NCLEX PN 3000 review questions

What would be a side effect of Procardia ?

swelling in the legs, but you should ask the patient when the swelling started to see if there is another underlying issue going on

The amount of air inspired and expired with each breath is called:

tidal volume.

What is the antidote for war fin ?

vitamin K

The nurse is collecting data on a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse would expect to find

weight gain in the trunk area and dorsocervical area

The nurse is to give a client a 325-mg aspirin suppository. The client has diarrhea and is in the bathroom. The best nursing approach at this time would be to:

withhold the suppository and notify the client's physician.

A client seeks care for hoarseness that has lasted for 1 month. To elicit the most appropriate information about this problem, the nurse should ask which question?

Do you smoke cigarettes, cigars, or a pipe?" Hoarseness could be a sign of cancer of the throat

A client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true?

During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature delivery.

What would be some signs of a patient that has diabetes ?

Increased thirst , increased urination , excessive hunger Polyuria , polydipsia , polyphagia

A client is about to undergo total hip replacement surgery. Before the surgery, the nurse conducts a preoperative teaching session with him. The nurse can tell that her teaching has been effective when the client verbalizes the importance of avoiding which actions?

Internally rotating the feet Bending to pick items up from the floor

What drug should a person with ulcerative colitis not take and why ?

Iron because there is hypersensitivity to this drug in the digestive tract

A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse assists with formulating a nursing diagnosis of Risk for injury. Which "related-to" phrase is appropriate for the nurse to add to complete the nursing diagnosis statement?

It would be related to balance problems , impaired balance

Before a client undergoes arthroscopy, the nurse reviews the data collection findings for contraindications for this procedure. Which finding is a contraindication?

Joint flexion of less than 50%, because the doctor would not be able to insert the instrument in the right location

If you client is diagnosed with prehypertension what would be the first treatment ?

Lifestyle modifications

The nurse is caring for a client diagnosed with antisocial personality disorder. The client has a history of fighting, cruelty to animals, and stealing. Which trait would the nurse be likely to uncover during data collection?

Low tolerance for frustration

A client is in Buck's skin traction after fracturing his right hip. The nurse should include which action in the plan of care?

Maintaining correct body alignment

A client that was involved in a head on collision is experiencing painful stimuli with decerebrate posturing what part of the brain is injured ?

Midbrain

How would you take a client to the bathroom that has had severe chest pain but has now stopped ?

Move a bedside commode to the side of the bed this will prevent straining and keep the patient safe if he experiences chest pain again

What would be some signs of hypocalcemia ?

Numbness , tingling , muscle twitching and spasms

What would be a risk factor for developing colon cancer with a patient who has a family history of this cancer ?

Obesity

The nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do?

Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes. These can be signs of hypocalcemia

What is the most common cause of appendicitis ?

Obstruction which can lead to rupture

What drugs interact with glucagon ?

Oral anticoagulants because it increases the affects of this drug

A client with a history of I.V. drug abuse is admitted to the medical-surgical unit for evaluation for infective endocarditis. Nursing assessment is most likely to reveal that this client has:

Osler's nodes and splinter hemorrhages.fever, diaphoresis, joint pain, weakness, abdominal pain, a new or altered heart murmur, and Janeway's lesions

A client is receiving heparin I.V. for the treatment of thrombophlebitis. Which laboratory value should the nurse monitor throughout heparin therapy?

Platelet and PT prothrombin time

The nurse should expect to administer which vaccine to the client after a splenectomy?

Pneumovax 23, because taking out the spleen lowers your immune system and puts you at a greater risk for developing infection and sepsis

What is the antidote for heparin ?

Protamine sulfate

The nurse correctly identifies which of the following as belonging to the dorsal cavity?

The dorsal cavity is divided into the cranial (skull) and vertebral canal (spinal cavity).

Following a transsphenoidal hypophysectomy, the nurse should assess the client carefully for:

The nurse should assess for hypocortisolism. Abrupt withdrawal of endogenous cortisol may lead to severe adrenal insufficiency. Steroids should be given during surgery to prevent hypocortisolism from occurring

When is the best time for the nurse to check a client for rebound tenderness?

This should be done at the end of the exam because it can be painful

After receiving chemotherapy for lung cancer, a client's platelet count falls to 98,000/μl. What term should the nurse use to refer to this drop in the platelet count?

Thrombocytopenia

The nurse should advise the client with an axillofemoral bypass graft to avoid:

Tight belts this can put pressure on the occlude the bypass

The nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. When describing a healthy stoma, which statement should the nurse be sure to include?

"At first, the stoma may bleed slightly when touched."

A client develops hepatic encephalopathy 1 week after portal caval shunt surgery. Her physician prescribes neomycin (Mycifradin), 4 g by mouth daily in four divided doses. Her husband asks how neomycin decreases his wife's serum ammonia concentration. How should the nurse respond?

"It decreases the number of ammonia-producing bacteria in the GI tract."

A client who has been treated for chronic renal failure (CRF) is ready for discharge. The nurse should reinforce which dietary instruction?

"Make sure to include carbohydrates in your diet." unrestricted intake of sodium, protein, potassium, and fluid may lead to a dangerous accumulation of electrolytes and protein metabolic products, such as amino acids and ammonia. Therefore, the client must limit intake of sodium; meat, which is high in protein; bananas, which are high in potassium; and fluid, because the failing kidneys can't secrete adequate urine

What is the usual course of muscular dystrophy ?

"You may experience progressive deterioration in all voluntary muscles."

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the plan of care?

. Measuring and documenting the drainage in the collection chamber

At 8 a.m., the nurse collects data on a client who's scheduled for surgery at 10 a.m. During data collection, the nurse detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next?

. Notify the physician immediately of these findings. This could be a sign of respiratory distress

To reverse hypoglycemia how much sugar should the patient ingest ?

10-15 grams of simple carbs

How should iron and antacids be taken ?

2 hours apart from each other , antacids decrease the absorption of iron in the GI tract

A client is to receive a glycerin suppository. When inserting the suppository, the nurse should advance it approximately how far into the client's rectum?

3" (7.5 cm)

The nurse has an order to administer an iron dextran 50 mg I.M. injection. When carrying out this order, the nurse should:

: Iron dextran is an iron preparation given using the Z-track technique to prevent leakage into the subcutaneous tissue and staining of the skin. When giving an I.M. injection using the Z-track technique

What is the main thing that should be checked after the patient has a bronchoscopy ?

AIRWAY :)

Which nursing diagnosis is most appropriate for a client with Addison's disease?

Addison's disease decreases the production of all adrenal hormones, compromising the body's normal stress response and increasing the risk of infection. hypocortisolism

The nurse understands that for the parathyroid hormone to exert its effect, what must be present?

Adequate levels of Vitamin D which helps in the absorption of calcium in the intestines

A client who sustained a head injury in a motor vehicle accident is prescribed phenytoin (Dilantin) liquid to prevent seizures. The client is unable to take anything by mouth and has a feeding tube in place for enteral feedings. Which intervention by the nurse is most appropriate when administering phenytoin to this client?

Administering the phenytoin 2 hours before or 2 hours after beginning the tube feedings

What would be a symptom of left sided heart failure ?

Air hunger - feeling of not getting enough oxygen

The nurse must apply an elastic bandage to a client's ankle and calf. She should apply the bandage beginning at the client's:

An elastic bandage should be applied from the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the client's foot

A client complains of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss, and fatigue. Suspecting gallbladder disease, the physician orders a diagnostic workup, which reveals gallbladder cancer. Which nursing diagnosis may be appropriate for this client?

Anticipatory grieving is an appropriate nursing diagnosis for this client because few clients with gallbladder cancer live more than 1 year after diagnosis

What would be a sign of right sided heart failure ?

Ascites, jugular vein distention, and pitting edema of the legs are signs of right-sided heart failure.

How would you describe a water hammer or corrgians pulse ?

Bounding with rapid rise and fall

A male client has been complaining of chest pain and shortness of breath for the past 2 hours. He has a temperature of 99° F (37.2° C), a pulse of 96 beats/minute, respirations that are irregular and 16 breaths/minute, and a blood pressure of 140/96 mm Hg. He's placed on continuous cardiac monitoring to:

prevent cardiac ischemia. Continuous cardiac monitoring can detect life-threatening arrhythmias, including ventricular tachycardia and fibrillation

What would be some symptoms of pericarditis ?

retrosternal pain that worsens during supine positioning, pulsus paradoxus., a scratchy pericardial friction rub

The nurse is assessing a client with Cushing's syndrome. Which observation should the nurse report to the physician immediately?

Because Cushing's syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician

What would be a long term side effect of taking aspirin ?

Bilateral Hearing Loss this can be resolved when the person discontinues aspirin

A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless, temporary change?

Bluish Urine , which is temporary

When inspecting a client's skin, the nurse finds a vesicle on the client's arm. Which description applies to a vesicle?

Circumscribed, elevated, and filled with serous fluid

What is the most appropriate nursing diagnosis for a client with acute pancreatitis?

Clients with acute pancreatitis commonly experience deficient fluid volume, which can lead to hypovolemic shock

A client is recovering from coronary artery bypass graft (CABG) surgery. Which nursing diagnosis takes highest priority at this time?

Decreased cardiac output related to depressed myocardial function, deficient fluid volume, or impaired electrical conduction

What would be the highest nursing diagnosis with a person that has gastroenteritis ? ( stomach flu )

Deficient fluid volume

A home care nurse is collecting data on a geriatric client. What is the most common cause of medication errors in noninstitutionalized geriatric clients

Deficient knowledge

A client with herpes zoster is prescribed acyclovir (Zovirax), 200 mg by mouth every 4 hours while awake. The nurse should inform the client that this drug may cause:

Diarrhea , can upset the GI tract overall and cause nausea and vomiting

What symptoms would you see in a patient with pneumonia ?

Fever , crackles or rhonchi, use of accessory muscles for breathing

What are the most common signs of pericarditis ?

Fever , elevated SED rate , chest discomfort ,

A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client's care, the nurse should focus on his need for:

Fluid Replacement because this type of protozoa can cause watery diarrhea

What is a major complication of developing osteoporosis ?

Fractures are more common

What would be a normal finding in a person with hyperparathyroidism ?

Hypercalcemia

To check for arterial insufficiency when a client is in a supine position, the nurse should elevate the extremity at a 45-degree angle and then have the client sit up. The nurse suspects arterial insufficiency if the assessment reveals which of the following?

If arterial insufficiency is present, elevation of the limb would yield a pallor from the lack of circulation.

Which nursing diagnosis takes highest priority for a client with hyperthyroidism?

Imbalanced nutrition: Less than body requirements related to thyroid hormone excess

What would be the highest nursing diagnosis priority for a patient with chest trauma ?

Impaired gas exchange

What would be signs of right sided heart failure ?

In right-sided heart failure, the client would exhibit hepatomegaly, jugular vein distention, and peripheral edema

A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received appropriate skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?

Inadequate protein intake, there is also a negative nitrogen balance as well for people that are on bedrest

How would you help a client that has dry mouth from chemotherapy and decrease the pain of stomatitis ?

Providing a solution of hydrogen peroxide and water for use as a mouth rinse

In a client who had major surgery 5 days ago, which data collection finding would be the best indication of a wound infection

Purulent wound drainage

During discharge teaching, a client with a fractured toe asks the emergency department nurse why ice should be applied to the fracture site. The nurse should explain that ice application has which effect?

Relieves swelling by reducing blood flow to the injury site

The nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, the nurse should consider which finding significant?

Rheumatic Fever because it can damage the heart

Which nursing diagnosis would be of most importance with a client with AIDS dementia ?

Risk for injury

What should you tell a person with lupus about home care upon discharge ?

Stay out of direst sunlight because this could lead to skin interactions , watch for a temperature , Corticosteroids must be tapered gradually once symptoms are relieved because they can suppress the function of the adrenal glands

The nurse explains to a client that she will administer his first insulin dose in his abdomen. How does absorption at the abdominal site compare to absorption at other sites?

Subcutaneous insulin is absorbed most rapidly at abdominal injection sites, more slowly at sites on the arms, and slowest at sites on the anterior thigh. Absorption after injection of the buttocks is less predictable. its absorbed more rapidly in the abdomen

What would you expect do see in blood pressure when you take it on the thigh instead of the upper extremities ?

Systolic readings in the thigh may be 10 to 40 mm Hg higher than in the arm.

The nurse is developing a teaching plan for a client who has just been diagnosed with breast cancer. The nurse should include information about which medication?

Tamoxifen is an estrogen-blocker used to treat premenopausal and postmenopausal breast cancer and to prevent breast cancer in certain women who are at high risk.

What would be in a nursing care plan for a patient that has hypothyroidism ?

Use of stool softeners because these patients can become constipated , high fiber low calorie diet because weight gain is common with hypothyroidism , thyroid supplements are needed

Echocardiography reveals vegetation on a client's heart valves. The nurse knows that this finding indicates

Vegetation would be a sign of a bacterial infection

A nurse administers bromocriptine (Parlodel) to a client diagnosed with acromegaly. After administering the medication, the nurse realizes that she gave the medication to the wrong client. What could have been done to prevent this error?

Verifying the client's identity on the identification band and medication administration record before providing the medication

What would be a warning sign of cerebral hemorrhage in a patient with hypertension ?

Vertigo

A client who sustained a closed head injury in a motor vehicle accident is diagnosed as brain dead by a neurosurgeon. The physician has scheduled a meeting with the client's family about discontinuing life support. Before the meeting, a family member asks the nurse her opinion about life support. Which response by the nurse is appropriate?

What has the physician explained about the client's prognosis?"

The nurse prepares to measure a client's blood pressure. What is the correct procedure for measuring blood pressure?

Wrapping the cuff around the limb, with the uninflated bladder covering about three-fourths of the limb circumference

A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these as signs and symptoms of:

acute pulmonary edema

A client's blood studies reveal a deficiency in all of the blood's formed elements. The physician suspects that the client's bone marrow is failing to generate enough new cells. Which disorder is most likely affecting this client?

aplastic amemia , it affects all blood cells

After a client receives an I.M. injection, he complains of burning pain in the injection site. Which nursing action would be the best to take at this time?

apply a warm compress to increase blood flow to the site of injection and helps absorb the medication into the muscular area

A 45-year-old female client is admitted to the hospital with Cushing's syndrome. Which nursing interventions are appropriate for this client?

assess for periperphial edema , measuring intake and output , weigh the patient daily , cushing commonly causes weight gain and edema , low-calorie, low-carbohydrate, high-protein diet is ordered for a client with this disorder. Fluid restriction is often prescribed as well. Treatment of Cushing's syndrome includes the administration of potassium replacements;

A young adult was told that he had a significant reaction to the Mantoux test. The nurse explains that this means he:

been exposed to TB

What would be a long term side effect of using aspirin ?

bilateral hearing loss but usually goes away 2 weeks after the asprin is stopped

Before discharge, which instruction should the nurse give to a client receiving digoxin (Lanoxin)?

call the doctor if you have a rapid heart rate , this could be a sign of toxicity

What medication would the nurse give to a patient that is on hemodialysis 3 times a week ?

epoetin alfa (Epogen)

Before discharge, which instruction should the nurse give to a client receiving flecainide (Tambocor) to reduce the risk of heart failure?

limit your fluid intake while taking the medication , diuretics should be taken in the morning , sodium should be checked in this case because of water retention , electrolytes do not need to be check weekly with this medication

What is the most serious problem with a patient that has hypertension in regards to their nursing diagnosis ?

noncompliance which can lead to much serious problems when the condition is not treated

A nurse is caring for a client who has been administered digoxin (Lanoxin) 0.125 mg by mouth daily. The client develops sinus bradycardia with a heart rate of 50 beats/minute. His vital signs are stable. Which of the following actions should the nurse take first?

notify the doctor , because this is a adverse side effect of this medication

What would be a sign of circulatory impairment in the lower legs ?

numbness , cool to the touch , pallor

What would be a affect of taking corticosteroids for a long period of time ?

osteoporosis , muscle wasting , hypertension , truncal obesity

What would be a sign of necrotizing fasciitis ?

pressurelike pain , this is the difference between cellulitis and necrotizing fasciitis