NCLEX questions

A client has been hospitalized for impaired function of the posterior pituitary gland. The nurse providing care for the client anticipates that he or she may exhibit altered secretion of which hormones?

Antidiuretic hormone (ADH) Rationale: ADH is secreted by the posterior pituitary gland. The other hormone stored in the posterior pituitary gland is oxytocin. Both ADH and oxytocin are synthesized by the hypothalamus and stored in the posterior pituitary gland. These hormones are released as needed into the bloodstream. The anterior pituitary gland produces GH, LH, and FSH.

A nurse reading the operative record for a client who has undergone cardiac surgery notes that the client's cardiac output immediately after surgery was 3.6 L/min. The nurse determines that this measurement indicates which finding?

Below the normal range Rationale: The normal cardiac output for the adult can range from 4 to 8 L/min and varies greatly with body size. The heart normally pumps 5 L of blood every minute.

A nurse is monitoring a newborn that was born to a client who abuses alcohol. Which finding should the nurse expect to note when assessing this newborn?

Irritability Rationale: Characteristic behaviors of the newborn with fetal alcohol syndrome (FAS) are similar to the behaviors common to the drug-exposed newborn. These behaviors include irritability, tremors, poor feeding, and hypersensitivity to stimuli. Newborns with FAS are smaller at birth and present with failure to thrive. Head circumference and weight are most affected.

A nurse working in the ambulatory care center is providing medication instructions about methylphenidate (Ritalin) to the mother of a child with attention-deficit/hyperactivity disorder (ADHD). At which time does the nurse recommend that the mother give the medication to the child?

Just before the noontime meal Rationale: Methylphenidate has stimulant effects and is best taken shortly before a meal. In addition, it should not be taken after 12 noon or 1 pm for children or after 6 pm for adults, because the stimulating effect may keep the client awake.

During physical examination of a client, which finding is characteristic of hypothyroidism?

Periorbital edema Because cellular edema occurs in hypothyroidism, the client's appearance is changed. Nonpitting edema occurs, especially around the eyes and in the feet and hands.

A client with tuberculosis (TB) has a prescription for rifampin (Rifadin). What instruction should the nurse include in the client's teaching plan?

Wearing glasses instead of soft contact lenses will be necessary.

The husband of an alcohol-troubled wife says, "If anyone had said I'd be henpecked, I'd have called them a liar, but now I realize that I'm codependent." Which statement by the nurse would be therapeutic?

"Can you tell me more about that? You see yourself as being codependent with your wife?"

The nurse is teaching the parents of a child with growth hormone deficiency about preparing and administering synthetic growth hormone to the child. Which statement, if made by the parents, would indicate an understanding of the procedure?

"We will rotate injection sites." Rationale: Synthetic growth hormone comes in a powdered form that must be diluted for administration. It is given as a subcutaneous injection six or seven times per week as prescribed at bedtime. Parents are taught that, once diluted, the hormone preparation is to be stored at 36° to 46° F (refrigerated). Injection sites should be rotated

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instructions?

"I need to lie flat on my back to perform the procedure." Rationale: The client should sit or lie quietly on her side to perform kick counts. Lying flat on the back is not necessary to perform this procedure, can cause discomfort, and presents a risk of vena cava (supine hypotensive) syndrome. The client is instructed to place her hands on the largest part of the abdomen and concentrate on the fetal movements. The client records the number of movements felt during a specified time period. The client needs to notify her health care provider if she feels fewer than 10 kicks over two, 2-hour intervals or as instructed by her HCP.

A client with schizophrenia says to the nurse, "Will you protect me from the Grand Duchess?" and points to an older client who is sitting reading a book. Which statement is the therapeutic response by the nurse?

"You will be safe here. Your thinking will be clearer after your medication starts to work." Rationale: The schizophrenic client is making a paranoid statement. It is important that the nurse provide the client with a supportive and protective intervention. To ask, "Where is she? I'll talk to her," is not therapeutic because the nurse feeds into the client's psychosis by asking where the fantasy client is. To state that you do not see the Grand Duchess and that the client needs to trust you begins by presenting reality, but it does not demonstrate any real support for the client's concern with safety. To say that you are the Queen and will order the Grand Duchess to stay away is sarcastic and belittling to the client.

The nurse is caring for a client diagnosed with a skin infection. The client is receiving tobramycin sulfate intravenously every 8 hours. Which finding would indicate to the nurse that the client is experiencing an adverse medication effect?

A blood urea nitrogen (BUN) level of 30 mg/dL Rationale: Adverse effects or toxic effects of tobramycin sulfate include nephrotoxicity as evidenced by an increased BUN and serum creatinine; irreversible ototoxicity as evidenced by tinnitus, dizziness, ringing or roaring in the ears, and reduced hearing; and neurotoxicity as evidenced by headaches, dizziness, lethargy, tremors, and visual disturbances. The normal BUN concentration is 8 to 25 mg/dL. The normal sedimentation rate is 0 to 30 mm/hr. The normal total bilirubin level is less than 1.5 mg/dL. A normal white blood cell count is 4500 to 11,000 cells/mm3.

The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs?

Actual or life-threatening concerns are the priority. Rationale: Setting priorities means deciding which client needs or problems require immediate action and which can be delayed until a later time because they are not urgent. Client problems that involve actual or life-threatening concerns are always considered first. Although completing care in a reasonable time frame, time constraints, and obtaining needed supplies are components of time management, these items are not the priority in planning care for the client, based on the options provided.

The nurse is assessing the renal function of a client at risk for acute kidney injury. After noting the amount of urine output and urine characteristics, the nurse proceeds to assess which as the best indirect indicator of renal status?

Blood pressure Rationale: The kidneys normally receive 20% to 25% of the cardiac output, even under conditions of rest. For kidney function to be optimal, adequate renal perfusion is necessary. Perfusion can best be estimated by the blood pressure, which is an indirect reflection of the adequacy of cardiac output. The heart rate affects the cardiac output but can be altered by factors unrelated to kidney function. Jugular vein distention and level of consciousness are unrelated items.

The nurse is caring for a client receiving morphine sulfate for pain. Because this medication has been prescribed for this client, which nursing action should be included in the plan of care?

Encourage the client to cough and deep breathe. Rationale: Morphine sulfate suppresses the cough reflex. Clients need to be encouraged to cough and deep breathe to prevent pneumonia.

A nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. How often should the nurse plan to check the IV infusions and IV sites of these clients?

Every 1 hour Rationale: Safe nursing practice includes monitoring an IV infusion at least once per hour in an adult client. The IV site may be checked even more frequently, depending on agency policy and whether medication also is being infused.

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. Which describes the sound of a heart murmur?

Gentle blowing or swooshing noise

A health care provider writes a prescription to begin to wean the client from the mechanical ventilator by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation (IMV/SIMV). The nurse determines that the process of weaning will occur by which mechanism?

Gradually decreasing the respiratory rate until the client can assume the work of breathing without ventilatory assistance

A nurse is planning teaching for a female client diagnosed with urethritis caused by chlamydial infection. Which point should the nurse plan to include in the teaching session?

Keep follow-up appointments for repeat cultures in 4 to 7 days. Rationale: Follow-up cultures are typically done in 4 to 7 days to evaluate the effectiveness of the medication. Using a spermicide does not change the perineal pH. The infection can be prevented by the use of latex condoms. Chlamydial infection is treated with antibiotics and, which are not discontinued until the prescribed course is completed. All sexual partners during the 30 days before diagnosis should be notified, examined, and treated as necessary.

When teaching a client with glaucoma about the effects of a miotic medication, the nurse should tell the client that the medication will produce which effect?

Lower intraocular pressure and improve blood flow to the retina. Rationale: Miotics are used to lower the intraocular pressure, which then increases blood flow to the retina. This in turn decreases retinal damage and loss of vision. Miotics cause a contraction or constriction of the ciliary muscle and widen the trabecular meshwork.

The client with a diagnosis of dependent personality disorder is most likely to have problems coping with which issue?

Making decisions Rationale: A central defining characteristic of the dependent personality is the inability to make decisions and excessive dependence on others.

The nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5 mEq/L on one client's laboratory report. The nurse understands that which client is most at risk for the development of a potassium value at this level?

The client who has sustained a traumatic burn Rationale: A serum potassium level higher than 5.0 mEq/L indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

Which interventions should the nurse include when preparing a care plan for a child with hepatitis? Select all that apply.

X 1.Providing a low-fat, well-balanced diet. X 2.Teaching the child effective hand-washing techniques. 3.Scheduling playtime in the playroom with other children. 4.Notifying the health care provider (HCP) if jaundice is present. X 5.Instructing the parents to avoid administering medications unless prescribed. 6.Arranging for indefinite home schooling because the child will not be able to return to school. Rationale: Hepatitis is an acute or chronic inflammation of the liver that may be caused by a virus, a medication reaction, or another disease process. Because hepatitis can be viral, standard precautions should be instituted in the hospital. The child should be discouraged from sharing toys, so playtime in the playroom with other children is not part of the plan of care. The child will be allowed to return to school 1 week after the onset of jaundice, so indefinite home schooling would not need to be arranged. Jaundice is an expected finding with hepatitis and would not warrant notification of the HCP. Provision of a low-fat, well-balanced diet is recommended. Parents are cautioned about administering any medication to the child because normal doses of many medications may become dangerous owing to the liver's inability to detoxify and excrete them. Hand-washing is the most effective measure for control of hepatitis in any setting, and effective hand-washing can prevent the immunocompromised child from contracting an opportunistic type of infection.

The nurse in the ambulatory care unit is caring for a child after a tonsillectomy. The child's mother tells the nurse that the child is complaining of a dry throat and would like something to relieve the dryness. Which item should the nurse provide for the mother to give to the child?

Yellow noncitrus Jell-O Rationale: After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and extremely hot or cold liquids should be avoided because they may irritate the throat. Milk and milk products, including pudding, are avoided because they coat the throat, which causes the child to clear the throat, thereby increasing the risk of bleeding. Red liquids should be avoided because they give the appearance of blood if the child vomits.

A nursing instructor is questioning a nursing student about the organs of the immune system and asks the student where Kupffer's cells are located. The student responds correctly by stating that these types of cells are located in which location?

Liver Rationale: The liver contains a large number of macrophages called Kupffer's cells. These cells help filter blood by phagocytizing microorganisms and other foreign particles that pass through the liver.

An ambulatory care nurse has provided instructions to a client who is scheduled for a cataract extraction. Which statement by the client indicates a need for further instruction?

"I cannot eat or drink anything for 24 hours before the surgery." Rationale: The client scheduled for cataract surgery should be instructed that oral intake is restricted for 6 to 8 hours preoperatively. It is not necessary that the client remain without oral intake for 24 hours before surgery.

A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse?

"I hear what you are saying, but I don't share your belief." Rationale: Paranoid beliefs are coping mechanisms used by the client and therefore are not easily relinquished. It is important not to support the belief and not to ridicule, argue, or criticize it.

The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder?

Polyuria Rationale: Hypercalcemia is the hallmark of hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis and thus polyuria. This diuresis leads to dehydration (weight loss rather than weight gain).

A male client arrives in the hospital emergency department and tells the nurse that he twisted his ankle while jogging. The client is seen by the health care provider (HCP) and is diagnosed with a sprained ankle. The nurse provides instructions to the client regarding home care for the injury. Which statement, if made by the client, would indicate an understanding of appropriate care measures for the next 24 hours

"I should elevate my foot above the level of the heart." Rationale: Soft tissue injuries such as sprains are treated with RICE (rest, ice, compression, and elevation) for the first 24 to 48 hours after the injury, depending on HCP prescription. Ice is applied intermittently for 20 to 30 minutes at a time. Heat is not used for the first 24 hours because this could cause venous congestion, thereby increasing edema and pain. Blankets would produce heat to the affected area. The client should rest and not walk around, and the foot should be elevated and not placed in a dependent position.

The nurse is reviewing the instillation technique for both eye ointment and eye drops with the parent of a pediatric client diagnosed with bacterial conjunctivitis. Which statement, if made by the parent, would indicate that learning has taken place?

"I will be careful not to touch the eye or eyelid during administration." Rationale: Touching the eye or eyelid during medication administration can contaminate the dropper and cause eye injury. The child should be placed in a supine position with the neck slightly hyperextended for administration. Eye drops should be administered before eye ointment is administered. Blinking will increase the loss of medication.

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?

"My contractions will increase in duration and intensity." Rationale: True labor is present when contractions increase in duration and intensity. Lightening or dropping is also known as engagement and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor.

A nurse instructor is evaluating a nursing student for knowledge regarding care of a client with acute kidney injury. Which statement by the student demonstrates the need for further education about the diuretic phase of acute kidney injury?

"The diuretic phase is characterized by an increase in urine output of about 500 mL in a 24-hour period." Rationale: The diuretic phase of acute kidney injury is characterized by an increase in urine output of more than 1000 mL in a 24 hour period. This increase in urine output indicates the return of some renal function; however, BUN and creatinine levels continue to rise during the first few days of diuresis. The diuretic phase develops about 14 days after the initial insult and lasts about 10 days.

The nurse is providing instructions to a client with psoriasis who will be receiving ultraviolet light (UVL) therapy. Which statement would be most appropriate for the nurse to include in the client's instructions?

"You will need to wear dark eye goggles during the treatment." Rationale: Safety precautions are required during UVL therapy. Protective dark eye goggles are required to prevent exposure of the eyes to the UVL; it may be necessary to wear the goggles for the remainder of the day following treatment. The face also is shielded with a loosely applied cloth if it is unaffected by the psoriasis. Most UVL therapies require the client to stand in a light treatment chamber for up to a maximum of 15 minutes. The client will not wear clothing on the body parts to be exposed and will expose only those areas requiring treatment to the UVL. Direct contact with the light bulbs used for the treatment should be avoided to prevent burning of the skin.

A client is diagnosed with pheochromocytoma. The nurse understands that pheochromocytoma is a condition that has which characteristic?

Causes the release of excessive amounts of catecholamines. Rationale: Pheochromocytoma is a catecholamine-producing tumor and causes secretion of excessive amounts of epinephrine and norepinephrine. Hypertension is the principal manifestation, and the client has episodes of high blood pressure accompanied by pounding headaches. The excessive release of catecholamine also results in excessive conversion of glycogen into glucose in the liver. Consequently, hyperglycemia and glucosuria occur during attacks. Pheochromocytoma is curable. The primary treatment is surgical removal of one or both of the adrenal glands, depending on whether the tumor is unilateral or bilateral.

A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places highest priority on telling the client to report which sensation during the procedur

Chest pain Rationale: The client is taught to report chest pain or any unusual sensations immediately. The client also is told that he or she may be asked to cough or breathe deeply from time to time during the procedure. The client is informed that a warm, flushed feeling may accompany dye injection and is normal. Because a local anesthetic is used, the client is expected to feel pressure at the insertion site.

A 2-year-old child with acute diarrhea has been diagnosed with mild dehydration. Which rehydration methods would the nurse expect the health care provider to prescribe?

Consume oral rehydration fluid, advancing to a regular diet. Rationale: Mild dehydration is usually treated at home and consists of age-appropriate diet along with oral rehydration fluids. The BRAT diet does not provide the rehydration needed in a child who is dehydrated. Water does not provide electrolyte fluid replacement, a need during dehydration. Hospitalization is not required with mild dehydration.

A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving after this episode if which breath sounds are noted?

Crackles in the bases Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. As the client's condition improves, the amount of fluid in the alveoli decreases, which may be detected by crackles in the bases. (Clear lung sounds indicate full resolution of the episode.) Rhonchi and wheezes are not associated with pulmonary edema. Auscultation of the lungs reveals crackles throughout the lung fields.

A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which medication?

Decongestants Rationale: In the client with benign prostatic hyperplasia, episodes of urinary retention can be triggered by certain medications, such as decongestants, anticholinergics, and antidepressants. The client should be questioned about the use of these medications if the client has urinary retention. Retention also can be precipitated by other factors, such as alcoholic beverages, infection, bed rest, and becoming chilled.

The nurse is caring for a client with acute kidney injury (AKI). When performing an assessment, the nurse would expect to note which breathing pattern?

Kussmaul's respirations Rationale: Clinical manifestations associated with AKI occur as a result of metabolic acidosis. The nurse would expect to note Kussmaul's respirations as a result of the metabolic acidosis because the bodily response is to exhale excess carbon dioxide.

The nurse caring for a client diagnosed with schizophrenia should include which interventions into the plan of care to assist in managing the client's concrete thinking?

Present verbal instructions regarding expectations in single, simple commands. Rationale: A client with concrete thinking often has difficulty with multiple-step tasks and commands. The information should be provided in clear, concise, and single-focused commands in order to minimize client confusion and maximize understanding. The client may be incapable of processing information in written form and is not likely able to restate directions because of thought process dysfunction. These methods do not address the limitations of concrete thinking. Using family to help determine the client's needs may be an appropriate intervention, but this is not directed at minimizing the effect of the client's altered thought processes.

The nurse is monitoring a client who has a closed chest tube drainage system. The nurse notes fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of this finding, the nurse should make which interpretation

The chest tube is functioning as expected. Rationale: The presence of fluctuation of the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if the suction is not working properly, or if the lung has re-expanded

A client with suspected opioid overdose has received a dose of naloxone hydrochloride (Narcan). The client subsequently becomes restless, starts to vomit, and complains of abdominal cramping. The blood pressure increases from 110/72 mm Hg to 160/86 mm Hg. The nurse provides emotional support and reassurance while administering care to the client, knowing which piece of information?

These are signs of opioid withdrawal. Rationale: Signs of opioid withdrawal include increased temperature and blood pressure, abdominal cramping, vomiting, and restlessness. Time of onset may be anywhere from a few minutes to a few hours after administration of naloxone hydrochloride, depending on the opioid involved, the degree of dependence, and the dose of naloxone.

A client arrives at the hospital emergency department and tells the nurse that there is something in his eye. The nurse looks into the client's eye and notes that the foreign body is visible and is not embedded. Which nursing action is appropriate?

Touch the object gently with a cotton swab and lift it out. Rationale: Lifting the foreign body from the eye by touching the object gently with a cotton swab and lifting it out will involve the least amount of trauma. Irrigating the eye with a solution may cause the foreign body to move, with the potential to cause trauma in another area of the eye. Allowing the object to remain in the eye may cause additional trauma if the object moves. Because the foreign body is not embedded and is easily seen by the nurse, a surgeon is not needed.

A client has been diagnosed with a bladder infection. The nurse plans care, knowing that the client will be at increased risk for extension of the infection to the kidneys if there is improper function of which area of the urinary system?

Ureterovesical junction Rationale: The ureterovesical junction is the point at which the ureters enter the bladder. At this juncture, the ureter runs obliquely for 1.5 to 2 cm through the bladder wall before opening into the bladder. This anatomical pathway prevents reflux of urine back into the ureter and, in essence, acts as a valve to prevent urine from traveling back into the ureter and up to the kidney.

The nurse is planning the menu for an Asian-American client in collaboration with the hospital dietitian. The meal plan is designed to incorporate which food as a usual component of an Asian diet?

Vegetables Rationale: The Asian-American diet generally is vegetarian, although meat may be consumed in small amounts. Native Asians generally do not drink milk or eat milk products because of a genetic tendency for lactose intolerance. Most Asian-Americans do not eat desserts high in sugar content.