NCLEX-RN Practice Questions - Quiz 4

Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client following a: a) Laminectomy b) Thoracotomy c) Hemorrhoidectomy d) Cystectomy

Laminectomy

Nurse Michelle should know that the drainage is normal four (4) days after a sigmoid colostomy when the stool is: a) Green liquid b) Solid formed c) Loose, bloody d) Semiformed

Loose, bloody

Nurse Monet is caring for a client recovering from gastrointestinal bleeding. The nurse should: a) Plan care so the client can receive 8 hours of uninterrupted sleep each night b) Monitor vital signs every 2 hours c) Make sure that the client takes food and medications at prescribed intervals d) Provide milk every 2 to 3 hours

Make sure that the client takes food and medications at prescribed intervals

Nurse John is caring for a male client receiving lidocaine IV. Which factor is the most relevant to the administration of this medication? a) Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter b) Increase in systemic blood pressure c) Presence of premature ventricular contractions (PVCs) on a cardiac monitor d) Increase in intracranial pressure (ICP)

Presence of premature ventricular contractions (PVCs) on a cardiac monitor

Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left homonymous hemianopsia? a) On the client's right side b) On the client's left side c) Directly in front of the client d) Where the client would like

On the client's right side

Nurse Kris is teaching a client with a history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to: a) Avoid focusing on his weight b) Increase his activity level c) Follow a regular diet d) Continue leading a high-stress lifestyle

Increase his activity level

Mark, a 7-year-old client, is brought to the emergency department. He's tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has a nonproductive cough. He recently had a cold. From this history; the client may have which of the following conditions? a) Acute asthma b) Bronchial pneumonia c) Chronic obstructive pulmonary disease (COPD) d) Emphysema

Acute asthma

What is the priority nursing diagnosis for a patient experiencing a migraine headache? a) Acute pain related to biologic and chemical factors b) Anxiety related to change in or threat to health status c) Hopelessness related to deteriorating physiological condition d) Risk for Side effects related to medical therapy

Acute pain related to biologic and chemical factors

When caring for a female client who is being treated for hyperthyroidism, it is important to: a) Provide extra blankets and clothing to keep the client warm b) Monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy c) Balance the client's periods of activity and rest d) Encourage the client to be active to prevent constipation

Balance the client's periods of activity and rest

George should be taught about testicular examinations during: a) When a sexual activity starts b) After age 69 c) After age 40 d) Before age 20

Before age 20

Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication: a) Bone fracture b) Loss of estrogen c) Negative calcium balance d) Dowager's hump

Bone fracture

An 89-year-old female patient who has been admitted to the medical unit with new-onset angina also has a diagnosis of Alzheimer's disease. The patient's husband reports to you that he rarely gets a good night's sleep because he needs to make sure his wife does not wander during the night. He insists on checking each of the medications you give her to be sure they are the same as the ones she takes at home. Based on this information, which nursing diagnosis is most appropriate for this patient? a) Decreased Cardiac Output related to poor myocardial contractility b) Caregiver Role Strain related to continuous need for providing care c) Ineffective Therapeutic Regimen Management related to poor patient memory d) Risk for Falls related to patient wandering behavior during the night

Caregiver Role Strain related to continuous need for providing care

A male client was on warfarin (Coumadin) before admission and has been receiving heparin IV for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do? a) Stop the IV infusion of heparin and notify the physician b) Continue treatment as ordered c) Expect the warfarin to increase the PTT d) Increase the dosage, because the level is lower than normal

Continue treatment as ordered

A male client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. Nurse Trish first response is to: a) Call the physician b) Place a saline-soaked sterile dressing on the wound c) Take blood pressure and pulse d) Pull the dehiscence closed

Place a saline-soaked sterile dressing on the wound

The patient who had a stroke needs to be fed. What instruction should you give to the nursing assistant who will feed the patient? a) Position the patient sitting up in bed before you feed her b) Check the patient's gag and swallowing reflexes c) Feed the patient quickly because there are three more waiting d) Suction the patient's secretions between bites of food

Position the patient sitting up in bed before you feed her

While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure? a) Blood pressure has decreased from 160/90 to 110/70 b) Pulse is increased from 87 to 95, with an occasional skipped beat c) The client is oriented when aroused from sleep and goes back to sleep immediately d) The client refuses dinner because of anorexia

The client is oriented when aroused from sleep and goes back to sleep immediately

Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4 breaths/minute. If action is not taken quickly, she might have which of the following reactions? a) Asthma attack b) Respiratory arrest c) Seizure d) Wake up on her own

Respiratory arrest

A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new-onset generalized tonic-clonic seizures. Which nursing activities included in the patient's care will be best to delegate to an LPN/LVN whom you are supervising? Select all that apply. a) Document the onset time, nature of seizure activity, and postictal behaviors for all seizures b) Administer phenytoin (Dilantin) 200mg PO daily c) Teach the patient about the need for good oral hygiene d) Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation e) Gather information about the seizure activity

-Administer phenytoin (Dilantin) 200mg PO daily -Gather information about the seizure activity

Which of these patients in the neurologic ICU will be best to assign to an RN who has floated from the medical unit? a) A 26-year-old patient with a basilar skull structure who has clear drainage coming out of the nose b) A 42-year-old patient admitted several hours ago with a headache and diagnosed with a ruptured berry aneurysm c) A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due d) A 65-year-old patient with an astrocytoma who has just returned to the unit after having a craniotomy

A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due

After receiving a change-of-shift report at 7:00am, which of these patient will you assess first? a) A 23-year-old with a migraine headache who is complaining of severe nausea associated with retching b) A 45-year-old who is scheduled for a craniotomy in 30 minutes and need preoperative teaching c) A 59-year-old with Parkinson's disease who will need a swallowing assessment before breakfast d) A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank pain

A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank pain

Mrs. Cruz, 80-years-old, is diagnosed with pneumonia. Which of the following symptoms may appear first? a) Altered mental status and dehydration b) Fever and chills c) Hemoptysis and Dyspnea d) Pleuritic chest pain and cough

Altered mental status and dehydration

Nurse Lynette is preparing a site for the insertion of an IV catheter. The nurse should treat excess hair at the site by: a) Leaving the hair intact b) Shaving the area c) Clipping the hair in the area d) Removing the hair with a depilatory

Clipping the hair in the area

Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to: a) Report incidents of diarrhea b) Avoid foods high in vitamin K c) Use a straight razor when shaving d) Take aspirin for pain relief

Avoid foods high in vitamin K

A 55-year-old client underwent cataract removal with intraocular lens implant. Nurse Oliver is giving the client discharge instructions. These instructions should include which of the following? a) Avoid lifting objects weighing more than 5lb b) Lie on your abdomen when in bed c) Keep rooms brightly lit d) Avoiding straining during a bowel movement or bending at the waist

Avoiding straining during a bowel movement or bending at the waist

Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse's next action? a) Call for help and note the time b) Clear the airway c) Give two sharp thumps to the precordium and check the pulse d) Administer two quick blows

Call for help and note the time

Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the purpose of performing the examination is to discover: a) Cancerous lumps b) Areas of thickness or fullness c) Changes from previous examinations d) Fibrocystic masses

Changes from previous examinations

As the manager in a long-term-care (LTC) facility, you are in charge of developing a standard plan of care for residents with Alzheimer's disease. Which of these nursing tasks is best to delegate to the LPN team leaders working in the facility? a) Check for improvement in resident memory after medication therapy is initiated b) Use the Mini-Mental State Examination to assess residents every 6 months c) Assist residents to the toilet every 2 hours to decrease the risk for urinary intolerance d) Develop individualized activity plans after consulting with residents and family

Check for improvement in resident memory after medication therapy is initiated.

A 77-year-old client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging? a) Increased elastic recoil of the lungs b) Increased number of functional capillaries in the alveoli c) Decreased residual volume d) Decreased vital capacity

Decreased vital capacity

In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and relieves angina by: a) Increasing contractility and slowing heart rate b) Increasing AV conduction and heart rate c) Decreasing contractility and oxygen consumption d) Decreasing venous return through vasodilation

Decreasing venous return through vasodilation

Nurse Bea is assessing a male client with heart failure. The breath sounds commonly auscultated in clients with heart failure are: a) Tracheal b) Fine crackles c) Coarse crackles d) Friction rubs

Fine crackles

A client has undergone spinal anesthetic, it will be important that the nurse immediately position the client in: a) On the side, to prevent obstruction of the airway by the tongue b) Flat on back c) On the back, with knees, flexed 15 degrees d) Flat on the stomach, with the head, turned to the side

Flat on back

A client underwent ileostomy, when should the drainage appliance be applied to the stoma? a) 24 hours later, when edema has subsided b) In the operating room c) After the ileostomy begins to function d) When the client is able to begin self-care procedures

In the operating room

You have just admitted a patient with bacterial meningitis to the medical-surgical unit. The patient complains of a severe headache with photophobia and has a temperature of 102.60 F orally. Which collaborative intervention must be accomplished first? a) Administer codeine 15mg orally for the patient's headache b) Infuse ceftriaxone (Rocephin) 2000mg IV to treat the infection c) Give acetaminophen (Tylenol) 650mg orally to reduce the fever d) Give furosemide (Lasix) 40mg IV to decrease intracranial pressure

Infuse ceftriaxone (Rocephin) 2000mg IV to treat the infection

You are caring for a patient with recurrent glioblastoma who is receiving dexamethasone (Decadron) 4mg IV every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns you the most? a) The patient does not recognize family members b) The blood glucose level is 234 mg/dL c) The patient complains of a continued headache d) The daily weight has increased 1 kg

The patient does not recognize family members

You are mentoring a student nurse in the intensive care unit (ICU) while caring for a patient with meningococcal meningitis. Which action by the student requires that you intervene immediately? a) The student enters the room without putting on a mask and gown b) The student instructs the family that visits are restricted to 10 minutes c) The student gives the patient a warm blanket when he says he feels cold d) The student checks the patient's pupil response to light every 30 minutes

The student enters the room without putting on a mask and gown

A patient recently started on phenytoin (Dilantin) to control simple complex seizures is seen in the outpatient clinic. Which information obtained during his chart review and assessment will be of greatest concern? a) The gums appear enlarged and inflamed b) The white blood cell count is 2300/mm3 c) Patient occasionally forgets to take the phenytoin until after lunch d) Patient wants to renew his driver's license next month

The white blood cell count is 2300/mm3

A 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence is admitted to the hospital ED. His wife tells you that he fell down the stairs about a month ago, but "he didn't have a scratch afterward." She feels that he has become gradually less active and sleepier over the last 10 days or so. Which of the following collaborative interventions will you implement first? a) Place on the hospital alcohol withdrawal protocol b) Transfer to radiology for a CT scan c) Insert a retention catheter to straight drainage d) Give phenytoin (Dilantin) 100mg PO

Transfer to radiology for a CT scan

While working in the ICU, you are assigned to care for a patient with a seizure disorder. Which of these nursing actions will you implement first if the patient has a seizure? a) Place the patient on a non-rebreather mask will the oxygen at 15 L/minute b) Administer lorazepam (Ativan) 1mg IV c) Turn the patient to the side and protect the airway d) Assess level of consciousness during and immediately after the seizure

Turn the patient to the side and protect the airway

Which action(s) should you delegate to the experienced nursing assistant when caring for a patient with a thrombotic stroke with residual left-sided weakness? Select all that apply. a) Assist the patient to reposition every 2 hours b) Reapply pneumatic compression boots c) Remind the patient to perform active ROM d) Check extremities for redness and edema

-Assist the patient to reposition every 2 hours -Reapply pneumatic compression boots -Remind the patient to perform active ROM

All of these nursing activities are included in the care plan for a 78-year-old man with Parkinson's disease who has been referred to your home health agency. Which ones will you delegate to a nursing assistant (NA)? Select all that apply. a) Check for orthostatic changes in pulse and blood pressure b) Monitor for improvement in tremor after levodopa (L-dopa) is given c) Remind the patient to allow adequate time for meals d) Monitor for abnormal involuntary jerky movements of extremities e) Assist the patient with prescribed strengthening exercises f) Adapt the patient's preferred activities to his level of function

-Check for orthostatic changes in pulse and blood pressure -Remind the patient to allow adequate time for meals -Assist the patient with prescribed strengthening exercises

A male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse? a) Check respiration, circulation, neurological response b) Align the spine, check pupils, and check for hemorrhage c) Check respirations, stabilize the spine, and check the circulation d) Assess level of consciousness and circulation

Check respirations, stabilize the spine, and check the circulation

A male client has active tuberculosis (TB). Which of the following symptoms will be exhibited? a) Chest and lower back pain b) Chills, fever, night sweats, and hemoptysis c) Fever of more than 104 F and nausea d) Headache and photophobia

Chills, fever, night sweats, and hemoptysis

Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are: a) Progressively deeper breath followed by shallower breaths with apneic periods b) Rapid, deep breathing with abrupt pauses between each breath c) Rapid, deep breathing and irregular breathing without pauses d) Shallow breathing with an increased respiratory rate

Progressively deeper breath followed by shallower breaths with apneic periods