FUNDAMENTALS

Question 1

The nurse is caring for a client who had a fenestrated tracheostomy tube placed one week ago. Which statements are true regarding fenestrated tracheostomies? Select all that apply.

A. This type of tracheostomy does not require trach care

B. The client with a fenestrated tracheostomy can speak

C. This is the only type of tracheostomy used with mechanical ventilation

D. A fenestrated tracheostomy can be capped if the cuff is deflated

Answer 1

Explanation

Answer: B and D

A is incorrect. A client with a fenestrated tracheostomy will require the same amount of trach care as other types of tracheostomies. It is very important to keep the tracheostomy site clean to prevent skin breakdown, infections of the stoma, tracheitis, and respiratory infections.

B is correct. It is true that clients with a fenestrated tracheostomy can speak. Fenestrated tracheostomy tubes have a small opening in the outer cannula. This allows some air to escape through the larynx, which means that the client will be able to speak with this type of tube.

C is incorrect. Fenestrated tracheostomy tubes are not the only type of tracheostomy used with mechanical ventilation, there are also non-fenestrated tracheostomy tubes. A fenestrated tube would be used as a client progresses and is being weaned from breathing only through the tracheostomy to starting some breathing through the nose and mouth. Fenestrated tracheostomy can also be used with mechanical ventilation, but the cuff must be inflated.

D is correct. A fenestrated tracheostomy can be capped if the cuff is deflated. It is very important to remember to deflate the cuff if capping a fenestrated tracheostomy tube, because if the tube is capped and the cuff is still inflated the client will not be able to breathe at all.

NCSBN Client Need: Physiological adaptation

Topic: Alterations in Body Systems

Subject: Adult Health

Lesson: Respiratory

Question 2

A client with left-sided pneumothorax had a chest tube inserted 3 hours ago. There is no fluctuation in the water-seal chamber of the Pleurovac. What should be the nurse’s first action?

A. Auscultate the client’s chest wall.

B. Assess the tubing for any kinks.

C. Instruct the client to take deep breaths.

D. Ask the client to turn from side to side.

Answer 2

Explanation

A is incorrect. The nurse should assess for breath sounds but should determine why there is no-tilling in the water-seal chamber first. Re-expansion of the lungs after 3 hours is too early to happen.

B is correct. If there is no-tilling in the water seal chamber, the nurse should first check the integrity of the chest tubes from the client’s chest wall down to the Pleurivac for dependent loops or kinks.

C is incorrect. The nurse should check the tubing for kinks or dependent loops first; afterward, the nurse can tell the client to deep breath and cough to push out clots through the pipe.

D is incorrect. Turning the client does not aid in troubleshooting the problem for the client.

Reference

Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012

Question 3

Simply stated, sensory deficits are:

A. Empirical losses.

B. Common with severe depression.

C. A normal part of the aging process.

D. Affective losses.

Answer 3

Explanation

The correct answer is A. Sensory deficits are empirical losses; the practical senses are vision, hearing, smell, and feel, or the feeling of tactile sensation like sensory abilities are.

Choice B is incorrect. Sensory deficits do not usually occur with depression; instead, feelings of hopelessness and hopelessness are common among clients affected with depression.

Choice C is incorrect. Although some sensory deficits, like decreased visual acuity and hearing, are more common among the elderly, those losses are not a normal part of the aging process.

Choice D is incorrect. Affect is the state of the person’s mood and expressions of emotion and not a sensory deficit.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.

Question 4

The nurse is conducting client and family education about dietary considerations related to Parkinson’s disease. One priority consideration that the nurse should highlight in teaching is to address the risk of:

A. Too much fluid and drooling

B. loss of appetite and aspiration

C. lose stools and choking

D. difficulty swallowing and constipation

Answer 4

Explanation

Rationale: With Parkinson’s disease, eating problems include dysphagia, aspiration, constipation, and risk of choking. Fluid overload, diarrhea, and loss of appetite (anorexia) are problems not directly related to Parkinson’s disease. Drooling is a symptom of Parkinson’s disease; however, it does not take priority over aspiration and dysphagia.

Reference:

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 5

A man is found lying on the ground, unconscious, covered with snow, and is brought to the ER to be treated. The nurse checks the client’s temperature and notes that it is 88° F. The nurse also notes respirations of 10, the pulse of 50, and blood pressure of 79/52 mm Hg. The nurse understands that the client is suffering from:

A. Mild Hypothermia

B. Moderate Hypothermia

C. Severe Hypothermia

D. Frostbite

Answer 5

xplanation

A is incorrect. Mild hypothermia presents with shivering, bradycardia or tachycardia. The patient may also be alert or may have lethargy or confusion.

B is correct. Manifestations of moderate hypothermia include decreased LOC or coma, hypoventilation, bradycardia, atrial fibrillation, hypovolemia, cessation of shivering, and possible hyperglycemia.

C is incorrect. Severe hypothermia manifests as coma, fixed and dilated pupils, bradycardia, apnea, hypotension, ventricular fibrillation, asystole.

D is incorrect. Frostbite is hypothermia in the extremities. Frostbitten areas may appear red and swollen or may be pale in color. Blisters containing clear of bloody purple fluid may appear.

Reference

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier

Question 6

appropriate expected goal or expected outcome for this client?

A. The client will maintain a serum albumin of 1.5 to 2.0 g/dL.

B. The client will maintain a serum albumin of 2.0 to 2.5 g/dL.

C. The client will gain 0.5 kg bodily weight each day.

D. The client will gain 1 kg of bodily weight each day.

Answer 6

Explanation

Correct Answer is D

Correct. “The client will gain 1 kg of body weight each day” is an appropriate expected goal or expected outcome for this client who is receiving TPN (total parenteral nutrition) because of extensive and severe thermal burns.

Choice A is incorrect. “The client will maintain serum albumin of 1.5 to 2.0 g/dL” is not an appropriate expected goal or expected outcome for this client who is receiving TPN (total parenteral nutrition) because of extensive and severe thermal burns. TPN (complete parenteral nutrition) is being administered to this client because the caloric demands of the body significantly increase as a result of severe injuries and other disorders like cancer.

Choice B is incorrect. “The client will maintain serum albumin of 2.0 to 2.5 g/dL” is not an appropriate expected goal or expected outcome for this client who is receiving TPN (total parenteral nutrition) because of extensive and severe thermal burns. Although TPN (complete parenteral nutrition) is being administered to this client, the serum albumin should not be maintained at 2.0 to 2.5 g/dL because the normal albumin, which is higher than this, is necessary for the wound healing of this client.

Choice C is incorrect. “The client will gain 0.5 kg bodily weight each day” is not an appropriate expected goal or expected outcome for this client who is receiving TPN (total parenteral nutrition) because of extensive and serious thermal burns because this client should be gaining more weight than this to meet the significantly increased demands of the body as a result of severe burns and other disorders like cancer.

Reference: Knippa, Audrey, Sheryl Sommer, Brenda Ball et al. (2010) Nutrition for Nursing 4.0; ATI Nursing Education.

Question 7

Your client has consumed an 8 ounce can of ginger ale, a 4-ounce container of apple sauce, and 6 ounces of lean meat for lunch. You will document this client’s fluid intake as:

A. 80

B. 160

C. 180

D. 240

Answer 7

explanation

Correct Answer is D

Correct. You will document this client’s fluid intake as 240 MLS or cc s because the client has consumed a total of 8 ounces of fluid and, because each ounce has 30 MLS or ccs, it is calculated as follows:

30 x 8 = 240 MLS or cc s

The apple sauce and lean meat do not count as fluid.

Choice A is incorrect. The client has consumed a total of 8 ounces of fluid, so the total consumed is more than 80 MLS or cc s. Try this calculation again.

Choice B is incorrect. The client has consumed a total of 8 ounces of fluid, so the total consumed is more than 160 MLS or cc s. Try this calculation again

Choice C is incorrect. The client has consumed a total of 8 ounces of fluid, so the total consumed is more than 180 MLS or cc s. Try this calculation again

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 8

A 15-month-old infant is brought to the well-baby clinic for immunizations. On assessment, he was found to have a “runny” nose, and his mother tells the nurse that he has had it for over a week. Overall assessment findings indicate that the baby is well, except for a mild upper respiratory infection. According to his immunization card, his last immunization was at nine months old when he received DPT 2, OPV 2, and HIB 2 vaccines. The plan of care for this infant would be:

A. Administer DPT 3, OPV3, HIB 3 and Hepatitis B vaccines

B. Administer DPT 3, OPV 3, HIB 3, hepatitis and MMR vaccines

C. refer the infant to the physician for mild upper respiratory tract infection

D. Do not administer any vaccine and schedule a return visit in 2 weeks to see if the URI has resolved

Answer 8

Explanation

At 15 months, the recommended vaccines are DPT 3, OPV 3, HIB 3, Hepatitis B, and MMR. A mild URI is not a contraindication to the administration of any vaccine.

It is not necessary to refer the child to a physician at the moment. The correct answer is option B. Options A, C, and D are incorrect.

Reference:

Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins

Question 9

Select the developmental age group that is accurately paired with the normal number of hours of sleep over 24 hours that are expected for this group.

A. The neonate: 14 to 15 hours of sleep each day

B. The infant: 13 to 14 hours of sleep each day

C. The toddler: 12 to 14 hours of sleep each day

D. The preschool age child: 12 to 14 hours of sleep each day

Answer 9

Explanation

Correct Answer is C

Correct. Under normal circumstances, the toddler is expected to have 12 to 14 hours of sleep each day for over 24 hours.

Under normal circumstances, the average number of hours of sleep over 24 hours that are expected for these developmental age groups are:

The neonate: 16 to 18 hours of sleep each day
The infant: 14 to 15 hours of sleep each day
The preschool-age child: 11 to 13 hours of sleep each day

Choice A is incorrect. The neonate is expected to have more than 14 to 15 hours of sleep each day.

Choice B is incorrect. The infant is expected to have more than 13 to 14 hours of sleep each day.

Choice D is incorrect. The preschool-age child is expected to have less than 12 to 14 hours of sleep each day.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 10

A patient is about to be inserted a Salem pump NG tube Which position should the nurse place the client?

A. Supine, with head of the bed elevated at 30° - 45°

B. Supine, with head of the bed elevated at 60° - 90°

C. Knee-chest position

D. Prone position

Answer 10

Explanation

A is incorrect. The nurse should position the patient so that the insertion of the NG tube is facilitated. An elevation of 30° - 45° is not enough to facilitate the movement of the machine down the GI tract.

B is correct. A supine position with a 60° - 90° elevation facilitates swallowing of the patient and lets gravity help in the movement of the tube down the GI tract.

C is incorrect. A knee-chest position does not facilitate the movement of the tube down the GI tract.

D is incorrect. A prone position does not facilitate the insertion of the NG tube.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 11

Select the client care supply or piece of equipment that is accurately paired with the correct type of asepsis.

A. Medical asepsis: An autoclave

B. Medical asepsis: Sterile gloves

C. Surgical asepsis: A single use blood pressure cuff

D. Surgical asepsis: An autoclave

Answer 11

Explanation

Correct Answer is D. An autoclave is used to sterilize client care supplies and equipment; therefore, an autoclave is accurately paired with surgical asepsis.

Choice A is incorrect. An autoclave is used to sterilize; therefore, it is not used for medical asepsis.

Choice B is incorrect. Sterile gloves are sterilized and used for sterile procedures, and not for medical asepsis procedures.

Choice C is incorrect. Single-use blood pressure cuffs are medically aseptic and not sterilized. Therefore, it is not an example of surgical asepsis.

References: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.DV

Question 12

Which of these medications can be mixed in the same syringe without the risk of any incompatibility?

A. Dexamethasone and midazolam

B. Haloperidol and ketorolac

C. Hydrocortisone and midazolam

D. NPH and regular insulin

Answer 12

Explanation

Correct Answer is D

Correct. NPH insulin and regular insulin can and are often mixed in the same syringe without the risk of incompatibility.

Dexamethasone and midazolam cannot be mixed in the same syringe because they are not compatible; haloperidol and ketorolac cannot be incorporated in the same needle because they are not compatible, and hydrocortisone and midazolam cannot be mixed in the same syringe because they too are not compatible.

Choice A is incorrect. Dexamethasone and midazolam cannot be mixed in the same syringe because they are not compatible. Dexamethasone and other medications such as metoclopramide, however, are compatible and as such, they can be mixed in the same syringe.

Choice B is incorrect. Haloperidol and ketorolac cannot be mixed in the same syringe because they are not compatible. Haloperidol and other medications such as hydromorphone, however, are fit, and as such, they can be mixed in the same syringe.

Choice C is incorrect. Hydrocortisone and midazolam cannot be mixed in the same syringe because they are not compatible. Hydrocortisone and other medications such as metoclopramide, however, are compatible and as such, they can be mixed in the same syringe.

Reference: Kee, Joyce LeFever, Evelyn Hays, and Linda McCistion (2011) Pharmacology: A Nursing Process Approach 7th edition. Elsevier Saunders.

Question 13

he client comes into the Emergency room complaining of unusual tiredness, ankle swelling, and seeing yellow rings all around. Upon assessment, the client has been experiencing loose bowels, and a review of medications reveals that the client is taking Digoxin. What is the nurse’s initial action?

A. Reassure the client that he will be okay.

B. Obtain an ECG.

C. Notify the physician and inform him of the findings.

D. Obtain a stool specimen.

Answer 13

Explanation

A is incorrect. The client presents signs of digitalis toxicity exacerbated by dehydration and hypokalemia brought about by loose bowel motion. The nurse would reassure the patient but should address his physiological problems beforehand.

B is incorrect. An ECG would be helpful to assess the cardiac status of the patient; however, the patient is showing clear signs of digitalis toxicity. The initial action of the nurse would be to inform the physician.

C is correct. Signs of digitalis toxicity include an unusual slow irregular pulse, rapid weight gain, yellow vision, unusual tiredness, ankle swelling. Loose bowels may lead to hypokalemia, which increases the toxic effects of digitalis. The nurse should immediately notify the physician that appropriate treatment can be started.

D is incorrect. Obtaining a stool specimen can be useful in ascertaining the cause of the patient’s loose stools. This is not, however, a priority nursing action.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins 2006

Question 14

A client with thrombocytopenia is currently having epistaxis. The most appropriate nursing intervention should be:

A. Instruct the client to lie flat with his neck suspended

B. Ask client to sit upright, leaning slightly forward

C. Ask client to blow his nose, then put lateral pressure on his nose

D. Ask client to hold his nose while bending forward from the waist

Answer 14

Explanation

Rationale: In the event of epistaxis, the client should be instructed to assume an upright position, leaning slightly forward to help prevent an increase of vascular pressure in the nose and help prevent aspiration of blood. Option B is therefore the correct answer. Lying in the supine position would predispose the client to aspiration. Blowing the nose would risk dislodging any clotting that has occurred and promote further bleeding. Bending at the waist increases the vascular pressure in the nose that would lead to further bleeding instead of stopping it. Options A, C, and D are therefore incorrect.

Reference:

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 15

Select the age group along the life span that is accurately paired with a physiological characteristic that places them at risk for adverse effects, contraindications, side effects, and/or interactions relating to medications.

A. Neonates: Acidic gastric acids that affect absorption

B. Toddler: Immature hepatic functioning that affects distribution

C. The elderly: Decreased renal perfusion that affects excretion

D. Adolescents: An undeveloped blood – brain barrier

Answer 15

Explanation

Correct Answer is C

Correct. The elderly population, as the result of the regular changes of the aging process, is at high risk for adverse medication effects, contraindications, side effects, and interactions. Among these frequent changes of the aging process include decreased renal perfusion and functioning, decreased hepatic perfusion and functioning, lowered bodily water, reduced gastric acid production, increased adipose tissue, and polypharmacy as the result of multiple chronic diseases and disorders which also increase the elderly’s risk for adverse effects, contraindications, side effects and/or interactions.

Choice A is incorrect. Neonates can be affected by adverse effects, contraindications, side effects, and interactions with medications because their gastric acid is more alkaline and not more acidic.

Choice B is incorrect. Neonates and infants less than one year of age have immature hepatic functioning that affects distribution, not toddlers.

Choice D is incorrect. Neonates and infants less than one year of age have an undeveloped blood-brain barrier and not adolescents.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 16

When communicating with a client who speaks a different language the nurse should

A. Speak loudly and slowly

B. Stand close to the client and speak in an exaggerated volume

C. Arrange for an interpreter when communicating with the client

D. Speak to the client and family together to promote comprehension and be understood

Answer 16

Explanation

Rationale: Arranging for an interpreter would be the best thing to do when communicating with a client who speaks a different language. Options A and B are inappropriate and are ineffective ways of communicating. Option D is inadequate because it does not ensure correct translation, and it violates the patient’s right to privacy.

References:

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6thEdition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7thed. St. Louis, MO: Elsevier; 2013.

Question 17

client is scheduled for hip replacement surgery. She expresses anxiety to the nurse about the upcoming surgery. Which response by the nurse is most therapeutic?

A. “Everyone is nervous before any surgery. What you feel is completely normal.”

B. “Here’s what’s going to happen to you during the procedure. I will explain to you in detail.”

C. “Can you tell me what you have been told about the surgery?”

D. “Let me tell you about the care you will receive and the pain you should anticipate after the surgery.”

Answer 17

Explanation

Rationale: Open-ended questions that facilitate further discussion is most therapeutic in this situation. Option C provides the patient with an opportunity to express her thoughts further and would give the nurse a baseline of the patient’s knowledge and readiness for the surgery; thus, the correct answer. This way, the nurse can come up with appropriate explanations around what the client already knows and by filling in facts. Options A, B, and D will only increase the patient’s level of anxiety and are, therefore, incorrect.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6th Edition. Saunders-Elsevier 2014

Question 18

The nurse is taking care of a patient with cardiac arrhythmias—the physician orders to give an additional dose of digoxin. The nurse finds that the patient’s heart rate is only 40 bpm, and serum potassium level is critically low and relays her findings to the physician. The physician, however, insists and threatens, “Give the digoxin now, or I will have you sacked!” The best response by the nurse would be:

A. “Fine. I’ll give the digoxin now but this patient will die.”

B. “I don’t have to listen to anyone like you.”

C. “Don’t you raise your voice at me again or we’ll see who gets fired.”

D. “I think we should discuss this with the pharmacist or the unit manager now.”

Answer 18

Explanation

Rationale: Options A, B, and C are all aggressive forms of communication and are not becoming of a professional. They are incorrect. Option D is assertive, does not infringe on the physician’s rights, and inclined to keep the patient safe.

Reference:

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins 2006

Question 19

After talking to her family, an elderly client says that she wants to change the living will she wrote two weeks ago. The nurse’s most appropriate reply would be:

A. “You can only change your living a year after it is formulated.”

B. “Let me see if I can find someone to help you.”

C. “You can only make changes to your will after 3 weeks.”

D. “Let’s call your lawyer first and see what he thinks.”

Answer 19

Explanation

A is incorrect. Living wills can be changed by the client anytime and how many times they wish as long as they are competent in making decisions.

B is correct. It is the nurse’s responsibility to be the client’s advocate. She should be responsible for finding someone that can help the client with her wish.

C is incorrect. Living wills can be changed by the client anytime and how many times they wish as long as they are competent in making decisions.

D is incorrect. The client does not need to ask permission from her lawyer to change her living will.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 20

The nurse is talking to the patient’s son who was just diagnosed with Coronary Heart Disease. He is asking about the risk factors that can be modified to decrease the chances of acquiring CHD. The nurse educates him by saying that the following are modifiable risk factors for CHD:

A. Gender, Cholesterol levels, Obesity

B. Age, Elevated Blood Pressure

C. Stress, Age, Gender

D. Smoking, Obesity, Physical Activity

Answer 20

Explanation

A is incorrect. Gender is a non-modifiable risk factor, while Cholesterol levels and obesity are modifiable risk factors.

B is incorrect. Age is a non-modifiable risk factor. Blood pressure is a modifiable risk factor.

C is incorrect. Stress is a contributing risk factor, while age and gender are non-modifiable risk factors.

D is correct. Smoking, Obesity, and Physical activity are all modifiable risk factors in CHD.

Reference

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 21

Which of the following classifications of medications can be used as an adjuvant medication for the pharmacological management of pain?

A. An adrenergic

B. A cholingeric

C. An anxiolytic

D. An antiarrythmic medication

Answer 21

Explanation

Correct Answer is D

Correct. Some antiarrhythmic medications are used as an adjuvant medication for the pharmacological management of pain. Mexiletine is an example of an antiarrhythmic drug that is used as an adjuvant medication for the pharmacological management of pain.

Other classifications of medications that are used as an adjuvant medication for the pharmacological management of pain, in addition to some antiarrhythmic remedies, are antidepressants, corticosteroids, and anticonvulsant medications.

Choice A is incorrect. Adrenergic medications are not used as an adjuvant medication for the pharmacological management of pain.

Choice B is incorrect. Cholinergic medications are not used as an adjuvant medication for the pharmacological management of pain.

Choice C is incorrect. Anxiolytic medications are not used as an adjuvant medication for the pharmacological management of pain.

Reference: McCuistion, Linda E., Joyce LeFever Kee, and Evelyn R. Hayes (2015). Pharmacology: A Patient-Centered Nursing Process Approach, 8th Edition. Saunders: Elsevier

Question 22

An elderly client has just finished a total knee replacement surgery. The nurse suspects of fluid overload in the client. Which of the following signs and symptoms would confirm the nurse’s suspicion?

A. Blood pressure of 90/55 mm Hg; Weak, thready pulse, slightly elevated temperature

B. Cool clammy skin; Bounding pulse; Cough

C. Headache, Lethargy, Abdominal pain

D. Fever; warmth, swelling, and redness at the operative site

Answer 22

Explanation

A is incorrect. Low blood pressure, weak and thready pulse, and a slightly elevated temperature would indicate Dehydration.

B is correct. Cool clammy skin, bounding pulses, productive cough, distended neck veins, edema, and polyuria are signs of fluid overload.

C is incorrect. These are not symptoms of fluid overload and may indicate other co-morbidities.

D is incorrect. Fever, warmth, swelling, and redness at the operative site indicate infection.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 23

A 78-year-old woman is brought to the emergency department for the treatment of a fractured arm. On physical assessment, the nurse notices old and new ecchymotic areas on the client’s chest and legs and asks the client how the bruises were sustained. The client reluctantly tells the nurse that her son frequently hits her if supper is not ready when he gets home from work. Which of the following is the most appropriate nursing response?

A. “Oh, really. Let me talk to your son.”

B. “I appreciate your honesty but this is a legal issue, and I must tell you that I will need to report it.”

C. “Let’s talk about the ways you can manage your time to prevent your son from getting upset.”

D. “Do you have any friends that can help you out or keep you safe until you resolve these important issues with your son?”

Answer 23

Explanation

Rationale: The nurse must and is compelled to report situations related to the child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Nurses must refrain from discussing confidential issues with nonmedical personnel or the client’s family or friends without the client’s permission. Clients are assured that information is kept confidential unless it places the nurse under a legal obligation. Options A, C, and D do not address the legal implications of the situation and do not ensure a safe environment for the client.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6thEdition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7thed. St. Louis, MO: Elsevier; 2013.

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8thedition, Nebraska: Elsevier 2009

Question 24

Your client has consumed an 8-ounce container of milk, a 4-ounce container of gelatin, and a 6-ounce hamburger for lunch. You will document this client’s fluid intake as:

A. 80 mLs or cc s

B. 160 mLs or cc s

C. 360 mLs or cc s

D. 640 mLs or cc s

Answer 24

Explanation

Correct Answer is C

Correct. You will document this client’s fluid intake as 360 MLS or cc s because the client has consumed a total of 12 ounces of fluid and, because each ounce has 30 MLS or ccs, it is calculated as follows:

30 x 12 = 360 MLS or cc s

The hamburger does not count as fluid.

Choice A is incorrect. The client has consumed a total of 12 ounces of fluid, so the total consumed is more than 80 MLS or cc s. Try this calculation again.

Choice B is incorrect. The client has consumed a total of 12 ounces of fluid, so the total consumed is more than 160 MLS or cc s. Try this calculation again.

Choice D is incorrect. The client has consumed a total of 12 ounces of fluid, so the total consumed is less than 640 MLS or cc s. Try this calculation again.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 25

Your client has an order for one unit of packed red blood cells. One of the other nurses picked the blood up at the blood bank at 11 am, and you began the infusion of the packed red blood cells at noon after you have completed all of the safety, client identification, and preparation procedures. At what time should this unit of packed red blood cells be thoroughly infused?

A. 1 pm

B. 2 pm

C. 3 pm

D. 4 pm

Answer 25

Explanation

Correct Answer is C

Correct. This unit of packed red blood cells must be infused entirely by 3 pm, which is 4 hours after the group of this unit of packed red blood cells was taken from the blood bank. This time limit prevents the degradation and damage to the red blood cells.

Choice A is incorrect. Although this unit of packed red blood cells must be infused entirely by a certain number of hours after the group of this unit of packed red blood cells was taken from the blood bank to prevent degradation and damage to the red blood cells, this time is more than 2 hours.

Choice B is incorrect. Although this unit of packed red blood cells must be infused entirely by a certain number of hours after the group of this unit of packed red blood cells was taken from the blood bank to prevent degradation and damage to the red blood cells, this time is more than 3 hours.

Choice D is incorrect. Although this unit of packed red blood cells must be infused entirely by a certain number of hours after the group of this unit of packed red blood cells was taken from the blood bank to prevent degradation and damage to the red blood cells, this time is less than 5 hours.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 26

A widower has been complaining that he could not sleep, he is short of breath, extremely anxious, and has been having a sense of impending doom. Which response by the nurse is most appropriate?

A. “Just relax. You’re in a safe place now. You have nothing to worry about.”

B. “Has anything happened recently, or is there anything in the past that could have triggered these feelings?”

C. “The medication I have given you will help decrease these feelings of anxiety.”

D. “Why don’t you take some deep breaths to help you calm down?”

Answer 26

Explanation

Rationale: Option B reassures the client and provides an opportunity to gain insight into the root of the client’s anxiety. Telling the client she has nothing to worry about dismisses the client’s feelings and only gives her false reassurance. Simply giving her medications and instructing her to calm down doesn’t allow the client to verbalize her feelings, which is necessary for her to understand and resolve the cause of anxiety. Options A, C, and D are therefore incorrect.

Reference:

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Halter, MJ. Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 7th Ed. St. Louis, MO: Mosby Elsevier; 2014:14

Question 27

A patient is rushed to the ER after a car accident. The patient has lost a lot of blood and is required an emergency blood transfusion. The nurse checks the blood bank, and the only available blood is “O” positive. The patient’s blood type is “A” positive. What is the nurse’s most appropriate action?

A. Arrange for a cross match between the available blood and the patient’s blood.

B. Call the other blood banks and ask if they have blood units available with the client’s blood type.

C. Notify the physician that there is no available blood in the blood bank.

D. Call the client’s family that he needs blood.

Answer 27

Explanation

A is correct. The ABO type of the donor should be compatible with the recipients. Type “A” can receive blood from type “A” or “O” as type “O” blood does not contain any antigens against type “A” or “B” blood. The blood can be administered once proper cross-matching is done.

B is incorrect. The nurse can do this once cross-matching is being done since the situation is an emergency. The nurse can find other compatible blood units as a second option for the patient.

C is incorrect. The nurse cannot tell the physician that there is no available blood in the blood bank since there is an open unit.

D is incorrect. The family is informed of the client’s condition, but it should not be responsible for procuring blood for the patient.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins 2006

Question 28

The nurse is administering 10 units of regular insulin and 15 units of NPH insulin to the client at 8:00 am in the morning. The nurse should offer a snack to the patient at what time?

A. 15 minutes after food ingestion

B. at around 10:30 am

C. at 2:00 pm

D. at 12:00 am

Answer 28

Explanation

A is incorrect. This is the wrong time for a snack.

B is correct. The first insulin peak will occur two to four hours after the administration of regular insulin. Regular insulin is classified as rapid-acting and will peak two to four hours after administration. A snack should be offered at around 10:30 am to prevent hypoglycemia. The second peak will occur eight to twelve hours after the administration of NPH insulin, or at around 4:00 pm.

C is incorrect. This is the wrong time for a snack—regular insulin peaks at 2-4 hours after administration and NPH peaks after 8-12 hours.

D is incorrect. This is the wrong time for a snack—regular insulin peaks at 2-4 hours after administration and NPH peaks after 8-12 hours.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 29

Select the theory of stress and coping that is accurately paired with an example of it.

A. Response based theories of stress: Selye’s general adaptation syndrome

B. Response based theories of stress: Lazarus’ model of stress and coping

C. Stimulus based theories of stress: Selye’s local adaptation syndrome

D. Transaction based theories of stress: Holmes and Rahe’s model of stress and coping

Answer 29

Explanation

Correct Answer is A

Correct. In broad terms, there are three categories of models and theories that describe stress and coping. These models include response based theories of stress, stimulus-based theories of stress, and transaction-based theories of stress. Selye’s general adaptation syndrome is an example of a response based theory of stress and this theory describes the physiological responses to stress.

Lazarus’ model of stress and coping is not a response based theory of stress, but instead, a transaction based theories of stress; Selye’s local adaptation syndrome is also a response based theory of stress; and Lazarus’ model of stress and coping is an example of a transaction based theory of stress.

Choice B is incorrect. Lazarus’ model of stress and coping is not a response based theory of stress, but instead, a transaction based theories of stress

Choice C is incorrect. Selye’s local adaptation syndrome is a response based theory of stress.

Choice D is incorrect. Holmes and Rahe’s model is an example of a stimulus-based theory of stress.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition). Upper Saddle River, New Jersey: Pearson.

Question 30

The nurse in charge of a patient with iron deficiency anemia is documenting care. Which nursing diagnosis is the most appropriate in the plan of care?

A. Impaired gas exchange

B. Ineffective airway clearance

C. Deficient fluid volume

D. Ineffective breathing pattern

Answer 30

Explanation

Rationale: The hemoglobin in the blood is the component responsible for oxygen transport in the body. Iron is an essential substance for hemoglobin synthesis. In iron deficiency anemia, the hemoglobin drops to subnormal levels, leading to impaired tissue oxygenation and reduces gas exchange. Option A is, therefore, the correct answer. Iron deficiency anemia does not cause fluid volume deficit and is not directly related to ineffective airway clearance nor breathing pattern. Options B, C, and D are incorrect.

Reference:

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Kelly, P; Marthaler, M; Nursing Delegation, Setting Priorities, and Making Patient Care Assignments, 2nd Edition; Cengage Learning, 2010

Question 31

Which of the following is (are) management functions that nurses fulfill? Select all that apply.

A. Being a visionary

B. Directing

C. Coordinating

D. Organizing

Answer 31

Explanation

Correct Answer is B, C, D.The four management functions that nurses fulfill are directing, coordinating, organizing, and planning. Serving as a visionary is a function of leadership and not management.

Choice A is incorrect. Being a visionary is part of the leadership role and not one of the functions that nurses fulfill as a manager.

References: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition) and Sommer, Johnson, Roberts, Redding, and Churchill. (2013) Nursing Leadership and Management: Review Module Edition 6.0; ATI Nursing Education.

Question 32

The registered nurse is having her shift in the emergency department of a pediatric hospital. There are four patients in the ED; which patient would the nurse see first?

A. A month old infant that is crying with retractions during inspiration

B. A 5 year old with pneumonia with 95% pulse oxygen saturation.

C. A 10 year old with diarrhea and vomiting with a potassium level of 3.6 mEq/L

D. A 15 year old diabetic with a blood glucose level of 190 mg/dL

Answer 32

Explanation

A is correct. The child with inspiratory retractions indicates respiratory distress in the child and should be assessed first.

B is incorrect. The child with pneumonia is stable. The nurse does not need to assess this patient urgently.

C is incorrect. The child still has an average potassium level even though he is having diarrhea and vomiting. The nurse does not need to assess this child first.

D is incorrect. A glucose level of 190 mg/disc is not threatening. The nurse does not need to assess this child first.

Reference

Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 33

You have been caring for a severely depressed client in the community. When you see this client today, the client is far less depressed than they were in the past. What priority critical thinking possibility should you be considering in terms of this client’s current psychological state?

A. The client has resolved the depression.

B. The client may have planned their suicide plan.

C. The antidepressant medications are effective.

D. Their cognitive behavioral therapy is effective.

Answer 33

Explanation

The Correct Answer is B.

Correct. The priority critical thinking possibility that you should be considering in terms of this client’s current psychological state is the possibility that this severely depressed client has planned their suicide because when a severely depressed client becomes far less depressed than they were in the past.

Although this client may be effectively treated with antidepressant medications and cognitive behavioral therapy, the priority concern is associated with a heightened risk of suicide.

Choice A is incorrect. Although the client may have resolved their depression, there is a chance that this patient may be experiencing less depression because something else severe that may be occurring.

Choice C is incorrect. Although this client may be effectively treated with antidepressant medications, something else very serious may be occurring.

Choice D is incorrect. Although this client may be effectively treated with their cognitive behavioral therapy, something else very serious may be occurring.

Reference: Sommer, Sheryl, Janean Johnson, Karin Roberts, Sharon Redding, Lois Churchill, Norma Jean Henry, and Mendy McMichael. (2013) RN Mental Health Nursing 9.0; ATI Nursing Education.

Question 34

e nurse is working in a women’s health clinic. Which patient should the nurse see first?

A. A 17 year-old complaining of severe cramping in her lower abdomen.

B. A 25 year-old primigravida with blurred vision.

C. A 50 year-old menopausal client expelling dark red blood clots.

D. A 70 year-old client who states her uterus is going to “fall out.”

Answer 34

Explanation

A is incorrect. The 17-year-old with severe lower abdominal cramping needs to be assessed if she is currently menstruating. It does not, however, hold priority over a client with signs of preeclampsia.

B is correct. Signs and symptoms of preeclampsia include blurred vision, hypertension, generalized edema, and proteinuria. The client is also a primigravida, which predisposes her for preeclampsia. The nurse should prioritize the client to include further assessment and intervention.

C is incorrect. Clients who undergo menopause experience expulsion of dark red blood clots. This should not cause concern to the nurse.

D is incorrect. This may indicate a possible uterine prolapse, but this is not a life-threatening situation. The client may need a hysterectomy to remove the uterus or use a pessary device.

Reference

Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 35

What tool, or graphic display, that is shown below can assist the nurse in understanding the health status of the family unit and its risk factors?

A. Genogram

B. Ecomap

C. Histogram

D. A scatter gram

Answer 35

Explanation

Correct Answer is A

Correct. The tool or graphic display tool that is shown which can assist the nurse in understanding the health status of the family unit and its risk factors is a genogram.

Ecomaps show the interrelationships of individuals, families, and communities with their external environment and the forces and relationships that impact the individual, family, and community.

Histograms and scattergrams show statistical data and not the interrelationships of individuals, families, and communities with their external environment and the forces and relationships that impact on the individual, family, and community.

Choice B is incorrect. Ecomaps show the interrelationships of individuals, families, and communities with their external environment and the forces and relationships that impact on the individual, family and community and not the health status of the family unit and its risk factors.

Choice C is incorrect. Histograms show statistical data and not the health status of the family unit and its risk factors.

Choice D is incorrect. Scatter grams show statistical data and not the health status of the family unit and its risk factors.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition).

Question 36

The nurse in the nursery is caring for a 24 hour-old infant. The nurse suspects the child having pyloric stenosis. Which manifestation by the infant would confirm the nurse’s suspicion?

A. Melena

B. Currant jelly” stools

C. Projectile vomiting

D. Steatorrhea

Answer 36

Explanation

A is incorrect. Melena would indicate upper GI bleeding. This is not a manifestation of pyloric stenosis.

B is incorrect. “Currant jelly” stools are characteristic manifestations of intussusception.

C is correct. Projectile vomiting is a manifestation of pyloric stenosis. This occurs due to the closure of the pyloric sphincter, which closes off the pathway of the food from the stomach.

D is incorrect. Steatorrhea or feces with excessive fat is a normal stool for malabsorption disorders, not pyloric stenosis.

Reference

Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 37

The nurse working in the Gynecology clinic talks to the client that is concerned that she missed taking her pill for four days already. The most appropriate instruction of the nurse is:

A. “Take one pill now and continue taking the pills on your regular schedule tomorrow.”

B. “Take two pills now and continue taking two pills for the rest of your regular schedule.”

C. “Take two pills now, and two pills tomorrow. Continue with your usual schedule the following day.”

D. “Here’s a new set of pills. Start taking the new pills this Sunday and throw away your old one, and use the second form of contraception for the next 7 days after starting your new pack.”

Answer 37

Explanation

A is incorrect. Taking a pill right away and continuing with the usual pill schedule is instructed for clients who missed only one day making their pill.

B is incorrect. Taking two pills right away and two pills for the rest of the cycle is not indicated. This increases the estrogen levels of the client way too much and increases her risk of thromboembolism.

C is incorrect. Taking two pills as soon as you remember, two capsules the following day, and continuing with one pill for the rest of the cycle is indicated for women who missed two consecutive pills.

D is correct. When a client misses three or more pills in a row, she should throw out the rest of the pack and start a new pack of pills the following Sunday. The nurse needs to inform her to use extra protection until seven days after starting a new pack of pills.

Reference

Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Question 38

The nurse in the postpartum ward is looking at laboratory results of clients that just arrived. The nurse would go to which client immediately?

A. A patient with WBC of 15,000 cu.mm.

B. A patient a Creatinine level of 0.8 mg/dL

C. A patient with a Platelet count of 360,000 cu.mm.

D. A client with a blood glucose of 260 mg/dL

Answer 38

Explanation

A is incorrect. During labor and after birth, the WBC count would rise to 25,000. This is a normal response of the body and should not warrant any concern.

B is incorrect. The serum creatinine level is within normal limits. This does not need any intervention.

C is incorrect. Normal platelet count is 150,000 to 450,000. This is within normal limits.

D is correct. The average blood glucose level is 70 – 120 mg/dL. The client’s blood glucose level is 260, thus warranting the attention and intervention of the nurse.

Reference

Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 39

The registered nurse is working together with the LPN in a psychiatric ward. Ina busy day, the nurse understands that it is necessary to delegate tasks to LPNs. Which job would the RN delegate to the LPN?

A. Escorting a client with a serum lithium level of 2.2 mEq/L to the ER

B. Accompanying a bulimic client for an hour after lunch.

C. Conducting art therapy to a group of clients in the day room.

D. Accompany the client who is talking to her mother on the phone.

Answer 39

Explanation

A is incorrect. A client, the nurse, is asking her to escort to the ER has lithium toxicity. This client is unstable; thus, the nurse must accompany this client to the ER.

B is correct. Clients with bulimia need someone to prevent them from purging and letting the LPN sit with her for one hour after her lunch precludes the client from inducing vomiting.

C is incorrect. The LPN is not trained in this type of activity. The registered psychiatric nurse should be the one conducting this.

D is incorrect. The LPN should be tasked to listen to the client’s phone conversation. This is a violation of her right to privacy.

Reference

Halter, MJ.Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 7th Ed. St. Louis, MO: Mosby Elsevier; 2014

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 40

lient is at the clinic for hypersensitivity testing with the intradermal technique. The proper technique of administering the allergen would be to position the needle:

A. at 0 degrees against the skin

B. at 15 degrees insertion

C. at 45 degrees

D. at 90 degrees with a dart-like motion

Answer 40

Explanation

Rationale: The proper angle for intradermal injections is at 15 degrees. A 45-degree perspective is used for subcutaneous injections, while a 90-degree angle is used for intramuscular injections. There are no injections administered at a 0-degree angle. The correct answer is option B, while options A, C, and D are incorrect.

Reference:

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 41

A client is scheduled for gastroscopy at 8:00 AM and has been placed on NPO since midnight. At 6:30 AM, the nurse checks the client’s capillary blood glucose level and gets a result of 40 mg/dl on the glucometer. The client is alert, coherent, and reports, “I feel fine. I don’t feel anything.” The most appropriate action for the nurse is:

A. Record the finding in the notes and withhold the client’s morning insulin.

B. Take a repeat sample of the capillary blood glucose.

C. Give the client simple sugar by mouth.

D. Administer intravenous dextrose 50 grams STAT.

Answer 41

Explanation

Choice B is correct. The nurse should repeat the test because the client does not display any symptoms of hypoglycemia. The glucometer readings are not always accurate. Many variables such as quality of blood sample, dirt on the meter, humidity, aged test strip, high hematocrit etc. may affect glucometer readings. In view of so many variables affecting the blood glucose reading in glucometer, the nurse must be alert while interpreting these values especially, in the absence of any symptoms.

Definition of hypoglycemia differs in diabetic patients differs from that of non-diabetic patients. In diabetic patients, Hypoglycemia is defined as a blood glucose of less than 70mg/dl. Many diabetics may also have a condition called “Hypoglycemia unawareness” where there may not be sufficient autonomic warning symptoms before the onset of neuroglycopenia (impaired cognition, coma). In a diabetic patient, therefore, hypoglycemia needs to be treated as soon as possible based on the lab values even in the absence of overt symptoms.

In non-diabetic adults with low glucose level, one should assess for symptoms. Symptoms may include cold, clammy skin, tachycardia, palpitations, impaired cognition, slurred speech, seizures, and confusion. A low blood glucose at the time of symptoms and improvement as soon as the blood glucose returns to normal confirm the diagnosis. In a non-diabetic client who has been fasting, a blood glucose less than 50 mg/dL can also be used to define hypoglycemia. In the absence of symptoms, however, the first step is to recheck the blood glucose and confirm the result.

Choice A is incorrect. Because the first reading was too low, it is appropriate for the nurse to recheck before documenting the findings to confirm accuracy.

Choice C is incorrect. The nurse should recheck and validate the results before deciding to administer glucose.
Choice D is incorrect. The nurse should recheck and validate the results before deciding to administer glucose. If the patient has significant symptoms, immediate IV dextrose is appropriate.
Reference:
Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier

Question 42

A postpartum client is preparing to be discharged home with her full-term newborn. She verbalizes, “I really should not get pregnant in the next three years so I could finish college.” History reveals that she smokes a pack a day of cigarettes. Which method of contraception would be most appropriate for her?

A. Depo-Provera injection

B. Condoms and foam

C. Natural family planning

D. Oral contraceptives

Answer 42

Explanation

Rationale: Hormonal contraception such as Depo-Provera injection and oral contraceptives increases the risk of clotting and stroke in women who smoke ten or more cigarettes per day, and are not the best option for this client. Options A and D are, therefore, incorrect. Natural family planning involves intricate planning and timing sexual contact around the menstrual cycle and signs of ovulation. Though an effective method of birth control, it entails motivation and maturity. It is not likely to be useful for an older adolescent. Option C is, therefore, incorrect. Combining condoms and contraceptive foam is highly effective in preventing pregnancy. It is accessible, easily obtained, and also inexpensive (free if taken from the public health department). This is the most appropriate method for this client. Therefore, option B is the correct answer.

Reference:

Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 43

A 14-year-old was taken to the Emergency department for having stepped on a broken piece of glass. The wound is cleansed and a dressing was applied. The nurse asks the adolescent to have a tetanus shot. He responds by saying that all his immunizations are up to date. All the other antibiotics were given and the client is sent home with instructions to return whenever changes in the wound occur. After a few days, the client was admitted to the hospital due to Tetanus. What is the nurse’s legal responsibility in this situation?

A. The nurse displayed adequate judgment and the client was treated accordingly.

B. The nurse performed an incomplete assessment.

C. Tetanus was not foreseen because of the clients’ complete immunization status

D. The nurse should have routinely given the Tetanus shot after such injury.

Answer 43

Explanation

A is incorrect. The nurse’s assessment was inadequate, thus leading to inadequate judgment regarding the situation. The nurse should have asked regarding the date the last tetanus immunization was given.

B is correct. The nurse’s assessment was inadequate and incomplete, thus leading to inadequate judgment regarding the situation. The nurse should have asked regarding the date the last tetanus immunization was given.

C is incorrect. The clients’ wound would have alerted the nurse to ask more regarding tetanus immunizations since a puncture wound is a “tetanus-prone” wound.

D is incorrect. The function of a nurse does not include giving orders of tetanus immunization. The nurse should have assessed further regarding the immunization date of the client so that the doctor was made aware and could have ordered a new tetanus shot.

Reference

Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012

Question 44

The nurse is preparing a client with peptic ulcer disease to undergo a barium study of the stomach and esophagus. What should be the initial nursing action?

A. Have the informed consent signed by the client for the procedure.

B. Teach the client the importance of increased oral fluids after the procedure.

C. Explain to the client that he or she will have to drink a white, chalky substance.

D. Instruct the client not to eat or drink anything before the procedure.

Answer 44

Explanation

A is incorrect. A barium study is a non-invasive procedure and does not require an informed consent form.

B is incorrect. A side effect of barium is constipation after the procedure. The nurse, therefore, needs to instruct the client to drink lots of fluids. It is not, however, the initial intervention of the nurse.

C is incorrect. The client needs to know that he will need to drink the barium, which is a white chalky substance during the procedure. However, this is not the initial nursing intervention.

D is correct. The first or initial intervention for the nurse is to inform the client that he or she needs to be on NPO at least 8 to 10 hours before the test. The barium study requires the upper GI tract to be empty during the procedure.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Question 45

The nursing director calls for a meeting of nurse managers in the facility. She has just come back from a visit to another hospital that was only commended for its superior patient care. She aims to formulate similar policies to improve patient care in her facility. The nurse manager is performing which management initiative?

A. Benchmarking

B. Continuous Quality Improvement

C. Performance Improvement

D. Quality Management

Answer 45

Explanation

A is correct. In Benchmarking, the nurse-manager compares best practices from top hospitals with her unit and adapts the unit’s methods to improve unit performance.

B is incorrect. Continuous quality improvement continually assesses and evaluates the effectiveness of client care.

C is incorrect. Establishes a system of formal evaluation of job performance and recommends ways to improve performance and promote professional growth

D is incorrect. Quality management is the act of overseeing all activities and tasks needed to maintain a desired level of excellence. This includes the determination of a quality policy, creating and implementing quality planning and assurance, and quality control and quality improvement.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 46

When should the rubber tip on a cane be changed?

A. At least every month

B. At least every 2 months

C. Whenever it appears even slightly worn

D. When the cane begins to slip while in use.

Answer 46

Explanation

Correct Answer is C. The rubber tip on a cane must be changed whenever it appears even slightly worn upon inspection. The same is true for the rubber tips on walkers and crutches. These pieces of equipment must be inspected and examined for safety before they are used.

Choice A is incorrect. You would not replace the rubber tips on a cane at least every month because, as based on the frequency of use and the surface that the client is walking on, these tips may be worn and unsafe more often than once a month.

Choice B is incorrect. You would not replace the rubber tips on a cane every two months because, as based on the frequency of use and the surface that the client is walking on, these tips may be worn and unsafe more often than once every two months.

Choice D is incorrect. You would not replace the rubber tips on a cane when the cane begins to slip while in use. This tip must be changed before moving, and possible client injury occurs.

References: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 47

Your client has had two intravenous infusions that had to be discontinued because of phlebitis, which is a commonly occurring complication of intravenous therapy. Before and as you are preparing to start another intravenous line, you would:

A. Apply a cold compress to the intravenous site that developed phlebitis.

B. Consider the use of a larger sized catheter to prevent further phlebitis.

C. Use the most proximal site as possible for the next in intravenous site.

D. Consider the use of a inline intravenous fluid filter for unmedicated intravenous fluids.

Answer 47

Explanation

Correct Answer is D

Correct. You would consider the use of inline intravenous fluid filter because the inline intravenous fluid filter can prevent the entry of air and particles, the latter of which can lead to mechanical phlebitis. Although many believe that intravenous fluid filters are only used for blood transfusions, they are also highly useful and used for intravenous fluid administration.

Choice A is incorrect. You would apply a warm and not a cold compress to the intravenous site that has developed phlebitis.

Choice B is incorrect. You would consider the use of a smaller, and not a more extensive, sized catheter to prevent further phlebitis.

Choice C is incorrect. You would not consider using the most proximal site as possible for the next in the intravenous section; however, you would use the most distal sites possible so you can preserve more proximal intravenous sites for future use, if necessary.

Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 48

A client recently diagnosed with peptic ulcer disease is being discharged. The nurse ascertains discharge teaching if he tells the nurse that he will read over-the-counter drugs and will avoid those that contain

A. Calcium

B. Magnesium

C. Sodium

D. Aspirin

Answer 48

Explanation

Rationale: Aspirin damages the gastric mucosa and should be avoided by clients with a history of peptic ulcer. Antacids that contain Calcium may cause constipation. Magnesium containing antacids may cause diarrhea. Antacids that contain sodium is not contraindicated in peptic ulcer disease.

Source:

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 49

A patient is rushed to the ER following a near-drowning episode at a local beach. Does the nurse anticipate which conditions to be present in the patient?

A. Hypoxia, hypercarbia, acidosis

B. Coma, hyperthermia, alkalosis

C. Hypothermia, hypocapnia, alkalosis

D. Hyperthermia, hyperoxia, acidosis

Answer 49

Explanation

A is correct. Following a near-drowning incident, the patient will most likely exhibit symptoms of hypoxia (decreased oxygen levels in the blood), hypercarbia (increased carbon dioxide levels in the blood), and acidosis (respiratory) due to a prolonged period of having a lack of oxygen.

B is incorrect. Although the patient may be in a coma after near-drowning, hyperthermia and alkalosis are least likely. There would be a high chance of acquiring hypothermia, mainly if the patient stayed in the water for too long before being rescued. Alkalosis will not result from a lack of oxygen in the body; instead, acidosis will occur.

C is incorrect. Although hypothermia is a possibility in near-drowning situations, lack of oxygen for long periods will produce hypercapnia/hypercarbia and acidosis.

D is incorrect. Hypoxia will result from long periods without oxygen, not hyperoxia. Hyperthermia is least likely to occur in near-drowning incidents.

References

Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012

Question 50

Select the fact about nonsteroidal anti-inflammatory drugs (NSAIDs) that is accurate. Nonsteroidal anti-inflammatory drugs (NSAIDs):

A. Vary significantly and greatly in terms of their analgesic effects among the different medications in this classification of medications.

B. Vary very little in terms of their antiinflammatory effects among the different medications in this classification of medications.

C. Cannot be given with an antacid medication because it will interact with the NSAID in terms of its effectiveness.

D. Have more dangerous side effects than opioids and they can lead to life threatening complications with long term use.

Answer 50

Explanation

Correct Answer is D

Correct. Nonsteroidal anti-inflammatory drugs (NSAIDs) have more dangerous side effects than opioids, and they can lead to life-threatening complications, such as gastrointestinal system bleeding and renal dysfunction, with long term use. Opioids, on the other hand, are associated with constipation, which is far less dangerous than gastrointestinal system bleeding and renal dysfunction.

Choice A is incorrect. It is not accurate to state that nonsteroidal anti-inflammatory drugs (NSAIDs) vary significantly and greatly in terms of their analgesic effects among the different medications in this classification of drugs. There is little difference between the different NSAID medications in terms of their analgesic effects.

Choice B is incorrect. It is not accurate to state that nonsteroidal anti-inflammatory drugs (NSAIDs) vary very little in terms of their anti-inflammatory effects among the different medications in this classification of drugs. There are significant differences among the different NSAID medications in terms of their anti-inflammatory effects.

Choice C is incorrect. It is not accurate to state that nonsteroidal anti-inflammatory drugs (NSAIDs) cannot be given with an antacid medication because it will interact with the NSAID in terms of its effectiveness. It is recommended that an antacid medication is given when the client is taking nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent gastrointestinal bleeding.

Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 51

In addition to the name of the client, the date and time of the medication order, the name, dosage, route, and frequency of the medication, and the signature of the ordering person, what other information in a medication order would be the most useful, although not required, to you, as the nurse administering the medication?

A. The client’s ethnicity

B. The form of the medication

C. The client’s allergies

D. The time(s) of administration

Answer 51

xplanation

Correct Answer is B

Correct. Other information in a medication order that would be the most useful to you, as the nurse administering the medication, would be the form of the drug. The type of medicine becomes particularly relevant, for example, when oral medication is ordered for a client with a swallowing disorder. Should the medication be given in a pill form or a liquid form?

Choice A is incorrect. The client’s ethnicity is not as relevant and as useful as another piece of information, and the client’s ethnicity should be found in the client’s history and physical.

Choice C is incorrect. The client’s allergies should be found on the client’s medication record and in other places, including on the client’s identification band and their history and physical, so this would not be as important and as useful as another piece of information.

Choice D is incorrect. The time(s) of administration is in the medication order when the frequency of administration is written.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 52

The nurse is preparing a client for a Bronchoscopy the following day. All of the following are appropriate interventions, except:

A. Educate the client that he will be experiencing a sore throat after the procedure.

B. Tell the client that he will be lying on his back for half an hour to 45 minutes.

C. He can eat right away after the procedure is done.

D. He must not eat or drink anything 6 hours prior to the test.

Answer 52

Explanation

A is incorrect. This is a correct statement. The patient is expected to feel sore throat after the procedure due to some trauma in the pharynx and larynx.

B is incorrect. This is a correct statement. The whole procedure lasts 30 – 45 minutes. During which, he will be lying supine with his neck hyperextended.

C is correct. This is an incorrect statement. The nurse should be kept on NPO until the cough and gag reflex returns. When the cough and gag reflex returns, the patient is given ice chips and small sips of water and is then slowly progressed into a regular diet.

D is incorrect. This is a correct statement. The client is kept NPO 6 hours before the procedure to decrease the risk of aspiration.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 53

The client has been prescribed fluoxetine for his depression. The nurse understands that fluoxetine should be given at what time?

A. In the morning

B. After lunch

C. Before dinner

D. Before bedtime

Answer 53

Explanation

A is correct. The medication should be given in the morning to avoid insomnia. Taking the drug during the later parts of the day will lead to insomnia.

B is incorrect. Taking the medication after lunch will lead to sleeping disturbances due to the effects of the drug.

C is incorrect. Taking the medication before dinner will lead to sleeping disturbances due to the effects of the drug.

D is incorrect. Taking the medication before dinner will lead to sleeping disturbances due to the effects of the drug.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 54

Calculate the body mass index (BMI) for a 43-year-old client who is 5’ 11” and weighs 190 pounds.

A. 18

B. 48

C. 38

D. 26

Answer 54

Explanation

Correct Answer is D

The body mass index (BMI) can be calculated by dividing the weight of the client in kg by the height of the client in terms of meters squared.

For example, the BMI for a client who is 5’ 11” and weighs 190 pounds is as follows:

190 pounds = x kg

190/2.2 = 86 kg

5’ 11” = x meters

71 “ = x meters

71 “/ 39.6 = 1.8 meters

86 kg/1.8 x 1.8 meters = 86/3.24 = 26.5 or a BMI of 26

Choice A is incorrect. This client’s BMI is not 18. The BMI is calculated by dividing the client’s weight in kilograms by the client’s height in terms of meters squared. Try this calculation again.

Choice B is incorrect. This client’s BMI is not 48. The BMI is calculated by dividing the client’s weight in kilograms by the client’s height in terms of meters squared. Try this calculation again.

Choice C is incorrect. This client’s BMI is not 38. The BMI is calculated by dividing the client’s weight in kilograms by the client’s height in terms of meters squared. Try this calculation again.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 55

The nurse is assigned to care for a client who is on digitalis therapy. A serum digoxin level was taken earlier in the day, and the nurse notes that the result is 2.5 ng/mL. The nurse should take which immediate action?

A. Notify the physician about the result.

B. Check the client’s file for the latest pulse rate recorded.

C. Record the normal value on the client’s flow sheet.

D. Administer the next dose of the medication as scheduled and prescribed.

Answer 55

Explanation

Rationale: The normal therapeutic range for digoxin is 0.5 to 2 ng/mL, and the latest level for the client indicates toxicity. The nurse’s immediate response should be to notify the client’s physician so that prompt action may be taken. Checking the latest pulse rate in the client’s file is immaterial at this point as the duration of time that has elapsed since the record was updated is a factor that could lead to confusion. The nurse should check the client’s pulse rate at the same time the result was received as additional data he/she can relay to the physician. The nurse must record the actual result in the client’s flow sheet and must not, at any time, alter the record. It is also not safe to administer the next dose of the medication because of toxicity. The correct answer, therefore, is option A, while options B, C, and D are incorrect.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6th Edition. Saunders-Elsevier 2014

Question 56

Which theory of aging describes the aging process as one that results from cellular death that results from collagen?

A. The endocrine theory of aging

B. The immunological theory of aging

C. The free radical theory of aging

D. The cross linked theory of aging

Answer 56

Explanation

Correct Answer is D. The cross-linked theory of aging describes the aging process as one that results from cellular death that results from collagen.

The endocrine theory of aging describes the aging process as one that results from the failure of the endocrine glands such as the pituitary gland and the hypothalamus gland. The immunological theory of aging describes the aging process as one that results from cellular death that results from the breakdown of the person’s immune system. The free radical theory of aging describes the aging process as one that results from the collection and accumulation of free radicals in the body.

Choice A is incorrect. The endocrine theory of aging describes the aging process as one that results from failure of the endocrine glands such as the pituitary gland and the hypothalamus gland and not one that results from cellular death that results from collagen.
.
Choice B is incorrect. The immunological theory of aging describes the aging process as one that results from cellular death that results from the breakdown of the person’s immune system and not one that results from cellular death that results from collagen.

Choice C is incorrect. The free radical theory of aging describes the aging process as one that results from the collection and accumulation of free radicals in the body and not one that results from cellular death that results from collagen.
.
References: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition), Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education and US National Library of MedicineNational Institutes of Health (2010). Modern Biological Theories of Aging. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2995895/.

Question 57

A client was brought to a psychiatric hospital when police found him walking around the neighborhood at night without shoes in the snow. He looks confused and disoriented. Which should be the priority at this point?

A. Assess and stabilize the client medically

B. Perform psychologic assessment and stabilize client psychologically

C. Locate nearest family members to get client’s history

D. arrange for a transfer to the nearest medical facility

Answer 57

Explanation

Rationale: Since the client walked barefoot in the snow, the possibility of frostbite should be evaluated, among other things. The client’s psychological needs, locating family members, or arranging for transfer may be addressed after the client’s immediate medical needs have been met. Option A is the correct answer, while options B, C, and D are incorrect.

Reference:

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Kelly, P; Marthaler, M; Nursing Delegation, Setting Priorities, and Making Patient Care Assignments, 2nd Edition; Cengage Learning, 2010

Question 58

The nurse is caring for a client receiving chemotherapy. The nurse identifies the chemo-drug as a vesicant. Which assessment finding would warrant immediate action by the nurse?

A. an inflamed and sore mouth

B. nausea and vomiting

C. pain at the infusion site

D. stomach ache

Answer 58

A is incorrect. This is an expected side effect of chemotherapy.

B is incorrect. This is an expected side effect of chemotherapy.

C is correct. Pain at the infusion site would indicate extravasation and would alert the nurse to stop the infusion to halt further damage to the vein.

D is incorrect. This is an expected side effect of chemotherapy.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 59

A nurse educator is shadowing a student nurse taking care of a psychiatric client. The nurse educators should instruct the student that a therapeutic nurse-client relationship starts with:

A. a sincere desire to help others

B. acceptance

C. understanding and self-awareness

D. knowledge of psychiatric nursing

Answer 59

Explanation

Rationale: The basis for a robust nurse-client relationship is a strong knowledge and awareness of self. Although all other options are desirable, the nurse should first be self-aware and understand his/her self and personal feelings before he/she can initiate a relationship with a psychiatric client.

Reference:

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Halter, MJ. Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 7th Ed. St. Louis, MO: Mosby Elsevier; 2014:14

Question 60

A client tells the nurse, “I never disagree with anyone. I have never disagreed with anyone I’ve known and probably never will.” The most appropriate response for the nurse would be

A. “Wow, how is that even possible?”

B. “Really? I find that unbelievable. A lot of people can’t do that.”

C. “How do you deal with your feelings of dissatisfaction or anger?”

D. “How did you develop such a way of life?”

Answer 60

Explanation

Rationale: Option D is an open-ended manner of asking about the client’s way of life and allows the client to express himself or openly talk about himself. Option D is the most appropriate response and the correct answer. Options A and B imply disbelief and may be misinterpreted by the client as a challenge and may make the client defensive. The nurse should not ask about feelings of dissatisfaction or anger because the nurse should not identify the client’s feelings for him. Options A, B, and C are incorrect.

Reference:

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 61

A 28-week client is admitted to the gynecology ward for induction of labor due to fetal demise. Does the nurse understand that which substance will be used for the effacement of the client’s cervix?

A. Normal saline solution

B. Oxytocin IV

C. Amniotomy

D. Laminaria

Answer 61

Explanation

A is incorrect. Normal saline is no longer effective in effacing the cervix in mid-trimester abortions.

B is incorrect. Oxytocin induces uterine contractions, not efface and soften the cervix.

C is incorrect. An amniotomy is performed during labor to aid in the descent of the fetal head once work is established. However, in fetal demise, it does help not help in effacing the cervix.

D is correct. Laminaria is dehydrated seaweed. They are inserted into the cervical canal, and once it absorbs the cervical secretions, it expands and aids in the effacement and dilatation of the cervix.

Reference

Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4thEdition; Lippincott, Williams & Wilkins, 2003

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6thEdition. Saunders-Elsevier 2014

Question 62

The client is having labor in the delivery room. The fetal monitor shows that there are late decelerations. What is the initial action of the nurse?

A. Call the doctor immediately.

B. Let the client deep-breathe slowly and relax.

C. Let the client lie on her left side.

D. Prepare for Cesarian delivery.

Answer 62

Explanation

A is incorrect. Late decelerations occur due to a lack of oxygen supply to the fetus. The nurse should first initiate to increase the blood supply of the fetus before calling the doctor.

B is incorrect. The nurse’s priority when there is a late deceleration is to increase blood supply to the fetus. Deep breathing may help decrease the mother’s anxiety, but restoring fetal blood flow is a priority.

C is correct. The left lateral position improves placental blood flow and oxygen supply to the fetus. This should be the nurse’s first intervention.

D is incorrect. The nurse should prepare for an emergency C-section, but the initial action should be to restore blood flow to the fetus.

Reference

Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6th Edition. Saunders-Elsevier 2014

Question 63

You are working in a long term care facility and doing the admission assessment of a new resident. Which of the following data would you include in the nutritional assessment of this resident?

A. Anthropometric data such as the mid arm circumference

B. Anthropometric data such as the urinary creatinine excretion

C. Dietary data such as the client’s body mass index (BMI)

D. Dietary data such as the client’s ideal body weight

Answer 63

Explanation

Correct Answer is A

Correct. A complete nutritional assessment of this resident would include, among other data, anthropometric data such as the mid-arm circumference, the client’s height, weight, body mass index (BMI), ideal body weight, triceps skinfold measurements, and mid-arm muscle area.

A complete nutritional assessment includes anthropometric data, biochemical data such as urinary creatinine excretion and serum albumin, clinical data such as skin condition and the condition of the mucous membranes, and dietary data such as the client’s food diary and 24-hour food recall. This method of assessment is referred to as the ABCD method of nutritional assessment, which represents anthropometric data, biochemical data, clinical data, and dietary data.

Choice B is incorrect. Although the urinary creatinine excretion is part of a complete nutritional assessment, this data is considered biochemical data and not anthropometric data.

Choice C is incorrect. Although data such as the client’s body mass index (BMI), is part of a complete nutritional assessment, this data is considered anthropometric data and not dietary data.

Choice D is incorrect. Although data such as the client’s ideal body weight is part of a complete nutritional assessment, this data is considered anthropometric data and not dietary data.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 64

The nurse is talking to an elderly client with osteomalacia regarding ways to strengthen his bones. Which statement by the client would necessitate further teaching by the nurse?

A. “I’ve started to walk more frequently under the sun.”

B. “I don’t like dairy products so I’ve stopped eating them. “

C. “I’ve enrolled myself in an exercise program for seniors at the community center.”

D. “I’ve been taking Vitamin D supplements lately.”

Answer 64

Explanation

A is incorrect. Clients with osteomalacia need Vitamin D to stimulate calcium absorption and mineralization. Vitamin D and exercise together with a calcium-rich diet, is recommended. Walking under the sun stimulates Vitamin D production in the body.

B is correct. The patient needs to be reinforced regarding a calcium-rich diet and calcium-rich foods. Milk and dairy products are one of the most common sources of dietary calcium. If the patient does not like milk or any other dairy product, the nurse should talk to him about different foods that are rich in calcium.

C is incorrect. Clients with osteomalacia need Vitamin D to stimulate calcium absorption and mineralization. Vitamin D and exercise together with a calcium-rich diet, is recommended. Enrolling in an exercise program indicates that the client understands the treatment regimen for osteomalacia.

D is incorrect. Clients with osteomalacia need Vitamin D to stimulate calcium absorption and mineralization. Vitamin D and exercise together with a calcium-rich diet, is recommended. Taking Vitamin D supplements indicates that the client understands the treatment regimen for osteomalacia.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Question 65

Which of these statements about special populations and the administration of analgesics is accurate?

A. Oncology clients with moderate pain typically need a strong opioid.

B. Oncology clients do not have a dosage limitation in terms of analgesics.

C. The elderly should be assessed for pain with behavioral cues rather than self reports.

D. The elderly should be assessed for pain with physical cues rather than self reports.

Answer 65

Explanation

Correct Answer is B

Correct. Oncology clients do not have a dosage limitation in terms of analgesics until effective pain management is accomplished. At times, very high dosages of analgesic medications are essential to relieve pain. However, on some occasions, the medication dosage may have to be titrated downward when the side effects of the drug outweigh its benefits in terms of pain relief.

Choice A is incorrect. Oncology clients with moderate pain do not typically need a potent opioid. According to the World Health Organization (WHO), clients with moderate pain usually benefit therapeutically with a mild opioid or a nonopioid analgesic with or without the combination of a co analgesic, adjuvant medication. However, the use of a potent opioid is not prohibited for oncology clients with moderate pain when it is needed to manage the client’s pain.

Choice C is incorrect. The elderly should be not assessed for pain with behavioral cues rather than self-reports of pain except when they are cognitively impaired, nonverbal clients who cannot self-report pain. When this occurs, the nurse must be knowledgable about the fact that nonverbal, behavioral indications of illness, such as facial expressions, are not as capable of self-reports of pain. Still, they are more effective than physiological indicators of pain, such as guarding the painful site and changes in the vital signs.

Choice D is incorrect. The elderly should not be assessed for pain with physical cues rather than self-reports except when they are cognitively impaired, a nonverbal client who cannot self-report pain or a client that is expressing behavioral indicators of illness. When this occurs, the nurse must be knowledgable about the fact that nonverbal, behavioral indications of pain, such as facial expressions, are not as capable of self-reports of pain. Still, they are more effective than physiological indicators of illness, such as guarding the painful site and changes in the vital signs.

Reference: McCuistion, Linda E., Joyce LeFever Kee, and Evelyn R. Hayes (2015). Pharmacology: A Patient-Centered Nursing Process Approach, 8th Edition. Saunders: Elsevier

Question 66

A client is admitted with a possible diagnosis of Guillain-Barré syndrome. Which probing question should the nurse include when taking this client’s history?

A. “Have you experienced frequent bruising?”

B. “Did you have a recent bout of upper respiratory tract infection?”

C. “Have you been overseas during the past 4 months?”

D. “Does anybody in your family have Guillain-Barré syndrome?”

Answer 66

Explanation

Rationale: Approximately 60-70% of clients diagnosed with Guillain-Barré syndrome experience upper respiratory tract infection 1-4 weeks before symptoms set in. This syndrome is idiopathic, but it may be a cell-mediated immune response that attacks the peripheral nerves as a response to a viral infection. Its significant pathologic effect is the segmental demyelination of the peripheral nerves, subsequently destroying the myelin sheath of the nerve. It is not a hereditary disorder, does not affect the body’s ability for clotting, and is not related to exposure during foreign travel. The correct answer is, therefore, option B, while options A, C, and D are incorrect.

Reference:

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Question 67

The nurse is administering digoxin to an infant when she notes that her pulse is 85 beats per minute. What should be the nurse’s most appropriate action?

A. Administer the medication.

B. Extract blood for serum digoxin levels.

C. Withhold the medication and check again after an hour.

D. Administer the medication intramuscularly.

Answer 67

Explanation

A is incorrect. The nurse should not give the medication if signs of bradycardia are present. The nurse should withhold the medicine and recheck the pulse in an hour.

B is incorrect. The initial action of the nurse is to withhold the medication and reassess the patient after an hour. If the pulse remains low, the nurse should inform the physician, and the nurse might extract serum for determination of the client’s digoxin level.

C is correct. If the pulse is less than 90 beats/min in an infant, the nurse should withhold the medication and check again in an hour. A consistently low pulse rate may indicate digoxin toxicity.

D is incorrect. Digoxin is not administered intramuscularly as it can be excruciating.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins 2006

Question 68

The client is brought to the ER due to vomiting, fever, and a severe headache. The doctor suspects meningitis and assesses the client for meningeal irritation and spinal nerve root inflammation. The nurse documents a positive Kernig’s sign when:

A. The client complains of pain when his hip and knee is bent.

B. The client has a stiff neck when the neck is flexed towards the chest.

C. The client’s forearm spasm when a blood pressure cuff is inserted into the upper arm and inflated

D. The client feels pain in the calf when his foot is dorsiflexed

Answer 68

Explanation

A is correct. Kernig’s sign is positive if pain occurs on the flexion of the hip and knee.

B is incorrect. Brezinski’s sign is also a sign of meningeal irritation. It is positive when severe neck stiffness occurs when the neck is flexed towards the chest, also causing the patient’s hips and knees to flex.

C is incorrect. This is a positive Trousseau’s sign. This indicates hypocalcemia and hypomagnesemia.

D is incorrect. This is a positive Homan’s sign. A positive Homan’s warning indicates that the patient may be having deep vein thrombosis.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 69

A diabetic client at 32 weeks gestation undergoes a stress test. The nurse notes that the FHR increases by 15 bpm with each contraction. The nurse would interpret this as:

A. Negative

B. Reactive

C. Nonreactive

D. Positive

Answer 69

Explanation

Rationale: Fetal accelerations with contractions are normal and are a reassuring finding related to fetal well-being. In an oxytocin stress test, the presence of fetal accelerations is usually reported as a negative result. Therefore, option A is the correct answer. A positive result in an oxytocin stress test usually involves the presence of late decelerations in the fetal heart rate of about 50% or more during uterine contractions and is a cause of concern. In a non-stress test (NST), a reactive result involves the presence of two or more accelerations with fetal movement/stimulation, usually, 15 bpm lasting 15 or more seconds in 10 minutes. The absence of fetal accelerations, or accelerations that do not meet the criteria for reactivity, denotes a nonreactive NST. Options B, C, and D are, therefore, incorrect.

Reference:

Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 70

A client on Carbamazepine (Tegretol) for the intermittent explosive disorder was for discharge. To get a baseline parameter for determining whether the client is experiencing adverse effects of the medication or not, which blood study should be drawn?

A. Complete electrolyte tests

B. Complete blood count

C. Fasting blood glucose

D. Cholesterol studies

Answer 70

Explanation

Rationale: Carbamazepine is known to cause immunosuppression. Therefore, the nurse should draw blood for a complete blood count before the patient is discharged. Carbamazepine does not affect fasting blood glucose, nor electrolyte tests, nor cholesterol studies. Option B is, therefore, the correct answer, while options A, C, and D are incorrect.

Reference

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 71

The nurse is caring for a client with Systemic Lupus Erythematosus in the acute phase of exacerbation. The nurses should focus on which aspect of nursing care?

A. Prevention of additional infection

B. Alleviation of feelings of powerlessness

C. Development of positive coping skills

D. Providing social support

Answer 71

Explanation

A is correct. During exacerbations, nursing care should be directed towards assessment and management of acute confusion, prevention of seizures, maintenance of skin integrity, prevention of new infection, evaluation of renal function, and management of impaired gas exchange.

B is incorrect. Feelings of powerlessness usually occur during the chronic phase of the illness.

C is incorrect. Helping the client develop positive coping skills occur at the later phase of the disease, where the patient is about to be discharged. The nurse helps the patient find support groups and networks to help in coping with SLE.

D is incorrect. We are providing the client with social support an essential part of the nurse’s role in the client’s care. However, social support comes after the acute exacerbation phase, where the priority is the physiological aspect of client care.

Reference

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 72

The mother of a 2-month-old infant brings her child to the outpatient clinic due to fever. The mother tells the nurse that her child had a DPT injection the week prior. She asks the nurse if the temperature is because of the DPT injection. What would be the nurse’s most appropriate response?

A. The fever after a DPT usually occurs within the first 2 hours of immunization.”

B. Fever is very rare in a child after a DPT immunization

C. Fever after DPT injection is usually low-grade and appears within the first 2 days.

D. The child’s fever should be treated.”

Answer 72

xplanation

A is incorrect. Fever after a DPT injection is low-grade and is expected within 24-48 hours.

B is incorrect. Fever after a DPT injection is low-grade and is expected within 24-48 hours.

C is correct. Fever after a DPT injection is low-grade and is expected within 24-48 hours.

D is incorrect. The fever should be reported to the physician so that an antipyretic is prescribed.

Reference

Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 73

The school nurse is talking to a group of mothers regarding poison prevention and management. Which statement by the mothers indicates a need for further teaching?

A. “I need to properly label the containers of poisonous liquids.”

B. “I need to make my child vomit in the instance he ingests gasoline.”

C. “I can give my child milk or some water to dilute the poison while I rush him to the hospital.”

D. “All poisonous materials should be stored away from children.”

Answer 73

Explanation

A is incorrect. This is a correct statement. Proper labeling can help prevent accidental ingestion of poisons at home.

B is correct. Induction of vomiting when a victim has ingested hydrocarbons is contraindicated. Vomiting may lead to inhalation of the poison, worsening the situation.

C is incorrect. This is a correct statement. Diluting the poison can buy some time in getting the child/victim some needed help.

D is incorrect. This is a correct statement. Poisonous materials should always be stored away from children and must be locked.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 74

Your adolescent client has been admitted to the adolescent psychiatric mental health unit. The first thing that you should do for this client is to:

A. Assess their current psychosocial functioning.

B. Generate a nursing diagnosis.

C. Establish trust with the client.

D. Allow the client to ventilate their feelings.

Answer 74

Explanation

Correct Answer is C

Correct. The first thing that you should do for this client is to establish trust with the client. Trust is the early stage of the therapeutic nurse-client relationship. After the trust is established, the nurse should encourage, facilitate, and allow the client to ventilate their feelings. This ventilation of feelings is used for and enfolded into the assessment of the client and their current psychosocial functioning, which is then used to generate a nursing diagnosis that is specific to the client’s needs.

Choice A is incorrect. Although the nurse will assess the client and their current psychosocial functioning, this cannot be done until other phases of the nursing process, and the therapeutic nurse-client relationship is done.

Choice B is incorrect. A nursing diagnosis is not established until other phases of the nursing process, and the therapeutic nurse-client relationship is done.

Choice D is incorrect. Although it is necessary to encourage, facilitate, and allow the client to ventilate their feelings, this cannot be done until something else in terms of the therapeutic nurse-client relationship must be done.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition). Upper Saddle River, New Jersey: Pearson.

Question 75

elect the hazard of immobility and complete bed rest that is accurately paired with one of its preventive measures?

A. The accumulation of respiratory secretions: Oxygen supplementation therapy

B. Dorsiflexion of the foot: Using a foot board or boots to maintain proper positioning

C. Venous stasis: The use of a sequential compression device

D. Skin breakdown: The use of a tilt table for clients at ris

Answer 75

Explanation

Correct Answer is C

Correct. Venous stasis, a complication of immobilization and bed rest can be prevented with the use of a sequential compression device, anti-embolic stockings, client positioning, range of motion exercises, and active leg exercises in bed to promote venous return and to prevent venous stasis, deep vein thrombosis, and pulmonary emboli.

Choice A is incorrect. Although the accumulation of respiratory secretions is a hazard of immobility, it is not prevented with oxygen supplementation therapy. Still, it can be prevented with adequate fluid intake and coughing and deep breathing exercises.

Choice B is incorrect. Dorsiflexion of the foot is not a hazard of immobility and bed rest; however, plantarflexion or foot drop is. Plantar flexion can be prevented with a footboard or boots to maintain proper positioning and exercising the feet.

Choice D is incorrect. Although skin breakdown and pressure ulcers are hazards of immobility, they are not prevented with a tilt table. Skin breakdown and pressure ulcers are prevented with good skincare, turning and positioning, and other preventive measures such as maintaining proper nutrition and avoiding the forces of pressure, friction, and shearing.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 76

A mental health clinic is being constructed at a local community. The unit hires a nurse manager to facilitate the unit’s nursing policies. The nurse manager understands that the best resource for these policies is:

A. Code of Ethics

B. Nurse Practice Act

C. Patient’s Bill of Rights

D. Rights for the Mentally Ill

Answer 76

Explanation

A is incorrect. The Code of Ethics for nurses provides ethical guidelines regarding nursing practice.

B is correct. Nurse practice acts describe the scope of nursing practice. It directs the philosophy and standards of nursing. The formulation of policies and procedures should be based on this document.

C is incorrect. The Patient’s Bill of Rights outlines the rights that are due to them when admitted and seeking health care.

D is incorrect. The Rights for the Mentally Ill provides people with mental illness the civil liberties that are due to them.

Reference

Potter, PA, Perry. AG, Stockert, PA, Hall, AM. Fundamentals of Nursing, 8th ed. St. Louis, MO: Elsevier Mosby;2013