NCLEX PRACTICE QUESTIONS
A triage nurse in the emergency department admits a male client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned? ______ percent
36 Explanation: The anterior and posterior portion of one leg is 18%. If both legs are burned, the total is 36%.
The nurse observes the client instill eyedrops. The client says, "I just try to hit the middle of my eyeball so the drops don't run out of my eye." The nurse explains to the client that this method may cause: a) Excessive lacrimation. b) Scleral staining. c) Corneal injury. d) Systemic drug absorption.
c) Corneal injury. Explanation: The cornea is sensitive and can be injured by eyedrops falling onto it. Therefore, eyedrops should be instilled into the lower conjunctival sac of the eye to avoid the risk of corneal damage
Atropine sulfate (Atropine) is contraindicated in all but which one of the following clients? a) A client with diabetes. b) A client with urine retention. c) A client with bowel obstruction. d) A client with glaucoma.
a) A client with diabetes. Explanation: The nurse can administer atropine sulfate, an anticholinergic, to a client with diabetes. Atropine is contraindicated in clients with glaucoma because it increases intraocular pressure. It is contraindicated in clients with urine retention because it relaxes smooth muscle in the urinary tract and can exacerbate the problem. It is contraindicated in clients with gastrointestinal obstruction because it relaxes smooth muscle in the gut and may worsen the obstruction.
A priority nursing diagnosis for a client with burns during the emergent period would be: a) Imbalanced nutrition: Less than body requirements. b) Risk for injury (falling). c) Risk for infection. d) Excess fluid volume.
c) Risk for infection. Explanation: Infection is a priority problem for the burned victim because of the loss of skin integrity and alteration in body defenses.
A physician orders an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond? a) "To minimize cracking of the dermis." b) "To prevent skin inflammation." c) "To make the skin feel soft." d) "To prevent evaporation of water from the hydrated epidermis."
d) "To prevent evaporation of water from the hydrated epidermis." Explanation: The nurse should tell the client that applying an emollient immediately after taking a bath or shower prevents evaporation of water from the hydrated epidermis, the skin's upper layer.
The nurse is developing a teaching plan for a client with stress incontinence. Which of the following instructions should be included? a) Limit physical exertion. b) Do not wear a girdle. c) Avoid activities that are stressful and upsetting. d) Avoid caffeine and alcohol.
d) Avoid caffeine and alcohol. Explanation: Clients with stress incontinence are encouraged to avoid substances, such as caffeine and alcohol, that are bladder irritants
When developing a teaching plan for a client taking hormonal contraceptives, a nurse should ensure that the client knows she must have which vital sign monitored regularly? a) Respirations b) Temperature c) Pulse d) Blood pressure
d) Blood pressure Explanation: The incidence of hypertension is three to six times greater in clients using hormonal contraceptives than in women who don't use these drugs
A client with chronic renal failure is experiencing central nervous system changes caused by uremic toxins. Which nursing intervention would be most appropriate for addressing the changes? a) Assess the client's mental status regularly. b) Restrict fluid intake to 1,000 ml/day. c) Restrict foods that are high in potassium. d) Allow the client to grieve for body image changes.
a) Assess the client's mental status regularly. Explanation: Central nervous system changes include such symptoms as apathy, lethargy, and decreased concentration. Seizures and coma can also occur. The nurse should assess the client's level of consciousness at regular intervals and maintain client safety. Allowing the client to express feelings related to body image changes and restricting foods high in potassium and fluid intake are all appropriate activities, but they are not related to the central nervous system changes
Which of the following abnormal blood values would not be improved by dialysis treatment? a) Decreased hemoglobin concentration. b) Elevated serum creatinine level. c) Hyperkalemia. d) Hypernatremia.
a) Decreased hemoglobin concentration. Explanation: Dialysis has no effect on anemia. Because some red blood cells are injured during the procedure, dialysis aggravates a low hemoglobin concentration. Dialysis will clear metabolic waste products from the body and correct electrolyte imbalances.
A nurse is caring for a client with a history of falls. The nurse's first priority when caring for a client at risk for falls is: a) keeping the bedpan available so that the client doesn't have to get out of bed. b) instructing the client not to get out of bed without assistance. c) keeping the bed in the lowest possible position. d) placing the call light on the bedside table.
a) keeping the bedpan available so that the client doesn't have to get out of bed
When witnessing an adult client's signature on a consent for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. The nurse should verify which of the following? Select all that apply. a) The client's relative, spouse or legal guardian was present. b) That there was adequate disclosure of information. c) That the client has full awareness of the potential complications. d) That there was voluntary consent on the client's part. e) That the client understood the information.
b) That there was adequate disclosure of information. c) That the client has full awareness of the potential complications. d) That there was voluntary consent on the client's part. e) That the client understood the information. Explanation: The role of the nurse in witnessing the signing of the consent is to witness that the client is informed of the procedure, understands the information, is aware of potential complications, and is signing of his or her own free will
A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 0.5 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client's lesions? a) Bullae b) Vesicles c) Cysts d) Pustules
b) Vesicles Explanation: Vesicles are elevated, sharply defined lesions that are usually less than 0.5 cm in diameter and contain serous fluid. Common examples of vesicles include blisters and the lesions caused by chickenpox and herpes simplex. Bullae are elevated, fluid-filled lesions greater than 0.5 cm in diameter; an example is a 0.5 blister. Cysts, such as sebaceous cysts, are elevated, thick-walled lesions containing fluid or semisolid matter. Pustules are elevated lesions less than 1 cm in diameter containing purulent material; examples include impetigo and acne lesions
A client with alcohol dependency is started on a regimen of disulfiram (Antabuse). Which statement should the nurse include when teaching the client about the intended effects of the drug? a) Antabuse improves the alcoholic's ability to drink limited amounts of alcohol. b) Antabuse acts to deter alcohol consumption. c) Antabuse decreases the need for alcohol. d) Antabuse creates a nerve block so that the effects of alcohol are not felt.
b) Antabuse acts to deter alcohol consumption. Explanation: Disulfiram (Antabuse) helps curb the impulsiveness of the problem drinker because disulfiram blocks the breakdown of alcohol in the blood, which produces marked discomfort, such as throbbing headache, flushing, and nausea and vomiting
The nurse is preparing to give a subcutaneous injection to an elderly, emaciated client. Which needle length and angle should the nurse plan to use to administer the injection safely? a) A 3/8-inch needle at a 90-degree angle. b) A 5/8-inch needle at a 90-degree angle. c) A 5/8-inch needle at a 45-degree angle. d) A ½-inch needle at a 15-degree angle.
d) A ½-inch needle at a 15-degree angle. Explanation: Elderly individuals have less subcutaneous tissue. An elderly, emaciated client will require a short needle and a shallow angle to avoid hitting an underlying bone. The nurse should choose the shortest subcutaneous needle available, and use the least angle.
When a central venous catheter dressing becomes moist or loose, what should a nurse do first? a) Draw a circle around the moist spot and note the date and time. b) Notify the physician. c) Remove the catheter, check for catheter integrity, and send the tip for culture. d) Remove the dressing, clean the site, and apply a new dressing.
d) Remove the dressing, clean the site, and apply a new dressing. Explanation: A nurse maintaining a central venous catheter should change the dressing every 72 hours or when it becomes soiled, moist, or loose. After removing the soiled dressing, the nurse should use sterile technique to clean around the site in accordance with facility policy. After the cleaning solution has dried, the nurse should cover the site with a transparent semipermeable dressing. A nurse who notes drainage on a wound dressing should draw a circle around the moist spot and note the date and time. She should notify the physician if she observes any catheter-related complications.
