NCLEX Sample Multiple Choice

An elderly client, who is not oriented to time, place, or person, had a total hip replacement. The client is attempting to get out of bed and pull out the IV line that is infusing antibiotics. The client has bilateral soft wrist restraints and a vest restraint. Which of the following interventions by the nurse are appropriate? Select all that apply. A. Ask the client if he needs to use the bathroom, and provide range-of-motion exercises every two hours B. Document the type of restraint used and assess the need for continued use C. Tie the restraints to the side rails fo the bed D. Obtain a new physician order for the restraint every 12 hours E. Observe for correct placement of restraints F. Tie the restraints in a quick-release knot

Ask the client if he needs to use the bathroom, and provide range-of-motion exercises every two hours, Document the type of restraint used and assess the need for continued use, Observe for correct placement of restraints, Tie the restraints in a quick-release knot (Toileting and range-of-motion exercises should be provided every two hours while a client is in restraints, the client must be assessed frequently to ascertain when restraints can be removed, and this information must be documented, Restraints should never be tied to the side rails, because this can cause injury if the side rail is lowered without untying the restraint, A new physician's order must be obtained every 24 hours if restraints are continued, the nurse should observe for correct placement of restraints, Restraints should be tied in knots that can be released quickly and easily.)

The nurse is preparing to administer a tuberculin (Mantoux) skin test to a client suspected of having tuberculosis (TB). The nurse knows that the test will reveal which of the following? A. How long the client has been infected with TB B. Active TB infection C. Latent TB infection D. Whether the client has been infected with TB bacteria

Whether the client has been infected with TB bacteria (A tuberculin skin test is performed to determine if a person has ever had TB. It cannot determine how long a person has been infected, if the infection is latent or active or if it can be passed to others.)

A client is admitted for gastrointestinal bleeding. He has a platelet count of 15,000/mm and platelets have been ordered from the blood bank. Which of the following does the nurse know are required for platelet transfusions? Select all that apply. A. ABO compatibility B. Rh compatibility C. Crossmatching D. A specialized platelet filter

ABO Compatibility, Rh Compatibility, and a Specialized platelet filter (The donor and recipient should be ABO-compatible, The donor and recipient should be Rh-compatible, and platelets are administered using specialized platelet filters)

The nurse is obtaining a health history for a client with osteoporosis. The nurse should specifically ask the client about which of the following? Select all that apply. A. Amount of alcohol consume daily B. Use of antacids C. Dietary intake of fiber D. Use of Vitamin K supplements E. Intake of fruit juices

Amount of alcohol consumed daily, Use of antacids, Dietary intake of fiber, Use of Vitamin K supplements (The nurse should ask the client about alcohol use, because heavy alcohol use causes fluid excretion resulting in heavy losses of calcium in urine. If the client uses antacids containing aluminum or magnesium, a net loss of calcium can occur. If the client has a high-fiber diet, the fiber can bind up some of the dietary calcium. People with hip fractures have been found to have low vitamin K intakes; vitamin K plays an important role in production of at least one bone protein. Fruit juices do not affect calcium absorption.

A woman has delivered an infant by cesarean section. Which factors place this woman at risk for thromboembolic disease? Select all that apply. A. Due to the surgical procedure, the client will be less active B. The platelet count is elevated as the body prepared for delivery C. The pregnant woman's blood volume decreases in later pregnancy D. Venous stasis in the lower extremities is common in late pregnancy E. The fetus produces platelets which cross the placenta into the maternal circulation

Due to the surgical procedure, the client will be less active, The platelet count is elevated as the body prepared for delivery, Venous stasis in the lower extremities is common in late pregnancy (Stasis of blood due to pressure of the term uterus and elevated platelet count in late pregnancy places all postpartum women at risk for thrombus. The cesarean client has the added burden of decreased mobility. The pregnant woman's blood volume increases, not decreases. The fetal blood components do not readily cross the placenta.)

The laboratory values of an adult male client reveals the presence of hepatits B surface antigens and hepatits B antibodies. Which of the following laboratory results should the nurse also expect to see? Select all that apply. A. Elevated serum albumin B. Low serum globulin C. Elevated serum transaminate (ALT and AST) D. Prolonged prothrombin time (PT) E. Low urine bilirubin

Elevated serum transaminate (ALT and AST), Prolonged prothrombin time (PT) (In viral hepatitis, serum albumin levels are low. In viral hepatitis, serum globulin levels are high. In viral hepatitis, urine bilirubin levels are elevated.)

A client's stools are light gray in color. The nurse should assess the client further for which of the following? Select all that apply. A. Intolerance to fatty foods B. Fever C. Jaundice D. Respiratory distress E. Pain at McBurney's point F. Peptic Ulcer disease

Intolerance to fatty foods, fever, jaundice (Bile is created in the liver, stored in the gallbladder, and released into the duodenum giving stool its brown color. A bile duct obstruction can cause pale colored stools. Other symptoms associated with cholelithiasis are right upper quadrant tenderness, fever from inflammation or infection, jaundice from elevated serum bilirubin levels, and nausea or right upper quadrant pain after a fatty meal. Pain at McBurney's point lies between the umbilicus and right iliac crest and is associated with appendicitis. A bleeding ulcer produces black, tarry stools. Respiratory distress is not a symptom of cholelithiasis.)

The best method to remove cerumen from a client's ear involves: A. Inserting a cotton-tipped applicator into the external canal B. Irrigating the ear gently C. Using aural suction D. Using a cerumen curette

Irrigating the ear gently (Irrigation is the first strategy to loosen cerumen. Successful removal of the cerumen involves gentle irrigation behind the impacted cerumen. The flow of the water must be behind the impaction to remove the cerumen from the canal. A cotton-tipped applicator or other device is not appropriate because it can cause damage to the eardrum. Use of aural suction or a cerumen curette is appropriate only if the impacted cerumen cannot be removed by irrigation.)

The nurse is preparing to administer blood to a client who requires postoperative blood replacement. The nurse should use a blood administration set that has a... A. Micron Mesh Filter B. Nonfiltered blood administration set C. Special Leukocyte-poor Filter D. Microdrip Administration Set

Micron mesh filter (All blood products should be administered through a micron mesh filter. Blood is never administered without a filter. Leukocytes can be removed by using leukocyte-poor filters, and this is recommended to decrease reactions in clients, such as hemophiliacs, who require frequent transfusions. Blood is too concentrated to administer through a microdrip set)

The critical care nurse is caring for a client with an arterial line (A-line). The nurse can utilize this line for which of the following? A. Monitoring blood pressure and heart rate, and infusing medications B. Monitoring blood pressure and heart rate, and obtaining blood gases and other laboratory samples C. Monitoring heart rate, obtaining blood gases and other laboratory samples, and infusing medications D. Obtaining blood gases and other laboratory samples, and infusing medications

Monitoring blood pressure and heart rate, and obtaining blood gases and other laboratory samples (Arterial lines are used for monitoring blood pressure and heart rate, especially in clients requiring the use of vasopressor medications intravenously. They are also used for clients requiring frequent blood draws. The nurse may also draw arterial blood gases and other laboratory samples from the line, following the proper procedure. This saves the client from frequent arterial and venous draws.)

To enhance the percutaneous absorption of nitroglycerin ointment, it would be MOST important for the nurse to select a site that is which of the following? A. Muscular B. Near the heart C. Non-hairy D. Over a bony prominence

Non-hairy (Skin site free of hairy will increase absorption; avoid distal part of extremities due to less than maximal absorption. Other aspects are not the most important.)

A 39-year-old client has been diagnosed with end-stage renal disease and is on the transplant waiting list. The client has been receiving dialysis through a subclavian central vein catheter while an arteriovenous fistula is maturing. Besides dialysis access, the surgical floor nurse can utilize this subclavian central vein catheter for which of the following? A. Nothing B. Blood draws only C. Infusion of normal saline (0.9% NS) and obtaining blood draws D. Infusion of medications, all intravenous fluids, and obtaining blood draws

Nothing (The nurse is not to access the subclavian central vein catheter that is being used for dialysis for blood draws, for infusions, or for any reason other than dialysis. Only in the event of a life-threatening emergency may the access be used for anything other than dialysis, and that is only under the physician's direct order. Any other use could jeopardize the access that must be patent for dialysis until the fistula matures.)

The nurse is admitting a client who is jaundiced due to pancreatic cancer. The nurse should give the HIGHEST priority to which of the following needs? A. Nutrition B. Self-image C. Skin integrity D. Urinary elimination

Nutrition (Profound weight loss and anorexia occur with pancreatic cancer. Jaundiced clients are concerned with how they look, but physiological needs take priority. Jaundice causes dry skin and pruritus, scratching can lead to skin breakdown, and in terms of urinary elimination, urine is dark due to obstructive process, but kidney function is not affected.)

A diabetic client who takes insulin is being seen by the nurse for a low blood glucose level. Which of the following would be the best choices to being to raise the blood glucose level? Select all that apply. A. One half cup of orange juice B. One cup of milk C. One ounce of tuna D. One tablespoon of peanut butter E. One piece of bread F. One half cup of regular soda

One half cup of orange juice, One cup of milk, One piece of bread, One half cup of regular soda (To treat a low blood glucose level, the nurse should provide the client with approximately 15 g of carbohydrate and monitor the blood glucose level within 15 minutes. The orange juice, milk, bread, and soda would provide approximately 15 g of carbohydrates. Meat or fish, such as tuna, does not contain carbohydrate, although some of it can be converted to carbohydrate is sufficient carbohydrate from other sources is not provided. Processed peanut butter may contain small amounts of carbohydrate, but it is also high in fat and protein. To raise a blood glucose level in a timely manner, peanut butter is not a good option.)

Which of the following is significant data to gather from a client who has been diagnosed with pneumonia? Select all that apply. A. Quality of breath sounds B. Presence of bowel sounds C. Occurence of chest pain D. Amount of peripheral edema E. Color of nail beds

Quality of breath sounds, Occurence of chest pain, Color of nail beds (A respiratory assessment, which includes auscultating breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client's ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the client with pneumonia.)

Which are characteristic assessment findings in a client with acute closed-angle glaucoma? Select all that apply. A. Persistent dull brow pain B. Inability to detect color changes C. Severe eye pain D. N&V E. Decreased vision with halos around lights F. Difficulty adjusting to darkness G. Enlarged, fixed pupil H. Erythematous conjunctiva

Severe eye pain, N&V, Decreased vision with halos around lights, Enlarged, fixed pupil, erythematous conjunctiva (Persistent dull brow pain, inability to detect color changes, and difficulty adjusting to darkness are all signs/symptoms of chronic open-angled glaucoma.)

The nurse is teaching a client with Raynaud phenomenon to prevent having vasospasms. The nurse should discuss which of the following lifestyle changes with this client? Select all that apply. A. Stop smoking B. Exercise fingers by using the keyboard or playing the piano C. Wear mittens when taking food out of the freezer D. Warm up the car before driving in cold weather E. Stop vasospasm by putting the affected part in ice water

Stop smoking, Wear mittens when taking food out of the freezer, Warm up the car before driving in cold weather (The nurse instructs the client to prevent vasospasms by taking measures to keep extremities warm, such as wearing mittens when exposed to cold temperatures and warming the car before driving in cold weather. The nurse also advises the client to stop smoking, as nicotine is a vasoconstrictor. Repetitive motions with a keyboard can induce symptoms. The client can stop the vasospasm by putting their hands or feet in warm water.)

A newborn is suspected of having hydrocephalus. For which symptoms would the nurse monitor the child? Select all that apply. A. Sunset eyes B. Depressed fontanels C. Thin scalp and sparse hair D. Increasing head circumference E. Head circumference equal to chest circumference

Sunset eyes, Thin scalp and sparse hair, Increasing head circumference (The fontanels would be bulging, not depressed. The head circumference is larger than the chest circumference at birth in normal children. In this child, the difference would be even greater.)

The client has a new order for placement of a Foley catheter due to urinary retention. Which of the following should the nurse do before starting the procedure? Select all that apply. A. The nurse should confirm the client's identity, because a procedure requires proper identification B. The nurse should confirm the client's medical record number via the wristband and order C. Ask the client his or her name only, because this is a procedure and not a medication administration D. The nurse should confirm the client's name via the wristband and order

The nurse should confirm the client's identity, because a procedure requires proper identification, The nurse should confirm the client's medical record number via the wristband and order, The nurse should confirm the client's name via the wristband and order (The nurse must always properly identify clients for any and all treatments, not just for medical administration.)

The client has returned to your unit after an escharotomy of the forearm. What is the priority nursing assessment? A. Infection B. Incision C. Pain D. Tissue perfusion

Tissue perfusion (They do the escharotomy for circulation problems, check circulation! Pain is the second best answer, the escharotomy for lack of circulation and pain is one indicator of adequate circulation, so go with the real thing first. The incision will be bad and ugly either way, and while infection is important, it isn't your first priority.)

The Mother of a two-year old who has been bitten by the family dog asks the nurse what to do about the bite. What should the nurse tell the mother? A. "You need to take the child to the local urgent care center immediately." B. "Wash the bite area with lots of running water, and then check the injury." C. "Determine when the child's latest tetanus vaccine was administered." D. "Make an appointment to see the child's physician now to start rabies shots."

Wash the bite area with lots of running water, and then check the injury (General wound care is appropriate initially. This includes washing the bite area with lots of water because infections occur frequently with animal bites, especially those on the arms or hands. Next, the mother should be advised to determine the extent of the injury and then follow-up with the child's physician if needed. A trip to the local care center would be warranted if the bite injury was extensive or there was severe bleeding. Although knowledge of when the child last had a tetanus vaccination is important, the child's wound takes priority. For rabies injections, there needs to be a history of rabies or unusual behavior in the pet.)