2023-24 Nclex Pn Final Exam Questions,Answers Update Assured Success, Exams of Nursing

Download 2023-24 Nclex Pn Final Exam Questions,Answers Update Assured Success and more Exams Nursing in PDF only on Docsity! 2023-24 Nclex Pn Final Exam Questions,Answers Update Assured Success • The client is diagnosed with multiple myoloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client? A. “Walk about a mile a day to prevent calcium loss.” B. “Increase the fiber in your diet.” C. “Report nausea to the doctor immediately.” D. “Drink at least eight large glasses of water a day.” • The client is taking rifampin 600mg po daily to treat his tuberculosis. Which action by the nurse indicates understanding of the medication? A. Telling the client that the medication will need to be taken with juice B. Telling the client that the medication will change the color of the urine C. Telling the client to take the medication before going to bed at night D. Telling the client to take the medication if night sweats occur • The client is taking prednisone 7.5mg po each morning to treat his systemic lupus errythymatosis. Which statement best explains the reason for taking the prednisone in themorning? A. There is less chance of forgetting the medication if taken in the morning. B. There will be less fluid retention if taken in the morning. C. Prednisone is absorbed best with the breakfast meal. D. Morning administration mimics the body’s natural secretion of corticosteroid. • A 20-year-old female has a prescription for tetracycline. While teaching the client how to take her medicine, the nurse learns that the client is also taking Ortho-Novum oral contraceptive pills. Which instructions should be included in the teaching plan? A. The oral contraceptives will decrease the effectiveness of the tetracycline. B. Nausea often results from taking oral contraceptives and antibiotics. C. Toxicity can result when taking these two medications together. D. Antibiotics can decrease the effectiveness of oral contraceptives, so the client should usean alternate method of birth control. • A 60-year-old diabetic is taking glyburide (Diabeta) 1.25mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching? A. “I will keep candy with me just in case my blood sugar drops.” B. “I need to stay out of the sun as much as possible.” C. “I often skip dinner because I don’t feel hungry.” D. “I always wear my medical identification.” • The physician prescribes regular insulin, 5 units subcutaneous. Regular insulin begins to exert an effect: A. In 5–10 minutes B. In 10–20 minutes C. In 30–60 minutes D. In 60–120 minutes • Vitamin K (aquamephyton) is administered to a newborn shortly after birth for which ofthe following reasons? A. To prevent dehydration • The client is admitted following repair of a fractured femur with cast application. Whichnursing assessment should be reported to the doctor? A. Pain B. Warm toes C. Pedal pulses rapid D. Paresthesia of the toes • Which would be an expected finding during injection of dye with a cardiac catheterization? A. Cold extremity distant to the injection site B. Warmth in the extremity C. Extreme chest pain D. Itching in the extremities • Which action by the healthcare worker indicates a need for further teaching? A. The nursing assistant wears gloves while giving the client a bath. B. The nurse wears goggles while drawing blood from the client. C. The doctor washes his hands before examining the client. D. The nurse wears gloves to take the client’s vital signs. • The client is having electroconvulsive therapy for treatment of severe depression. Whichof the following indicates that the client’s ECT has been effective? A. The client loses consciousness. B. The client vomits. C. The client’s ECG indicates tachycardia. D. The client has a grand mal seizure. • A 5-year-old is being tested for pinworms. To collect a specimen for assessment ofpinworms, the nurse should teach the mother to: A. Examine the perianal area with a flashlight 2–3 hours after the child is asleep and tocollect any eggs on a clear tape B. Scrape the skin with a piece of cardboard and bring it to the clinic C. Obtain a stool specimen in the afternoon D. Bring a hair sample to the clinic for evaluation • Which instruction should be given regarding the medication used to treat enterobiasis(pinworms)? A. Treatment is not recommended for children less than 10 years of age. B. The entire family should be treated. C. Medication therapy will continue for 1 year. D. Intravenous antibiotic therapy will be ordered. • Which client should be assigned to the pregnant licensed practical nurse? A. The client who just returned after receiving linear accelerator radiation therapy for lungcancer B. The client with a radium implant for cervical cancer C. The client who has just been administered soluble brachytherapy for thyroid cancer D. The client who has returned from placement of iridium seeds for prostate cancer • Which client should be assigned to a private room if only one is available? A. The client with Cushing’s syndrome B. The client with diabetes C. The client with acromegaly D. The client with myxedema • The nurse caring for a client on the pediatric unit administers adult- strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with: A. Negligence B. Tort C. Assault D. Malpractice • Which assignment should not be performed by the licensed practical nurse? A. Inserting a Foley catheter B. Discontinuing a nasogastric tube C. Obtaining a sputum specimen D. Initiating a blood transfusion • The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the client for: A. Hypovolemia B. Pain C. Nutritional status D. Immobilizer • Which statement made by the family member caring for the client with a percutaneousgastrotomy tube indicates understanding of the nurse’s teaching? A. “I must flush the tube with water after feedings and clamp the tube.” B. “I must check placement four times per day.” C. “I will report to the doctor any signs of indigestion.” D. “If my father is unable to swallow, I will discontinue the feeding and call the clinic.” • The nurse is assessing the client with a total knee replacement 2 hours post- operative.Which information requires notification of the doctor? A. Bleeding on the dressing is 2cm in diameter. B. The client has a low-grade temperature. C. The client’s hemoglobin is 6g/dL. D. The client voids after surgery. • The nurse is caring for the client with a 5-year-old diagnosed with plumbism. Which information in the health history is most likely related to the development of plumbism? A. The client has traveled out of the country in the last 6 months. B. The client’s parents are skilled stained-glass artists. C. The client lives in a house built in 1990. D. The client has several brothers and sisters. • A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with prevention of dislocation of the prosthesis? A. An abduction pillow B. A straight chair C. A pair of crutches D. A soft mattress • The client with a joint replacement is scheduled to receive Lovenox (enoxaparin). Whichlab value should be reported to the doctor? A. PT of 20 seconds B. PTT of 300 seconds C. Protime of 30 seconds D. INR 3 • The nurse is responsible for performing a neonatal assessment on a full- term infant. At 1minute, the nurse could expect to find: A. An apical pulse of 100 B. Absence of tonus C. Cyanosis of the feet and hands D. Jaundice of the skin and sclera • A client with sickle cell anemia is admitted to the labor and delivery unit during the firstphase of labor. The nurse should anticipate the client’s need for: A. Supplemental oxygen B. Fluid restriction C. Blood transfusion D. Delivery by Caesarean section • A client with diabetes has an order for ultrasonography. Preparation for an ultrasoundincludes: A. Increasing fluid intake B. Limiting ambulation C. Administering an enema D. Withholding food for 8 hours • An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at1 year? A. 14 pounds B. 16 pounds C. 18 pounds D. 24 pounds • A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. Thenonstress test: D. Prevent pain and discomfort • A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse’s response is based on the knowledge that hemodialysis worksby: A. Passing water through the dialyzing membrane B. Eliminating plasma proteins from the blood C. Lowering the pH by removing nonvolatile acids D. Filtering waste through a dialyzing membrane • During a home visit, a client with AIDS tells the nurse that he has been exposed tomeasles. Which action by the nurse is most appropriate? A. Administering an antibiotic B. Contacting the physician for an order for immune globulin C. Administering an antiviral D. Telling the client that he should remain in isolation for 2 weeks • A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact? A. The client should be placed in a room with negative pressure. B. Infection requires close contact; therefore, the door may remain open. C. Transmission is highly likely, so the client should wear a mask at all times. D. Infection requires skin-to-skin contact and is prevented by handwashing, gloves, and agown. • A client with an above-the-knee amputation is being taught methods to prevent hip-flexion deformities. Which instruction should be given to the client? A. “Lie supine with the head elevated on two pillows.” B. “Lie prone every 4 hours during the day for 30 minutes.” C. “Lie on your side with your head elevated.” D. “Lie flat during the day.” • A client with cancer of the pancreas has undergone a Whipple procedure. The nurse isaware that, during the Whipple procedure, the doctor will remove the: A. Head of the pancreas B. Proximal third section of the small intestines C. Stomach and duodenum D. Esophagus and jejunum • The physician has ordered a minimal bacteria diet for a client with neutropenia. Theclient should be taught to avoid eating: A. Fruits B. Salt C. Pepper D. Ketchup • A client is discharged home with a prescription for Coumadin (warfarin sodium). The client should be instructed to: A. Have a Protime done monthly B. Eat more fruits and vegetables C. Drink more liquids D. Avoid crowds • The nurse is assisting the physician with removal of a central venous catheter. Tofacilitate removal, the nurse should instruct the client to: A. Perform the Valsalva maneuver as the catheter is advanced B. Turn his head to the left side and hyperextend the neck C. Take slow, deep breaths as the catheter is removed D. Turn his head to the right while maintaining a sniffing position • A client has an order for streptokinase. Before administering the medication, the nurseshould assess the client for: A. Allergies to pineapples and bananas B. A history of streptococcal infections C. Prior therapy with phenytoin D. A history of alcohol abuse • The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid: A. Using oil- or cream-based soaps B. Flossing between the teeth C. The intake of salt D. Using an electric razor • A client hospitalized with severe depression and suicidal ideation refuses to talk with D. Obtaining a blood glucose by finger stick • The nurse is teaching a group of parents about gross motor development of the toddler.Which behavior is an example of the normal gross motor skill of a toddler? A. She can pull a toy behind her. B. She can copy a horizontal line. C. She can build a tower of eight blocks. D. She can broad-jump. • A client hospitalized with a fractured mandible is to be discharged. Which piece ofequipment should be kept on the client with a fractured mandible? A. Wire cutters B. Oral airway C. Pliers D. Tracheostomy set • The nurse is to administer digoxin (Lanoxin) elixir to a 6-month-old with a congenital heart defect. The nurse auscultates an apical pulse rate of 100. The nurse should: A. Record the heart rate and call the physician B. Record the heart rate and administer the medication C. Administer the medication and recheck the heart rate in 15 minutes D. Hold the medication and recheck the heart rate in 30 minutes • A mother of a 3-year-old hospitalized with lead poisoning asks the nurse to explain thetreatment for her daughter. The nurse’s explanation is based on the knowledge that lead poisoning is treated with: A. Gastric lavage B. Chelating agents C. Antiemetics D. Activated charcoal • An 18-month-old is scheduled for a cleft palate repair. The usual type of restraints for thechild with a cleft palate repair are: A. Elbow restraints B. Full arm restraints C. Wrist restraints D. Mummy restraints • A client with glaucoma has been prescribed Timoptic (timolol) eyedrops. Timoptic should be used with caution in the client with a history of: A. Diabetes B. Gastric ulcers C. Emphysema D. Pancreatitis • An elderly client who experiences nighttime confusion wanders from his room into theroom of another client. The nurse can best help decrease the client’s confusion by: A. Assigning a nursing assistant to sit with him until he falls asleep B. Allowing the client to room with another elderly client C. Administering a bedtime sedative D. Leaving a nightlight on during the evening and night shifts • Which of the following is a common complaint of the client with end- stage renal failure? A. Weight loss B. Itching C. Ringing in the ears D. Bruising • A client with AIDS is admitted for treatment of wasting syndrome. Which of the following dietary modifications can be used to compensate for the limited absorptive capabilityof the intestinal tract? A. Thoroughly cooking all foods B. Offering yogurt and buttermilk between meals C. Forcing fluids D. Providing small, frequent meals • The treatment protocol for a client with acute lymphocytic leukemia includes prednisone,methotrexate, and cimetadine. The purpose of the cimetadine is to: A. Decrease the secretion of pancreatic enzymes B. Enhance the effectiveness of methotrexate C. Promote peristalsis D. Prevent a common side effect of prednisone • Which of the following meal choices is suitable for a 6-month-old infant? • The licensed practical nurse is assisting the charge nurse in planning care for a client witha detached retina. Which of the following nursing diagnoses should receive priority? A. Alteration in comfort B. Alteration in mobility C. Alteration in skin integrity D. Alteration in O2 perfusion • The primary purpose for using a CPM machine for the client with a total knee repair is tohelp: A. Prevent contractures B. Promote flexion of the artificial joint C. Decrease the pain associated with early ambulation D. Alleviate lactic acid production in the leg muscles • Which of the following statements reflects Kohlberg’s theory of the moral developmentof the preschool-age child? A. Obeying adults is seen as correct behavior. B. Showing respect for parents is seen as important. C. Pleasing others is viewed as good behavior. D. Behavior is determined by consequences. • A toddler with otitis media has just completed antibiotic therapy. A recheck appointmentshould be made to: A. Determine whether the ear infection has affected her hearing B. Make sure that she has taken all the antibiotic C. Document that the infection has completely cleared D. Obtain a new prescription in case the infection recurs • Before administering a client’s morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to: A. Record the pulse rate and administer the medication B. Administer the medication and monitor the heart rate C. Withhold the medication and notify the doctor D. Withhold the medication until the heart rate increases • What information should the nurse give a new mother regarding the introduction of solidfoods for her infant? A. Solid foods should not be given until the extrusion reflex disappears, at 8– 10 months ofage. B. Solid foods should be introduced one at a time, with 4- to 7-day intervals. C. Solid foods can be mixed in a bottle or infant feeder to make feeding easier. D. Solid foods should begin with fruits and vegetables. • A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priorityto: A. Withholding all morning medications B. Ordering a CBC and CPK C. Administering prescribed anti-Parkinsonian medication D. Transferring the client to a medical unit • A client with human immunodeficiency syndrome has gastrointestinal symptoms,including diarrhea. The nurse should teach the client to avoid: A. Calcium-rich foods B. Canned or frozen vegetables C. Processed meat D. Raw fruits and vegetables • A 4-year-old is admitted with acute leukemia. It will be most important to monitor thechild for: A. Abdominal pain and anorexia B. Fatigue and bruising C. Bleeding and pallor D. Petechiae and mucosal ulcers • A 5-month-old is diagnosed with atopic dermatitis. Nursing interventions will focus on: A. Preventing infection B. Administering antipyretics C. Keeping the skin free of moisture D. Limiting oral fluid intake • The physician has discussed the need for medication with the parents of an infant with congenital hypothyroidism. The nurse can reinforce the physician’s teaching by telling the parents that: A. The medication will be needed only during times of rapid growth. B. The medication will be needed throughout the child’s lifetime. C. The medication schedule can be arranged to allow for drug holidays. D. The medication is given one time daily every other day. • The LPN is reviewing the lab results of an elderly client when she notes a specific gravity of 1.025. The nurse recognizes that: A. The client has impaired renal function. B. The client has a normal specific gravity. C. The client has mild to moderate dehydration. D. The client has diluted urine from fluid overload. • A client with acute pancreatitis has requested pain medication. Which pain medication isindicated for the client with acute pancreatitis? A. Demerol (meperidine) B. Toradol (ketorolac) C. Morphine (morphine sulfate) D. Codeine (codeine) • A client with a hiatal hernia has been taking magnesium hydroxide for relief of heartburn.Overuse of magnesium-based antacids can cause the client to have: A. Constipation B. Weight gain C. Anorexia D. Diarrhea • When performing a newborn assessment, the nurse measures the circumference of the neonate’s head and chest. Which assessment finding is expected in the normal newborn? A. The head and chest circumference are the same. B. The head is 2cm larger than the chest. C. The head is 3cm smaller than the chest. D. The head is 4cm larger than the chest. • A client with a history of clots is receiving Lovenox (enoxaparin). Which drug is given to counteract the effects of enoxaparin? A. Calcium gluconate B. Aquamephyton C. Methergine D. Protamine sulfate • The nurse is formulating a plan of care for a client with a cognitive disorder. Which activity is most appropriate for the client with confusion and short attention span? A. Taking part in a reality-orientation group B. Participating in unit community goal setting C. Going on a field trip with a group of clients D. Meeting with an assertiveness training group • The nurse is providing dietary teaching regarding low-sodium diets for a client withhypertension. Which food should be avoided by the client on a low-sodium diet? A. Dried beans B. Swiss cheese C. Peanut butter D. American cheese • A client is admitted to the emergency room with partial-thickness burns of his head and both arms. According to the Rule of Nines, the nurse calculates that the TBSA (total body surface area) involved is: A. 20% B. 27% C. 35% D. 50% • The physician has ordered a paracentesis for a client with severe ascites. Before theprocedure, the nurse should: A. Instruct the client to void B. Shave the abdomen C. Encourage extra fluids D. Request an abdominal x-ray B. 28.5mL C. 10 grams D. 152.5 grams • The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurseshould explain the need for: A. Additional calcium in the infant’s diet B. Careful handling to prevent fractures C. Providing extra sensorimotor stimulation D. Frequent testing of visual function • Which snack is best for the child following a tonsillectomy? A. Banana popsicle B. Chocolate milk C. Fruit punch D. Cola • The physician has prescribed Xanax (alprazolam) for a client with acute anxiety. The nurse should teach the client to avoid: A. Sun exposure B. Drinking beer C. Eating cheese D. Taking aspirin • The nurse is instructing a post-operative client on the use of an incentive spirometer. Thenurse knows that the correct use of the incentive spirometer is directly related to: A. Promoting the client’s circulation B. Preparing the client for amubulation C. Strengthening the client’s muscles D. Increasing the client’s respiratory effort • The nurse is assisting the physician with the insertion of an esophageal tamponade.Before insertion, the nurse should: A. Inflate and deflate the gastric and esophageal balloons B. Measure from the tip of the client’s nose to the xiphoid process C. Explain to the client that the tube will remain in place for 5–7 days D. Insert a nasogastric tube for gastric suction • The physician has ordered Cephulac (lactulose) for a client with increased serum ammonia. The nurse knows the medication is having its desired effect if the client experiences: A. Increased urination B. Diarrhea C. Increased appetite D. Decreased weight • The nurse is assessing a client immediately following delivery. The nurse notes that theclient’s fundus is boggy. The nurse’s next action should be to: A. Assess for bladder distention B. Notify the physician C. Gently massage the fundus D. Administer pain medication • Which breakfast selection is suitable for the client on a high-fiber diet? A. Danish pastry, tomato juice, coffee, and milk B. Oatmeal, grapefruit wedges, coffee, and milk C. Cornflakes, toast and jam, and milk D. Scrambled eggs, bacon, toast, and coffee • A male client is admitted with a tentative diagnosis of Hodgkin’s lymphoma. The client with Hodgkin’s lymphoma commonly reports: A. Finding enlarged nodes in the neck while shaving B. Projectile vomiting upon arising C. Petechiae and easy bruising D. Frequent, painless hematuria • A client with acquired immunodeficiency syndrome has begun treatment with Pentam(pentamidine). The nurse recognizes that the medication will help to prevent: A. Candida albicans B. Pneumocystis carinii C. Cryptosporidiosis D. Cytomegaloretinitis • During a well-baby visit, the mother asks the nurse when the “soft spot” on the front of her baby’s head will close. The nurse should tell the mother that the anterior fontanel • A client with a history of alcoholism cannot remember the events of the past week even though he has receipts from various places of business. The client’s inability to recall events isknown as: A. Alcoholic hallucinosis B. A hangover C. A blackout D. Sunday morning paralysis • Which food is the best source of calcium and potassium? A. Broccoli B. Sweet potato C. Spinach D. Avocado • The physician has ordered a PSA and acid phosphatase for a client admitted with complaints of dysuria. The nurse knows that a PSA and acid phosphatase are screening tests for: A. Cancer of the bladder B. Cancer of the prostate C. Cancer of the vas deferens D. Cancer of the testes • The client’s morning lithium level is 1.2mEq/L. The nurse recognizes that: A. The level is too low to be therapeutic. B. The client can be expected to have signs of toxicity. C. The level is within the therapeutic range. D. The client needs to eat more sodium-rich foods. • Which emergency treatment is appropriate for the client who suddenly developsventricular fibrillations? A. Cardioversion B. Intubation C. Defibrillation D. Anticonvulsant medication • The nurse is caring for a client following a stroke that left him with apraxia. The nurse knows that the client will: A. Be unable to communicate through speech B. Have difficulty swallowing C. Have difficulty with voluntary movements D. Be unable to perform previously learned skills • The nurse is positioning a client with right hemiplegia. To prevent subluxation of theclient’s right shoulder, the nurse should: A. Use a pillow to support the client’s arm when she is sitting in a chair B. Elevate the arm and hand above chest level when she is lying in bed C. Place a pillow under the axilla to elevate the elbow when she is lying in bed D. Use a pillow to support the client’s hand when she is sitting in a chair • A client with thrombophlebitis is receiving Lovenox (enoxaparin). Which method is recommended for administering Lovenox? A. Z track in the dorsogluteal muscle B. Intramuscularly in the deltoid muscle C. Subcutaneously in the abdominal tissue D. Orally after breakfast • A client with angina is to be discharged with a prescription for nitroglycerin tablets. Theclient should be instructed to: A. Take one tablet daily with a glass of water B. Leave the medication in a dark-brown bottle C. Replenish the medication supply every year D. Leave the cotton in the bottle to protect the tablets • The physician has ordered Parnate (tranylcypromine) for a client with depression. Thenurse should tell the client to avoid foods containing tryamine because it can result in: A. Elevations in blood pressure B. Decreased libido C. Elevations in temperature D. Increased depression • A client is receiving external radiation for cancer of the larynx. As a result of the treatment, the client will most likely complain of: A. Generalized pruritis • A client with Addison’s disease has a diagnosis of fluid volume deficit related to inadequate adrenal hormone secretion. Which fluids are most appropriate for the client withAddison’s disease? A. Milk and diet soda B. Water and tea C. Bouillon and juice D. Coffee and juice • The nurse is preparing to administer a DTP, Hib, and hepatitis B immunizations to an infant. The nurse should: A. Administer all the immunizations in one site B. Administer the DTP in one leg, and the Hib and the hepatitis B in the other leg C. Administer the DTP in the leg, the Hib in the other leg, and the hepatitis B in the arm D. Administer the DTP and Hib in one leg, and the hepatitis B in the arm • Lab results indicate that a client receiving heparin has a prolonged bleeding time. Whichmedication is the antidote for heparin? A. Aquamephyton (phytonadione) B. Ticlid (ticlopidine) C. Protamine sulfate (protamine sulfate) D. Amicar (aminocaproic acid) • A newborn of 32 weeks gestation is diagnosed with respiratory distress syndrome 3 hoursafter birth. An assessment finding in the newborn with respiratory distress syndrome is: A. Feeding difficulties B. Nasal flaring C. Increased blood pressure D. Temperature instability • To reduce the risk of SIDS (sudden infant death syndrome), the nurse should tell parentsto place the infant: A. Prone while he is sleeping B. Side-lying while he is awake C. On his back while he is sleeping D. Prone while he is awake • Which of the following play activities is most developmentally appropriate for thetoddler? A. Watching cartoons B. Pulling a toy wagon C. Watching a mobile D. Coloring with crayons in a coloring book • The physician has discharged a client with diverticulitis with a prescription for Metamucil (psyllium). When teaching the client how to prepare the medication, the nurse shouldtell the client to: A. Dissolve the medication in gelatin or applesauce B. Mix the medication with water and drink it immediately C. Sprinkle the medication on ice cream or sherbet D. Take the medication with an ounce of antacid • A client with end stage cirrhosis can sometimes develop mental changes. What is themost likely cause? A. Elevated blood ammonia B. Decreased serum proteins C. Leukocytosis D. Hyperglycemia • The nurse is caring for a client after a liver biopsy. The nurse should carefully monitor the client for the development of which of the following? A. Respiratory alkalosis B. Metabolic acidosis C. Pneumothorax D. Cardiac tamponade • The LPN/LVN is assisting a client immediately after a paracentesis. Which of the following actions is the priority? A. Obtaining vital signs B. Positioning the client for comfort C. Detailed documentation of the procedure 4320 A. 2160 B. C. 6480 D. 8640 • Diphenoxylate hydrochloride and atropine sulfate (Lomotil) is prescribed for the client with ulcerative colitis. The nurse realizes that the medication is having a therapeutic effect whenwhich of the following is noted? A. There is an absence of peristalTashies.nBu. mber of diarrhea stools decreases. C. Cramping in the abdomen has increased. D. Abdominal girth size increases. • The physician is about to remove a chest tube. Which client instruction is appropriate? A. B. Hold the breath for 2 minutes and exhale slowly C. Exhale upon actual removal of the tube D. Continually breathe deeply in and out during removal • A client with severe anxiety has been prescribed haloperidol (Haldol). What clinical manifestation suggests that the client is experiencing side effects from this medication? A. Cough B. Tremors Take a deep breath, exhale, and bear down C. Diarrhea D. Pitting edema • A client with a femur fracture is exhibiting shortness of breath, pain upon deep breathing, and a cough that produces blood-tinged sputum. The nurse would determine that these clinical manifestations are indicative of which of the following? A. Congestive heart failure B. Pulmonary embolus C. Adult respiratory distress syndrome D. Tension pneumothorax • A client with Alzheimer’s disease has been prescribed donepezil (Aricept). Which information should the nurse include when explaining about Aricept? A. “Take the medication with meals.” B. “The medicine can cause dizziness, so rise slowly.” C. “If a dose is skipped, take two the next time.” D. “The pill can cause an increase in heart rate.” • A client who had an abdominal aortic aneurysm repair is having delayed healing of thewound. Which laboratory test result would most closely correlate to this problem? A. Decreased albumin B. Decreased creatinine C. Increased calcium D. Increased sodium • A client is admitted to the chemical dependency unit due to cocaine addiction. The client states, “I don’t know why you are all so worried. I am in control. I don’t have a problem.” Whichdefense mechanism is being utilized? A. Rationalization B. Projection C. Dissociation D. Denial • A 24-year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse? A. Taking the vital signs B. Obtaining the permit C. Explaining the procedure D. Checking the lab work • The nurse is working in the emergency room when a client arrives with severe burns ofthe left arm, hands, face, and neck. Which action should receive priority? A. Starting an IV B. Applying oxygen C. Obtaining blood gases D. Medicating the client for pain • The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client? A. Rest in bed after taking the medication for at least 30 minutes B. Avoid rapid movements after taking the medication • The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client’s diet? A. Roasted chicken B. Noodles C. Cooked broccoli D. Custard • A client arrives in the emergency room with a possible fractured femur. The nurse shouldanticipate an order for: A. Trendelenburg position B. Ice to the entire extremity C. Buck’s traction D. An abduction pillow • A client with cancer is to undergo an intravenous pyelogram. The nurse should: A. Force fluids 24 hours before the procedure B. Ask the client to void immediately before the study C. Hold medication that affects the central nervous system for 12 hours pre- and post-test D. Cover the client’s reproductive organs with an x-ray shield • The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor: A. That cannot be assessed B. That is in situ C. With increasing lymph node involvement D. With distant metastasis • A client is 2 days post-operative colon resection. After a coughing episode, the client’swound eviscerates. Which nursing action is most appropriate? A. Reinsert the protruding organ and cover with 4×4s B. Cover the wound with a sterile 4×4 and ABD dressing C. Cover the wound with a sterile saline-soaked dressing D. Apply an abdominal binder and manual pressure to the wound • The nurse is preparing a client for surgery. Which item is most important to removebefore sending the client to surgery? A. Hearing aid B. Contact lenses C. Wedding ring D. Artificial eye • The nurse on the 3–11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action? A. Call the surgeon and ask him or her to see the client to clarify the information B. Explain the procedure and complications to the client C. Check in the physician’s progress notes to see if understanding has been documented D. Check with the client’s family to see if they understand the procedure fully • The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client’s ability to care for himself. Which statement made by the client would indicate a need for follow-up after discharge? A. “I live by myself.” B. “I have trouble seeing.” C. “I have a cat in the house with me.” D. “I usually drive myself to the doctor.” • The client is receiving total parenteral nutrition (TPN). Which lab test should be evaluated while the client is receiving TPN? A. Hemoglobin B. Creatinine C. Blood glucose D. White blood cell count • The client with a myocardial infarction comes to the nurse’s station stating that he is ready to go home because there is nothing wrong with him. Which defense mechanism is theclient using? A. Rationalization B. Denial C. Projection D. Conversion reaction • The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient’s mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy? A. “She is very irritable lately.” B. “She sleeps quite a bit of the time.” C. “Her gums look too big for her teeth.” D. “She has gained about 10 pounds in the last 6 months.” • A 5-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery? A. Decreased appetite B. A low-grade fever C. Chest congestion D. Constant swallowing • A 6-year-old with cerebral palsy functions at the level of an 18-month- old. Whichfinding would support that assessment? A. She dresses herself. B. She pulls a toy behind her. C. She can build a tower of eight blocks. D. She can copy a horizontal or vertical line. • Which information obtained from the mother of a child with cerebral palsy most likelycorrelates to the diagnosis? A. She was born at 42 weeks gestation. B. She had meningitis when she was 6 months old. C. She had physiologic jaundice after delivery. D. She has frequent sore throats. • A 10-year-old is being treated for asthma. Before administering Theodur, the nurseshould check the: A. Urinary output B. Blood pressure C. Pulse D. Temperature • An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with a fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals and cloudiness in the IV medication? A. Discard the solution and order a new bag B. Warm the solution C. Continue the infusion and document the finding D. Discontinue the medication