decreased by withholding food and fluids, answer C is incorrect.
The nurse is administering digoxin (Lanoxin) to a client with congestive heart failure. What is the expected therapeutic effect of this drug?
Show answer and rationale
Correct answer: C. Increased force of heart contraction
Digoxin (Lanoxin) increases the force of the contraction of the heart, thus increasing the cardiac output. Answer D is incorrect because Lanoxin increases cardiac output. Lanoxin slows the heart rate, making answer B incorrect. Answer C could result in a myocardial infarction and is not the effect of the drug.
A client has just returned from a bronchoscopy. Which safety measure is most important for the nurse to implement?
Show answer and rationale
Correct answer: A. Monitoring the client for return of the gag reflex before PO intake
A loss of gag reflex can occur due to the anesthetizing agent used for the tube insertion. It is most important to ensure an intact reflex before administering food or fluids because of the danger of aspiration. The position inanswer A would be contraindicated because of possible increased secretions. Answer B would be instituted at a later time. Answer D would be necessary for clients with abdominal surgery.
A 45-year-old client returned from a colon resection 2 hours ago.Which vital signs indicate possible hemorrhagic shock?
Show answer and rationale
Correct answer: C. BP 96/60, heart rate 120
Vital sign changes with hemorrhagic shock are decreasing blood pressure with an increased heart rate. Answer A is a normal BP and heart rate. Answers B and C are abnormal vital signs but do not correlate with hemorrhagic shock.
A client with newly diagnosed acquired immunodeficiency syndrome (AIDS) asks the nurse if it’s necessary to tell co-workers about the diagnosis. The nurse’s response is based on which correct understanding?
Show answer and rationale
Correct answer: B. Transmission of AIDS doesn’t occur through casual contact
AIDS is transmitted by transfer of blood and bodily fluids, not by casual contact. Answers B, C, and D are incorrect statements about AIDS. Some states require sexual contact notification; otherwise, confidentially is maintained.
A client is returning to the room after a thyroidectomy. Which piece of equipment should the nurse place at the bedside?
Show answer and rationale
Correct answer: B. A tracheotomy set
A tracheotomy set is placed at the bedside as a safety measure in case the client has severe edema or respiratory distress. The pieces of equipment in answers B, C, and D are not required or helpful after a thyroidectomy
A client with a hip fracture is receiving heparin sub-cutaneously. Which laboratory test should the nurse monitor when administering this medication?
Show answer and rationale
Correct answer: B. Activated partial thromboplastin time
aPTTs should be monitored on clients receiving heparin. The goal is 1.5 to 2 times the control for prevention of deep vein thrombosis. Answer A is used for the monitoring of Coumadin therapy. Answer B is the antidote for too much Coumadin. Answer D is not a test used for heparin or Coumadin.
What teaching should the nurse reinforce to a young male adult regarding when he should perform testicular self-examinations?
Show answer and rationale
Correct answer: B. Monthly while in the shower
This is the American Cancer Society’s recommendation for testicular examination. Answers A, C, and D are not the correct timing sequences for a testicular examination.
The nurse is reinforcing teaching to a client with a hiatal hernia. Which would be included in the teaching plan?
Show answer and rationale
Correct answer: B. Remain in an upright position after meals
Remaining upright will decrease the chance of esophageal reflux. Clients should avoid fatty foods, coffee, tea, cola, chocolate, alcohol, and spicy and acidic foods, which makes answers B and D incorrect. Pur�ed diets, as in answer A, are not recommended.
A client who is in end-stage cirrhosis should restrict which of these foods?
Show answer and rationale
Correct answer: B. Beef
With clients who are in end-stage cirrhosis, proteins are restricted because of the inability of the liver to convert the protein for excretion. This results in build-up of ammonia in the body. Answers A, B, and D are not restricted foods.
The nurse is providing initial first aid for a client with thermal burn injury in a community setting. Which action is appropriate?
Show answer and rationale
Correct answer: A. Flush the burned area with cool water
Cooling the burn stops the burn process, relieving pain and limiting edema. This is the initial action. Answers A and B are not initial actions to be performed in the field. Adherent clothing should remain in place after being cooled, so answer D is incorrect.
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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