NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023, Exams of Nursing

Download NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 and more Exams Nursing in PDF only on Docsity! NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 1. The nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. The nurse should be particularly alert for: A. Nasal congestion B. Abdominal tenderness C. Muscle tetany D. Oliguria Answer A: Removal of the pituitary gland is usually done by a transsphenoidal approach, through the nose. Nasal congestion further interferes with the airway. Answers B, C, and D are not correct because they are not directly associated with the pituitary gland. 2. A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following? A. Hypernatremia B. Hypokalemia C. Myelosuppression D. Leukocytosis Answer B: Hypokalemia is evident from the lab values listed. The other laboratory findings are within normal limits, making answers A, C, and D incorrect. 3. 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 NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 Answer A: The primary responsibility of the nurse is to take the vital signs before any surgery. The actions in answers B, C, and D are the responsibility of the doctor and, therefore, are incorrect for this question. 4. The nurse is working in the emergency room when a client arrives with severe burns of the 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 Answer B: The client with burns to the neck needs airway assessment and supplemental oxygen, so applying oxygen is the priority. The next action should be to start an IV and medicate for pain, making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor. 5. 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 C. Take the medication with water only D. Allow at least 1 hour between taking the medicine and taking other medications Answer B: The client with burns to the neck needs airway assessment and supplemental oxygen, so applying oxygen is the priority. The next action should be to start an IV and medicate for pain, making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor. NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 Answer C: The client with diverticulitis should avoid foods with seeds. The foods in answers A, B, and D are allowed; in fact, bran cereal and fruit will help prevent constipation. 12. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? A. Teaching how to irrigate the illeostomy B. Stopping electrolyte loss in the incisional area C. Encouraging a high-fiber diet D. Facilitating perineal wound drainage Answer D: The client with a perineal resection will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illeostomy, as in answer A; he will have some electrolyte loss, but treatment is not focused on preventing the loss, so answer B is incorrect. A high-fiber diet, in answer C, is not ordered at this time. 13. 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 Answer C: The client with diverticulitis should avoid eating foods that are gas forming and that increase abdominal discomfort, such as cooked broccoli. Foods such as those listed in answers A, B, and D are allowed. 14. The nurse is caring for a new mother. The mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is: A. The baby is dehydrated due to polyuria. NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 D. The baby can lose up to 10% of weight due to meconium stool, loss of B. The baby is hypoglycemic due to lack of glucose. C. The baby is allergic to the formula the mother is giving him. extracellular fluid, and initiation of breast-feeding. Answer D: After birth, meconium stool, loss of extracellular fluid, and initiation of breastfeeding cause the infant to lose body mass. There is no evidence to indicate dehydration, hypoglycemia, or allergy to the infant formula; thus, answers A, B, and C are incorrect. 15. The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis? A. Foul breath B. Dysphagia C. Diarrhea D. Chronic hiccups Answer C: Diarrhea is not common in clients with mouth and throat cancer. All the findings in answers A, B, and D are expected findings. 16. A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usually be included in the plan? A. Closed chest drainage B. A tracheostomy C. A mediastinal tube D. Percussion vibration and drainage Answer A: The client with a lung resection will have chest tubes and a drainage- collection device. He probably will not have a tracheostomy or mediastinal tube, and he will not have an order for percussion, vibration, or drainage. Therefore, answers B, C, and D are incorrect. NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 17. Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as: A. A cephalohematoma B. Molding C. Subdural hematoma D. Caput succedaneum Answer A: A swelling over the right parietal area is a cephalohematoma, an area of bleeding outside the cranium. This type of hematoma does not cross the suture line because it is outside the cranium but beneath the periosteum. Answer B, molding, is overlapping of the bones of the cranium and, thus, incorrect. In answer C, a subdural hematoma, or intracranial bleeding, is ominous and can be seen only on a CAT scan or x-ray. A caput succedaneum, in answer D, crosses the suture line and is edema. 18. The nurse is assisting the RN with discharge instructions for a client with an implantable defibrillator. What discharge instruction is essential? A. “You cannot eat food prepared in a microwave.” B. “You should avoid moving the shoulder on the side of the pacemaker site for 6 weeks.” C. “You should use your cellphone on your right side.” D. “You will not be able to fly on a commercial airliner with the defibrillator in place.” Answer C: The client with an internal defibrillator should learn to use any battery- operated machinery on the opposite side. He should also take his pulse rate and report dizziness or fainting. Answers A, B, and D are incorrect because the client can eat food prepared in the microwave, move his shoulder on the affected side, and fly in an airplane. NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 after repair, but not for the entire extremity, so answer B is incorrect. An abduction pillow is ordered after a total hip replacement, not for a fractured femur; therefore, answer D is incorrect. 24. 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 Answer B: The client having an intravenous pyelogram will have orders for laxatives or enemas, so asking the client to void before the test is in order. A full bladder or bowel can obscure the visualization of the kidney ureters and urethra. In answers A, C, and D, there is no need to force fluids before the procedure, to withhold medications, or to cover the reproductive organs. 25. 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 Answer B: Cancer in situ means that the cancer is still localized to the primary site. Cancer is graded in terms of tumor, grade, node involvement, and mestatasis. Answer A is incorrect because it is an untrue statement. Answer C is incorrect because T indicates tumor, not node involvement. Answer D is incorrect because a tumor that is in situ is not metastasized. NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 26. A client is 2 days post-operative colon resection. After a coughing episode, the client’s wound 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 Answer C: If the client eviscerates, the abdominal content should be covered with a sterile saline-soaked dressing. Reinserting the content should not be the action and will require that the client return to surgery; thus, answer A is incorrect. Answers B and D are incorrect because they are not appropriate to this case. 27. The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery? A. Hearing aid B. Contact lenses C. Wedding ring D. Artificial eye Answer B: It is most important to remove the contact lenses because leaving them in can lead to corneal drying, particularly with contact lenses that are not extended-wear lenses. Leaving in the hearing aid or artificial eye will not harm the client. Leaving the wedding ring on is also allowed; usually, the ring is covered with tape. Therefore, answers A, C, and D are incorrect. 28. 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 NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 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 Answer A: It is the responsibility of the physician to explain and clarify the procedure to the client. Answers B, C, and D are incorrect because they are not within the nurse’s purview. 29. When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain? A. A history of radiation treatment in the neck region B. A history of recent orthopedic surgery C. A history of minimal physical activity D. A history of the client’s food intake Answer A: Previous radiation to the neck might have damaged the parathyroid glands, which are located on the thyroid gland, and interfered with calcium and phosphorus regulation. Answer B has no significance to this case; answers C and D are more related to calcium only, not to phosphorus regulation. 30. A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170meq/L. What behavior changes would be most common for this client? A. Anger B. Mania C. Depression D. Psychosis Answer B: The client with serum sodium of 170meq/L has hypernatremia and might exhibit manic behavior. Answers A, C, and D are not associated with hypernatremia and are, therefore, incorrect. NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 36. The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because: A. The client is at risk for evisceration. B. The client will require frequent dressing changes. C. The straps provide support for drains that are inserted in the incision. D. No sutures or clips are used to secure the incision. Answer B: Montgomery straps are used to secure dressings that require frequent dressing changes because the client with a cholecystectomy usually has a large amount of drainage on the dressing. Montgomery straps are also used for clients who are allergic to several types of tape. This client is not at higher risk of evisceration than other clients, so answer A is incorrect. Montgomery straps are not used to secure the drains, so answer C is incorrect. Sutures or clips are used to secure the wound of the client who has had gallbladder surgery, so answer D is incorrect. 37. The physician has ordered that the client’s medication be administered intrathecally. The nurse is aware that medications will be administered by which method? A. Intravenously B. Rectally C. Intramuscularly D. Into the cerebrospinal fluid Answer D: Intrathecal medications are administered into the cerebrospinal fluid. This method of administering medications is reserved for the client with metastases, the client with chronic pain, or the client with cerebrospinal infections. Answers A, B, and C are incorrect because intravenous, rectal, and intramuscular injections are entirely different procedures. 38. Which client can best be assigned to the newly licensed practical nurse? NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 A. The client receiving chemotherapy B. The client post–coronary bypass C. The client with a TURP D. The client with diverticulitis Answer D: The best client to assign to the newly licensed nurse is the most stable client; in this case, it is the client with diverticulitis. The client receiving chemotherapy and the client with a coronary bypass both need nurses experienced in these areas, so answers A and B are incorrect. Answer D is incorrect because the client with a transurethral prostatectomy might bleed, so this client should be assigned to a nurse who knows how much bleeding is within normal limits. 39. The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the registered nurse? A. Notify the police department as a robbery B. Report this behavior to the charge nurse C. Monitor the situation and note whether any items are missing D. Ignore the situation until items are reported missing Answer B: The best action at this time is to report the incident to the charge nurse. Further action might be needed, but it should be determined by the charge nurse. Answers A, C, and D are incorrect because notifying the police is overreacting at this time, and monitoring or ignoring the situation is an inadequate response. 40. The nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should: A. Change the nursing assistant’s assignment B. Explore the interaction with the nursing assistant C. Discuss the matter with the client’s family D. Initiate a group session with the nursing assistant NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 Answer B: The best action for the nurse to take is to explore the interaction with the nursing assistant. This will allow for clarification of the situation. Changing the assignment in answer A might need to be done, but talking to the nursing assistant is the first step. Answer C is incorrect because discussing the incident with the family is not necessary at this time; it might cause more problems. Answer C is not a first step, even though initiating a group session might be a plan for the future. 41. A home health nurse is planning for her daily visits. Which client should the home health nurse visit first? A. A client with AIDS being treated with Foscarnet B. A client with a fractured femur in a long leg cast C. A client with laryngeal cancer with a laryngetomy D. A client with diabetic ulcers to the left foot Answer C: The client with laryngeal cancer has a potential airway alteration and should be seen first. The clients in answers A, B, and D are not in immediate danger and can be seen later in the day. 42. The nurse is assigned to care for an infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin? A. Increasing the infant’s fluid intake B. Maintaining the infant’s body temperature at 98.6°F C. Minimizing tactile stimulation D. Decreasing caloric intake Answer A: Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temperature is important but will not assist in eliminating bilirubin; therefore, answer B is incorrect. Answers C and D are incorrect because they do not relate to the question. 43. The graduate licensed practical nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority? NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 48. The licensed practical nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching? A. The graduate places the client in a supine position to read the manometer. B. The graduate turns the stop-cock to the off position from the IV fluid to the client. the CVP reading. D. The graduate notes the level at the top of the meniscus. Answer C: The client should breathe normally during a central venous pressure monitor reading. Answer A indicates understanding because the client should be placed supine if he can tolerate being in that position. Answers B and D indicate understanding because the stop-cock should be turned off to the IV fluid, and the reading should be done at the top of the meniscus. 49. Which of the following roommates would be most suitable for the client with myasthenia gravis? A. A client with hypothyroidism B. A client with Crohn’s disease C. A client with pylonephritis D. A client with bronchitis Answer A: The most suitable roommate for the client with myasthenia gravis is the client with hypothyroidism because he is quiet. The client with Crohn’s disease in answer B will be up to the bathroom frequently; the client with pylonephritis in answer C has a kidney infection and will be up to urinate frequently. The client in answer D with bronchitis will be coughing and will disturb any roommate. 50. The nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care? A. A 10-year-old with lacerations of the face C. The graduate instructs the client to perform the Valsalva maneuver during NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 B. A 15-year-old with sternal bruises C. A 34-year-old with a fractured femur D. A 50-year-old with dislocation of the elbow Answer B: The teenager with sternal bruising might be experiencing airway and oxygenation problems and, thus, should be seen first. In answer A, the 10-year-old with lacerations might look bad but is not in distress. The client in answer C with a fractured femur should be immobilized but can be seen after the client with sternal bruising. The client in answer D with the dislocated elbow can be seen later as well. 51. The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should: A. Document the finding B. Send a specimen to the lab C. Strain the urine D. Obtain a complete blood count Answer B: If the dialysate returns cloudy, infection might be present and must be evaluated. Documenting the finding, as stated in answer A, is not enough; straining the urine, in answer C, is incorrect; and dialysate, in answer D, is not urine at all. However, the physician might order a white blood cell count. 52. The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is: A. To lower the blood glucose level B. To lower the uric acid level C. To lower the ammonia level D. To lower the creatinine level Answer C: Lactulose is administered to the client with cirrhosis to lower ammonia levels. Answers A, B, and D are incorrect because this does not have an effect on the other lab values. NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 53. 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.” Answer B: A client with diabetes who has trouble seeing would require follow-up after discharge. The lack of visual acuity for the client preparing and injecting insulin might require help. Answers A, C, and D will not prevent the client from being able to care for himself and, thus, are incorrect. 54. 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 Answer C: When the client is receiving TPN, the blood glucose level should be drawn. TPN is a solution that contains large amounts of glucose. Answers A, B, and D are not directly related to the question and are incorrect. 55. 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 the client using? A. Rationalization B. Denial C. Projection NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 Answer B: The client scheduled for a pericentesis should be told to empty the bladder, to prevent the risk of puncturing the bladder when the needle is inserted. A pericentesis is done to remove fluid from the peritoneal cavity. The client will be positioned sitting up or leaning over a table, making answer A incorrect. The client is usually awake during the procedure, and medications are not commonly inserted into the peritoneal cavity during this procedure; thus, answers C and D are incorrect (although this could depend on the circumstances). 61. To ensure safety while administering a nitroglycerine patch, the nurse should: A. Wear gloves B. Shave the area where the patch will be applied C. Wash the area thoroughly with soap and rinse with hot water D. Apply the patch to the buttocks Answer A: To protect herself, the nurse should wear gloves when applying a nitroglycerine patch or cream. Answer B is incorrect because shaving the shin might abrade the area. Answer C is incorrect because washing with hot water will vasodilate and increase absorption. The patches should be applied to areas above the waist, making answer D incorrect. 62. A 25-year-old male is brought to the emergency room with a piece of metal in his eye. Which action by the nurse is correct? A. Use a magnet to remove the object. B. Rinse the eye thoroughly with saline. C. Cover both eyes with paper cups. D. Patch the affected eye only. NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 Answer C: Covering both eyes prevents consensual movement of the affected eye. The nurse should not attempt to remove the object from the eye because this might cause trauma, as stated in answer A. Rinsing the eye, as stated in answer B, might be ordered by the doctor, but this is not the first step for the nurse. Answer D is not correct because often when one eye moves, the other also does. 63. The physician has ordered sodium warfarin (Coumadin) for the client with thrombophlebitis. The order should be entered to administer the medication at: A. 0900 B. 1200 C. 1700 D. 2100 Answer C: Sodium warfarin is administered in the late afternoon, at approximately 1700 hours. This allows for accurate bleeding times to be drawn in the morning. Therefore, answers A, B, and D are incorrect. 64. The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion? A. The security guard B. The registered nurse C. The licensed practical nurse D. The nursing assistant Answer B: The registered nurse is the only one of these who can legally put the client in seclusion. The only other healthcare worker who is allowed to initiate seclusion is the doctor; therefore, answers A, C, and D are incorrect. 65. The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal pH 7.36, CO2 45, O2 84, HCO3 28. The nurse would assess the client to be in: A. Uncompensated acidosis B. Compensated alkalosis NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 C. Compensated respiratory acidosis D. Uncompensated metabolic acidosis Answer C: The client is experiencing compensated respiratory acidosis. The pH is within the normal range but is lower than 7.40, so it is on the acidic side. The CO2 level is elevated, the oxygen level is below normal, and the bicarb level is slightly elevated. In respiratory disorders, the pH will be the inverse of the CO2 and bicarb levels. This means that if the pH is low, the CO2 and bicarb levels will be elevated. Answers A, B, and D are incorrect because they do not fall into the range of symptoms. 66. The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to: A. Take the blood pressure, pulse, and temperature B. Ask the client to rate his pain on a scale of 0–5 C. Watch the client’s facial expression D. Ask the client if he is in pain Answer B: The best way to evaluate pain levels is to ask the client to rate his pain on a scale. In answer A, the blood pressure, pulse, and temperature can alter for other reasons than pain. Answers C and D are not as effective in determining pain levels. 67. The nursing is participating in discharge teaching for the post-partal client. The nurse is aware that an effective means of managing discomfort associated with an episiotomy after discharge is: A. Promethazine B. Aspirin C. Sitz baths D. Ice packs NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 73. A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first? A. A client with brain attack (stroke) with tube feedings B. A client with congestive heart failure complaining of nighttime dyspnea C. A client with a thoracotomy 6 months ago D. A client with Parkinson’s disease Answer B: The client with congestive heart failure who is complaining of nighttime dyspnea should be seen first because airway is number one in nursing care. In answers A, C, and D, the clients are more stable. 74. A client with glomerulonephritis is placed on a low-sodium diet. Which of the following snacks is suitable for the client with sodium restriction? A. Peanut butter cookies B. Grilled cheese sandwich C. Cottage cheese and fruit D. Fresh peach Answer D: The fresh peach is the lowest in sodium of these choices. Answers A, B, and C have much higher amounts of sodium. 75. Due to a high census, it has been necessary for a number of clients to be transferred to other units within the hospital. Which client should be transferred to the postpartum unit? A. A 66-year-old female with a gastroenteritis B. A 40-year-old female with a hysterectomy C. A 27-year-old male with severe depression D. A 28-year-old male with ulcerative colitis Answer B: The best client to transport to the postpartum unit is the 40-year- old female with a hysterectomy. The nurses on the postpartum unit will be aware of NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 normal amounts of bleeding and will be equipped to care for this client. The clients in answers A and D will be best cared for on a medical- surgical unit. The client with depression in answer C should be transported to the psychiatric unit. 76. During the change of shift, the oncoming nurse notes a discrepancy in the number of Percocet (Oxycodone) listed and the number present in the narcotic drawer. The nurse’s first action should be to: A. Notify the hospital pharmacist B. Notify the nursing supervisor C. Notify the Board of Nursing D. Notify the director of nursing Answer B: The first action the nurse should take is to report the finding to the nurse supervisor and follow the chain of command. If it is found that the pharmacy is in error, it should be notified, as stated in answer A. Answers C and D, notifying the director of nursing and the Board of Nursing, might be necessary if theft is found, but not as a first step; thus, these are incorrect answers. 77. The nurse is assigning staff for the day. Which assignment should be given to the nursing assistant? A. Taking the vital signs of the 5-month-old with bronchiolitis B. Taking the vital signs of the 10-year-old with a 2-day post-appendectomy C. Administering medication to the 2-year-old with periorbital cellulites D. Adjusting the traction of the 1-year-old with a fractured tibia Answer B: The client with the appendectomy is the most stable of these clients and can be assigned to a nursing assistant. The client with bronchiolitis has an alteration in the airway, the client with periorbital cellulitis has an infection, and the client with a fracture might be an abused child. Therefore, answers A, C, and D are incorrect. NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 78. A new nursing graduate indicates in charting entries that he is a licensed practical nurse, although he has not yet received the results of the licensing exam. The graduate’s action can result in what type of charge: A. Fraud B. Tort C. Malpractice D. Negligence Answer A: Identifying oneself as a nurse without a license defrauds the public and can be prosecuted. A tort is a wrongful act; malpractice is failing to act appropriately as a nurse or acting in a way that harm comes to the client; and negligence is failing to perform care. Therefore, answers B, C, and D are incorrect. 79. A client with acute leukemia develops a low white blood cell count. In addition to the institution of isolation, the nurse should: A. Request that foods be served with disposable utensils B. Ask the client to wear a mask when visitors are present C. Prep IV sites with mild soap and water and alcohol D. Provide foods in sealed single-serving packages Answer D: Because the client is immune-suppressed, foods should be served in sealed containers, to avoid food contaminants. Answer B is incorrect because of possible infection from visitors. Answer A is not necessary, but the utensils should be cleaned thoroughly and rinsed in hot water. Answer C might be a good idea, but alcohol can be drying and can cause the skin to break down. 80. A 70-year-old male who is recovering from a strike exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect? A. The client is observed shaving only one side of his face. B. The client is unable to distinguish between two tactile stimuli presented simultaneously. NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 D. The 30-year-old with an exacerbation of multiple sclerosis being treated B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line with cortisone via a centrally placed venous catheter Answer D: The priority client is the one with multiple sclerosis who is being treated with cortisone via the central line. This client is at highest risk for complications. MRSA, in answer C, is methicillin-resistant staphylococcus aureas. Vancomycin is the drug of choice and can be administered later, but its use must be scheduled at specific times of the day to maintain a therapeutic level. Answers A and B are incorrect because these clients are more stable. 86. The nurse is found to be guilty of charting blood glucose results without actually performing the procedure. After talking to the nurse, the charge nurse should: A. Call the Board of Nursing B. File a formal reprimand C. Terminate the nurse D. Charge the nurse with a tort Answer B: The action after discussing the problem with the nurse is to document the incident and file a formal reprimand. If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but this is not the first step. A tort is a wrongful act committed against a client or his belongings. Answers A, C, and D are incorrect. 87. Which information should be reported to the state Board of Nursing? A. The facility fails to provide literature in both Spanish and English. B. The narcotic count has been incorrect on the unit for the past 3 days. C. The client fails to receive an itemized account of his bills and services received during his hospital stay NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath. Answer B: The Joint Commission on Accreditation of Hospitals will probably be interested in the problems in answers A and C. The failure of the nursing assistant to assist the client with hepatitis should be reported to the charge nurse. If the behavior continues, termination may result. Answer D is incorrect because failure to feed and bathe the client should be reported to the superior, not the Board of Nursing. 88. Which nurse should be assigned to care for the postpartal client with preeclampsia? A. The nurse with 2 weeks of experience on postpartum B. The nurse with 3 years of experience in labor and delivery C. The nurse with 10 years of experience in surgery D. The nurse with 1 year of experience in the neonatal intensive care unit Answer B: The nurse in answer B has the most experience with possible complications involved with preeclampsia. The nurse in answer A is a new nurse to this unit and should not be assigned to this client; the nurses in answers C and D have no experience with the postpartal client and also should not be assigned to this client. 89. The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority? A. Continue to monitor the vital signs B. Contact the physician C. Ask the client how he feels D. Ask the LPN to continue the post-op care Answer B: The vital signs are abnormal and should be reported to the doctor immediately. Answer A, continuing to monitor the vital signs, can result in deterioration of the client’s condition. Answer C, asking the client how he feels, NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 would supply only subjective data. Involving the LPN, in answer D, is not the best solution to help this client because he is unstable. 90. 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 Answer D: A licensed practical nurse should not be assigned to initiate a blood transfusion. The LPN can assist with the transfusion and check ID numbers for the RN. The licensed practical nurse can be assigned to insert Foley and French urinary catheters, discontinue Levine and Gavage gastric tubes, and obtain all types of specimens, so answers A, B, and C are incorrect. 91. The nurse witnesses the nursing assistant hitting the client in the long- term care facility. The nursing assistant can be charged with: A. Negligence B. Tort C. Assault D. Malpractice Answer C: Assault is defined as striking or touching the client inappropriately, so a nurse assistant striking a client could be charged with assault. Answer A, negligence, is failing to perform care for the client. Answer B, a tort, is a wrongful act committed on the client or their belongings. Answer D, malpractice, is failure to perform an act that the nursing assistant knows should be done, or the act of doing something wrong that results in harm to the client. 92. The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available? NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 Answer B: A persistent cough might be related to an adverse reaction to Captoten. Answers A and D are incorrect because tinnitus and diarrhea are not associated with the medication. Muscle weakness might occur when beginning the treatment but is not an adverse effect; thus, answer C is incorrect. 97. The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes: A. Rotating application sites B. Limiting applications to the chest C. Rubbing it into the skin D. Covering it with a gauze dressing Answer A: Sites for the application of nitroglycerin should be rotated, to prevent skin irritation. It can be applied to the back and upper arms, not to the lower extremities, making answer B incorrect. Answer C is contraindicated to the question, and answer D is incorrect because the medication should be covered with a prepared dressing made of a thin paper substance, not gauze. 98. Lidocaine is a medication frequently ordered for the client experiencing: A. Atrial tachycardia B. Ventricular tachycardia C. Heart block D. Ventricular brachycardia Answer B: Lidocaine is used to treat ventricular tachycardia. This medication slowly exerts an antiarrhythmic effect by increasing the electric stimulation threshold of the ventricles without depressing the force of ventricular contractions. It is not used for atrial arrhythmias; thus, answer A is incorrect. Answers C and D are incorrect because it slows the heart rate, so it is not used for heart block or brachycardia. 99. The client is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 response rate of 130 beats per minute. The doctor orders quinidine sulfate. While he is receiving quinidine, the nurse should monitor his ECG for: A. Peaked P wave B. Elevated ST segment C. Inverted T wave D. Prolonged QT interval Answer D: Quinidine can cause widened Q-T intervals and heart block. Other signs of myocardial toxicity are notched P waves and widened QRS complexes. The most common side effects are diarrhea, nausea, and vomiting. The client might experience tinnitus, vertigo, headache, visual disturbances, and confusion. Answers A, B, and C are not related to the use of quinidine. 100. The physician has prescribed tranylcypromine sulfate (Parnate) 10mg bid. The nurse should teach the client to refrain from eating foods containing tyramine because it may cause: A. Hypertension B. Hyperthermia C. Melanoma D. Urinary retention Answer A: If the client eats foods high in tyramine, he might experience malignant hypertension. Tyramine is found in cheese, sour cream, Chianti wine, sherry, beer, pickled herring, liver, canned figs, raisins, bananas, avocados, chocolate, soy sauce, fava beans, and yeast. These episodes are treated with Regitine, an alpha- adrenergic blocking agent. Answers B, C, and D are not related to the question. 101. 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.” NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 C. “Her gums look too big for her teeth.” D. “She has gained about 10 pounds in the last 6 months.” Answer C: Hyperplasia of the gums is associated with Dilantin therapy. Answer A is not related to the therapy; answer B is a side effect, and answer D is not related to the question. 102. 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 Answer D: A complication of a tonsillectomy is bleeding, and constant swallowing may indicate bleeding. Decreased appetite is expected after a tonsillectomy, as is a low-grade temperature; thus, answers A and B are incorrect. In answer C, chest congestion is not normal but is not associated with the tonsillectomy. 103. A 6-year-old with cerebral palsy functions at the level of an 18-month- old. Which finding 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. Answer B: Children at 18 months of age like push-pull toys. Children at approximately 3 years of age begin to dress themselves and build a tower of eight blocks. At age four, children can copy a horizontal or vertical line. Therefore, answers A, C, and D are incorrect. 104. Which information obtained from the mother of a child with cerebral palsy most likely correlates to the diagnosis? NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 corticosteroid. Answer D: Taking corticosteroids in the morning mimics the body’s natural release of cortisol. Answers A is not necessarily true, and answers B and C are not true. 110. 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 use an alternate method of birth control. Answer D: Taking antibiotics and oral contraceptives together decreases the effectiveness of the oral contraceptives. Answers A, B, and C are not necessarily true. 111. 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.” Answer C: The client should be taught to eat his meals even if he is not hungry, to prevent a hypoglycemic reaction. Answers A, B, and D are incorrect because they indicate an understanding of the nurse’s teaching. D. Morning administration mimics the body’s natural secretion of NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 112. 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 Answer C: The time of onset for regular insulin is 30–60 minutes; therefore, answers A, B, and D are incorrect. 113. The client is admitted from the emergency room with multiple injuries sustained from an auto accident. His doctor prescribes a histamine blocker. The reason for this order is: A. To treat general discomfort B. To correct electrolyte imbalances C. To prevent stress ulcers D. To treat nausea Answer C: Histamine blockers are frequently ordered for clients who are hospitalized for prolonged periods and who are in a stressful situation. They are not used to treat discomfort, correct electrolytes, or treat nausea; therefore, answers A, B, and D are incorrect. 114. The client with a recent liver transplant asks the nurse how long he will have to take cyclosporine (Sandimmune). Which response is correct? A. 1 year B. 5 years C. 10 years D. The rest of his life NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 Answer D: Cyclosporin is an immunosuppressant, and the client with a liver transplant will be on immunosuppressants for the rest of his life. Answers A, B, and C, therefore, are incorrect. 115. Shortly after the client was admitted to the postpartum unit, the nurse notes heavy lochia rubra with large clots. The nurse should anticipate an order for: A. Methergine B. Stadol C. Magnesium sulfate D. Phenergan Answer A: Methergine is a drug that causes uterine contractions. It is used for postpartal bleeding that is not controlled by Pitocin. Answers B, C, and D are incorrect: Stadol is an analgesic; magnesium sulfate is used for preeclampsia; and phenergan is an antiemetic. 116. The client is scheduled to have an intravenous cholangiogram. Before the procedure, the nurse should assess the patient for: A. Shellfish allergies B. Reactions to blood transfusions C. Gallbladder disease D. Egg allergies Answer A: Clients having dye procedures should be assessed for allergies to iodine or shellfish. Answers B and D are incorrect because there is no need for the client to be assessed for reactions to blood or eggs. Because an IV cholangiogram is done to detect gallbladder disease, there is no need to ask about answer C. 117. A new diabetic is learning to administer his insulin. He receives 10U of NPH and 12U of regular insulin each morning. Which of the following statements reflects understanding of the nurse’s teaching? NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 A. Administer a bolus of IV fluid B. Administer pain medication C. Administer an antiemetic D. Allow the patient a chance to eat Answer C: Before chemotherapy, an antiemetic should be given because most chemotherapy agents cause nausea. It is not necessary to give a bolus of IV fluids, medicate for pain, or allow the client to eat; therefore, answers A, B, and D are incorrect. 123. Before administering Methytrexate orally to the client with cancer, the nurse should check the: A. IV site B. Electrolytes C. Blood gases D. Vital signs Answer D: The vital signs should be taken before any chemotherapy agent. If it is an IV infusion of chemotherapy, the nurse should check the IV site as well. Answers B and C are incorrect because it is not necessary to check the electrolytes or blood gases. 124. Vitamin K (aquamephyton) is administered to a newborn shortly after birth for which of the following reasons? A. To prevent dehydration B. To treat infection C. To replace electrolytes D. To facilitate clotting Answer D: Vitamin K is given after delivery because the newborn’s intestinal tract is sterile and lacks vitamin K needed for clotting. Answer A is incorrect because NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 vitamin K is not directly given to prevent dehydration, but will facilitate clotting. Answers B and C are incorrect because vitamin K does not prevent infection or replace electrolytes. 125. The client with an ileostomy is being discharged. Which teaching should be included in the plan of care? A. Use Karaya powder to seal the bag. B. Irrigate the ileostomy daily. C. Stomahesive is the best skin protector. D. Neosporin ointment can be used to protect the skin. Answer C: The best protector for the client with an ileostomy to use is tomahesive. Answer A is not correct because the bag will not seal if the client uses Karaya powder. Answer B is incorrect because there is no need to irrigate an ileostomy. Neosporin, answer D, is not used to protect the skin because it is an antibiotic. 126. The client has an order for FeSo4 liquid. Which method of administration would be best? A. Administer the medication with milk B. Administer the medication with a meal C. Administer the medication with orange juice D. Administer the medication undiluted Answer C: FeSO4 or iron should be given with ascorbic acid (vitamin C). This helps with the absorption. It should not be given with meals or milk because this decreases the absorption; thus, answers A and B are incorrect. Giving it undiluted, as stated in answer D, is not good because it tastes bad. 127. The client arrives in the emergency room with a hyphema. Which action by the nurse would be best? A. Elevate the head of the bed and apply ice to the eye B. Place the client in a supine position and apply heat to the knee NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 C. Insert a Foley catheter and measure the intake and output D. Perform a vaginal exam and check for a discharge Answer A: Hyphema is blood in the anterior chamber of the eye and around the eye. The client should have the head of the bed elevated and ice applied. Answers B, C, and D are incorrect and do not treat the problem. 128. The nurse is making assignments for the day. Which client should be assigned to the nursing assistant? A. The 18-year-old with a fracture to two cervical vertebrae B. The infant with meningitis C. The elderly client with a thyroidectomy 4 days ago D. The client with a thoracotomy 2 days ago Answer C: The most stable client is the client with the thyroidectomy 4 days ago. Answers A, B, and D are incorrect because the other clients are less stable and require a registered nurse. 129. The client arrives in the emergency room with a “bull’s eye” rash. Which question would be most appropriate for the nurse to ask the client? A. “Have you found any ticks on your body?” B. “Have you had any nausea in the last 24 hours?” C. “Have you been outside the country in the last 6 months?” D. “Have you had any fever for the past few days?” Answer A: The “bull’s eye” rash is indicative of Lyme’s disease, a disease spread by ticks. The signs and symptoms include elevated temperature, headache, nausea, and the rash. Although answers B and D are important, the question asks which would be best. Answer C has no significance. 130. Which of the following is the best indicator of the diagnosis of HIV? A. White blood cell count NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 135. The nurse is caring for the client who has been in a coma for 2 months. He has signed a donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle the topic of organ donation with the wife? A. Contact organ retrieval to come talk to the wife B. Tell her that because her husband signed a donor card, the hospital has the right to take the organs upon the death of her husband C. Drop the subject until a later time D. Refrain from talking about the subject until after the death of her husband Answer A: Contacting organ retrieval to talk to the family member is the best choice because a trained specialist has the knowledge to assist the wife with making the decision to donate or not to donate the client’s organs. The hospital will certainly honor the wishes of family members even if the patient has signed a donor card. Answer B is incorrect; answer C might be done, but there might not be time; and answer D is not good nursing etiquette and, therefore, is incorrect. 136. The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is: A. Inspection, auscultation, palpation B. Auscultation, palpation, inspection C. Palpation, inspection, auscultation D. Inspection, palpation, auscultation Answer A: The nurse should inspect first, then auscultate, and finally palpate. If the nurse palpates first, the assessment might be unreliable. Therefore, answers B, C, and D are incorrect. 137. The nurse is assisting in the assessment of the patient admitted with abdominal pain. Why should the nurse ask about medications that the client is taking? A. Interactions between medications can be identified. B. Various medications taken by mouth can affect the alimentary tract. NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 D. “Peptic ulcers are associated with H. pylori, although there are other ulcers C. This will provide an opportunity to educate the patient regarding the medications used. D. The types of medications might be attributable to an abdominal pathology not already identified. Answer B: Many medications can irritate the stomach and contribute to abdominal pain. For answer A, the primary reason for asking about medications is not to identify interactions between medication. Although this might provide an opportunity for teaching, this is not the best time to teach. Therefore, answers C and D are incorrect. 138. The nurse is asked by the nurse aide, “Are peptic ulcers really caused by stress?” The nurse would be correct in replying with which of the following: A. “Peptic ulcers result from overeating fatty foods.” B. “Peptic ulcers are always caused from exposure to continual stress.” C. “Peptic ulcers are like all other ulcers, which all result from stress.” that are associated with stress.” Answer D: H. pylori bacteria and stress are directly related to peptic ulcers. Answers A and B are incorrect because peptic ulcers are not caused by overeating or always caused by continued stress. Answer C is incorrect because peptic ulcers are related to but not directly caused by stress. 139. The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority? A. Anxiety B. Pain C. Knowledge deficit D. Altered thought process Answer C: The new diabetic has a knowledge deficit. Answers A, B, and D are not supported within the stem and so are incorrect. NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 140. The nurse understands that the diagnosis of oral cancer is confirmed with: A. Biopsy B. Gram Stain C. Scrape cytology D. Oral washings for cytology Answer A: The best diagnostic tool for cancer is the biopsy. Other assessment includes checking the lymph nodes. Answers B, C, and D will not confirm a diagnosis of oral cancer. 141. The nurse is assisting in the care of a patient who is 2 days post- operative from a hemorroidectomy. The nurse would be correct in instructing the patient to: A. Avoid a high-fiber diet because this can hasten the healing time B. Continue to use ice packs until discharge and then when at home C. Take 200mg of Colace bid to prevent constipation D. Use a sitz bath after each bowel movement to promote cleanliness and comfort Answer D: The use of a sitz bath will help with the pain and swelling associated with a hemorroidectomy. The client should eat foods high in fiber, so answer A is incorrect. Ice packs, as stated in answer B, are ordered immediately after surgery only. Answer C, a stool softener, can be ordered, but only by the doctor. 142. The nurse is caring for a patient with a colostomy. The patient asks, “Will I ever be able to swim again?” The nurse’s best response would be: A. “Yes, you should be able to swim again, even with the colostomy.” B. “You should avoid immersing the colostomy in water.” C. “No, you should avoid getting the colostomy wet.” D. “Don’t worry about that. You will be able to live just like you did before.” NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 D. Instructing the client to limit his intake of fruits and vegetables Answer A: The nurse should reinforce the need for a diet balanced in all nutrients and fiber. Foods that often cause diarrhea and bloating associated with irritable bowel syndrome include fried foods, caffeinated beverages, alcohol, and spicy foods. Therefore, answers B, C, and D are incorrect. 148. The nurse is planning care for the patient with celiac disease. In teaching about the diet, the nurse should instruct the patient to avoid which of the following for breakfast? A. Cream of wheat B. Banana C. Puffed rice D. Cornflakes Answer A: Clients with celiac disease should refrain from eating foods containing gluten. Foods with gluten include wheat barley, oats, and rye. The other foods are allowed. 149. The nurse is caring for a patient with suspected diverticulitis. The nurse would be most prudent in questioning which of the following diagnostic tests ordered? A. Colonoscopy B. Barium enema C. Complete blood count D. Computed tomography (CT) scan Answer B: A barium enema is contraindicated in the client with diverticulitis because it can cause bowel perforation. Answers A, C, and D are appropriate diagnostic studies for the client with diverticulitis. NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 150. When the nurse is gathering information for the assessment, the patient states, “My stomach hurts about 2 hours after I eat.” Based upon this information, the nurse knows the patient likely has a: A. Gastric ulcer B. Duodenal ulcer C. Peptic ulcer D. Curling’s ulcer Answer B: Individuals with ulcers within the duodenum typically complain of pain occurring 2–3 hours after a meal, as well as at night. The pain is usually relieved by eating. The pain associated with gastric ulcers, answer A, occurs 30 minutes after eating. Answer C is too vague and does not distinguish the type of ulcer. Answer D is associated with stress. 151. The registered nurse is conducting an in-service for colleagues about peptic ulcers. The nurse would be correct in identifying which of the following as a causative factor? A. N. gonorrhea B. H. influenza C. H. pylori D. E. coli Answer C: H. pylori bacteria has been linked to peptic ulcers. Answers A, B, and D are not typically cultured within the stomach, duodenum, or esophagus, and are not related to the development of peptic ulcers. 152. The nurse is caring for the patient’s post-surgical removal of a 6mm oral cancerous lesion. The priority nursing measure would be to: A. Maintain a patent airway B. Perform meticulous oral care every 2 hours NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 C. Ensure that the incisional area is kept as dry as possible D. Assess the client frequently for pain using the visual analogue scale Answer A: Maintaining a patient’s airway is paramount in the post-operative period. This is the priority of nursing care. Answers B, C, and D are applicable but are not the priority. The nurse should instruct the client to perform mouth care using a soft sponge toothette or irrigate the mouth with normal saline. The incision should be kept as dry as possible, and pain should be treated. Pain medications should be administered PRN. 153. The nurse is assisting in the care of a patient with diverticulosis. Which of the following assessment findings would necessitate a report to the doctor? A. Bowel sounds of 5–20 seconds B. Intermittent left lower-quadrant pain C. Constipation alternating with diarrhea D. Hemoglobin 26% and hematocrit 32 Answer D: Low hemoglobin and hematocrit might indicate intestinal bleeding. Answers A, B, and C are normal lab values. 154. The nurse is assessing the client admitted for possible oral cancer. The nurse identifies which of the following as a late-occurring symptom of oral cancer? A. Warmth B. Odor C. Pain D. Ulcer with flat edges Answer C: Pain is a late sign of oral cancer. Answers A, B, and D are incorrect because a feeling of warmth, odor, and a flat ulcer in the mouth are all early occurrences of oral cancer. NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 159. The doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the client with chronic back pain. The nurse teaching the client with a TENS unit should tell the client: A. “You may be electrocuted if you use water with this unit.” B. “Please report skin irritation to the doctor.” C. “The unit may be used anywhere on the body without fear of adverse reactions.” D. “A cream should be applied to the skin before applying the unit.” Answer B: Skin irritation can occur if the TENS unit is used for prolonged periods of time. To prevent skin irritations, the client should change the location of the electrodes often. Electrocution is not a risk because it uses a battery pack; thus, answer A is incorrect. Answer C is incorrect because the unit should not be used on sensitive areas of the body. Answer D is incorrect because no creams are to be used with the device. 160. The doctor has ordered a patient-controlled analgesia (PCA) pump for the client with chronic pain. The client asks the nurse if he can become overdosed with pain medication using this machine. The nurse demonstrates understanding of the PCA if she states: A. “The machine will administer only the amount that you need to control your pain without your taking any action.” B. “The machine has a locking device that prevents overdosing to occur.” C. “The machine will administer one large dose every 4 hours to relieve your pain.” D. “The machine is set to deliver medication only if you need it.” Answer B: The client is concerned about overdosing himself. The machine will deliver a set amount as ordered and allow the client to self-administer a small amount of medication. PCA pumps usually are set to lock out the amount of medication that the client can give himself at 5- to 15-minute intervals. Answer A NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 does not address the client’s concerns, answer C is incorrect, and answer D does not address the client’s concerns. 161. The 84-year-old male has returned from the recovery room following a total hip repair. He complains of pain and is medicated by morphine sulfate and promethazine. Which medication should be kept available for the client being treated with opoid analgesics? A. Nalozone (Narcan) B. Ketorolac (Toradol) C. Acetylsalicylic acid (aspirin) D. Atropine sulfate (Atropine) Answer A: Narcan is the antidote for the opoid analgesics. Toradol (answer B) is a nonopoid analgesic; aspirin (answer C) is an analgesic, anticoagulant, and antipyretic; and atropine (answer D) is an anticholengergic. 162. The nurse is taking the vital signs of the client admitted with cancer of the pancreas. The nurse is aware that the fifth vital sign is: A. Anorexia B. Pain C. Insomnia D. Fatigue Answer B: The fifth vital sign is pain. Nurses should assess and record pain just as they would temperature, respirations, pulse, and blood pressure. Answers A, C, and D are included in the charting but are not considered to be the fifth vital sign and are, therefore, incorrect. 163. The client with AIDS tells the nurse that he has been using acupuncture to help with his pain. The nurse should question the client regarding this treatment because acupuncture: NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 A. Uses pressure from the fingers and hands to stimulate the energy points in the body B. Uses oils extracted from plants and herbs C. Uses needles to stimulate certain points on the body to treat pain D. Uses manipulation of the skeletal muscles to relieve stress and pain Answer C: Acupuncture uses needles, and because HIV is transmitted by blood and body fluids, the nurse should question this treatment. Answer A describes acupressure, and answers B and D describe massage therapy with the use of oils. 164. The client has an order for heparin to prevent post-surgical thrombi. Immediately following a heparin injection, the nurse should: A. Aspirate for blood B. Check the pulse rate C. Massage the site D. Check the site for bleeding Answer D: After administering any subcutaneous anticoagulant, the nurse should check the site for bleeding. Answers A and C are incorrect because aspirating and massaging the site are not done. Checking the pulse is not necessary, as in answer B. 165. Which of the following lab studies should be done periodically if the client is taking sodium warfarin (Coumadin)? A. Stool specimen for occult blood B. White blood cell count C. Blood glucose D. Erthyrocyte count Answer A: An occult blood test should be done periodically to detect any intestinal bleeding on the client with coumadin therapy. Answers B, C, and D are not directly related to the question. NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 171. The physician has ordered atropine sulfate 0.4mg IM before surgery. The medication is supplied in 0.8mg per milliliter. The nurse should administer how many milliliters of the medication? A. 0.25mL B. 0.5mL C. 1mL D. 1.25mL Answer B: If the doctor orders 0.4mgm IM and the drug is available in 0.8/1mL, the nurse should make the calculation: ?mL = 1mL / 0.8mgm; × 0.4mg / 1 = 0.5m:. Answers A, C, and D are incorrect. 172. If the nurse is unable to illicit the deep tendon reflexes of the patella, the nurse should ask the client to: A. Pull against the palms B. Grimace the facial muscles C. Cross the legs at the ankles D. Perform Valsalva maneuver Answer A: If the nurse cannot elicit the patella reflex (knee jerk), the client should be asked to pull against the palms. This helps the client to relax the legs and makes it easier to get an objective reading. Answers B, C, and D will not help with the test. 173. A client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which of the following should be reported to the doctor? A. An elevated white blood cell count B. An abdominal bruit C. A negative Babinski reflex D. Pupils that are equal and reactive to light NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 Answer A: The elevated white blood cell count should be reported because this indicates infection. A bruit will be heard if the client has an aneurysm, and a negative Babinski is normal in the adult, as are pupils that are equal and reactive to light and accommodation; thus, answers B, C, and D are incorrect. 174. A 4-year-old male is admitted to the unit with nephotic syndrome. He is extremely edematous. To decrease the discomfort associated with scrotal edema, the nurse should: A. Apply ice to the scrotum B. Elevate the scrotum on a small pillow C. Apply heat to the abdominal area D. Administer a diuretic Answer B: The child with nephotic syndrome will exhibit extreme edema. Elevating the scrotum on a small pillow will help with the edema. Applying ice is contraindicated; heat will increase the edema. Administering a diuretic might be ordered, but it will not directly help the scrotal edema. Therefore, answers A, C, and D are incorrect. 175. The nurse is taking the blood pressure of an obese client. If the blood pressure cuff is too small, the results will be: A. A false elevation B. A false low reading C. A blood pressure reading that is correct D. A subnormal finding Answer A: If the blood pressure cuff is too small, the result will be a blood pressure that is a false elevation. Answers B, C, and D are incorrect. If the blood pressure cuff is too large, a false low will result. Answers C and D have basically the same meaning. 176. The client is admitted with thrombophlebitis and an order for heparin. The medication should be administered using: NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 A. Buretrol B. A tuberculin syringe C. Intravenous controller D. Three-way stop-cock Answer B: To safely administer heparin, the nurse should obtain an infusion controller. Too rapid infusion of heparin can result in hemorrhage. Answers A, C, and D are incorrect. It is not necessary to have a buretrol, an infusion filter, or a three-way stop-cock. 177. The client is admitted to the hospital in chronic renal failure. A diet low in protein is ordered. The rationale for a low-protein diet is: A. Protein breaks down into blood urea nitrogen and metabolic waste. B. High protein increases the sodium and potassium levels. C. A high-protein diet decreases albumin production. D. A high-protein diet depletes calcium and phosphorous. Answer A: A low-protein diet is required because protein breaks down into nitrogenous waste and causes an increased workload on the kidneys. Answers B, C, and D are incorrect. 178. The client is admitted to the unit after a motor vehicle accident with a temperature of 102°F rectally. The nurse is aware that the most likely explanation for the elevated temperature is: A. There was damage to the hypothalamus. B. He has an infection from the abrasions to the head and face. C. He will require a cooling blanket to decrease the temperature. D. There was damage to the frontal lobe of the brain. Answer A: Damage to the hypothalamus can result in an elevated temperature because this portion of the brain helps to regulate body temperature. Answers B, C, and D are incorrect because there is no data to support the possibility of an NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 Answer C: The client taking an anticoagulant should not take aspirin because it will further thin the blood. He should return to have a Protime drawn for bleeding time, report a rash, and use an electric razor. Therefore, answers A, B, and D are incorrect. 184. A client with a femoral popliteal bypass graft is assigned to a semiprivate room. The most suitable roommate for this client is the client with: A. Hypothyroidism B. Diabetic ulcers C. Ulcerative colitis D. Pneumonia Answer A: The best roommate for the post-surgical client is the client with hypothyroidism. This client is sleepy and has no infectious process. Answers B, C, and D are incorrect because the client with a diabetic ulcer, ulcerative colitis, or pneumonia can transmit infection to the post-surgical client. 185. The nurse has just received shift report and is preparing to make rounds. Which client should be seen first? A. The client who has a history of a cerebral aneurysm with an oxygen saturation rate of 99% B. The client who is three days post–coronary artery bypass graft with a temperature of 100.2°F C. The client who was admitted 1 hour ago with shortness of breath D. The client who is being prepared for discharge following a femoral popliteal bypass graft Answer C: The client admitted 1 hour ago with shortness of breath should be seen first because this client might require oxygen therapy. The client in answer A with a low-grade temperature can be assessed after the client with shortness of breath. The client in answer B can also be seen later. This client will have some inflammatory process after surgery, so a temperature of 100.2°F is not unusual. The low-grade temperature should be re-evaluated in 1 hour. The client in answer D can be reserved for later. NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 186. The doctor has ordered antithrombolic stockings to be applied to the legs of the client with peripheral vascular disease. The nurse knows that the proper method of applying the stockings is: A. Before rising in the morning B. With the client in a standing position C. After bathing and applying powder D. Before retiring in the evening Answer A: The best time to apply antithrombolytic stockings is in the morning before rising. If the doctor orders them later in the day, the client should return to bed, wait 30 minutes, and apply the stockings. Answers B, C, and D are incorrect because there is likely to be more peripheral edema if the client is standing or has just taken a bath; before retiring in the evening is wrong because, late in the evening, more peripheral edema will be present. 187. The nurse is preparing a client with an axillo-popliteal bypass graft for discharge. The client should be taught to avoid: A. Using a recliner to rest B. Resting in supine position C. Sitting in a straight chair D. Sleeping in right Sim’s position Answer C: The client with a femoral popliteal bypass graft should avoid activities that can occlude the femoral artery graft. Sitting in the straight chair and wearing tight clothes are prohibited for this reason. Resting in a supine position, resting in a recliner, or sleeping in right Sim’s are allowed, as stated in answers A, B, and D. 188. While caring for a client with hypertension, the nurse notes the following vital signs: BP of 140/20, pulse 120, respirations 36, temperature 100.8°F. The nurse’s initial action should be to: A. Call the doctor NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 B. Recheck the vital signs C. Obtain arterial blood gases D. Obtain an ECG Answer A: The client is exhibiting a widened pulse pressure, tachycardia, and tachypnea. The next action after obtaining these vital signs is to notify the doctor for additional orders. Rechecking the vital signs, as in answer B, is wasting time. It is the doctor’s call to order arterial blood gases and an ECG. 189. The nurse is caring for a client with peripheral vascular disease. To correctly assess the oxygen saturation level, the monitor may be placed on the: A. Abdomen B. Ankle C. Earlobe D. Chin Answer C: If the finger cannot be used, the next best place to apply the oxygen monitor is to the earlobe. It can also be placed on the forehead, but the choices in answers A, B, and D are incorrect. 190. Dalteparin (Fragmin) has been ordered for a client with pulmonary embolis. Which statement made by the graduate nurse indicates inadequate understanding of the medication? A. “I will administer the medication before meals.” B. “I will administer the medication in the abdomen.” C. “I will check the PTT before administering the medication.” D. “I will not need to aspirate when I give Dalteparin.” Answer C: Giving the medication in the abdomen provides for the best absorption. A is incorrect because there is no need to give this medication prior to meals. B is incorrect because checking the glucose level is unnecessary. D is incorrect because the nurse should not aspirate when administering any heparin derivative subcutaneously. NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 196. Which of the following examples represents parallel play? A. Jenny and Tommy share their toys. B. Jimmy plays with his car beside Mary, who is playing with her doll. C. Kevin plays a game of Scrabble with Kathy and Sue. D. Mary plays with a handheld game while sitting in her mother’s lap. Answer B: Parallel play is play that is demonstrated by two children playing side by side but not together. The play in answers A and C is participative play because the children are playing together. The play in answer D is solitary play because the mother is not playing with Mary. 197. Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning? A. A 6-month-old B. A 4-year-old C. A 10-year-old D. A 13-year-old Answer B: The 4-year-old is more prone to accidental poisoning because children at this age are much more mobile and this makes them more likely to ingest poisons than the other children. Answers A, C, and D are incorrect because the 6-month-old is still too small to be extremely mobile, the 10- year-old has begun to understand risk, and the 13-year-old is also aware of the risks of poisoning and is less likely to ingest poisons than the 4-year-old. 198. An important intervention in monitoring the dietary compliance of a client with bulimia is: A. Allowing the client privacy during mealtimes NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 B. Praising her for eating all her meals C. Observing her for 1–2 hours after meals D. Encouraging her to choose foods she likes and to eat in moderation Answer C: To prevent the client from inducing vomiting after eating, the client should be observed for 1–2 hours after meals. Allowing privacy as stated in answer A will only give the client time to vomit. Praising the client for eating all of a meal does not correct the psychological aspects of the disease; thus, answer B is incorrect. Encouraging the client to choose favorite foods might increase stress and the chance of choosing foods that are low in calories and fats. 199. The client is admitted for evaluation of aggressive behavior and diagnosed with antisocial personality disorder. A key part of the care of such a client is: A. Setting realistic limits B. Encouraging the client to express remorse for behavior C. Minimizing interactions with other clients D. Encouraging the client to act out feelings of rage Answer A: Clients with antisocial personality disorder must have limits set on their behavior because they are artful in manipulating others. Answer B is not correct because they do express feelings and remorse. Answers C and D are incorrect because it is unnecessary to minimize interactions with others or encourage them to act out rage more than they already do. 200. A client with a diagnosis of passive-aggressive personality disorder is seen at the local mental health clinic. A common characteristic of persons with passive-aggressive personality disorder is: A. Superior intelligence B. Underlying hostility C. Dependence on others D. Ability to share feelings NCLEX-PN Test-Bank (200 Questions with Answers Latest Updated Examination Study Guide 2023 Answer B: The client with passive-aggressive personality disorder often has underlying hostility that is exhibited as acting-out behavior. Answers A, C, and D are incorrect. Although these individuals might have a high IQ, it cannot be said that they have superior intelligence. They also do not necessarily have dependence on others or an inability to share feelings.