NCLEX PN TEST BANK|ACTUAL NCLEX PN 2023- 2024 LATEST EXAM 200 QUESTIONS WITH ANSWERS, Exams of Nursing

Download NCLEX PN TEST BANK|ACTUAL NCLEX PN 2023- 2024 LATEST EXAM 200 QUESTIONS WITH ANSWERS and more Exams Nursing in PDF only on Docsity! NCLEX PN TEST BANK|ACTUAL NCLEX PN 2023- 2024 LATEST EXAM 200 QUESTIONS WITH ANSWERS & RATIONALES 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 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 9. The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug? A. Uric acid of 5mg/dL B. Hematocrit of 33% C. WBC 2,000 per cubic millimeter D. Platelets 150,000 per cubic millimeter Answer C: Tegretol can suppress the bone marrow and decrease the white blood cell count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers A and D are within normal limits, and answer B is a lower limit of normal; therefore, answers A, B, and D are incorrect. 10. A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis? A. “Tell me about his pain.” B. “What does his vomit look like?” C. “Describe his usual diet.” D. “Have you noticed changes in his abdominal size?” Answer C: The least-helpful questions are those describing his usual diet. A, B, and D are useful in determining the extent of disease process and, thus, are incorrect. 11. The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided? A. Bran B. Fresh peaches C. Cucumber salad D. Yeast rolls 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 order for percussion, vibration, or drainage. Therefore, answers B, C, and D are incorrect. 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. 19. A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure? A. Bradycardia B. Tachycardia C. Premature ventricular beats D. Heart block Answer A: Suctioning can cause a vagal response and bradycardia. Answer B is unlikely and, therefore, not most important, although it can occur. Answers C and D can occur as well, but they are less likely. 20. The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period? A. Assessment of the client’s level of anxiety B. Evaluation of the client’s exercise tolerance C. Identification of peripheral pulses D. Assessment of bowel sounds and activity Answer C: The assessment that is most crucial to the client is the identification of peripheral pulses because the aorta is clamped during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities. Answer A is of lesser concern, answer B is not advised at this time, and answer D is of lesser concern than answer A. 21. A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session? A. “You will be sitting for the examination procedure.” this client, so answer A is incorrect. Ice might be ordered 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. 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 31. The nurse is obtaining a history of an 80-year-old client. Which statement made by the client might indicate a possible fluid and electrolyte imbalance? A. “My skin is always so dry.” B. “I often use a laxative for constipation.” C. “I have always liked to drink a lot of ice tea.” D. “I sometimes have a problem with dribbling urine.” Answer B: Frequent use of laxatives can lead to diarrhea and electrolyte loss. Answers A, C, and D are not of particular significance in this case and, therefore, are incorrect. 32. A client visits the clinic after the death of a parent. Which statement made by the client’s sister signifies abnormal grieving? A. “My sister still has episodes of crying, and it’s been 3 months since Daddy died.” B. “Sally seems to have forgotten the bad things that Daddy did in his lifetime.” C. “She really had a hard time after Daddy’s funeral. She said that she had a sense of longing.” D. “Sally has not been sad at all by Daddy’s death. She acts like nothing has happened.” Answer D: Abnormal grieving is exhibited by a lack of feeling sad; if the client’s sister appears not to grieve, it might be abnormal grieving. This family member might be suppressing feelings of grief. Answers A, B, and C are all normal expressions of grief and, therefore, incorrect. 33. The nurse recognizes that which of the following would be most appropriate to wear when providing direct care to a client with a cough? A. Mask B. Gown C. Gloves D. Shoe covers Answer A: If the nurse is exposed to the client with a cough, the best item to wear is a mask. If the answer had included a mask, gloves, and a gown, all would be appropriate, but in this case, only one item is listed; therefore, answers B and C are incorrect. Shoe covers are not necessary, so answer D is incorrect. 34. The nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention? A. Suggest that the client take warm showers B.I.D. B. Add baby oil to the client’s bath water C. Apply powder to the client’s skin D. Suggest a hot-water rinse after bathing Answer B: Oils can be applied to help with the dry skin and to decrease itching, so adding baby oil to bath water is soothing to the skin. Answer A is incorrect because bathing twice a day is too frequent and can cause more dryness. Answer C is incorrect because powder is also drying. Rinsing with hot water, as stated in answer D, dries out the skin as well. 35. A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate? A. Blood pressure every 15 minutes B. Insertion of a Levine tube C. Cardiac monitoring D. Dressing changes two times per day Answer B: The client with pancreatitis frequently has nausea and vomiting. Lavage is often used to decompress the stomach and rest the bowel, so the insertion of a Levine tube should be anticipated. Answers A and C are incorrect because blood pressures are not required every 15 minutes, and cardiac monitoring might be needed, but this is individualized to the client. 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 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; powders beforehand because powders and deodorants can be interpreted as abnormal. Answer A is incorrect because there is no need for dietary restrictions before a mammogram. Answer C is incorrect because the mammogram does not replace the need for self-breast exams. Answer D is incorrect because a mammogram does not require higher doses of radiation than an x-ray. 46. Which of the following roommates would be best for the client newly admitted with gastric resection? A. A client with Crohn’s disease B. A client with pneumonia C. A client with gastritis D. A client with phlebitis Answer D: The most suitable roommate for the client with gastric resection is the client with phlebitis because phlebitis is an inflammation of the blood vessel and is not infectious. Crohn’s disease clients, in answer A, have frequent stools that might spread infections to the surgical client. The client in answer B with pneumonia is coughing and will disturb the gastric client. The client with gastritis, in answer C, is vomiting and has diarrhea, which also will disturb the gastric client. 47. The licensed practical nurse is working with a registered nurse and a patient care assistant. Which of the following clients should be cared for by the registered nurse? A. A client 2 days post-appendectomy B. A client 1 week post-thyroidectomy C. A client 3 days post-splenectomy D. A client 2 days post-thoracotomy Answer D: The most critical client should be assigned to the registered nurse; in this case, that is the client 2 days post-thoracotomy. The clients in answers A and B are ready for discharge, and the client in answer C who had a splenectomy 3 days ago is stable enough to be assigned to an LPN. 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 C. The graduate instructs the client to perform the Valsalva maneuver during Answers A, B, and D are incorrect because this does not have an effect on the other lab values. 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 C. “You will be asleep during the procedure.” D. “The doctor will inject a medication to treat your illness during the procedure.” 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. 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 Answer C: A sitz bath will help with swelling and improve healing. Ice packs, in answer D, can be used immediately after delivery. Answers A and B are not used in this instance. 68. Which of the following post-operative diets is most appropriate for the client who has had a hemorroidectomy? A. High-fiber B. Low-residue C. Bland D. Clear-liquid Answer D: After surgery, the client will be placed on a clear-liquid diet and progressed to a regular diet. Stool softeners will be included in the plan of care, to avoid constipation. Later, a high-fiber diet, in answer A, is encouraged, but this is not the first diet after surgery. Answers B and C are not diets for this type of surgery. 69. The physician has ordered a culture for the client with suspected gonorrhea. The nurse should obtain which type of culture? A. Blood B. Nasopharyngeal secretions C. Stool D. Genital secretions Answer D: A culture for gonorrhea is taken from the genital secretions. The culture is placed in a warm environment, where it can grow nisseria gonorrhea. Answers A, B, and C are incorrect because these cultures do not test for gonorrhea. 70. The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because: A. Grimacing and writhing movements decrease with relaxation and rest. B. Hypoactive deep tendon reflexes become more active with rest. C. Stretch reflexes are increased with rest. D. Fine motor movements are improved. Answer A: Frequent rest periods help to relax tense muscles and preserve energy. Answers B, C, and D are incorrect because they are untrue statements. 71. The nurse is making assignments for the day. Which client should be assigned to the nursing assistant? A. A client with Alzheimer’s disease B. A client with pneumonia C. A client with appendicitis D. A client with thrombophebitis Answer A: The client with Alzheimer’s disease is the most stable of these clients and can be assigned to the nursing assistant, who can perform duties such as feeding and assisting the client with activities of daily living. The clients in answers B, C, and D are less stable and should be attended by a registered nurse. 72. A client with cancer develops xerostomia. The nurse can help alleviate the discomfort associated with xerostomia by: A. Offering hard candy B. Administering analgesic medications C. Splinting swollen joints D. Providing saliva substitute Answer D: Xerostomia is dry mouth, and offering the client a saliva substitute will help the most. Eating hard candy in answer A can further irritate the mucosa and cut the tongue and lips. Administering an analgesic might not be necessary; thus, answer B is incorrect. Splinting 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 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. 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? 83. The nurse has just received a change-of-shift report. Which client should the nurse assess first? A. A client 2 hours post-lobectomy with 150ccs drainage B. A client 2 days post-gastrectomy with scant drainage C. A client with pneumonia with an oral temperature of 102°F D. A client with a fractured hip in Buck’s traction Answer A: The first client to be seen is the one who recently returned from surgery. The other clients in answers B, C, and D are more stable and can be seen later. 84. Several clients are admitted to the emergency room following a three-car vehicle accident. Which clients can be assigned to share a room in the emergency department during the disaster? A. The schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm C. A child whose pupils are fixed and dilated and his parents, and the client with a frontal head injury D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain Answer B: Out of all of these clients, it is best to hold the pregnant client and the client with a broken arm and facial lacerations in the same room. The clients in answer A need to be placed in separate rooms because these clients are disruptive or have infections. In the case of answer C, the child is terminal and should be in a private room with his parents. 85. The home health nurse is planning for the day’s visits. Which client should be seen first? A. The 78-year-old who had a gastrectomy 3 weeks ago with a PEG tube 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 D. The 30-year-old with an exacerbation of multiple sclerosis being treated 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, 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? A. The client with Cushing’s disease B. The client with diabetes C. The client with acromegaly D. The client with myxedema Answer A: The client with Cushing’s disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immune suppressed. In answer B, the client with diabetes poses no risk to other clients. The client in answer C has an increase in growth hormone and poses no risk to himself or others. The client in answer D has hyperthyroidism or myxedema, and poses no risk to others or himself. 93. The nurse is making assignments for the day. Which client should be assigned to the pregnant nurse? A. The client receiving linear accelerator radiation therapy for lung cancer B. The client with a radium implant for cervical cancer C. The client who has just been administered soluble brachytherapy for thyroid cancer D. The client who returned from placement of iridium seeds for prostate cancer Answer A: The pregnant nurse should not be assigned to any client with radioactivity present. Therefore, the client receiving linear accelerator therapy is correct because this client travels to the radium department for therapy, and the radiation stays in the department; the client is not radioactive. The client in answer B does pose a risk to the pregnant client. The client in answer C is radioactive in very small doses. For approximately 72 hours, the client should dispose of urine and feces in special containers and use plastic spoons and forks. The client in answer D is also radioactive in small amounts, especially upon return from the procedure. 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 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 104. Which information obtained from the mother of a child with cerebral palsy most likely correlates to the diagnosis? A. She was born at 42 weeks gestation. B. She had meningitis when she was 6 months old. C. She had physiologic jaundice after delivery. D. She has frequent sore throats. Answer B: The diagnosis of meningitis at age 6 months correlates to a diagnosis of cerebral palsy. Cerebral palsy, a neurological disorder, is often associated with birth trauma or infections of the brain or spinal column. Answers A, C, and D are not related to the question. 105. A 10-year-old is being treated for asthma. Before administering Theodur, the nurse should check the: A. Urinary output B. Blood pressure C. Pulse D. Temperature Answer C: Theodur is a bronchodilator, and a side effect of bronchodilators is tachycardia, so checking the pulse is important. Extreme tachycardia should be reported to the doctor. Answers A, B, and D are not necessary. 106. An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with a fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals and cloudiness in the IV medication? A. Discard the solution and order a new bag B. Warm the solution C. Continue the infusion and document the finding D. Discontinue the medication Answer A: Crystals in the solution are not normal and should not be administered to the client. Discard the bad solution immediately. Answer B is incorrect because 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 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 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 Answer C: Viokase is a pancreatic enzyme that is used to facilitate digestion. It should be given with meals and snacks, and it works well in foods such as applesauce. Answers A, B, and D are incorrect times to administer this medication. 120. Isoniazid (INH) has been prescribed for a family member exposed to tuberculosis. The nurse is aware that the length of time that the medication will be taken is: A. 6 months B. 3 months C. 18 months D. 24 months Answer A: The expected time for contact to tuberculosis is 1 year. Therefore, answers B, C, and D are incorrect. 121. The client is admitted to the postpartum unit with an order to continue the infusion of Pitocin. Which finding indicates that the Pitocin is having the desired effect? A. The fundus is deviated to the left. B. The fundus is firm and in the midline. C. The fundus is boggy. D. The fundus is two finger breadths below the umbilicus. Answer B: Pitocin is used to cause the uterus to contract and decrease bleeding. A uterus deviated to the left, as stated in answer A, indicates a full bladder. It is not desirable to have a boggy uterus, making answer C incorrect. This lack of muscle tone will increase bleeding. Answer D is incorrect because the position of the uterus is not related to the use of Pitocin. 122. The nurse is teaching a group of new graduates about the safety needs of the client receiving chemotherapy. Before administering chemotherapy, the nurse should: 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 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 B. ELISA C. Western Blot D. Complete blood count Answer C: The most definitive diagnostic tool for HIV is the Western Blot. The white blood cell count, as stated in answer A, is not the best indicator, but a white blood cell count of less than 3,500 requires investigation. The ELISA test, answer B, is a screening exam. Answer D is not specific enough. 131. The client has an order for gentamycin to be administered. Which lab results should be reported to the doctor before beginning the medication? A. Hematocrit B. Creatinine C. White blood cell count D. Erythrocyte count Answer B: Gentamycin is a drug from the aminoglycocide classification. These drugs are toxic to the auditory nerve and the kidneys. The hematocrit is not of significant consideration in this client; therefore, answer A is incorrect. Answer C is incorrect because we would expect the white blood cell count to be elevated in this client because gentamycin is an antibiotic. Answer D is incorrect because the erythrocyte count is also particularly significant 132. The nurse is caring for the client with a mastectomy. Which action would be contraindicated? A. Taking the blood pressure in the side of the mastectomy B. Elevating the arm on the side of the mastectomy C. Positioning the client on the unaffected side D. Performing a dextrostix on the unaffected side 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. 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 D. “Peptic ulcers are associated with H. pylori, although there are other ulcers D. “Don’t worry about that. You will be able to live just like you did before.” Answer A: The client with a colostomy can swim and carry on activities as before the colostomy; therefore, answers B and C are incorrect. Answer D shows a lack of empathy. 143. Which is true regarding the administration of antacids? A. Antacids should be administered without regard to mealtimes. B. Antacids should be administered with each meal and snack of the day. C. Antacids should be administered within 1–2 hours of all other medications. D. Antacids should be administered with all other medications, for maximal absorption. Answer C: Antacids should be administered within 1–2 hours of other medications. If antacids are taken with many medications, they render the other medications inactive. All other answers are incorrect. 144. The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the following before initiating the feeding? A. Assess for tube placement by aspirating stomach content B. Place the patient in a left-lying position C. Administer feeding with 50% H20 concentration D. Ensure that the feeding solution has been warmed in a microwave for 2 minutes Answer A: Before beginning feedings, an x-ray is often obtained to check for placement. Aspirating stomach content and checking the pH for acidity is the best method of checking for placement. Other methods include placing the end in water and checking for bubbling, and injecting air and listening over the epigastric area. Answers B and C are not correct. Answer D is incorrect because warming in the microwave is contraindicated. 145. The patient is prescribed metronidazole (Flagyl) for adjunct treatment for a duodenal ulcer. When teaching about this medication, the nurse would say: