NCLEX Practice Questions Prep

The nurse assesses the client diagnosed with a spinal cord injury. Which findings suggests the complication of autonomic dysreflexia? Select all that apply. 1. Urinary bladder spasm pain. 2. Severe pounding headache. 3. Profuse sweating. 4. Tachycardia. 5. Severe hypotension. 6. Nasal congestion.

1) may be the cause of autonomic dysreflexia due to overfilling of the bladder, but pain is not perceived 2) CORRECT — severe headache results from rapid onset of hypertension 3) CORRECT — especially of forehead 4) pulse will slow 5) BP will increase 6) CORRECT — also causes piloerection (goose flesh)

Several days after the delivery of a stillborn, the parents say, "We wish we could talk with other couples who have gone through this trauma." Which response by the nurse is best? 1. "SIDS will provide you with this opportunity." 2. "SHARE will provide you with this opportunity." 3. "RESOLVE will provide you with this opportunity." 4. "CANDLELIGHTERS will provide you with this opportunity."

1) support group for parents who have had an infant die from sudden infant death syndrome 2) CORRECT — SHARE is a support group for parents who have lost a newborn or have experienced a miscarriage 3) support group for infertile clients 4) support group for families who have lost a child to cancer

The toddler diagnosed with lead poisoning is admitted to the pediatric unit. The health care provider writes an order to encourage fluids. Which fluid is best for the nurse to offer to the toddler? 1. Milk. 2. Water. 3. Orange juice. 4. Fruit punch.

1. Milk. milk contains calcium; calcium binds to lead and inhibits its absorption

The home care nurse visits a new parent and a 2-week-old infant. The client asks the nurse which solid foods to give the child first. Which response does the nurse give? 1. Rice cereal is usually the first solid food and is started around 4 to 5 months. 2. Strained fruits are well tolerated as the first solid food, and infants like them. 3. Introduction of solid foods is not important at this time. 4. Solid foods are usually not started until the infant is around 6 months old.

1. Rice cereal is usually the first solid food and is started around 4 to 5 months.

Which observation suggests to the nurse the client has developed an Addisonian crisis? 1. Muscular weakness and fatigue. 2. Restlessness and rapid, weak pulse. 3. Dark pigmentation of the skin. 4. Gastrointestinal disturbances and anorexia.

2. Restlessness and rapid, weak pulse. (Muscular weakness and fatigue, Dark pigmentation of the skin, Gastrointestinal disturbances and anorexia are signs and symptoms of Addison's disease, but do not indicate a crisis.)

Which information does the nurse recognize as being the most pertinent to the diagnosis of cholecystitis? 1. Flatulence. 2. Nausea and vomiting. 3. Right upper abdominal pain. 4. Dyspepsia.

3. Right upper abdominal pain. -N/V/ Flatulencia, dyspepsia indicates other GI problems

The nurse prepares the older client for an intravenous pyelogram (IVP). The client asks the nurse to explain the reason why the procedure is performed. The nurse's response is based on which explanation? 1. The health care provider is able to directly observe the kidney pelvis. 2. An IVP assesses the glomerular filtration rate. 3. The health care provider is able to examine the urinary tract by x-ray. 4. Medication is injected into the urinary system

3. The health care provider is able to examine the urinary tract by x-ray. x-rays of entire urinary tract taken, evaluates kidney function

The nurse cares for clients in a drug rehabilitation facility. Which complication of IV drug abuse is the nurse most likely to observe? 1. Jaundice. 2. Rash. 3. Bruising. 4. Cellulitis.

4. Cellulitis. Most narcotic addicts do not inject sterile purified material with aseptic techniques; cellulitis is a common complication because of skin popping or using an infected drug apparatus.

The nurse cares for the client with ataxia. Which action is most important? 1. Supervise ambulation. 2. Measure the intake and output accurately. 3. Consult the speech therapist. 4. Elevate the foot of the bed.

1) CORRECT — client's coordination is poor; the only relevant nursing action is to supervise ambulation 2) unnecessary 3) not relevant 4) not relevant

The nurse prepares a teaching plan regarding colostomy irrigation. The nurse includes which information? 1. The colostomy needs to be irrigated at the same time every day. 2. Irrigate the colostomy after meals to increase peristalsis. 3. Insert the catheter about 10 inches into the stoma. 4. The solution should be very warm to increase dilation and flow.

1) CORRECT — colostomy irrigation should be done at same time each day to assist in establishing a normal pattern of elimination 2) colostomy should be irrigated only once a day 3) catheter should never be inserted more than 4 inches. 4) solution should be at body temperature; increasing the temperature does not make irrigation more efficient

The nurse recognizes which symptoms are early signs of lithium toxicity? Select all that apply. 1. Fine motor tremors. 2. Involuntary muscle movements. 3. Seizures. 4. Nausea and vomiting. 5. Orthostatic hypotension. 6. Diarrhea

1. Fine motor tremors. 4. Nausea and vomiting. 6. Diarrhea

The nurse is discussing growth and development with the parents of a 4-year-old child. The nurse identifies which type of play as characteristic of this age group? 1. Solitary play. 2. Parallel play. 3. Associative play. 4. Aggressive play.

1. Solitary play.-Describes play for an infant 2. Parallel play.-Describes play for a toddler Correct-3. Associative play. 4. Aggressive play.-Is not play but a behavior

The client develops a postoperative infection and receives ceftriaxone sodium IV every day. It is most important for he nurse to monitor for which changes? 1. The surface of the tongue. 2. Hemoglobin and hematocrit. 3. Skin surfaces in skin folds. 4. Changes in urine characteristics.

1. The surface of the tongue. long-term use of Rocephin can cause overgrowth of organisms; monitoring of tongue and oral cavity is recommended

The nurse identifies the primary reason for elderly adults to have problems with constipation is because of which process? 1. Elderly adults eat a small volume of food with decreased bulk. 2. Elderly adults engage in less activity and have decreased GI muscle tone. 3. Elderly adults have neurological changes in the gastrointestinal tract. 4. Elderly adults have decreased sensation in the gastrointestinal tract.

2. Elderly adults engage in less activity and have decreased GI muscle tone.

Which type of foods does the nurse encourage for the client diagnosed with hypoparathyroidism? 1. Foods high in phosphorus. 2. Foods high in calcium. 3. Foods low in sodium. 4. Foods low in potassium.

2. Foods high in calcium. Diet for the client should provide high calcium and low phosphorus because the parathyroid controls calcium balance

Which statement is documented by the nurse to reflect a client's emotional adjustment to being hospitalized in the intensive care unit? 1. "The client is unable to complete activities of daily living without assistance." 2. "The client appears to be depressed and anxious regarding impending surgery." 3. "The client constantly calls for nurses and cries uncontrollably." 4. "The family is unable to visit more often than once a week because they live far away."

3. "The client constantly calls for nurses and cries uncontrollably." gives an objective description of the client's behavior and affect

The nurse cares for the postoperative client diagnosed with type 2 diabetes controlled with oral antihyperglycemic agents. The client asks why the health care provider ordered subcutaneous insulin injections after surgery. The nurse's response is based on knowing which physiological process? 1. Tissue injury after surgery decreases blood glucose. 2. Anesthesia acts to increase glycogen stores. 3. Being NPO inhibits normal blood glucose control. 4. Surgery often leads to insulin dependency.

3. Being NPO inhibits normal blood glucose control. Being NPO inhibits normal blood sugar control.inability to control diabetes mellitus by diet and oral agents, coupled with surgically induced metabolic changes, being NPO both before and after surgery, and the infusion of intravenous fluids necessitates temporary control by insulin.

The nurse cares for a patient receiving chlorpromazine hydrochloride (Thorazine). The nurse notes the patient is restless, unable to sit still, and complains of insomnia and fine tremors of the hands. The nurse identifies which of the following as the BEST explanation about why these symptoms are occurring? 1. A side effect of the medication that will disappear as time passes. 2. The reason the patient is receiving this medication. 3. Extrapyramidal side effects resulting from this medication. 4. An indication that the dosage of the medication needs to be increased.

3. Extrapyramidal side effects resulting from this medication. side effects include akathisia (motor restlessness), dystonias (protrusion of tongue, abnormal posturing), pseudoparkinsonism (tremors, rigidity), and dyskinesia (stiff neck, difficulty swallowing)

The client, gravida 2 para 1, is admitted with hypertension. The client reports her wedding band is tight. The nurse assesses for which indications of mild pre-eclampsia? 1. Blurred vision and proteinuria. 2. Epigastric pain and headache. 3. Facial swelling and proteinuria. 4. Polyuria and hypertonic reflexes.

3. Facial swelling and proteinuria. Abnormal condition associated with pregnancy, marked by high blood pressure, proteinuria (loss of protein in urine), and edema

The health care provider orders naproxen sodium for the elderly client. The nurse assesses the client for which symptoms? 1. Stomatitis and photosensitivity. 2. Bradycardia and dry mouth. 3. Fluid retention and dizziness. 4. Gynecomastia and impotence.

3. Fluid retention and dizziness. NSAID (nonsteroidal anti-inflammatory drug) used as analgesic; side effects include headache, dizziness, gastrointestinal distress, pruritus, and rash.

The nurse administers oral verapamil to a client. Which assessment does the nurse make before administering the medication? 1. The client's electrolytes. 2. The client's urine output. 3. The client's weight. 4. The client's heart rate.

4. The client's heart rate. Verapamil Antidysrhythmic class IV; antihypertensive: CA channel blocker -verapamil is indicated for the treatment of supraventricular tachycardias, so the client's heart rate should be checked prior to administration

18-month-old is admitted to the unit with a diagnosis of laryngotracheobronchitis (LTB), early symptoms? 1. Kussmaul respirations and bradycardia. 2. Elevated temperature and slow respiratory rate 3. Expiratory wheezing and substernal retractions. 4. Inspiratory stridor and restlessness.

4. Inspiratory stridor and restlessness. this condition is characterized by edema and inflammation of upper airways

The nurse supervises an LPN/LVN administering an enema to a client. The nurse determines the LPN/LVN's actions are appropriate if which action is observed? 1. The LPN/LVN places the solution 20 inches above the anus. 2. The LPN/LVN adjusts the temperature of the solution. 3. The LPN/LVN inserts the tube 6 inches. 4. The LPN/LVN positions the client left Sims' position.

4. The LPN/LVN positions the client left Sims' position. -tube inserted no more that 4 inches