Exam Cram NCLEX-PN PRACTICE QUESTIONS
Which of the following roommates would be most suitable for the client with myasthenia gravis? A. A client with hypothyroidism B. A client with Chron's disease C. A client with pylonephritis D. A client with bronchitis
A. A client with hypothyroidism why? The most suitable roommate for the client with myasthenia gravis is the client with hypothyroidism because he is quiet.
A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usually be included? A. Closed chest drainage B. A tracheostomy C. A mediastinal tube D. Percussion vibration and drainage
A. A closed chest drainage why? The client with a lung resection will have chest tubes and a drainage-collection device. He probably will not have a tracheoostomy or mediastinal tube, and he will not have an order for percussion, vibration, or drainage.
Which action by the novice nurse indicates need for further teaching? A. A nurse fails to wear gloves to remove a dressing B. The nurse applies the oxygen saturation monitor to the earlobe C. The nurse elevates the head of the bed to check blood pressure D. The nurse places the extremity to a dependent position to acquire a peripheral blood sample
A. A nurse fails to wear gloves to remove a dressing why? The nurse who fails to wear gloves to remove a contaminated dressing needs further instruction
The nurse is making assignments for the day. Which client should be assigned to the pregnant nurse? A. The client receiving linear accelerator radiation therapy for lung cancer. B. The client with a radium implant for cervical cancer C. The client who has just been administered soluble brachytherapy for thyroid cancer D. The client who returned from placement of iridium seeds for prostate cancer
A. The client receiving linear accelerator radiation therapy for lung cancer why? The pregnant nurse should not be assigned to any client with radioactivity present. Therefore, the client receiving linear accelerator therapy is correct because this client travels to the radium department for therapy, and the radiation stays in the department; the client is not radioactive
The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available? A. The client with Cushing's disease B. The client with diabetes C. The client with acromegaly D. The client with myxedema
A. The client with Cushing's disease why? The client with Cushing's disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immune suppressed
To ensure safety while administering a Nitroglycerin patch, the nurse should: A. Wear gloves B. Shave the area where the patch should be applied C. Wash the area thoroughly with soap and rinse with hot water D. Apply the patch to the buttocks
A. Wear gloves why? To protect herself, the nurse should wear gloves when applying a nitroglycerin patch or cream.
A 24 year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse? A. taking the vital signs B. obtaining the permit C. explaining the procedure D. Checking the lab work
A. taking the vital signs why? the primary responisblity of the nurse is to take the vital signs before any surgery. answers B,C and D are the responsibility of the doctor.
The nurse is obtaining a history of an 80 year old client. Which statement made by the client might indicate a possible fluid and electrolyte imbalance? A. "My skin is always so dry." B. "I often use laxatives for constipation." C. "I have always liked to drink ice tea." D. "I sometimes have a problem with dribbling urine."
B. "I often use laxatives for constipation." why? Frequent use of laxatives can lead to diarrhea and electrolyte loss.
A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session? A. "You will be sitting for the examination procedure." B. "Portions of the procedure will cause pain or discomfort." C. "You will be given some medication to anesthetize the area." D. "you will not be able to drink fluids for 24 hours before the study."
B. "Portions of the procedure will cause pain or discomfort." why? Portions of the exam are painful especially when the sample is being withdrawn so this should be included in the session with the client.
The client is scheduled for a pericentesis. Which instruction should be given to the client before the exam? A. "You will need to lay flat during the exam." B. "You need to empty your bladder before the procedure." C. "You will be alseep during the procedure." D. "The doctor will injuect a medication to treat your illness during the procedure."
B. "You need to empty your bladder before the procedure." why? The client scheduled for a pericentesis should be told to empty the bladder, to prevent the risk of puncturing the bladder when the needle is inserted. A pericentesis is done to remove fluid from the peritoneal cavity.
The nurse employed in the ER is responsible for triage for 4 clients injured in a motor vehicle accident. Which of the following clients should receive priority in care? A. A 10 year old with lacerations to the face B. A 15 year old with sternal bruising C. A 34 year old with fractured femur D. A 50 year old with dislocation of the elbow
B. A 15 year old with sternal bruising why? The teenager with sternal bruising might be experiencing airway and oxygenation problems and, thus, should be seen first.
Due to a high census, it had been necessary for a number of clients to be transferred to another unit within the hospital. Which client should be transferred to the post-partum unit? A. A 66 year old female with gastroenteritis B. A 40 year old female with a hysterectomy C. A 27 year old male with sever depression D. A 28 year old male with ulcerative colitis
B. A 40 year old female with a hysterectomy why? The best client to transport to the postpartum units it the 40 year old female with a hysterectomy. The nurses on the postpartum unit will be aware of moral amounts of bleeding and will be equipped to care for this client.
The nurse is making initial rounds on a client with a C5 fracture and crutchfield thongs. Which equipment should be kept at the bedside? A. A pair of forceps B. A torque wrench C. A pair or wire cutters D. A screwdriver
B. A torque wrench why? A tourque wrench is kept at the bedside to tighten and loosen the screws of crutchfield tongs. This wrench controls the amount of pressure that is placed on the screws.
The nurse is caring for a client with a diagnosis of Hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention? A. Suggest that the client take warm showers b.i.d. B. Add baby oil to the client's bath water C. Apply powder to the client's skin D. Suggest a hot water rinse after bathing.
B. Add baby oil to the client's bath water why? Oil can be applied to help with the dry skin and to decrease itching, so adding baby oil to bath water is soothing to the skin.
The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. which action should receive priority? A. starting an IV? B. Applying oxygen C.Obtaining blood gas D. Medicating the client foe pain
B. Applying oxygen why? the client with burns to the neck needs airway assessments and supplemental oxygen, so applying oxygen is priority. the next action should be to start an IV and medicate for pain.
The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to: A. Take blood pressure, pulse, and temp B. Ask the client to rate his pain from 1-5 C. Watch the client's facial expression D. Ask the client if he is in pain
B. Ask the client to rate his pain from 1-5 why? The best way to evaluate pain levels is to ask the client to rate his pain on a scale.
A client with caner is to undergo an intravenous pyelogram. The nurse should: A. Force fluids 24 hours before the procedure. B. Ask the client to void immediately before the study. C. Hold medication that affects the central nervous system for 12 hours pre- and post-test. D. Cover the client's reproductive organs with an x-ray shield.
B. Ask the client to void immediately before the study. why? The client having an intravenous pyelogram will have orders for laxatives of enemas so asking the client to void before the test is in order. A full bladder or bowel can obscure the visualization of the kidney, ureters, and urethra.
The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery? A. Hearing aid B. Contact lenses C. Wedding ring D. Artificial eye
B. Contact lenses why? It is most important to remove the contact lenses because leaving them in can lead to corneal drying, particularly with contact lenses that are not extended wear lenses.
The nurse is found to be guilty of charting blood glucose results without actually performing the procedure. After talking to the nurse, the charge nurse should: A. Call the Board of Nursing B. File a formal reprimand C. Terminate the nurse D. Charge the nurse with a tort
B. File a formal reprimand why? The action after discussing the problem with the nurse is to document the incident and file a formal reprimand. If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but this is not the first step.
A client with cancer is a, admitted to the oncology unit. Stat lab values revel Hgb 12.6, WBC 6500, K+1.9, uric acid 7.0, Na+136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following? A. Hypernatremia B. Hypokalemia C. Myelosuppression D. Leukocytosis
B. Hypokalemia why? Hypokalemia is evident from the lab values listed. The other laboratory findings are within normal limits. making answers A,C and D incorrect
A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate? A. Blood pressure every 15 minutes B. Insertion of a levine tube C. Cardiac monitoring D. Dressing changes 2x per day
B. Insertion of a levine tube why? The client with pancreatitis frequently has nausea and vomiting. Lavage is often used to decompress the stomach and rest the bowel, so the insertion of a levine tube should be anticipated.
A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170 meq/L. What behavioral changes would be common for this client? A. Anger B. Mania C. Depression D. Pyschosis
B. Mania why? The client with serum sodium of 170 meq/L has hypernatrimia and might exhibit manic behvior.
During the change of the shift, the ongoing nurse notes a discrepancy in the number of Perocept (oxycodone) listed in the number present in the narcotics drawer. The nurse's first action should be to: A. Notify the hospital pharmacist B. Notify the nursing supervisor C. Notify the board of nursing D. Notify the director of nursing
B. Notify the nursing supervisor why? The first action the nurse should take is to report the finding to the nurse supervisor and follow the chain of command.
The physician prescribes capropril (Capoten) 25 mg po tid for the client with hypertension. Which of the following adverse reactions can occur with administration of Capoten? A. Tinnitus B. Persistent coughing C. Muscle weakness D. Diarrhea
B. Persistent coughing why? A persistent cough might be related to an adverse reaction to Captoten.
The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin? A. Cyanocoblalmine B. Protamine sulfate C. Streptokinase D. Sodium warfarin
B. Protamine sulfate why? The antidote for heparin is protamine sulfate. Cyanocolbalamine is B12, Strptokinase is a thrombolytic, and sodium warfarin is an anticoagulant.
The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion? A. Secrurity guard B. RN C. LPN D. The nursing assistant
B. RN why? The RN is the only one of these who can legally put the client in seclusion. The only other healthcare worker who is allowed to initiate seclusion is the doctor.
The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the RN? A. Notify the police department as a robbery B. Report this behavior to the charge nurse C. Monitor the situation and note whether any items are missing D. Ignore the situation until items are reported missing
B. Report the behavior to the charge nurse why? The best action at this time is to report the incident to the charge nurse. Further action might be needed, but it should be determined by the charge nurse.
The client is receiving peritoneal dialysis. If the dialysis returns cloudy the nurse should" A. Document the finding B. Send a specimen to the lab C. Strain the urine D. Obtain a complete blood count
B. Send a specimen to the lab why? If the dialysate returns cloudy, infection might be present and must be evaluated
The nurse is assigning staff for the day. Which assignment should be given to the nursing assistant? A. Taking the vital signs of the 5 month old with brochiolitis B. Taking the vital signs of a 10 year old with a 2 day post- appendectomy C. Administering medication to the 2 year old with periorbital cellulitis D. Adjusting the traction of a 1 year with a fractured tibia
B. Taking the vital signs of a 10 year old with a 2 day post-appendectomy why? The client with the appendectomy is the most stable of these clients and can be assigned to a nursing assistant. The client with bronchiolitis has an alteration in the airway, the client with periorbital cellulitis has an infection, and the client with a fracture might be an abused child.
Which nurse should be assigned to care for the postpartal client with preeclampsia? A. The nurse with 2 weeks of experience on postpartum B. The nurse with 3 years of experience in labor and delivery C. The nurse with 10 years of experience in surgery D. The nurse with 1 year of experience in the neonatal intensive care unit
B. Th nurse with 3 years of experience in labor and delivery why? The nurse in answer B has the most experience with possible complications involved with preeclampsia.
The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor: A. That cannot be assessed B. That is in situ C. With increasing lymph node involvement D. With distant mestastasis
B. That is in situ. why? Cancer in situ means that the cancer is still localized in the primary site. Cancer is graded in terms of tumor, grade, node, involvement, and mestatasis.
Several clients are admitted to the ER following a three- car vehicle accident. Which clients can be assigned to share a room in the emergency department during the disaster? A. The schizophrenic client having visual and auditory hallucinations and the client with ulcerative collitis B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm C. A child whose pupils are fixed and dilated and his parents, and the client with a frontal head injury D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain
B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm why? Out of all these clients, it is best to hold the pregnant client and the client with a broken arm and facial lacerations in the same room.
A home health nurse is making preparations for morning visits. Which of the following clients should the nurse visit first? A. A client with brain- attack (stroke) with tube feeding B. A client with congestive heart failure complaining of nighttime dyspnea C. A client with a thoracotomy 6 months ago D. A client with Parkinson disease
B. The client with congestive heart failure complaining of nighttime dyspnea why? The client with congestive heart failure who is complaining of nighttime dyspnea should be seen first because airway si number one in nursing care
Which information should be reported to the state Board of Nursing? A. The facility fails to provide literature in both Spanish and English B. The narcotic count has been incorrect on the unit for the past 3 days. C. The client fails to receive an itemized account of his bills and services received during his hospital stay D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath
B. The narcotic count has been incorrect on the unit for the past 3 days. why? The Joint Commission on Accreditation of Hospitals will probably be interested in the problems in answers A and C. The failure of the nursing assistant to assist the client with hepatitis should be reported to the charge nurse. If the behavior continues, termination may result.
The nurse is preparing the client for a mammogram. To prepare the client for a mammogram, the nurse should tell the client: A. Restrict her fat intake for one week before the test B. To omit creams, powders, or deodorants before the exam C. The mammography replaces the need for self breast exams D. That mammography requires higher does of radiation than an x-ray.
B. To omit creams, powders, or deodorants before the exam. why? The client having the mammogram should be instructed to omit deodorants or powders beforehand because powders and deodorants can be interpreted as abnormal.
Lidocaine is a medication frequently ordered for the client experiencing: A. Atrial tachycardia B. Ventricular tachycardia C. Heart block D. Ventricular brachycardia
B. Ventricular tachycardia why? Lidocaine is used to treat ventricular tachycardia. This medication slowly exerts an antiarrhythmic effect by increasing the electric stimulation threshold of the ventricle without depressing the force of ventricular contractions.
The physician has order sodium warfrin ( Coumadin) for the client with thrombophlebitis. The order should be entered to administer the medication at: A. 0900 B. 1200 C. 1700 D. 2100
C. 1700 why? Sodium warfarin is administered in the late afternoon, at approximately 1700 hours. this allows for accurate bleeding times to be drawn in the morning.
A home health nurse is planning for her daily visits. Which client should the home health nurse visit first? A. A client with AIDS being treated with Foscarnet B. A client with a fractured femur in a long leg cast C. A client with a laryngeal cancer with a laryngetomy D. A client with diabetic ulcers to the left foot
C. A client with a laryngeal cancer with a laryngetomy why? The client with laryngeal cancer has a potential airway alteration and should be seen first.
The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis? A. A weight loss of 10 pounds in 2 weeks. B. Complaints of numbness and tingling in the extremities. C. A red, beefy tongue. D. A hemoglobin level of 12.0 gm/dL
C. A red, beefy tongue why? A red, beefy tongue is characteristic of a client with pernicious anemia.
The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal a pH of 7.36, CO2 at 45, O2 at 84, HCO3 at 28. The nurse would assess the client to be in: A. Uncompensated acidosis B. Compensated alkalosis C. Compensated respiratory acidosis D. Uncompensated metabolic acidosis
C. Compensated respiratory acidosis why? The client is experiencing compensated respiratory acidosis. The pH is within the normal range but is lower than 7.40, so it is on the acidic side. The CO2 level is elevated, the oxygen level is below normal, and the bicarb level is slightly elevated. In respiratory disorders, the pH will be in inverse of the CO2 and bicarb level. This means that if the pH is low, the CO2 and bicarb levels will be elevated.
The nurse is performing discharge teaching on a client with diverticulitis who has been placed on low-roughage diet. Which food would have to be eliminated from this client's diet? A. Roasted Chicken B. Noodles C. Cooked Broccoli D. Custard
C. Cooked Broccoli why? the client with diverticulitis should avoid eating foods that are gas forming and that increase abdominal discomfort, such as cooked broccoli.
A 25 year old male is brought to the ER with a piece of metal in his eye. Which action by the nurse is correct? A. Use a magnet to remove the object B. Rinse the eye thoroughly with saline C. Cover both eyes with paper cups D. Patch the affected eye only
C. Cover both eyes with paper cups why? Covering both eyes prevents consensual movement of the affected eye.
A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate? A. Reinsert the protruding organ and cover with 4x4s B. Cover the wound with a sterile 4x4 and ABD dressing C. Cover the wound with a sterile saline-soaked dressing D. Apply an abdominal binder and manual pressure to the wound
C. Cover the wound with a sterile saline-soaked dressing. why? If the client eviscerates, the abdominal content should be covered with a sterile saline-soaked dressing.
The nurse is assisting a client with diverticulosis to select appropiate foods. Which food should be avoided? A. Bran B. Fresh Peaches C. Cucumber salad D. Yeast Rolls
C. Cucumber salad why? the client with diverticulitis should avoid foods with seeds.
The nurse if caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis? A. Foul breath B. Dysphagia C. Diarrhea D. Chronic hiccups
C. Diarrhea why? Diarrhea is not common in clients with mouth and throat cancer
The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period? A. Assessment of the client's level of anxiety. B. Evaluation of the client's exercise tolerance C. Identification of peripheral pulses. D. Assessment of bowel sounds and activity.
C. Identification of peripheral pulses why? The assessment that is most crucial to the client is identification of peripheral pulses because aorta is clammed during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities.
The nurse is providing discharge teaching for a client who is taking dissulfiram (Antabuse). The nurse should instruct the client to avoid eating: A. Peanuts, dates, raisins B. Figs, chocolate, eggplant C. Pickles, salad with vinaigrette dressing, and beef D. Milk, cottage cheese, ice cream
C. Pickles, salad with vinaigrette dressing, beef why? The client taking antabuse should not eat or drink anything containing alcohol or vinegar
The nursing is participating in a discharge teaching for the post-partal client. The nurse is aware that an effective means of managing discomfort associated with a episiotomy after discharge is: A. Promethazine B. Aspirin C. Sitz bath D. Ice bath
C. Sitz bath why? A sitz bath will help with swelling and improve healing
The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instructions should be given to the client A. rest in bed after taking the medication for at least 30 mins B. Avoid rapid movements after taking the medication C. Take medication with water only D. Allow at least 1 hour between taking the medicine and taking other medications
C. Take medication with water only why? Fosmax should be taken with water only. The client should also remain upright for at least 30 mins after taking the medication.
The LPN is observing a graduate nurse as she assess the central venous pressure. Which observation indicates that the graduate needs further teaching? A. The graduate places the client in a supine position to read the manometer B. The graduate turns the stopcock to the off position from the IV fluid to the client C. The graduate instructs the client to perform the Valsalva manuever during the CVP reading D. The graduate notes the level at the top of the meniscus
C. The Graduate instructs the client to perform the Valsalva manuever during the CVP reading. why? The client should breathe normally during a central venous pressure monitor reading.
The client with cirrhosis of the liver is receiving lactulose. The nurse is aware that the ratio for the order of lactulose is : A. To lower the blood glucose level B. To lower the uric acid level C. To lower ammonia level D. To lower the creatinine level
C. To lower ammonia level why? Lactulose is administered to the client with cirrhosis to lower ammonia levels.
The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which labatory value might be a indicate a serious side effect of this drug? A. Uric acid of 5mg/dL B. Hematoccrit of 33% C. WBC 2,000 per cubic millimeter D. Platelets 150,000 per cubic millimeter
C. WBC 2,000 per cubic millimeter why? Tegratol can suppress the bone marrow and decrease the white blood cells count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug.
A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis? A. "tell me about the pain" B."what does his vomit look like?" C." Describe his usual diet." D. " have you noticed changes in his adominal size?"
C." Describe his usual diet." why? The least-helpful questions are those describing his usual diet. A, B, and D are useful in determining the extent of disease process and thus, are incorrect
An infant weighs 7 pounds at birth. The excpectd weight by 1 year should be: A. 10 pounds B.12 pounds C. 18 pounds D. 21 pounds
D. 21 pounds why? A birth weight of 7 pounds would indicate 21 pounds in 1 year or triple the his birth weight.
The licensed practical nurse is working with a RN and a patient care assistant. Which of the following clients should be cared for by the RN? A. A client two days post-appendectomy B. A client one week post-thyroidectomy C. A client 3 days post- splenectomy D. A client 2 days post- thoracotomy
D. A client 2 days post-thoracotomy why? The most critical client should be assigned to the RN; in this case, that is the client 2 days post-thoracotomy.
Which of the following roommates would be best for the client with gastric resection? A. A client with Chron's disease B. A client with pneuomia C. A client with gastritis D. A client with phlebitis
D. A client with phlebitis why? The most suitable roommate for the client with gastric resection is the client with phlebitis because phlebitis is an inflammation of the blood vessel and is not infectious.
The licensed practical nurse assigned to the post-partal unit is preparing to administer Rhogam to a post-patrum client. Which of the women is not a candidate for the RhoGam? A. A gravida IV para 3 that is Rh negative with a Rh postivie baby B. A gravida I para I that is Rh negative with a Rh positive baby C. A gravida II para 0 that is Rh negative attempted after a still birth delivery D. A gravida IV para II that is Rh negative with a Rh negative baby
D. A gravida IV para II that is Rh negative with a Rh negative baby why? The mother in answer D is the only one who does not require a RhoGam injection.
A client is admitted with a Ewing's sacroma. which symptoms would be expected due to this tumor's location? A. Hemiplegia B. Aphasia C. Nausea D. Bone Pain
D. Bone Pain why? Sacroma is a type of bone cancer, therefor, bone pain would be expected
Which of the following post-op diets are most appropriate for a client who has had a hemorroidectomy? A. High fiber B. Low-residue C. Bland D. Clear liquids
D. Clear liquids why? After surgery, the client will be placed o n a clear-liquid diet and progressed to a regular diet. stool softeners will be included in the plan of care, to avoid constipation.
A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? A. Teaching how to irrigate the illeostomy B. Stopping electrolytes loss in the incisional area C. Encouraging a high fiber diet D. Facilitating perineal wound drainage
D. Facilitating perineal wound drainage why? the client with a perineal resection will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illestomy. as in answer A he will have some electrolyte loss, but treatment is not focused on preventing the loss, so answer B is incorrect A high fiber diet in answer C is not ordered at this time.
A client with glomerulonephritis is placed on a low sodium diet. Which of the following snacks is suitable for the client with low sodium restritctions? A. Peanut butter cookies B. Grilled cheese sandwich C. Cottage cheese and fruit D. Fresh peach
D. Fresh peach why? The fresh peach is the lowest in sodium of these choices
The physician has ordered a culture for the client with suspected Gonorrhea. The nurse should obtain what type of culture? A. Blood B. Nasopharyngeal secretions C. Stool D. Genital secretions
D. Genital secretions why? A culture for gonorrhea is taken from the genital secretions. The culture is placed in a warm environment, where it can grow nisseria gonorrhea
Which assignment should not be performed by the licensed practical nurse? A. Inserting a Foley catheter B. Discounting a nasogastric tube C. Obtaining a sputum specimen D. Initiating a blood transfusion
D. Initiating a blood transfusion why? A LPN should not assigned to initiate a blood transfusion. The LPN can assist with the transfusion and check ID numbers for the RN. The LPN can be assigned to insert Foley and French urinary catheters, discontinue Levine and Gavage gastric tubes, and obtain all types of specimens.
The physician has order that the client's medication be administered intrathecally. The nurse is aware that the medications will be administered by which method? A. Intravenously B. Rectally C. Intramuscularly D. Into the cerebrospinal fluid
D. Into the cerebrospinal fluid why? Intrathecal medications are administered into the cerebrospinal fluid. This method of administering medications is reserved for the client with metastases, the client with chronic pain, or the client with cerebrospinal infections.
A client with acute leukemia develops a low white blood cell count. In addition to the institute of isolation the nurse should: A. Request that food be served with disposable utensils B. Ask the client to wear a mask when visitors are present C. Prep IV with mild soap, water, and alcohol D. Provide foods in seal single serving packages
D. Provide foods in seal single serving packages why? Because the client is immune-suppressed, foods should be served in sealed containers, to avoid food contaminants.
A client with cancer develops xerostomia. The nurse can help alleviate the discomfort associated with xerostomia by: A. Offering a hard candy B. Administering an analgesic medication C. Splinting swollen joints D. Providing saliva substitue
D. Providing saliva substitute why? Xerostomia is dry mouth, and offering the client a saliva substitute will help the most.
A client has been receiving cyanocobalamine (B12) injections for the past 6 weeks. Which lab finding indicates that the medication is having the desired effect? A. Neutrophil count of 60% B. Basophil count of 0.5% C. Monocyte count of 2% D. Reticlocyte count of 1%
D. Reticlocyte count of 1 % why? Cyanocolamine is a B12 medication that is used for pernicious anemia, and a reticulocyte count of 1% indicates that it is having the desired effect.
The first exercise that should be performed by a client with a mastectomy is: A. Walking the hand up the wall B. Sweeping the floor C. Combing her hair D. Squeezing a ball
D. Squeezing a ball why? The first exercise that should be done by the client with a mastectomy is squeezing the ball
The home health nurse is planning for the day's visits. Which client should be seen first? A. The 78 year old who had a gastrectomy 3 weeks ago with a PEG tube B. The 5 month old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension C. The 50 year old with MRSA being treated with Vancomycin via a PICC line D. The 30 year old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter
D. The 30 year old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter why? The priority client is the one with multiple sclerosis who is being treated with cortisone via the central line. This client is at highest risk for complications.
The nurse is caring for a new mother. The mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is: A. The baby is dehydrated due to polyuria. B. The baby is hypoglycemic due to glucose. C. The baby is allergic to the formula the mother is giving him. D. The baby can lose up to 10% of weight due to meconium still, loss of extracelluar fluid, and initiation of breast-feeding.
D. The baby can lose up to 10% of weight due to meconium still, loss of extraceullar fluid, and initiation of breast-feeding. why? After birth, meconium stool, loss of extracellular fluid, and initiation of breastfeeding cause the infant to lose body mass. There is no evidence to indicate dehydration, hypoglycemia, or allergy to the infant formula
Which client can be best assigned to the newely licensed to the Practical Nurse? A. The client receiving chemotherapy B. The client post-coronary bypass C. The client with a TURP D. The client with diverticulitis
D. The client with diverticulitis why? The best client to assign to the newly licensed nurse is the most stable client; in this case, it's the client with diverticulitis.
The nurse is caring for a client with cerebral plasy. The nurse should provide frequent rest periods because: A: Grimacing and withering movements decrease with relaxation and rest. B. Hypoactive deep tendon reflexes become more active with rest C. Stretch reflexes become more increases with rest D. Fine motor movements are improved
A. Grimacing and withering movements decrease with relaxation and rest. why? Frequent rest periods help to relx tense muscles and preserve energy
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority? A. Continue to monitor the vital signs B. Contact the physician C. Ask the client how he feels D. Ask the LPN to continue the post-op care
B. Contact the physician why? The vital signs are abnormal and should be reported to the doctor immediately.
The client with a myocardial farction comes to the nurse's station stating that he is ready to go come because there is nothing wrong with him. Which defense mechanism is the client using? A. Rationalization B. Denial C. Projection D. Conversion reaction
B. Denial why? The client who says he has nothing wrong is in denial about his myocardial infarction.
The nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should: A. Change the nursing assistant's assignment B. Explore the interaction with the nursing assistant C. Discuss the matter with the client's family D. Initiate a group session with the nursing assistant.
B. Explore the interaction with the nursing assistant why? The best action for the nurse to take is to explore the interaction with the nursing assistant. This will allow for clarification of the situation.
The nurse witnesses the nursing assistant hitting the client in the long-term care facility. The nursing assistant can be changed with: A. Negligence B. Tort C. Assault D. Malpractice
C. Assault why? Assault is defined as striking or touching the client inappropriately, so a nurse assistant striking a client could be charged with assault.
The client is receiving total parenteral nutrition (TPN). Which lab should be evaluated while the client is receiving TPN? A. Hemoglobin B. Creatinine C. Blood glucose D. White blood cell count
C. Blood glucose why? When the client is receiving TPN, the blood glucose level should be drawn. TPN is a solution that contains large amounts of glucose.
A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for: A. Trendelenburg position B. Ice to the entire extremity C. Bucks traction D. An abduction pillow
C. Bucks traction why? The client with a fractured femur will be placed in Bucks traction to realign the leg and decrease spasms and pain.
The physician has prescibed tranylcypromine sulfate (Parnate) 10 mg bid. The nurse should teach the client to refrain from eating foods containing tyramine because it may cause: A. Hypertension B. Hyperthermia C. Melanoma D. Urinary retention
A. Hypertension why? If the client eats foods high in tyramine, he might experience malignant hypertension. Tyramine is found in cheese, sour cream, Chianti wine, sherry, beer, pickled herring, liver, canned figs, raisins, bananas, avocados, chocolate, soy sauce, fava beans, and yeast. These episodes are treated with Regitine, and alpha-adrenergic blocking agent.
The nurse is assigned to care from infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin? A. Increase the infant's fluid intake B. Maintain the infant's body temp at 98.6 F C. Minimize tactile stimulation D. Decrease caloric intake
A. Increase the infant's fluid intake why? Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temp is important but will not assist in eliminating bilirubin.
A 70 year old man who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggested of unilateral neglect? A. The client is observed by shaving only one side of his face B. The client is unable to distinguish between two tactile stimuli presented simultaneously C. The client is unable to complete a range a vision without turning his head side to side D. The client is unable to carry out cognitive and motor activity at the same time
A. The client is observed by shaving only one side of his face why? The client with unilateral neglect will neglect one side of the body
The graduate licensed practical nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority? A.Maintain the client's systolic blood pressure at 70 mm/Hg or greater B. Maintain the client's urinary output greater than 300 cc/hr C. Maintain the client's body temp of greater than 33 F rectal D. Maintain the client's hematocrit less than 30%
A. Maintain the client's systolic blood pressure at 70 mm/Hg or greater why? When the cadaver client is being prepared to donate and organ, the systolic blood pressure should be maintained at 70 mm/Hg or greater to ensure a blood supply to the donor organ.
The nurse recognizes that which of the following would be most appropriate to wear when providing direct care to a client with a cough? A. Mask B. Gown C. Gloves D. Shoe covers
A. Mask why? If the nurse is exposed to the client with a cough, the best item to wear is a mask. If the answer had included a mask, gloves, and a gown, all would be appropriate.
the nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. the nurse should be particularly alert to: A. Nasal congestion B. Abdominal Tenderness C. Muscle Tetany D. Oliguria
A. Nasal congestion why? removal of the pituitary gland is usually done by transsphernoidal approach through the nose. Nasal congestion further interferes with the airway.
When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain? A. A history of radiation treatment in the neck region B. A history of recent orthopedic surgery C. A history of minimal physical activity D. A history of the client's food intake
A. A history of radiation treatment in the neck region why? Previous radiation to the neck might have damaged parathyroid glands, which are located on the thyroid gland and interfered with calcium and phosphorus regulation.
The doctor orders 2% nitroglycerin ointment on a 1-inch dose over 12 hours. Proper application of nitroglycerin ointment includes: A. Rotating application sites B. Limiting applications to the chest C. Rubbing it into the skin D. Covering it with a gauze dressing
A. Rotating application sites why? Sites for the application of nitroglycerin should be rotated, to prevent skin irritation. It can be applied to the back and upper arms, not to the lower extremities.
Which lab test would be the least effective in making the diagnosis of myocardial infarction? A. AST B. Troponin C. CK-MB D. Myoglobin
A. AST why? AST is not specific for a myocardial infarction
This client is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication should be kept during the test? A. Atropine sulfate B. Furosemide C. Prostigmin D.Promethazine
A. Atropine sulfate why? Atropine sulfate is the antidote for Tensilon and is given to treat cholenergic crises
A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure? A. Bradycardia B. Tachycardia C. Premature ventricular beats D. Heart block
A. Bradycardia why? Suctioning can cause a vagal response and bradycardia.
The client is admitted with a BP of 210/120. Her doctor orders furosemide (Lasix) 40 mg IV stat. How should the nurse administer the prescribed furosemide to this client? A. By giving it over 1-2 minutes B. By hanging it IV piggyback C. With normal saline only D. By administering it through a venous access device
A. By giving it over 1-2 minutes why? Lasix should be given approximately 1mL per minute to prevent hypotesion
The nurse on the 3-11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action? A. Call the surgeon and ask him or her to see the client to clarify the information B. Explain the procedure and complications to the client C. Check in the physician's progress notes to see if understanding has been documented. D. Check with the client's family to see if they understand the procedure fully
A. Call the surgeon and ask him or her to see the client to clarify the information why? It is the responsibility of the physician to explain and clarify the procedure to the client.
A new nursing graduate indicates in charting enteries that he is a licensed practical nurse, although he has not received the results of the licensing exam. The graduate's actions can result in what type of charge? A. Fraud B. Tort C. Malpractice D. Negligence
A. Fraud why? Identifying oneself as a nurse without a license defrauds the public and can be prosecuted. A tort is a wrongful; malpractice is failing to act appropriately as a nurse or acting in a way that harm comes to the client; and negligence is failing to perform care.
Six hours after birth, the infant is found to have an areas of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as: A. A cephalohematoma B. Molding C. Subdural hematoma D. Caput succedaneum
A. A cephalohematoma why? The swelling over the right parietal area is a cephalohematoma, an area of bleeding outside the cranium. This type of hematoma does not cross the suture line because it's outside the cranium but beneath the periosteum.
The nurse has just received a change of shift report. Which client should the nurse assess first? A. A client 2 hours post-lobectomy with 150 cc drainage B. A client 2 days post-gastrectomy with scant drainage C. A client with pnuemonia with a oral temp of 102 F D. A client with a fractured hip in Bucks traction
A. A client 2 hours post-lobectomy with 150 cc drainage why? The first client to be seen is the one who recently returned from surgery.
The nurse is making assignments for the day. Which client should be assigned to the nursing assistant? A. A client with Alzheimer's B. A client with pnuemonia C. A client with appendicitis D. A client with thrombophebitis
A. A client with Alzheimer's why? The client with Alzheimer's disease is the most stable of these clients and can be assigned to the nursing assistant, who can perform duties such as feeding and assisting the client with activities of daily living.
The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client's ability to care for himself. Which statement by the client indicates a need for follow-up after discharge? A."I live by myself." B." I have trouble seeing." C. "I have a cat in the house with me." D. " I usually drive myself to the doctor."
B. "I have trouble seeing" why? A client with diabetes who has trouble seeing would require follow-up after discharge. The lack of visual acuity for the client preparing and injecting insulin might require help.
The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because: A. The client is at risk for evisceration B. The client will require frequent dressing changes C. The straps provide support for drains that are inserted into the incision D. No sutures or clips are used to secure the incision.
B. The client will require frequent dressing changes why? Montgomery straps are used to secure dressing that require frequent dressing changes because the client with a cholescystectomy usually has a large amount of drainage on the dressing. Montgomery straps are also used for clients who are allergic to several types of tape.
The nurse is assisting the RN with discharge instructions for a client with an implantable defibrillator. What discharge instruction is essential? A. "You cannot eat food prepared in a microwave." B. "You should avoid moving the should on the side of the pacemaker site for 6 weeks." C. "You should use your cellphone on your right side." D. "You will not be able to fly on a commercial airliner with the defibrillator in place."
C. "You should use your cellphone on your right side." why? The client with an internal defibrilliator should learn to use any battery operated machinery on the opposite side. He should also take his pulse rate and report dizziness or fainting.
A client visits the clinic after the death of a parent. Which statement made by the client's sister signifies abnormal grieving? A. "My sister still has episodes of crying and it's been 3 months since daddy died." B. "Sally seems to have forgotten the bad things that daddy did in his lifetime." C. "She really had a hard time after daddy's funeral. She said that she had a sense of longing." D. "Sally has not been sad at all by daddy's death. She acts like nothing has happened."
D. "Sally has not been sad at all by daddy's death. She acts like nothing has happened at all." why? Abnormal grieving is exhibited by a lack of feeling sad; if the client's sister appears not to grieve, it might be abnormal grieving. This family member might be suppressing feelings of grief.
The client is admitted to the ER with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. Te doctor orders quinidne sulfate. While he is receiving quinidine, the nurse should monitor his ECG for: A. Peaked P waves B. Elevated ST segment C. Inverted T wave D. Prolonged QT interval
D. Prolonged QT interval why? Quinidine can cause widened Q-T intervals and heart block. Other signs of myocardial toxicity are notched P waves and widened QRS complexes. The most common side effects are diarrhea, nausea, and vomiting. The client might experience tinnitus, veritgo, headache, visual disturbances, and confusion.
