NCLEX pre-test

7. Gentamicin sulfate, 80 mg in 100 mL normal saline (NS), is to be administered over 30 minutes. The drop factor is 10 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

33.3 gtt/min Rationale (total volume) x (drop factor) / (time in minutes) = gtt/min (100) x (10) / (30 min)= 33.3 gtt/min

40. The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? a.Chess b.Writing c.Ping pong d.Basketball

b.Writing Rationale: Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. The remaining options have a competitive element to them and should be avoided because they can stimulate aggression and increase psychomotor activity.

29. The nurse is evaluating goal achievement for a client in traction with impaired physical mobility. The nurse determines that the plan of care needs to be revised if which outcome is noted? a.Intact skin surfaces b.Bowel movement every 4 days c.Active range of motion of uninvolved joints d.Absence of redness and swelling in the affected extremity

c.Active range of motion of uninvolved joints Rationale: A bowel movement every 4 days is insufficient. The client should be having a bowel movement a minimum of every other day. Expected outcomes for impaired physical mobility for the client in traction include absence of thrombophlebitis (redness and swelling in the affected extremity), active range of motion to uninvolved joints, clear lung sounds, intact skin, and bowel movement every other day.

37. The nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply. a.The nurse who never had roseola b.The nurse who never had mumps c.The nurse who never had chickenpox d.The nurse who never had German measles e.The nurse who never received the varicella-zoster vaccine

c.The nurse who never had chickenpox e.The nurse who never received the varicella-zoster vaccine Rationale The nurses who have not had chickenpox or did not receive the varicella zoster vaccine are susceptible to the herpes zoster virus and should not be assigned to care for the client with herpes zoster. Nurses who have not contracted roseola, mumps, or rubella are not necessarily susceptible to herpes zoster. Herpes zoster (shingles) is caused by a reactivation of the varicella zoster virus, the causative virus of chickenpox. Individuals who have not been exposed to the varicella zoster virus or who did not receive the varicella zoster vaccine are susceptible to chickenpox. Health care workers who are unsure of their immune status should have varicella titers done before exposure to a person with herpes zoster.

71. A client receiving a cleansing enema complains of pain and cramping. The nurse should take which corrective action? a.Discontinue the enema. b.Reassure the client, and continue the flow. c.Raise the enema bag so that the solution can be completed quickly. d.Clamp the tubing for 30 seconds, and restart the flow at a slower rate.

d.Clamp the tubing for 30 seconds, and restart the flow at a slower rate. Rationale: Enema fluid should be administered slowly. If the client complains of fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate. This action decreases the likelihood of intestinal spasm and premature ejection of the solution. Therefore, the actions in the remaining options are incorrect.

49. The child who weighs 17 lb is to receive 72 mg/kg/day of a prescribed medication intravenously every 4 hours. How many milligrams should the nurse administer to the child in a single dose? a.92.64 b.139.1 c.448.8 d.673.2

a. 92.64 Rationale: Convert pounds to kilograms: 17 lb/2.2 kg = 7.72 kg. Next, multiply the prescribed milligrams per day by the child's weight in kilograms and divide the answer by 6 (every 4 hours) to determine how many milligrams the nurse administers to the child in a single dose: 72 mg/day × 7.72 kg = 555.84 mg/day. So, for a single dose: 555.84 mg per day/6 (every 4 hours) = 92.64 mg per single dose.

61. The nurse is assisting a primary health care provider (PHCP) examine a 3-week-old infant with developmental dysplasia of the hip. What test or sign should the nurse expect the PHCP to assess? a.Babinski's sign b.The Moro reflex c.Ortolani's maneuver d.The palmar-plantar grasp

c. Ortolani's maneuver Rationale: In developmental dysplasia of the hip, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Ortolani's maneuver is a test to assess for hip instability and can be done only before 4 weeks of age. The examiner abducts the thigh and applies gentle pressure forward over the greater trochanter. A "clicking" sensation indicates a dislocated femoral head moving into the acetabulum. Babinski's sign is abnormal in anyone older than 2 years of age and indicates central nervous system abnormality. The Moro reflex is normally present at birth but is absent by 6 months; if still present at 6 months, there is an indication of neurological abnormality. The palmar-plantar grasp is present at birth and lessens within 8 months.

63. A client has been taking omeprazole for 4 weeks. The ambulatory care nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom? 1.Diarrhea 2.Heartburn 3.Flatulence 4.Constipation

2.Heartburn Rationale: Omeprazole is a proton pump inhibitor classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often called heartburn by clients. Omeprazole is not used to treat the conditions identified in options 1, 3, and 4.

27. The nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the primary health care provider's prescriptions and should expect to note which prescribed treatment for this condition? a. Oxytocin infusion b.Increased hydration c.Administration of a tocolytic medication d.Administration of a medication that will provide sedation

a. Oxytocin infusion Rationale: Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows. A cesarean birth will be performed if no progress in labor occurs. The remaining options identify therapeutic measures for a client with hypertonic dysfunction.

33. In monitoring a client's response to disease-modifying antirheumatic drugs (DMARDs), which assessment findings would the nurse consider acceptable responses? Select all that apply. a.Control of symptoms during periods of emotional stress b.Normal white blood cell, platelet, and neutrophil counts c.Radiological findings that show no progression of joint degeneration d.An increased range of motion in the affected joints 3 months into therapy e.Inflammation and irritation at the injection site 3 days after the injection is given f.A low-grade temperature on rising in the morning that remains throughout the day

a.Control of symptoms during periods of emotional stress b.Normal white blood cell, platelet, and neutrophil counts c.Radiological findings that show no progression of joint degeneration d.An increased range of motion in the affected joints 3 months into therapy Rationale: Because emotional stress frequently exacerbates the symptoms of rheumatoid arthritis, the absence of symptoms is a positive finding. DMARDs are given to slow the progression of joint degeneration. In addition, an improvement in the range of motion after 3 months of therapy with normal blood work is a positive finding. Temperature elevation and inflammation and irritation at the medication injection site could indicate signs of infection

57. The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply. a.Cyanosis b.Tachypnea c.Hypotension d.Retractions e.Audible grunts f.Presence of a barrel chest

a.Cyanosis b.Tachypnea d.Retractions e.Audible grunts Rationale: A newborn infant with respiratory distress syndrome may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. Hypotension and a barrel chest are not clinical manifestations associated with respiratory distress syndrome.

45. A homeless client is being seen at a local outreach clinic. What action(s) taken by the nurse is best to help ensure the client's adherence and follow-up to the new treatment plan? Select all that apply. a.Focusing on reported symptoms b.Being nonjudgmental and nonthreatening c.Setting a follow-up appointment for the client d.Focusing on the obvious health abnormalities e.Assisting the client to bathe first to feel presentable

a.Focusing on reported symptoms b.Being nonjudgmental and nonthreatening c.Setting a follow-up appointment for the client Rationale: Health visits for clients in the homeless population should be nonjudgmental and nonthreatening; this will build trust between the caregiver and the client and is more likely to promote adherence to the plan of care. Also, the nurse should focus on reported symptoms first and not what the nurse thinks is a problem, based on subjective findings. Additionally, close monitoring and follow-up may be needed, so helping set up future appointments may help the client have better adherence to the treatment plan and follow-up. Focusing on the obvious health abnormalities and expecting the client to bathe before receiving health care is demeaning.

66. The nurse is caring for a client in the early stages of disseminated intravascular coagulation (DIC). At this stage, what medication would the nurse expect to be prescribed? a.Heparin b.Platelets c.Antibiotic d.Clotting factors

a.Heparin Rationale: During the early phase of DIC, anticoagulants (especially heparin) are given to limit clotting and prevent the rapid consumption of circulating clotting factors and platelets. Antibiotics are given when sepsis is suspected in an attempt to prevent DIC from occurring.

36. The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 19,500 mm3 (19.5 × 109/L). On the basis of this laboratory result, which intervention should the nurse include in the plan of care? a.Initiate bleeding precautions. b.Monitor closely for signs of infection. c.Monitor the temperature every 4 hours. d.Initiate protective isolation precautions.

a.Initiate bleeding precautions. Rationale: Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. It affects the bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia, and bleeding from decreased platelet production (thrombocytopenia). If a child is has a low platelet count usually less than 50,000 mm3 (50.0 × 109/L), bleeding precautions need to be initiated because of the increased risk of bleeding or hemorrhage. Precautions include limiting activity that could result in head injury, using soft toothbrushes, checking urine and stools for blood, and administering stool softeners to prevent straining with constipation. In addition, suppositories, enemas, and rectal temperatures are avoided. Options 2, 3, and 4 are related to the prevention of infection rather than bleeding

35. The nurse reviews the record of a child who is suspected to have glomerulonephritis and expects to note which finding that is associated with this diagnosis? a. Hypotension b.Brown-colored urine c.Low urinary specific gravity d.Low blood urea nitrogen level

b.Brown-colored urine Rationale: Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Gross hematuria resulting in dark, smoky, cola-colored, or brown-colored urine is a classic symptom of glomerulonephritis. Hypertension is also common. Blood urea nitrogen levels may be elevated. A moderately elevated to high urinary specific gravity is associated with glomerulonephritis.

9. The nurse caring for a terminally ill client has developed a close relationship with the client's family. Which interventions should the nurse include in dealing with the family during this difficult time? Select all that apply a.Making decisions for the family b.Encouraging family discussion of feelings c.Accepting the family's expressions of anger d.Preserving the family's sense of self-direction and control e.Maintaining open communication among family members f.Facilitating the use of spiritual practices identified by the family

b.Encouraging family discussion of feelings c.Accepting the family's expressions of anger d.Preserving the family's sense of self-direction and control e.Maintaining open communication among family members f.Facilitating the use of spiritual practices identified by the family Rationale: Maintaining effective and open communication among family members affected (e) by death and grief is of utmost importance. The nurse needs to maintain and enhance communication as well as preserve the family's sense of self-direction and control (d). The incorrect option removes autonomy and decision making from the family at a time when they are already experiencing feelings of loss of control. This is an ineffective intervention that could impair communication. Encouraging family discussion of feelings and maintaining open communication among family members are likely to enhance communication (b). Spiritual practices give meaning to life and have an impact on how people react to crisis, so this option should be included (f). Accepting the family's expression of anger (c) and preserving the family's sense of self-direction and control are effective techniques so that the family knows there is someone there who is supportive and nonjudgmental.

69. The nurse is performing a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine. Which information would be important for the nurse to obtain during this client visit regarding the side and adverse effects of the medication? a.Cardiovascular symptoms b.Gastrointestinal dysfunctions c.Problems with mouth dryness d.Problems with excessive sweating

b.Gastrointestinal dysfunctions Rationale: The most common side and adverse effects related to fluoxetine include central nervous system and gastrointestinal system dysfunction. Fluoxetine affects the gastrointestinal system by causing nausea and vomiting, cramping, and diarrhea. Cardiovascular symptoms, dry mouth, and excessive sweating are not side and adverse effects associated with this medication.

14. The nurse is using a standard framework and professional norms when preparing a change-of-shift report. What are some other ethical strategies the nurse needs to employ when preparing this report? Select all that apply. a.Respect assumptions. b.Monitor language and tone. c.Adopt a "need-to-know" policy. d.Be alert to the presence of gossip. e.Try to limit the use of obscene language. f.Hold yourself and one another accountable

b.Monitor language and tone. c.Adopt a "need-to-know" policy. d.Be alert to the presence of gossip. f. Hold yourself and one another accountable Rationale: Some ethical strategies to use when preparing a change-of-shift report include the following: monitoring language and tone, adopting a "need-to-know" policy, being alert to the presence of gossip, and holding oneself and one another accountable. Respecting assumptions and limiting the use of obscene language are not appropriate strategies. A change-of-shift report is given from 1 caregiver to another caregiver who is taking on responsibility for the client's care to ensure continuity of care.

43. The nurse has provided instructions to a client with a urinary tract infection regarding foods and fluids to consume that will acidify the urine. Which fluids should the nurse include in the client's teaching plan that will aid in acidifying the urine? Select all that apply. a.Milk b.Prune juice c. Apricot juice d.Cranberry juice e.Carbonated drinks

b.Prune juice c. Apricot juice d.Cranberry juice Rationale: Acidification of the urine inhibits multiplication of bacteria. Fluids that acidify the urine include prune, apricot, cranberry, and plum juice. Carbonated drinks should be avoided because they increase urine alkalinity. Two glasses of milk a day can make the urine more alkaline, which could aid in the development of kidney stones.

21. A client with a tracheostomy tube who is on a ventilator is at risk for impaired gas exchange. The nurse should assess for which finding as the best indicator of adequate ongoing respiratory status? a.Oxygen saturation of 89% b.Respiratory rate of 16 breaths/minute c.Moderate amounts of tracheobronchial secretions d.Small to moderate amounts of frank blood suctioned from the tube

b.Respiratory rate of 16 breaths/minute Rationale: Impaired gas exchange could occur after tracheostomy because of excessive secretions, bleeding into the trachea, restricted lung expansion because of immobility, or concurrent respiratory conditions. An oxygen saturation of 89% is less than optimal. A respiratory rate of 16 breaths/minute is in the normal range.

41. The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position? a.Supine b.Side-lying c.High-Fowler's d.Trendelenburg's

b.Side-lying Rationale: A tonsillectomy is the surgical removal of the tonsils. The child should be placed in a prone or side-lying position after the surgical procedure to facilitate drainage. Options 1, 3, and 4 would not achieve this goal.

47. A client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which actions are most appropriate? Select all that apply. a.Tell the client that testing is not necessary unless arthralgia develops. b.Tell the client to avoid any woody, grassy areas that may contain ticks. c.Instruct the client to immediately start to take the antibiotics that are prescribed. d.Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. e.Tell the client that if this happens again, to never remove the tick but vigorously scrub the area with an antiseptic

b.Tell the client to avoid any woody, grassy areas that may contain ticks. c.Instruct the client to immediately start to take the antibiotics that are prescribed. d.Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. Rationale: A blood test is available to detect Lyme disease; however, the test is not reliable if performed before 4 to 6 weeks following the tick bite. Antibody formation takes place in the following manner. Immunoglobulin M is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks, and then gradually disappears; immunoglobulin G is detected 2 to 3 months after infection and may remain elevated for years. Areas that ticks inhabit need to be avoided. Ticks should be removed with tweezers and then the area is washed with an antiseptic. Options 1 and 5 are incorrect.

51. A client who is taking a stimulant laxative develops abdominal cramps. The nurse interprets that this clinical manifestation most likely indicates the presence of which problem? a.The client has peptic ulcer disease. b.The client is experiencing a case of influenza. c.This is a common side effect of this medication. d.The client may have a partial bowel obstruction.

c. This is a common side effect of this medication. Rationale: Stimulant laxatives commonly cause abdominal cramps as a side effect. The health problems noted in the other options are not determined based on a single symptom.

73. The home care nurse visits a child recently discharged from the hospital with a diagnosis of hepatitis A virus (HAV) infection. The mother asks the nurse when the child can return to school. The nurse should make which response to the mother? a."In about 2 months." b."When the jaundice disappears." c."One week after the onset of jaundice." d."At the beginning of the next academic year."

c."One week after the onset of jaundice." Rationale: Because HAV is not infectious 1 week after the onset of jaundice, a return to school at that time is permitted if the child feels well enough. Options 1, 2, and 4 are incorrect

52. The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate (FHR) decelerations? a.Prepare the client for a cesarean delivery. b.Monitor the FHR every 30 minutes. c.Encourage an upright or side-lying maternal position. d.Increase the rate of the oxytocin infusion every 10 minutes.

c.Encourage an upright or side-lying maternal position. Rationale: Side-lying and upright positions such as walking, standing, and squatting can improve venous return and encourage effective uterine activity. Many nursing actions are available to prevent FHR decelerations, without necessitating surgical intervention. Monitoring the FHR every 30 minutes will not prevent FHR decelerations. The nurse should discontinue an oxytocin infusion in the presence of FHR decelerations, thereby reducing uterine activity and increasing uteroplacental perfusion.

19. The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action? a.Hold the next dose of insulin. b.Come to the clinic immediately. c.Encourage the child to drink liquids. d.Administer an additional dose of regular insulin.

c.Encourage the child to drink liquids. Rationale: When the child is sick, the mother should test for urinary ketones with each voiding. If ketones are present, liquids are essential to aid in clearing the ketones. The child should be encouraged to drink liquids. Bringing the child to the clinic immediately is unnecessary. Insulin doses should not be adjusted or changed.

72. The nurse is caring for a client who is receiving growth hormone replacement therapy. The nurse monitors the client for which option as an adverse effect of this therapy? a.Hypocalciuria b.Hypoglycemia c.Hyperglycemia d.Hyperthyroidism

c.Hyperglycemia Rationale: Hyperglycemia can occur as a result of the administration of growth hormone, particularly in a client with diabetes mellitus. Hypercalciuria can occur, particularly during the first 2 to 3 months of therapy. Growth hormone therapy is associated with a decline in thyroid function.

39. The ambulatory care nurse is preparing to assist the primary health care provider in performing a liver biopsy on a client. The client is receiving a local anesthetic for the procedure. The nurse should assist the client into which position for this test to be performed? a.Right lateral side-lying b.Flat with the head elevated c.Supine with the right hand under the head d.Prone with the hands crossed under the head

c.Supine with the right hand under the head Rationale: A client undergoing liver biopsy with the use of a local anesthetic will be positioned supine with the client's right hand placed under the head. An alternative position is the left lateral side-lying position. The client also will be asked to remain as still as possible during the test. The remaining options are inappropriate positions for this procedure

4. The nurse in the labor room is caring for a client who is in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Based on this finding, which is the appropriate nursing action? a.Contact the primary health care provider (PHCP). b.Place the client in Trendelenburg's position. c.Administer oxygen to the client by face mask. Contact the primary health care provider (PHCP). d. Document the findings and continue to monitor fetal patterns.

d. Document the findings and continue to monitor fetal patterns. Rationale: Early deceleration of the FHR refers to a gradual decrease in the heart rate, followed by a return to baseline, in response to compression of the fetal head. It is a normal and benign finding. Because early decelerations are considered benign, interventions are not necessary. Therefore, contacting the PHCP, changing the client' position, or administering oxygen is not necessary.

62. A client has a tumor that is interfering with the function of the hypothalamus. The nurse should monitor for signs and symptoms related to which imbalance? a.Melatonin excess or deficit b.Glucocorticoid excess or deficit c.Mineralocorticoid excess or deficit d.Antidiuretic hormone (ADH) excess or deficit

d.Antidiuretic hormone (ADH) excess or deficit Rationale: The hypothalamus exerts an influence on both the anterior and the posterior pituitary gland. Abnormalities can result in excess or deficit of substances normally mediated by the pituitary. ADH could be affected by disease of the hypothalamus because the hypothalamus produces ADH and stores it in the posterior pituitary gland. The pineal gland is responsible for melatonin production. The adrenal cortex is responsible for the production of glucocorticoids and mineralocorticoids.

54. When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse plans care based on which purpose of this approach? a.Providing a supportive environment b.Examining intrapsychic conflicts and past issues c.Emphasizing social interaction with clients who withdraw d.Helping the client to examine dysfunctional thoughts and beliefs

d.Helping the client to examine dysfunctional thoughts and beliefs Rationale: Cognitive behavioral therapy is used to help the client identify and examine dysfunctional thoughts and to identify and examine values and beliefs that maintain these thoughts. The remaining options, while therapeutic in certain situations, are not the focus of cognitive behavioral therapy.

18. A week after kidney transplantation, a client develops a temperature of 101° F (38.3° C), the blood pressure is elevated, and there is tenderness over the transplanted kidney. The serum creatinine is rising and urine output is decreased. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment? a.Antibiotic therapy b.Peritoneal dialysis. c.Removal of the transplanted kidney d.Increased immunosuppression therapy

d.Increased immunosuppression therapy Rationale Acute rejection most often occurs within 1 week after transplantation but can occur any time post-transplantation. Clinical manifestations include fever, malaise, elevated white blood cell count, acute hypertension, graft tenderness, and manifestations of deteriorating renal function. Treatment consists of increasing immunosuppressive therapy. Antibiotics are used to treat infection. Peritoneal dialysis cannot be used with a newly transplanted kidney due to the recent surgery. Removal of the transplanted kidney is indicated with hyperacute rejection, which occurs within 48 hours of the transplant surgery.