CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED, Exams of Nursing

Download CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED and more Exams Nursing in PDF only on Docsity! CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED 1. The nurse is caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply. a. A patient who is older than 50 b. A patient who has already fallen twice c. A patient who is taking antibiotics d. A patient who experiences postural hypotension e. A patient who is experiencing nausea from chemotherapy f. A 70-year-old patient who is transferred to long-term care 2. A school nurse is teaching parents about home safety and fires. What information would be accurate to include in the teaching plan? Select all that apply. a. Sixty percent of U.S. fire deaths occur in the home b. Most fatal fires occur when people are cooking c. Most people who die in fires die of smoke inhalation d. Fire-related injury and death have declined due to the availability and use of smoke alarms e. Fires are more likely to occur in homes without electricity or gas f. Fires are less likely to spread if bedroom doors are kept open when sleeping 3. A nurse is assessing the following children. Which child would the nurse identify as having the greatest risk for choking and suffocating? a. A toddler playing with his 9-year-old brother’s construction set b. A 4-year-old eating yogurt for lunch c. An infant covered with a small blanket and asleep in the crib d. A 3-year-old drinking a glass of juice CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED 4. While discussing home safety with the nurse, a patient admits that she always smokes a cigarette in bed before falling asleep at night. Which nursing diagnosis would be the priority for this patient? a. Impaired gas exchange related to cigarette smoking b. Anxiety related to inability to stop smoking c. Risk for suffocation related to unfamiliarity with fire prevention guidelines d. Deficient knowledge related to lack of follow-through of recommendation to stop smoking 5. A nurse working in a pediatrician’s office receives calls from parents whose children have ingested toxins. What would be the nurse’s best response? a. Administer activated charcoal in the tablet form and take the child to the ED b. Administer syrup of ipecac and take child to the ED c. Bring the child in to the primary care provider for gastric lavage d. Call the PCC immediately before attempting any home remedy 6. A nurse is teaching parents in a parenting class about the use of car seats and restraints for infants and children. Which information is accurate and should be included in the teaching plan? a. Booster seats should be used for children until they are 4’9” tall and weigh between 80 to 100 lb b. Most U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle c. Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should be in a front-facing safety seat d. Children older than 6 years may be restrained using a car seat belt in the back seat 7. Based on the statistics for the leading cause of hospital admission for trauma in older adults, CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED b. Introduce the patient to her roommate c. Review the hospital policy on visiting hours d. Explain how to operate the call bell Study Guide book 1. A school nurse is preparing a teaching session on safety for parents of school-aged children. What would be an appropriate topic for this age group? a. Selecting toys for the developmental level b. Providing drug, alcohol, and sexuality education c. Teaching stress reduction techniques d. Providing close supervision to prevent injuries 2. A nurse follows the universal patient compact principles for partnership when providing care for patients. Which nursing action does not reflect this philosophy? a. The nurse includes the patient as a member of the health care team b. The nurse asks for family input from the assigned advocate of the patient c. The nurse makes health care decisions for a patient who is uncooperative d. The nurse allows the patient to review his own medical information 3. A nurse is filing a safety event report for an elderly patient who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process? a. The nurse adds the information in the safety event report to the patient medical record b. The nurse calls the primary health care provider to fill out and sign the safety even report c. The nurse provides an opinion of the physical and mental condition of the patient that may have precipitated the incident CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED d. The nurse details the patient’s response and the examination and treatment of the patient after the incident 4. The nurse is performing a safety belt fit test for a young patient at a well-child check up. What criteria confirms that the child may sit in the back seat of a vehicle with a lap and shoulder belt in place? a. The knees do not bend at the edge of the seat when back is against vehicle’s seat back b. The seat belt stays low on the hips and is not resting on the soft part of the stomach c. The shoulder belt does not lay on the collarbone or shoulder when fastened d. The child’s feet touch the floor of the care when belted in with the lap and shoulder belt 5. A nurse is assessing a client who was exposed to botulism from contaminated food supplies. Which symptom would the nurse expect to find in this client? a. Skeletal muscle paralysis that progresses symmetrically and in a descending manner b. Flu-like symptoms c. Skin lesion with local edema that progresses. Enlarges, ulcerated, and becomes necrotic d. Petechial hemorrhages 6. A nurse is caring for an 80-year-old patient who is admitted to the hospital in a confused and dehydrated state. After the patient got out of bed and fell and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this patient? a. Sedate her with sleeping pills and leave the restraints on b. Take the restraints off, stay with her, and talk gently to her c. Leave the restraints on and talk with her, explaining that she must calm down d. Talk with the patient’s family about taking her home because she is out of control CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED 7. A nurse is working in a long-term care facility institutes interventions to prevent falls in the elderly population. Which intervention would be an appropriate alternative to the use of restraints for ensuring patient safety and preventing falls? a. Involve family members in the patient’s care b. Allow the patient to use the bathroom independently c. Keep the patient sedated with tranquilizers d. Maintain a high bed position so the patient will not attempt to get out unassisted Chapter 32 Textbook 1. Thirty-six hours after having surgery, a patient had a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical sit. Which intervention is most important to include in this patient’s nursing care plan? a. Document the findings and continue to monitor the patient. b. Administer antipyretics, as ordered. c. Increase the frequency of assessment to every hour and notify the patient's primary care provider d. Increase the frequency of wound care and contact the primary care provider for an antibiotic prescription 2. A nurse caring for patients in the PACU teach a novice nurse hoe to assess and document would drainage. Which statements accurately describe a characteristic of would drainage? a. Serous drainage is composed of the clear portion of the blood and serous membranes. b. Sanguineous drainage is composed of a large number of red blood cells and looks like blood c. Bright-red sanguineous drainage indicates fresh bleeding and darker drainage indicates CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED a. Use standardized precautions or transmission-based precautions when indicated. b. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. c. Clean the wound in full or half circles beginning on the outside and working toward the center. d. Work outward from the incision in lines that are parallel to it from the dirty area to the clean area. e. Clean to at least 1 in beyond the end of the new dressing if one is being applied. f. Clean to at least 3 in beyond the wound if a new dressing is not being applied. 9. A nurse is developing a plan of care for an 86-year-old woman who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure ulcer development for this patient? Select all that apply. a. The patient takes time to think about her responses to questions. b. The patient's age of 86 years. c. Patient reports inability to control urine. d. A scheduled hip arthroplasty. e. Lab findings include BUN 12 (elderly normal 8-23 mg/dL) and creatinine 0.9 adult female normal 0.6-1 mg/dL). f. Patient reports increased pain in right hip when repositioning in bed or chair. 10. A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation? a. "I can expect to have more discomfort in the area where the cold is applied." b. "I should expect more drainage from the incision after the ice has been in place." CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED c. "I should see less swelling and redness with the cold treatment." d. "My incision may bleed more when the ice is first applied." 11. A nurse is providing patient teaching regarding the use of negative-pressure wound therapy. Which explanation provides the most accurate information to the patient? a. The therapy is used to collect excess blood loss and prevent the formation of a scab. b. The therapy will prevent infection, ensuring that the wound heals with less scar tissue. c. The therapy provides a moist environment and stimulates blood flow to the wound. d. The therapy irritates the wound to keep it free from debris and excess wound fluid. 12. After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this ulcer would be classified as: a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 13. The nurse uses the RYB wound classification system to assess the wound of a client who cut his arm on a factory machine. The nurse documents the wound as "red". What would be the priority nursing intervention for this type of wound? a. Irrigate the wound. b. Provide gentle cleansing of the wound. c. Debride the wound. d. Change the dressing frequently. 14. A nurse is developing a care plan related to prevention of pressure injuries for residents in a long- term care facility. Which action accurately describes a priority intervention in preventing a patient CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED from developing a pressure injury? a. Keeping the head of the bed elevated as often as possible b. Massaging over bony prominences c. Repositioning bed-bound patients every 4 hours d. Using a mild cleaning agent when cleansing the skin 15. A nurse is measuring the depth of a patient's puncture wound. Which technique is recommended? a. Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90- degree angle with the tip down. b. Draw the shape of the wound and describe how deep it appears in centimeters. c. Gently insert a sterile applicator into the wound and move it in a clockwise direction. d. Insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface with a marker. Chapter 32 Study Guide book 1. A female patient who is being treated for self-inflicted wound tells the nurse that she is anorexic. What criteria would alert the health care worker to her nutritional risk? a. Albumin level of 3.5 mg/dL b. Total lymphocyte count of 1,500/mm3 c. Body weight decrease of 5% d. Arm muscle circumference 90% of standard 2. The nurse is caring for a patient with a pressure ulcer on his back. What nursing intervention would the nurse perform? a. The nurse places a foam wedge under his body to keep body weight off the patient’s back b. The nurse uses a ring cushion to protect reddened areas from additional pressure CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED 9. The nurse is performing pressure ulcer assessment for patients in a hospital setting. Which patient would the nurse consider to be at greatest risk for developing a pressure ulcer? a. A newborn b. A patient with cardiovascular disease c. An older patient with arthritis d. A critical care patient 10. The nurse considers the impact of shearing forces in the development of pressure ulcers in patients. Which patient would be most likely to develop a pressure ulcer from shearing forces? a. A patient sitting in a chair who slides down b. A patient who lifts himself up on his elbows c. A patient who lies on wrinkled sheets d. A patient who must remain on his back for long periods of time 11. The nurse is assessing the wounds of patients in a burn unit. Which wound would most likely heal by primary intention? a. A surgical incision with sutures approximated edges b. A large wound with considerable tissue loss allowed to heal naturally c. A wound left open for several days to allow edema to subside d. A wound healing naturally that becomes infected Chapter 33 Textbook 1. A nurse is preparing an exercise for a patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? Select all that apply. a. Instruct the patient to avoid sudden position changes that may cause dizziness b. Recommend that the patient restrict fluid until after exercising if finished CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED c. Instruct the patient to push a little further beyond fatigue each session d. Instruct the patient to avoid exercising in very cold or very hot temperatures e. Encourage the patient to modify exercise if weak or ill f. Recommend that the patient consume a high-card, low-protein diet 2. A nurse is providing range-of-motion exercises for a patient who is recovering from a stroke. During the session, the patient complains that she is "too tired to go on." What would be priority nursing actions for this patient? a. Stop performing the exercises b. Decrease the number of repetitions performed c. Reevaluate the nursing plan of care d. Move to the patient’s other side to perform exercise e. Encourage the patient to finish the exercise and then rest f. Assess the patient for other symptoms 3. A nurse is ambulating a 48-year-old female patient for the first time following surgery for a knee replacement. Shortly after beginning to walk, the patient tells the nurse that she is dizzy and feels like she might fall. Place these nursing actions in the order in which the nurse should perform them to protect the patient: a. Grasp the gait belt (3) b. Stay with the patient and call for help (6) c. Place feet wide apart with one foot (1) d. Gently slide patient down to the floor, protecting her head (5) e. Pull the weight of the patient backward against your body (4) f. Rock your pelvis out on the side nearest the patient (2) CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED 4. A nurse caring for patients in a pediatrician's office assesses infants and toddlers for physical developmental milestones. Which patient would the nurse refer to a specialist based on failure to achieve these milestones? a. A 4-month-old infant who is unable to roll over b. A 6-month-old infant who is unable to hold his head up himself c. An 11-month-old infant who cannot walk unassisted d. An 18-month-old toddler who cannot jump 5. A nurse is caring for a 26-year-old male patient who has been hospitalized for a spinal cord injury following a motor vehicle accident. Which action would the nurse perform when logrolling the patient to reposition him on his side? a. Have the patient extend his arms outward and cross his legs on top of a pillow. b. Stand at the side of the bed in which the patient will be turned while another nurse gently pushes the patient from the other side c. Have the patient cross his arms on his chest and place a pillow between his knees. d. Place a cervical collar on the patient's neck and gently roll him to the other side of the bed. 6. A nurse is caring for a patient in a long-term care facility who has had two urinary tract infections in the past year related to immobility. Which finding would the nurse expect in this patient? a. Improved renal blood supply to the kidneys b. Urinary stasis c. Decreased urinary calcium d. Acidic urine formation 7. A nurse is caring for a patient who is hospitalized with pneumonia and is experiencing some CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED d. Have the patient sit down on the bed and dangle her feet before moving. 14. A patient who injured the spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for him correctly tells the aide not to place him in which position? a. Side-lying b. Fowler's c. Sims' d. Prone 15. A nurse is using the Katz Index of Independence in Activities of Daily Living to assess the mobility of a hospitalized patient. During the patient interview the nurse documents the following patient data: "Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving from bed to chair. Patient follows directions and can feed self." Based on this data, which score would the patient receive on the Katz index? a. 2 b. 4 c. 5 d. 6 Chapter 33 Study Guide Book 1. A nurse is performing range-of-motion exercises on a patient who is on bedrest. What would be the nurse’s best action when the patient complains: “I’m just too tired to do these exercises today.” a. Encourage the patient to finish the exercises and then reevaluate the nursing plan CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED b. Stop the exercises and reevaluate the nursing plan of care. c. Finish the exercises and report the incident to the primary care provider d. Modify the number of repetitions for each exercise and then modify 2. The nurse moves a person’s arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement? a. Adduction b. Abduction c. Circumduction d. Extension 3. Using proper body mechanics, which motions would the nurse make to move an object? a. The nurse balances the head over the shoulders, leans forward, and relaxes the stomach muscles when moving an object? b. The nurse uses the muscles of the back to help provide the power needed in strenuous activities c. The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. d. The nurse directly lifts an object rather than sliding, rolling, pushing, or pulling it to reduce the energy needed to lift the weight against the pull of gravity 4. The nurse is assisting a patient from the bed into a wheelchair. Which nursing action is appropriate? a. The nurse discourages the patient from helping with the transfer b. The nurse administers pain medication following the transfer c. The nurse grabs and holds the patient by his arms CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED d. The nurse uses assistive devices when lifting more than 35 pounds of patient weight 5. The nurse uses gait belts when assisting patients to ambulate. Which patient would be a likely candidate for this assistive device? a. A patient who has leg strength and can cooperate with the movement b. A patient who has an abdominal incision c. A patient with a thoracic incision d. A patient who is confined to bedrest 6. The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk? a. Increase in the movement of secretions in the respiratory tract b. Increase in circulating fibrinolysin c. Predisposition to renal calculi d. Increased metabolic rate 7. A nurse is promoting exercise and activities for an elderly patient. Which teaching point would be appropriate for this patient? a. Encourage the patient to quickly increase the repetitions for arm and leg exercises b. Encourage the patient to warm up before beginning exercises and to cool down after exercising c. Instruct the patient to continue exercise even if feeling weakness, to build up stamina d. Teach the patient to force joints to meet their natural limit and beyond prior to modifying exercises 8. The nurse is assessing an ambulatory patient for gait. Which documentation describes this mobility status? CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED c. The knees are slightly bent d. The base of support is on the soles of the feet Chapter 37 Textbook 1. A nurse caring for patients in a long-term care facility is often required to collect urine specimens from patients for laboratory testing. Which techniques for urine collection are performed correctly? Select all that apply. a. The nurse catheterizes a patient to collect a sterile urine sample for routine urinalysis. b. The nurse collects a clean-catch urine specimen in the morning from a patient and stores it at room temperature until an afternoon pick-up. c. The nurse collects a sterile urine specimen from the collection receptacle of a patient's indwelling catheter. d. The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine culture. e. The nurse collects a urine specimen from a patient with a urinary diversion by catheterizing the stoma. f. The nurse discards the first urine of the day when performing a 24-hour urine specimen collection on a patient. 2. A nurse caring for patients in an extended-care facility performs regular assessments of the patients' urinary functioning. Which patients would the nurse screen for urinary retention? Select all that apply. a. A 78-year-old male patient diagnosed with an enlarged prostate b. An 83-year-old female patient who is on bedrest c. A 75-year-old female patient who is diagnosed with vaginal prolapse CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED d. An 89-year-old male patient who has dementia e. A 73-year-old female patient who is taking antihistamines to treat allergies f. A 90-year-old male patient who has difficulty walking to the bathroom 3. A nurse is preparing a brochure to teach patients how to prevent urinary tract infections. Which teaching points would the nurse include? Select all that apply. a. Wear underwear with a synthetic crotch. b. Take baths rather than showers. c. Drink 8 to10 8-oz glasses of water per day. d. Drink a glass of water before and after intercourse and void afterwards. e. Dry the perineal area after urination or defecation from the front to back f. Observe the urine for color, amount, odor, and frequency 4. A patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patient's urine output? a. Decreased and highly concentrate b. Decreased and highly dilute c. Increased and concentrated d. Increased and dilute 5. The health care provider has ordered an indwelling catheter inserted in a hospitalized male patient. What consideration would the nurse keep in mind when performing this procedure? a. The male urethra is more vulnerable to injury during insertion. b. In the hospital, a clean technique is used for catheter insertion. c. The catheter is inserted 2 to 3 in into the meatus. CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED d. Since it uses a closed system, the risk for urinary tract infection is absent. 6. A nurse is ordered to perform continuous irrigation for a patient with long-term urinary catheter. What rationale would the nurse expect for this order? a. Irrigation of long-term urinary catheters is a routine order b. Irrigation is recommended to prevent the introduction of pathogens into the bladder c. A blood clot threatens to block the catheter d. It is preferred to irrigate the catheter rather than increase fluid intake by the patient 7. A nurse is caring for a patient diagnosed with bladder cancer who has a urinary diversion. Which actions would the nurse take when caring for this patient? Select all that apply a. Measure the patient's fluid intake and output. b. Keep the skin around the stoma moist. c. Empty the appliance frequently. d. Report any mucous in the urine to the primary care provider e. Encourage the patient to look away when changing the appliance. f. Monitor the return of intestinal function and peristalsis. 8. A nurse is changing the stoma appliance on a patient's ileal conduit. Which characteristic of the stoma would alert the nurse that the patient is experiencing ischemia? a. The stoma is hard and dry. b. The stoma is a pale pink color. c. The stoma is swollen. d. The stoma is a purple-blue color. 9. After surgery, a patient is having difficulty voiding. Which nursing action would most likely lead to an increased difficulty with voiding? CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED d. Age of the patient Chapter 37 Study Guide Book 1. The nurse is assessing a female patient who states that she notices and involuntary loss of urine following a coughing episode. What would be the nurse’s best reply? a. "You are experiencing total incontinence. Have you had any surgeries or trauma that may be causing this?" b. "You are experiencing transient incontinence. Have you been administered diuretics or IV fluids lately?" c. "You are experiencing stress incontinence. Do you know how to do Kegel exercises?" d. d) "You are experiencing reflex incontinence. Have you had a spinal cord injury in the past?" 2. The nurse measures a client's residual urine by catheterization after the client voids. Which condition would this test verify? a. Urinary tract infection (UTI) b. Urinary retention c. Urinary incontinence d. Urinary suppression 3. Which catheter would the nurse use to drain a client's bladder for short periods (5 to 10 minutes)? a. Foley catheter b. suprapubic catheter c. indwelling urethral catheter d. straight catheter 4. The nurse is preparing to catheterize a patient who is incontinent of urine following CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED bladder surgery. What fact should the nurse keep in mind when performing catheterization? a. The bladder normally is a sterile cavity. b. The external opening to the urethra should always be sterilized c. Pathogens introduced into the bladder remain in the bladder d. A normal bladder is as susceptible to infection as an injured one 5. The nurse is collecting a clean-catch specimen from a patient. which nursing action is performed correctly in this procedure? a. Clean the area at the meatus with antiseptic solution. b. Collect the first 10 mL of urine voided in the sterile specimen container. c. Position the container near the meatus, and collect at least 10 mL of urine. d. Continue collecting the urine in the container until the bladder is empty. 6. The nurse is choosing a collection device to collect urine from a nonambulatory male client? What would be the nurse's best choice? a. Specimen hat b. Large urine collection bag c. Bedpan d. Urinal 7. A male patient is being transferred to the hospital from a long-term care facility with a diagnosis of dehydration and urinary bladder infection. His skin is also extorted from urinary incontinence. Which nursing diagnosis is most appropriate for this patient? a. Urinary Incontinence related to urinary tract infection b. Risk for Urinary Tract Infection related to dehydration CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED c. Impaired Skin Integrity related to urinary bladder infection and dehydration d. Impaired Skin Integrity related to functional incontinence 8. The nurse is inserting a catheter into a female urinary bladder. Which nursing action is performed correctly? a. Clean the perineal area with a gauze pad and alcohol using a different corner of the gauze with each stroke b. Assist the patient to a prone position with knees flexed, feet about 2 feet apart, with legs abducted c. Using dominant hand, hold the catheter 12 inches from the tip and insert slowly into the urethra. d. Use dominant hand to inflate the catheter balloon, and inject entire volume of sterile water supplied in prefilled syringe. 9. A nurse determines that a patient has costovertebral tenderness. What condition is indicated by this physical finding? a. A bladder infection b. A bladder obstruction c. An inflamed kidney d. The presence of a kidney stone 10. A nurse assessing an elderly patient finds that the patient has had four UTI’s in the past year. Which physiologic change of aging would the nurse suspect is the cause? a. Decreased bladder contractibility b. Diminished ability to concentrate urine c. Decreased bladder muscle tone CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED e. A patient who is taking amoxicillin for an infection f. A patient taking over-the-counter antacids 5. A patient has a fecal impaction. The nurse correctly administers an oil-retention enema by: a. The nurse administers a large volume of solution (500-1,000 mL) b. The nurse mixes milk and molasses in equal parts for an enema c. The nurse instructs the patient to retain the enema for at least 30 minutes d. The nurse administers the enema while the patient is sitting on the toilet 6. A nurse prepares to assist a patient with her newly created ileostomy. Which recommended patient teaching points would the nurse stress? Select all that apply. a. "When you inspect the stoma, it should be dark purple-blue." b. "The size of the stoma will stabilize within 2 weeks." c. "Keep the skin around the stoma site clean and moist." d. "The stool from an ileostomy is normally liquid." e. "You should eat dark green vegetables to control the odor of the stool." f. "You may have a tendency to develop food blockages." 7. A nurse is preparing a hospitalized patient for a colonoscopy. Which nursing action is the recommended preparation for this test? a. Have the patient follow a low fiber several days before this test b. Have the patient take bisacodyl and ingest a gallon of bowel cleaner on day 1. c. Prepare the patient for the use of general anesthesia during the test. d. Explain that barium contrast mixture will be given to drink before the test. 8. A nurse is performing digital removal of stool on a female patient with a fecal impaction. During the procedure the patient tells the nurse she is feeling dizzy and nauseated, and then vomits. CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED What should be the nurse's next action? a. Reassure the patient that this is a normal reaction to the procedure. b. Stop the procedure, prepare to administer CPR, and notify the primary care provider. c. Stop the procedure, assess vital signs, and notify the primary care provider d. Stop the procedure, wait five minutes, and then resume the procedure. 9. A nurse is scheduling tests for a patient who has been experiencing epigastric pain. The physician ordered the following tests: (a) barium enema, (b) fecal occult blood test, (c) endoscopic studies, and (d) upper gastrointestinal series. Which is the correct order in which the tests would normally be performed? a. c, b, d, a b. d, c, a, b c. a, b, d, c d. b, a, d, c (fecal occult blood test, barium enema, upper gastrointestinal series, endoscopic studies) 10. A nurse is caring for a patient who has a nasogastric tube in place for gastric decompression. Which nursing actions are appropriate when irrigating a nasogastric tube connected to suction? Select all that apply. a. Draw up 30 mL of saline solution into the syringe. b. Unclamp the suction tubing near the connection site to instill solution. c. Place the tip of the syringe in the tube to gently insert saline solution. d. Place syringe in the blue air vent of a Salem sump or double-lumen tube. e. After instilling irrigant, hold the end of the NG tube over an irrigation tray. CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED f. Observe for return flow of NG drainage into an available container. 11. A nurse is planning bowel-training program for patient with frequent constipation. What is the recommended intervention? a. Using a diet that is low in bulk b. Decreasing fluid intake to 1000 mL c. Administering an enema once a day to stimulate peristalsis d. Monitoring bowel movement 12. A nurse is caring for a patient who is post-surgical following an IPAA. For which adverse effect would the nurse monitor in this patient? a. Incontinence b. Constipation c. Electrolyte balances d. Infection 13. For which patient would the nurse expect the primary care provider to order colostomy irrigation? a. A patient with IBS b. A patient with a left-sided end colostomy in the sigmoid colon c. A patient the post-radiation damage to the bowel d. A patient with Crohn's disease 14. A nurse assisting a patient to empty and change an ostomy appliance. When the procedure is finished, the nurse notes that the stoma is protruding into the bag. What would be the nurse first action in this situation? a. Reassure the patient that this is normal finding with a new ostomy b. Notify the primary care provider that the stoma has prolapsed CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED 6. The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis? a. Barium studies, endoscopic examination, fecal occult blood test b. Fecal occult blood test, barium studies, endoscopic examination c. Barium studies, fecal occult blood test, endoscopic examination d. Endoscopic examination, barium studies, fecal occult blood test 7. The nurse is administering magnesium sulfate to a patient with constipation. What mechanism of action would the nurse expect from this drug? a. Chemical stimulation of peristalsis b. Softening of the fecal material c. Increasing intestinal bulk to enhance mechanical stimulation of the intestine d. Drawing water into the intestines to stimulate peristalsis Chapter 39 Textbook 1. A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient? a. Dyspnea b. Hypotension c. Decreased respiratory rate d. Decreased pulse rate 2. A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? a. The patient vomits during suctioning. b. The secretions appear to be stomach contents. CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED c. The catheter touches an unsterile surface. d. Epistaxis is noted with continued suctioning. 3. A nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which action would be the first that should be taken by the nurse related to this occurrence? a. Remove the catheter b. Notify the primary care provider c. Check that the airway is the appropriate size for the patient d. Place the patient on his or her back 4. A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the catheter to use? a. The age of the patient b. The size of the endotracheal tube c. The type of secretions to be suctioned d. The height and weight of the patient 5. A nurse is caring for a 16-year-old male patient who has been hospitalized for an acute asthma exacerbation. Which testing methods might the nurse use to measure the patient's oxygen saturation? Select all that apply. a. Thoracentesis b. Spirometry c. Pulse oximetry d. Peak expiratory flow rate e. Diffusion capacity f. Maximal respiratory pressure CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED 6. A patient with COPD is unable to perform activities of daily living (ADLs) without becoming exhausted. Which nursing intervention would be appropriate for this patient? a. Assist with bathing and hygiene tasks even if the patient feels capable of performing them alone b. Teach the patient not to talk about the procedure just to perform it at the best of his or her ability c. Teach the patient to take short shallow breaths when performing hygiene measures d. Group personal care activities into smaller steps, allowing rest periods between activities 7. A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. a. Refrain from exercise. b. Reduce anxiety. c. Eat meals 1 to 2 hours prior to breathing treatments. d. Eat a high-protein/high-calorie diet. e. Maintain a high-Fowler's position when possible. f. Drink 2 to 3 pints of clear fluids daily. 8. A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended? a. A postoperative adult b. An adult with COPD c. A teenager with cystic fibrosis d. A child with pneumonia CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED d. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve e. Use an appropriate suction pressure (80 to 150 mmHg) f. Insert the suction catheter no further than 1 cm pas the length of the tracheal or endotracheal tube Chapter 39 Study Guide Book 1. The nurse schedules a pulmonary function test to measure the amount of air left in a patient’s lungs at maximal expiration. What test does the nurse order? a. Tidal volume (TV) b. Total lung capacity (TLC) c. Forced Expiratory Volume (FEV) d. Residual Volume (RV) 2. The nurse is assessing the respiratory rates of patients in a community health care facility. Which patient exhibits an abnormal value? a. An infant with a respiratory rate of 20 bpm b. A 4-year-old with a respiratory rate of 40 bpm c. A 12-year-old with a respiratory rate of 20 bpm d. A 70-year-old with a respiratory rate of 18 bpm 3. The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations? a. Hyperventilation b. Hypoxia CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED c. Perfusion d. Atelectasis 4. When inspecting a patient’s chest to assess respiratory status, the nurse should be aware of which normal finding? a. The contour of the intercostal spaces should be rounded b. The skin at the thorax should be cool and moist c. The anteroposterior diameter should be greater than the transverse diameter d. The chest should be slightly convex with no sternal depression 5. When percussing a normal lung, which sound should the nurse hear? a. Tympany b. Resonance c. Dullness d. Hyperresonance 6. The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? a. They are loud, high-pitched sounds heard primarily over the trachea and larynx. b. They are medium-pitched blowing sounds heard over the major bronchi. c. They are low-pitched, soft sounds heard over peripheral lung fields. d. They are soft, high-pitched discontinuous (intermittent) popping lung sounds. 7. A nurse auscultates the lungs of a client with asthma. Which lung sound is characteristic of this condition? a. Crackles b. Bronchial sounds CMI EXAM 3 NCLEX QUESTIONS WITH ANSWERS 2023 A+SUCCESS ASSURED c. Wheezes d. Vesicular sounds 8. What assessment would a nurse make when auscultating the lungs? a. Cardiovascular function b. Abnormal chest structures c. Presence of edema d. Volume of air exhaled or inhaled 9. The nurse is caring for a client who reports difficulty breathing. In what position would the nurse place this client? a. Prone position b. Lateral position c. Supine position d. Fowler's position 10. To drain the apical sections of the upper lobes of the lungs, the nurse should place the patient in which of the following positions? a. Left side with a pillow under the chest wall b. Side-lying position, half on the abdomen and half on the side c. High Fowler's position d. Trendelenburg position 11. The nurse is teaching an adolescent with asthma how to use a meter-dosed inhaler. Which teaching point follows recommended guidelines? a. Inhale through the nose instead of the mouth b. Be sure to shake the canister before using it.