NCLEX-PN NGN EXAM Quiz Bank Latest Update 2024 Questions & Answers with Rationales, Exams of Nursing

Download NCLEX-PN NGN EXAM Quiz Bank Latest Update 2024 Questions & Answers with Rationales and more Exams Nursing in PDF only on Docsity! NCLEX-PN NGN EXAM Quiz Bank Latest Update 2023/2024 Questions & Answers with Rationales NCLEX-PN NGN EXAM 2023/2024 Question No : 1 - Teaching the client with gonorrhea how to prevent reinfection and further spread is an example of: A. primary prevention. B. secondary prevention. C. tertiary prevention. D. primary health care prevention. Answer: B Explanatio n: Secondary prevention targets the reduction of disease prevalence and disease morbidity through early diagnosis and treatment. Physiological Adaptation Question No : 2 - Which of the following foods is a complete protein? A. corn B. eggs C. peanutsDsunflower seeds Answer: B Explanatio n: Eggs are a complete protein. The remaining options are incomplete proteins. Health Promotion and Maintenance B. every person is worthy of dignity and respect. C. human needs are individual to each person. D. some behaviors have no meaning and cannot be understood. Answer: B Explanatio n: Every person is worthy of dignity and respect. Every person has the potential to change and grow. All people have basic human needs in common with others. All behavior has meaning and can be understood from the client’s perspective. Psychosocial Integrity Question No : 8 - A teenage client is admitted to the hospital because of acetaminophen (Tylenol) overdose. Overdoses of acetaminophen can precipitate life- threatening abnormalities in which of the following organs? A. lungs B. liver C. kidneys D. adrenal glands Answer: B Explanatio n: Acetaminophen is extensively metabolized in the liver. Choices 1, 3, and 4 are incorrect because prolonged use of acetaminophen might result in an increased risk of renal dysfunction, but a single overdose does not precipitate life-threatening problems in the respiratory system, renal system, or adrenal glands. Pharmacological Therapies Question No : 9 - All of the following factors, when identified in the history of a family, are correlated with poverty except: A. high infant mortality rate. B. frequent use of Emergency Departments. C. consultation with folk healers. and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley’s level of anxiety as: A. mild. B. moderate. C. severe. D. panic. Answer: C Explanatio n: The person whose anxiety is assessed as severe is unable to solve problems and has a poor grasp of what’s happening in his or her environment. Somatic symptoms such as those described by Ashley are usually present. Vital sign changes are observed. The individual with mild anxiety might report being mildly uncomfortable and might even find performance enhanced. The individual with moderate anxiety grasps less information about the situation, has some difficulty problem-solving, and might have mild changes in vital signs. The individual in panic demonstrates markedly disturbed behavior and might lose touch with reality. Psychosocial Integrity Question No : 12 - Which of the following methods of contraception is able to reduce the transmission of HIV and other STDs? A. intrauterine device (IUD) B. Norplant C. oral contraceptives D. vaginal sponge Answer: D Explanatio n: The vaginal sponge is a barrier method of contraception that, when used with foam or jelly contraception, reduces the transmission of HIV and other STDs as well as reducing the risk of pregnancy. IUDs, Norplant, and oral contraceptives can prevent pregnancy but not the transmission HIV and STDs. Clients using the contraceptive methods in Choices 1, 2, and 3 should be counseled to use a chemical or barrier contraceptive to decrease transmission of HIV or STDs. Health Promotion and Maintenance Question No : 13 - Which fetal heart monitor pattern can indicate cord compression? A. variable decelerations B. early decelerations C. bradycardia D. tachycardia Answer: A Explanatio n: Variable decelerations can be related to cord compression. The other patterns are not.Reduction of Risk Potential Question No : 14 - The nurse teaching about preventable diseases should emphasize the importance of getting the following vaccines: A. human papilloma virus, genital herpes, measles. B. pneumonia, HIV, mumps. C. syphilis, gonorrhea, pneumonia. D. polio, pertussis, measles. Answer: D Explanatio n: Vaccines are one of the most effective methods of preventing and controlling certain communicable diseases. The smallpox vaccine is not currently in use because the smallpox virus has been declared eradicated from the world’s population. Diseases such as polio, diphtheria, pertussis, and measles are Which sign might the nurse see in a client with a high ammonia level? A. coma B. edema C. hypoxia D. polyuria Answer: A Explanatio n: Coma might be seen in a client with a high ammonia level. Reduction of Risk Potential Question No : 18 - What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36mmHg, and HCO3 24 mEq/L? A. metabolic alkalosis B. homeostasis C. respiratory acidosis D. respiratory alkalosis Answer: B Explanatio n: These ABG values are within normal limits. Choices 1, 3, and 4 are incorrect because the ABG values indicate none of these acid-base disturbances. Physiological Adaptation Question No : 19 - Which of the following is the primary force in sex education in a child’s life? A. school nurse B. peers C. parents D. media Answer: C Explanatio n: Parents are the primary force in sex education in a child’s life. The school nurse is involved with formal sex education and counseling. Peers become more important in sex education during adolescence but might lack correct information. The media play a powerful role in what children learn about sex through movies, TV, and video games. Health Promotion and Maintenance Question No : 20 - The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to examine? A. 6 B. 8 C. 12 D. 16 Answer: C Explanatio n: In general, children begin dentition around 6 months of age. During the first 2 years of life, a quick guide to the number of teeth a child should have is as follows: Subtract the number 6 from the number of months in the age of the child. In this example, the child is 18 months old, so the formula is 18 – 6 = 12. An 18-month-old child should have approximately 12 teeth.Health Promotion and Maintenance Question No : 21 - Which of the following medications is a serotonin antagonist that might be used to relieve nausea and vomiting? B. upper left C. lower right D. lower left Answer: C Explanatio n: The nurse should expect to find abdominal tenderness in the lower-right quadrant in a client with appendicitis. Physiological Adaptation Question No : 24 - Assessment of a client with a cast should include: A. capillary refill, warm toes, no discomfort. B. posterior tibial pulses, warm toes. C. moist skin essential, pain threshold. D. discomfort of the metacarpals. Answer: A Explanatio n: Assessment for adequate circulation is necessary. Signs of impaired circulation include slow capillary refill, cool fingers or toes, and pain.Basic Care and Comfort Question No : 25 - Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority? A. open leg fracture B. open head injury C. stab wound to the chest D. traumatic amputation of a thumb Answer: C Explanatio n: A stab wound to the chest might result in lung collapse and mediastinal shift that, if untreated, could lead to death. Treatment of an obstructed airway or a chest wound is a higher priority than hemorrhage. The principle of ABC (airway, breathing, and circulation) prioritizes care decisions.Physiological Adaptation Question No : 26 - Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma? A. The clothing is the property of another and must be treated with care. B. Such care facilitates repair and salvage of the clothing. C. The clothing of a trauma victim is potential evidence with legal implications. D. Such care decreases trauma to the family members receiving the clothing. Answer: C Explanatio n: Trauma in any client, living or dead, has potential legal and/or forensic implications. Clothing, patterns of stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death, and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health care facilities have policies governing the collection of forensic Answer: C Explanation: Perimenopause refers to a period of time in which hormonal changes occur gradually, ovarian function diminishes, and menses become irregular. Perimenopause lasts approximately five years. Climacteric is a term applied to the period of life in which physiologic changes occur and result in cessation of a woman’s reproductive ability and lessened sexual activity in males. The term applies to both genders. Climacteric and menopause are interchangeable terms when used for females. Menopause is the period when permanent cessation of menses has occurred. Postmenopause refers to the period after the changes accompanying menopause are complete.Health Promotion and Maintenance Question No : 29 - Which of the following might be an appropriate nursing diagnosis for an epileptic client? A. Dysreflexia B. Risk for Injury C. Urinary Retention D. Unbalanced Nutrition Answer: B Explanatio n: The epileptic client is at risk for injury due to the complications of seizure activity, such as possible head trauma associated with a fall. The other choices are not related to the question.Reduction of Risk Potential Question No : 30 - Which of the following diseases or conditions is least likely to be associated with increased potential for bleeding? A. metastatic liver cancer B. gram-negative septicemia C. pernicious anemia D. iron-deficiency anemia Answer: C Explanatio n: Pernicious anemia results from vitamin B12 deficiency due to lack of intrinsic factor. This can result from inadequate dietary intake, faulty absorption from the GI tract due to a lack of secretion of intrinsic factor normally produced by gastric mucosal cells and certain disorders of the small intestine that impair absorption. The nurse should instruct the client in the need for lifelong replacement of vitamin B12, as well as the need for folic acid, rest, diet, and support.Physiological Adaptation Question No : 31 - When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula? A. 2 liters/minute B. 4 liters/minute C. 6 liters/minute D. 8 liters/minute Answer: C Explanatio n: The highest flow rate that oxygen can be delivered via nasal cannula is 6 liters/minute. Higher flow rates must be delivered by mask.Reduction of Risk Potential Question No : 32 - The kind of man who beats a woman is: B. somatizing C. withdrawal D. problem-solving Answer: B Explanatio n: Somatizing means one experiences an emotional conflict as a physical symptom. Ashley manifests several physical symptoms associated with severe anxiety. Acting out refers to behaviors such as anger, crying, laughter, and physical or verbal abuse. Withdrawal is a reaction in which psychic energy is withdrawn from the environment and focused on the self in response to anxiety. Problem-solving takes place when anxiety is identified and the unmet need is met.Psychosocial Integrity Question No : 35 - A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client’s weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as: A. within normal limits, so a weight-reduction diet is unnecessary. B. lower than normal, so education about nutrient-dense foods is needed. C. indicating obesity because the BMI is 35. D. indicating overweight status because the BMI is 27. Answer: C Explanatio n: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. It is calculated by utilizing a chart or nomogram that plots height and weight. This client’s BMI is 35, indicating obesity. Goals of diet therapy are aimed at decreasing weight and increasing activity to healthy levels based on a client’s BMI, activity status, and energy requirements.Physiological Adaptation Question No : 36 - Which of the following instructions should the nurse give a client who will be undergoing mammography? A. Be sure to use underarm deodorant. B. Do not use underarm deodorant. C. Do not eat or drink after midnight. D. Have a friend drive you home. Answer: B Explanatio n: Underarm deodorant should not be used because it might cause confusing shadows on the X-ray film. There are no restrictions on food or fluid intake. No sedation is used, so the client can drive herself home.Reduction of Risk Potential Question No : 37 - Teaching about the need to avoid foods high in potassium is most important for which client? A. a client receiving diuretic therapy B. a client with an ileostomy C. a client with metabolic alkalosis D. a client with renal disease Answer: D Explanatio n: Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. Choices 1, 2, and 3 are incorrect because clients receiving diuretics with ileostomy or with metabolic alkalosis are at risk for hypokalemia and should be encouraged to eat foods high in potassium.Physiological Adaptation Question No : 38 - A diet high in fiber content can help an individual to: A. lose body weight fast. B. reduce diabetic ketoacidosis. C. lower cholesterol. D. reduce the need for folate. Answer: C Explanatio n: Fiber-rich foods (such as grains, apples, potatoes, and beans) can help lower cholesterol.Nonpharmacological Therapies Question No : 39 - When administering intravenous electrolyte solution, the nurse should take which of the following precautions? A. Infuse hypertonic solutions rapidly. B. Mix no more than 80 mEq of potassium per liter of fluid. C. Prevent infiltration of calcium, which causes tissue necrosis and sloughing. D. As appropriate, reevaluate the client’s digitalis dosage. He might need an increased dosage because IV calcium diminishes digitalis’s action. Answer: C Explanatio n: Preventing tissue infiltration is important to avoid tissue necrosis. Choice 1 is incorrect because hypertonic solutions should be infused cautiously and checked with the RN if there is a concern. Choice 2 is incorrect because potassium, mixed in the pharmacy per physician order, is mixed at a concentration no higher than 60 mEq/L. Physiological Adaptation following assessment findings indicates a positive response to Heparin therapy? A. increased platelet count B. increased fibrinogen C. decreased fibrin split products D. decreased bleeding Answer: B Explanatio n: Effective Heparin therapy should stop the process of intravascular coagulation and result in increased availability of fibrinogen. Heparin administration interferes with thrombin-induced conversion of fibrinogen to fibrin. Bleeding should cease due to the increased availability of platelets and coagulation factors.Physiological Adaptation Question No : 45 - Which of the following is an appropriate nursing goal for a client at risk for nutritional problems? A. provide oxygen B. promote healthy nutritional practices C. treat complications of malnutrition D. increase weight Answer: B Explanatio n: Promoting healthy nutritional practices is an appropriate nursing goal for a client at risk for nutritional problems. Choice 1 is incorrect because it is a nursing intervention, not a goal statement. Choice 3 is incorrect because it is a therapeutic treatment. Choice 4 is incorrect because weight gain is an appropriate goal only if the client is underweight.Basic Care and Comfort Question No : 46 - Major competencies for the nurse giving end-oflife care include: A. demonstrating respect and compassion, and applying knowledge and skills in care of the family and the client. B. assessing and intervening to support total management of the family and client. C. setting goals, expectations, and dynamic changes to care for the client. D. keeping all sad news away from the family and client. Answer: A Explanatio n: There are many competencies that the nurse must have to care for families and clients at the end of life. Demonstration of respect and compassion as well as using knowledge and skills in the care of the client and family are major competencies.Basic Care and Comfort Question No : 47 - Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes a serosanguious drainage on the dressing. The most appropriate intervention is to: A. notify the physician of the drainage. B. change the dressing. C. reinforce the dressing. D. apply an abdominal binder. Answer: C Explanatio n: Choices 1 and 2 are contraindicated. A urinalysis might be ordered by the physician, but the question does not provide enough information to make Choice 3 the correct answer.Physiological Adaptation Question No : 50 - A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes. Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image? A. administering immune globulin intravenously B. assessing the extremities for edema, redness and desquamation every 8 hours C. explaining progression of the disease to the client and his or her family D. assessing heart sounds and rhythm Answer: C Explanatio n: Teaching the client and family about progression of the disease includes explaining when symptoms can be expected to improve and resolve. Knowledge of the course of the disease can help them understand that no permanent disruption in physical appearance will occur that could negatively affect body image. Clients with Kawasaki disease might receive immune globulin intravenously to reduce the incidence of coronary artery lesions and aneurysms. Cardiac effects could be linked to body image, but Choice 3 is the most direct link to body image. The nurse assesses symptoms to assist in evaluation of treatment and progression of the disease.Health Promotion and Maintenance Question No : 51 - A client, age 28, was recently diagnosed with Hodgkin’s disease. After staging, therapy is planned to include combination radiation therapy and systemic chemotherapy with MOPP— nitrogen mustard, vincristine (Onconvin), Question No : 53 - The goals of palliative care include all of the following except: A. giving clients with life-threatening illnesses the best quality of life possible. B. taking care of the whole person—body, mind, spirit, heart, and soul. C. no interventions are needed because the client is near death. D. support of needs of the family and client. Answer: C Explanatio n: The goals of palliative care include choices 1, 2, and 4. Choice 3 is not part of palliative care. All aspects of medical, emotional, social, and spiritual needs of the dying client should be focused on until the end of life.Basic Care and Comfort Question No : 54 - When helping a client gain insight into anxiety, the nurse should: A. help relate anxiety to specific behaviors. B. ask the client to describe events that precede increased anxiety. C. instruct the client to practice relaxation techniques. D. confront the client’s resistive behavior. Answer: B Explanatio n: To gain insight, the client needs to recognize causal events. The other activities focus on recognition of anxiety.Psychosocial Integrity Question No : 55 - A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy’s mother indicates a need for further teaching by the nurse? A. “I should make sure he gets plenty of rest.” B. “I should get him a medic alert bracelet.” C. “I should lay him on his back during a seizure.” D. “I should loosen his clothing during a seizure.” Answer: C Explanatio n: A client having a seizure should be turned to the side to prevent aspiration of secretions. The other statements are correct and indicate adequate understanding of teaching.Reduction of Risk Potential Question No : 56 - To remove hard contact lenses from an unresponsive client, the nurse should: A. gently irrigate the eye with an irrigating solution from the inner canthus outward. B. grasp the lens with a gentle pinching motion. C. don sterile gloves before attempting the procedure. D. ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens. Answer: D Explanatio n: To remove hard contact lenses, the upper and lower eyelids are gently maneuvered to help loosen the lens and slide it out of the eye. The lens must be situated on the cornea, not the sclera, before removal. An attempt to grasp a hard lens might result in a scratch on the cornea. Clean gloves are an option if drainage is present.Basic Care and Comfort n: Duodenal intestinal fluid is rich in K+, NA+, and bicarbonate. Suctioning to remove excess fluids decreases the client’s K+ and NA+ levels.Basic Care and Comfort Question No : 61 - Which of the following terms refers to soft-tissue injury caused by blunt force? A. contusion B. strain C. sprain D. dislocation Answer: A Explanatio n: A contusion is a soft-tissue injury caused by blunt force. It is an injury that does not break the skin, is caused by a blow and is characterized by swelling, discoloration, and pain. The immediate application of cold might limit the development of a contusion. A strain is a muscle pull from overuse, overstretching, or excessive stress. A sprain is caused by a wrenching or twisting motion. A dislocation is a condition in which the articular surfaces of the bones forming a joint are no longer in anatomic contact.Physiological Adaptation Question No : 62 - Which of the following indicates a hazard for a client on oxygen therapy? A. A No Smoking sign is on the door. B. The client is wearing a synthetic gown. C. Electrical equipment is grounded. D. Matches are removed. Answer: B A. refusal to walk B. not pulling to a standing position C. negative Trendelenburg sign D. negative Ortolani sign Answer: B Explanatio n: The nurse might be concerned about developmental dysplasia of the hip if an 11–12month-old child doesn’t pull to a standing position. An infant who does not walk by 15 months of age should be evaluated. Children should start walking between 11–15 months of age. Trendelenberg sign is related to weakness of the gluteus medius muscle, not hip dysplasia. Ortolani sign is used to identify congenital subluxation or dislocation of the hip in infants.Health Promotion and Maintenance Question No : 67 - A client with which of the following conditions is at risk for developing a high ammonia level? A. renal failure B. psoriasis C. lupus D. cirrhosis Answer: D Explanatio n: A client with cirrhosis is at risk for developing a high ammonia level.Reduction of Risk Potential Question No : 68 - What is the primary nutritional deficiency of concern for a strict vegetarian? A. vitamin C B. vitamin B12 C. vitamin E D. magnesiu m Answer: B Explanation: Vitamin B12 is the primary nutritional deficiency of concern for a strict vegetarian.Health Promotion and Maintenance Question No : 69 - Which of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophgeal reflux disease (GERD)? A. lettuce B. eggs C. chocolate D. butterscotch Answer: C Explanatio n: Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure leading to reflux and clinical symptoms of GERD. The other foods do not affect LES pressure.Basic Care and Comfort Question No : 70 - A client has been taking alprazolam (Xanax) for four years to manage anxiety. The client reports taking 0.5 mg four times a day. Which statement indicates that the client understands the nurse’s teaching about discontinuing the medication? A. “I can drink alcohol now that I am decreasing my Xanax.” B. “I should not take another Xanax pill. Here is what is left of my last prescription.” C. “I should take three pills per day next week, then two pills for one week, then one pill for one week.” D. “I can expect to be sleepy for several days after stopping the medicine.” Answer: C Explanatio n: Xanax, like other benzodiazepines, can cause withdrawal symptoms that include agitation, insomnia, hypertension, seizures, and abdominal pain. The drug must be slowly decreased to prevent withdrawal symptoms. Psychosocial Integrity Question No : 71 - A client is taking hydrocodone (Vicodin) for chronic back pain. The client has required an increase in the dose and asks whether this means he is addicted to Vicodin. The nurse should base her reply on the knowledge that: A. the client’s body has developed tolerance, requiring more drug to produce the same effect. B. the client is preoccupied with getting the drug and is experiencing loss of control, indicating drug dependence. C. addiction is the term used to describe physical dependence with withdrawal symptoms and tolerance. D. the client has a dual diagnosis of substance abuse and chronic back pain. Answer: A Explanatio n: Drug tolerance is characterized by the ability to ingest a larger dose without adverse effect and decreased sensitivity to the substance. Substance dependence is a severe condition indicating Clients with dumping syndrome should lie down after eating to decrease dumping syndrome. GERD clients should sit up to prevent backflow of acid into the esophagus.Basic Care and Comfort Question No : 74 - Which of the following organs of the digestive system has a primary function of absorption? A. stomach B. pancreas C. small intestine D. gallbladder Answer: C Explanatio n: The small intestine has a primary function of absorption. The remaining digestive organs have other primary functions.Physiological Adaptation Question No : 75 - Which of the following neurological disorders is characterized by writhing, twisting movements of the face and limbs? A. epilepsy B. Parkinson’s C. muscular sclerosis D. Huntington’s chorea Answer: D Explanatio n: Huntington’s chorea is characterized by writhing, twisting movements of the face and limbs. The remaining options are neurological disorders that do not have such movements as part of their disease process.Reduction of Risk Potential Question No : 76 - The nurse is teaching parents of a newborn about feeding their infant. Which of the following instructions should the nurse include? A. Use the defrost setting on microwave ovensto warm bottles. B. When refrigerating formula, don’t feed the baby partially used bottles after 24 hours. C. When using formula concentrate, mix two parts water and one part concentrate. D. If a portion of one bottle is left for the next feeding, go ahead and add new formula to fill it. Answer: A Explanatio n: Parents must be careful when warming bottles in a microwave oven because the milk can become superheated. When a microwave oven is used, the defrost setting should be chosen, and the temperature of the formula should be checked before giving it to the baby. Refrigerated, partially used bottles should be discarded after 4 hours because the baby might have introduced some pathogens into the formula. Returning the bottle to the refrigerator does not destroy pathogens. Formula concentrate and water are usually mixed in a 1:1 ratio of one part concentrate and one part water. Infants should be offered fresh formula at each feeding. Partially used bottles should not have fresh formula added to them. Pathogens can grow in partially used bottles of formula and be transferred to the new formula.Health Promotion and Maintenance Question No : 77 - A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the B. was an only child. C. was physically or psychologically abused. D. admits he has a problem with anger. Answer: C Explanatio n: Many batterers report having been abused as children.Psychosocial Integrity Question No : 80 - A 20-year-old obese female client is preparing to have gastric bypass surgery for weight loss. She says to the nurse, “I need this surgery because nothing else I have done has helped me to lose weight.” Which response by the nurse is most appropriate? A. “If you eat less, you can save some money.” B. “Exercise is a healthier way to lose weight.” C. “You should try the Atkins diet first.” D. “I respect your decision to choose surgery.” Answer: D Explanatio n: This statement is most appropriate, as it shows respect and empathy. The other statements are both insensitive and unprofessional.Physiological Adaptation Question No : 81 - In teaching clients with Buck’s Traction, the major areas of importance should be: A. nutrition, ROM exercises. B. ROM exercises, transportation. C. nutrition, elimination, comfort, safety. D. elimination, safety, isotonic exercises. Answer: C Explanatio n: Nutrition, elimination, comfort, and safety are the major areas of importance. The diet should be high in protein with adequate fluids.Basic Care and Comfort Question No : 82 - Light therapy can be effective for: A. overcoming weight problems. B. helping with allergies. C. use in alternative medical treatments. D. working with sleep patterns. Answer: D Explanatio n: Light therapy can be effective in treating problems associated with sleep patterns, stress, moods, jaundice in newborns, and seasonal affective disorders.Nonpharmacological Therapies Question No : 83 - Assessment of the client with an arteriovenous fistula for hemodialysis should include: A. inspection for visible pulsation. B. palpation of thrill. C. percussion for dullness. D. auscultation of blood pressure. Answer: B Explanatio n: choices refer to other nutritional deficiencies.Health Promotion and Maintenance Question No : 86 - Which is the proper hand position for performing chest percussion? A. cup the hands B. use the side of the hands C. flatten the hands D. spread the fingers of both hands Answer: A Explanatio n: The hands are cupped for performing percussion, producing a vibration that helps loosen respiratory secretions. The other hand positions do not accomplish this task.Reduction of Risk Potential Question No : 87 - Which of the following is likely to increase the risk of sexually transmitted disease? A. alcohol use B. certain types of sexual practices C. oral contraception use D. all of the above Answer: D Explanatio n: STDs affect certain groups in groups in greater numbers. Factors associated with risk include being younger than 25 years of age, being a member of a minority group, residing in an urban setting, being impoverished, and using crack cocaine.Physiological Adaptation Question No : 88 - Why might breast implants interfere with mammography? A. They might cause additional discomfort. B. They are contraindications to mammography. C. They are likely to be dislodged. D. They might prevent detection of masses. Answer: D Explanatio n: Breast implants can prevent detection of masses. Choices 1, 2, and 3 are not ways in which breast implants interfere with mammography.Reduction of Risk Potential Question No : 89 - A health care worker is concerned about a new mother being overwhelmed by caring for her infant. The health care worker should: A. immediately contact child protective services. B. provide the mother with literature about child care. C. consult a therapist to help the mother work out her fears. D. refer the mother to parenting classes. Answer: D Explanatio n: Prevention of child abuse is centered on teaching the parents how to care for their child and cope with the demands of infant care. Parenting classes can help build self-confidence, self-esteem, and coping skills. Parents benefit by understanding the developmental needs of their children, while learning how to manage their home environment more effectively. The classes also increase the parents’ social contacts and teach about community resources.Psychosocial Integrity Question No : 90 - Which is the proper hand position for performing chest vibration? A. cup the hands B. use the side of the hands C. flatten the hands D. spread the fingers of both hands Answer: C Explanatio n: The hands are flattened over the area of the body where chest percussion is used to conduct vibration through to the chest and loosen secretions. The other hand positions do not accomplish this task.Reduction of Risk Potential Question No : 91 - Which of the following lab values is associated with a decreased risk of cardiovascular disease? A. high HDL cholesterol B. low HDL cholesterol C. low total cholesterol D. low triglycerides Answer: A Explanatio n: High HDL cholesterol and low LDL cholesterol are associated with a decreased risk of cardiovascular disease.Reduction of Risk Potential Question No : 92 - A client is having a seizure; his blood oxygen saturation drops from 92% to 82%. What should the nurse do first? A. Open the airway. B. Administer oxygen. C. Suction the client. D. Check for breathing. Answer: A Explanatio n: The nurse needs to open the airway first when the oxygen saturation drops. The other actions might be appropriate, but the airway must be patent.Reduction of Risk Potential Question No : 95 - To remove a client’s gown when she has an intravenous line, the nurse should: A. temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown. B. cut the gown with scissors. C. thread the bag and tubing through the gown sleeve, keeping the line intact. D. temporarily disconnect the tubing from the intravenous container and thread it through the gown. Answer: C Explanatio n: Threading the bag and tubing through the gown sleeve keeps the system intact. Opening an intravenous line causes a break in a sterile system and introduces the potential for infection. Cutting a gown off is not an alternative except in an emergency. IV gowns, which open along sleeves, are widely available.Basic Care and Comfort Question No : 96 - Which of the following is most likely to impact the body image of an infant newly diagnosed with Hemophilia? A. immobility B. altered growth and development C. hemarthrosis D. altered family processes Answer: D Explanation: Altered Family Processes is a potential nursing diagnosis for the family and client with a new diagnosis of Hemophilia. Infants are aware of how their caregivers respond to their needs. Stresses can have an immediate impact on the infant’s development of trust and how others relate to them because of their diagnosis. The longterm effects of hemophilia can include problems related to immobility. Altered growth and development could not have developed in a newly diagnosed client. Hemarthrosis is acute bleeding into a joint space that is characteristic of hemophilia. It does not have an immediate effect on the body image of a newly diagnosed hemophiliac.Health Promotion and Maintenance Question No : 97 - Which of the following values should the nurse monitor closely while a client is on total parenteral nutrition? A. calcium B. magnesium C. glucose D. cholesterol Answer: C Explanatio n: Glucose is monitored closely when a client is on total parenteral nutrition, due to high glucose concentration in the solutions. The other values are not monitored as closely.Health Promotion and Maintenance Question No : 98 - A client with stress incontinence should be advised: A. to purchase absorbent undergarments. B. that Kegel exercises might help. C. that effective surgical treatments are nonexistent. D. that behavioral therapy is ineffective. Answer: B Explanatio n: Kegel exercises, tightening and releasing the pelvic floor muscles, might improve stress incontinence. Choice 1 is not an appropriate treatment for stress incontinence. Several effective surgical treatments exist. Lifestyle and dietary modifications can also be helpful.Physiological Adaptation Question No : 99 - Diagnostic genetic counseling, for procedures such as amniocentesis and chorionic villus sampling, allows clients to make all of the following choices except: A. terminating the pregnancy. B. preparing for the birth of a child with special needs. C. accessing support services before the birth. D. completing the grieving process before the birth. Answer: D Explanatio n: If findings are ominous, the grieving process will not be completed A. closure of the posterior fontanel. B. closure of the anterior fontanel. C. overlap of cranial bones. D. ossification of the sutures. Answer: A Explanatio n: The posterior fontanel should close by the age of 2 months.Health Promotion and Maintenance Question No : 102 - Attaching a restraint to a side rail or other movable part of the bed can: A. do nothing to the client. B. injure the client if the rail or bed is moved. C. help the client stay in the bed without falling out. D. help the client with better posture. Answer: B Explanatio n: Attaching a restraint to a movable part of the bed can cause client injury if that part of the bed is moved before releasing restraints.Safety and Infection Control Question No : 103 - The chemotherapeutic DNA alkylating agents such as nitrogen mustards are effective because they: A. cross-link DNA strands with covalent bonds between alkyl groups on the drug and guanine bases on DNA. B. have few, if any, side effects. C. are used to treat multiple types of cancer. D. are cell-cycle-specific agents. Answer: A Explanatio n: Alkylating agents are highly reactive chemicals that introduce alkyl radicals into biologically active molecules and thereby prevent their proper functioning, replication, and transcription. Choice 2 is incorrect because alkylating agents have numerous side effects including alopecia, nausea, vomiting, and myelosuppression. Choice 3 is incorrect because nitrogen mustards have a broad spectrum of activity against chronic lymphocytic leukemia, non-Hodgkin’s lymphoma, and breast and ovarian cancer, but they are effective chemotherapeutic agents because of DNA crosslinkage. Choice 4 is incorrect because alkylating agents are non-cell-cyclespecific agents.PharmacologicalTherapies Question No : 104 - Using clichés in therapeutic communication leads the client toward: A. viewing the nurse as human. B. accepting himself as human. C. self-disclosing. D. feeling discounted. Answer: D Explanatio n: The use of clichés in therapeutic communication is commonly construed by the client as the nurse’s lack of understanding, involvement, and caring, so the client might feel demeaned and discounted.Psychosocial Integrity Question No : 105 - Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep? C. negative D. false negative Answer: B Explanatio n: A false-positive result occurs when a test result is labeled positive in error, when the actual result is negative. Safety and Infection Control Question No : 108 - A nurse observes a client sitting alone and talking. When asked, the client reports that he is “talking to the voices.” The nurse’s next action should be: A. touching the client to help him return to reality. B. leaving the client alone until reality returns. C. asking the client to describe what is happening. D. telling the client there are no voices. Answer: C Explanatio n: Nurses might observe behavioral cues that can indicate the presence of hallucinations. Talking about the hallucinations is reassuring and validating to the client who has them. Focusing on the symptoms and asking about the hallucinations helps the client gain control.Psychosocial Integrity Question No : 109 - A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except: A. B.the physician in charge of the case is the only person allowed to decide whether organ donation can occur. B. C.the client’s legally responsible party may make the decision for organ donation for the donor if the client is unable to do so. C. D.the organ procurement organization makes the decision regarding which organs to harvest. Answer: C Explanatio n: The client’s legally responsible party may make the decision for organ donation if the client is unable to do so. The donor (or legally responsible party for the donor), the physician, and the organprocurement organization are all involved in the process regarding whether organ donation is appropriate for a specific donor.Coordinated Care Question No : 110 - High uric acid levels can develop in clients who are receiving chemotherapy. This can be caused by: A. the inability of the kidneys to excrete the drug metabolites. B. rapid cell catabolism. C. toxic effects of the prophylactic antibiotics that are given concurrently. D. the altered blood pH from the acid medium of the drugs. Answer: B Explanatio n: Chemotherapy causes damage to cells, and uric acid is a cell metabolite.Physiological Adaptation Question No : 111 - A nurse is planning a brief treatment program for a client who was raped. A realistic, shortterm goal is to: A. identify all psychosocial problems. C. the supervisor wants to control the style in which a staff member correctly performs a task. D. the supervisor does not delegate. Answer: A Explanatio n: Facilitating the development of staff members is an important goal for a supervisor. Micromanagement, intolerance for individual differences in style, and inability to delegate all interfere with team building and overall effectiveness.Coordinated Care Question No : 114 - The nurse is caring for a client who is dying. While assessing the client for signs of impending death, the nurse observes the client for: A. elevated blood pressure. B. Cheyne-Stokes respiration. C. elevated pulse rate. D. decreased temperature. Answer: B Explanatio n: Cheyne-Stokes respirations are rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea, often associated with cardiac failure. This can be a sign of impending death.Psychosocial Integrity Question No : 115 - A client with asthma develops respiratory acidosis. Based on this diagnosis, what should the nurse expect the client’s serum potassium level to be? A. normal B. elevated C. low D. unrelated to the pH Answer: B Explanatio n: Hyperkalemia occurs in a state of acidosis because potassium moves from injured cells into the bloodstream. Physiological Adaptation Question No : 116 - The nurse should teach parents of small children that the most common type of first-degree burn is: A. scalding from hot bath water or spills. B. contact with hot surfaces such as stoves and fireplaces. C. contact with flammable liquids or gases resulting in flash burns. D. sunburn from lack of protection and overexposure. Answer: D Explanatio n: The most common type of first-degree burn is sunburn, underscoring the need for education regarding the use of sunscreens and avoiding exposure.Safety and Infection Control Question No : 117 - A 57-year-old woman is recently widowed. She states, “I will never be able to learn how to manage the finances. My husband did all of that.” Select the nurse’s response that could help raise the client’s self-esteem. A. “You feel inadequate because you have never learned to balance a checkbook.” A. nasal flaring. B. grunting. C. seesaw breathing. D. quivering lips. Answer: D Explanatio n: Lip quivering is a distracter. Signs of impaired breathing in infants and children include all the other options. Physiological Adaptation Question No : 120 - On first meeting, a new nurse manager makes eye contact, smiles, initiates conversation about the previous work experience of nurses, and encourages active participation by nurses in the dialogue. Her behavior is an example of: A. aggressiveness. B. passive aggressiveness. C. passiveness. D. assertivene ss. Answer: D Explanation: This nurse manager is demonstrating assertive behavior. Aggressive behavior dominates or embarrasses. Passive behavior is nervous or timid. Passive-aggressive behavior is dominating or manipulative without directness. Coordinated Care Question No : 121 - A 35-year-old Latin-American client wishes to lose weight to reduce her chances of developing heart disease and diabetes. The client states, “I do not know how to make my diet work with the kind of foods that my family eats.” What should the nurse do first to help the client determine a suitable diet for disease prevention? A. Provide her with copies of the approved dietary guidelines for the