NCLEX-RN Exam Pack Set 4: 75 Questions & Answers (Updated 2022), Exams of Nursing

Download NCLEX-RN Exam Pack Set 4: 75 Questions & Answers (Updated 2022) and more Exams Nursing in PDF only on Docsity! o Option D: Assessing for redness and swelling (signs of deep venous thrombosis {DVT}) requires additional education and is still appropriate to the professional nurse. Correct Answer: A, B, & C. The experienced nursing assistant would know how to reposition the patient and how to reapply compression boots and would remind the patient to perform activities he has been taught to perform. NCLEX-RN Exam Pack Set 4 (75 Questions & Answers Updated 2022) 1. 1. Question Which action(s) should you delegate to the experienced nursing assistant when caring for a patient with a thrombotic stroke with residual left-sided weakness? Select all that apply. o A. Assist the patient to reposition every 2 hours. o B. Reapply pneumatic compression boots. o C. Remind the patient to perform active ROM. o D. Check extremities for redness and edema. • 2. Question The patient who had a stroke needs to be fed. What instruction should you give to the nursing assistant who will feed the patient? o A. Position the patient sitting up in bed before you feed her. o B. Check the patient’s gag and swallowing reflexes. Correct Answer: B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection. Option B: The nursing assistant is not trained to assess gag or swallowing reflexes. Option C: The patient should not be rushed during feeding. Option D: A patient who needs to be suctioned between bites of food is not handling secretions and is at risk for aspiration. This patient should be assessed further before feeding. Correct Answer: A. Position the patient sitting up in bed before you feed her. Positioning the patient in a sitting position decreases the risk of aspiration. o C. Feed the patient quickly because there are three more waiting. o D. Suction the patient’s secretions between bites of food. • 3. Question You have just admitted a patient with bacterial meningitis to the medical-surgical unit. The patient complains of a severe headache with photophobia and has a temperature of 102.60 F orally. Which collaborative intervention must be accomplished first? o A. Administer codeine 15 mg orally for the patient’s headache. o B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection. o C. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever. o D. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure. Option B: Administration of lorazepam should be the next action since it will act rapidly to control the seizure. Option A: Although oxygen may be useful during the postictal phase, the hypoxemia during tonic-clonic seizures is caused by apnea. Option D: Checking the level of consciousness is not appropriate during the seizure, because generalized tonic-clonic seizures are associated with a loss of consciousness. Correct Answer: C. Turn the patient to the side and protect the airway. The priority action during a generalized tonic-clonic seizure is to protect the airway. o A. Place the patient on a non-rebreather mask will the oxygen at 15 L/minute. o B. Administer lorazepam (Ativan) 1 mg IV. o C. Turn the patient to the side and protect the airway. o D. Assess level of consciousness during and immediately after the seizure. • 7. Question A patient recently started on phenytoin (Dilantin) to control simple complex seizures is seen in the outpatient clinic. Which information obtained during his chart review and assessment will be of greatest concern? o A. The gums appear enlarged and inflamed. o B. The white blood cell count is 2300/mm3. o C. Patient occasionally forgets to take the phenytoin until after lunch. o D. Patient wants to renew his driver’s license next month. Correct Answer: D. A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank pain. Urinary tract infections are a frequent complication in patients with multiple sclerosis because of the effect on bladder function. The elevated temperature and decreased breath sounds suggest that this patient may have pyelonephritis. The physician should be notified immediately so that antibiotic therapy can be started quickly. o Option A: This patient needs further assessment, but does not require immediate Option A: Inflammation of the gums should be reported to the physician, but it does not require immediate attention. Option C: The nurse should include in the patient teaching the importance of taking medications on time to avoid episodes of seizure. Option D: Driving is prohibited for a client with a seizure disorder. This should be included in the patient’s teaching, but will not require a change in medical treatment for the seizures. Correct Answer: B. The white blood cell count is 2300/mm3. Leukopenia is a serious adverse effect of phenytoin and would require discontinuation of the medication. • 8. Question After receiving a change-of-shift report at 7:00 AM, which of these patients will you assess first? o A. A 23-year-old with a migraine headache who is complaining of severe nausea associated with retching. o B. A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching. o C. A 59-year-old with Parkinson’s disease who will need a swallowing assessment before breakfast. o D. A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank pain. • 9. Question All of these nursing activities are included in the care plan for a 78-year-old man with Parkinson’s disease who has been referred to your home health agency. Which ones will you delegate to a nursing assistant (NA)? Select all that apply. o A. Check for orthostatic changes in pulse and blood pressure. o B. Monitor for improvement in tremor after levodopa (L- dopa) is given. o C. Remind the patient to allow adequate time for meals. o D. Monitor for abnormal involuntary jerky movements of extremities. o E. Assist the patient with prescribed strengthening exercises. o F. Adapt the patient’s preferred activities to his level of function. usually on one side of the head. It’s often accompanied by nausea, vomiting, and extreme sensitivity to light and sound. Migraine attacks can last for hours to days, and the pain can be so severe that it interferes with daily activities. o Option B: Preoperative teaching must be done but it is not the nurse’s priority. A craniotomy is the surgical removal of part of the bone from the skull to expose the brain. Specialized tools are used to remove the section of bone called the bone flap. The bone flap is temporarily removed, then replaced after the brain surgery has been done. o Option C: The patient should be assessed soon, but does not have an urgent need. In MS, the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problems Option B: Increased blood glucose levels is an expected side effect but not an emergency. Option C: The continued headache also indicates that the ICP may be elevated, but it is not a new problem. Option D: The weight gain is a common adverse effect of dexamethasone that may require treatment, but is not an emergency. Correct Answer: A. The patient does not recognize family members. The inability to recognize a family member is a new neurologic deficit for this patient, and indicates a possible increase in intracranial pressure (ICP). This change should be communicated to the physician immediately so that treatment can be initiated. • 12. Question You are caring for a patient with recurrent glioblastoma who is receiving dexamethasone (Decadron) 4 mg IV every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns you the most? o A. The patient does not recognize family members. o B. The blood glucose level is 234 mg/dL. o C. The patient complains of a continued headache. o D. The daily weight has increased 1 kg. o Option C: Ineffective Therapeutic Regimen Management is not a priority as based on the statement. o Option D: Risk for falls is not the priority at this time. Falls are a leading cause of broken hips and other serious injuries in the elderly, and those with Alzheimer’s are at particularly high risk of falling. Problems with vision, perception, and balance increase as Alzheimer’s advances, making the risk of a fall more likely. Option A: This can be done after the treatment for any intracranial lesion has been implemented. Option C: This intervention should be done but is not the priority. Option D: Administration of phenytoin should be implemented as soon as possible, but the initial nursing activities should be directed toward treatment of any intracranial lesion. Correct Answer: B. Transfer to radiology for a CT scan. The patient’s history and assessment data indicate that he may have a chronic subdural hematoma. The priority goal is to obtain a rapid diagnosis and send the patient to surgery to have the hematoma evacuated. • 13. Question A 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence is admitted to the hospital ED. His wife tells you that he fell down the stairs about a month ago, but “he didn’t have a scratch afterward.” She feels that he has become gradually less active and sleepier over the last 10 days or so. Which of the following collaborative interventions will you implement first? o A. Place on the hospital alcohol withdrawal protocol. o B. Transfer to radiology for a CT scan. o C. Insert a retention catheter to straight drainage. o D. Give phenytoin (Dilantin) 100 mg PO. • 14. Question Which of these patients in the neurologic ICU will be best to assign to an RN who has floated from the medical unit? o A. A 26-year-old patient with a basilar skull structure who has clear drainage coming out of the nose. o B. A 42-year-old patient admitted several hours ago with a headache and diagnosed with a ruptured berry aneurysm. Correct Answer: A. Acute pain related to biologic and chemical factors The priority for interdisciplinary care for the patient experiencing a migraine headache is pain management. o Option B: Anxiety is a correct diagnosis, but it is not the priority. Tension headaches are Option A: This patient may need the attention of an experienced neurologic RN. Option B: A rupture of an aneurysm is fatal and should be assigned to a more experienced RN. Option D: This patient requires assessment and care from RNs more experienced in caring for patients with neurologic diagnoses. Correct Answer: C. A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due. This patient is the most stable of the patients listed. An RN from the medical unit would be familiar with administration of IV antibiotics. o C. A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due. o D. A 65-year-old patient with an astrocytoma who has just returned to the unit after having a craniotomy. • 15. Question What is the priority nursing diagnosis for a patient experiencing a migraine headache? o A. Acute pain related to biologic and chemical factors o B. Anxiety related to change in or threat to health status o C. Hopelessness related to deteriorating physiological condition o D. Risk for Side effects related to medical therapy Correct Answer: D. Decreasing venous return through vasodilation. The significant effect of nitroglycerin is vasodilation and decreased venous return, so the heart does not have to work hard. o Option A: Nitroglycerin does not increase contractility. Cardiac work is decreased by venodilation, reducing anginal symptoms secondary to demand ischemia. Option A: These assessments should be made, but keeping the spine stable is also a priority since the patient has been in an accident. Option B: The first priority is always to check the airway, then the rest of the assessments would follow. Patency is assessed through the presence/absence of obstructive symptoms or findings suggesting an airway that may become obstructed. Option D: The level of consciousness and circulation can be assessed after securing a patent airway. Correct Answer: C. Check respirations, stabilize the spine, and check the circulation Checking the airway would be the priority, and a neck injury should be suspected. Airway patency and adequate respiratory effort are both essential for normal oxygenation and ventilation within the body so that normal physiological processes can proceed without metabolic derangement. o D. Assess level of consciousness and circulation • 19. Question In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and relieves angina by: o A. Increasing contractility and slowing heart rate o B. Increasing AV conduction and heart rate o C. Decreasing contractility and oxygen consumption o D. Decreasing venous return through vasodilation Option B: A patent airway has been established the moment the nurse declares that the client is unconscious and calls for help. Option C: This action can be done if there is an unwitnessed, unmonitored, unstable ventricular tachycardia when a defibrillator is not immediately available. Option D: Administering two quick blows to the precordium is less effective and its use is more limited ideally. Correct Answer: A. Call for help and note the time Having established, by stimulating the client, that the client is unconscious rather than sleep, the nurse should immediately call for help. This may be done by dialing the operator from the client’s phone and giving the hospital code for cardiac arrest and the client’s room number to the operator, or if the phone is not available, by pulling the emergency call button. Noting the time is important baseline information for cardiac arrest procedures. • 20. Question Nurse Patricia finds a female client who is post- myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse’s next action? o A. Call for help and note the time o B. Clear the airway o C. Give two sharp thumps to the precordium and check the pulse o D. Administer two quick blows o Option B: AV conduction is not increased through nitroglycerin, and an increased heart may increase the blood pressure, which is contrary to the desired effects of nitroglycerin, o Option C: Contractility is not significantly affected by nitroglycerin. The desired vasodilatory effect increases perfusion and does not directly reduce oxygen consumption. Option A: Uninterrupted sleep for 8 hours is good, but it does not directly affect the production of acid. Option B: Monitoring vital signs every 2 hours is unnecessary. It can be monitored every shift or every 4 hours. Option D: Milk could aggravate the production of hydrochloric acid. The nutrients in milk, particularly fat, may stimulate the stomach to produce more acid. Correct Answer: C. Make sure that the client takes food and medications at prescribed intervals. Food and drug therapy will prevent the accumulation of hydrochloric acid or will neutralize and buffer the acid that does accumulate. • 21. Question Nurse Monett is caring for a client recovering from gastrointestinal bleeding. The nurse should: o A. Plan care so the client can receive 8 hours of uninterrupted sleep each night. o B. Monitor vital signs every 2 hours. o C. Make sure that the client takes food and medications at prescribed intervals. o D. Provide milk every 2 to 3 hours. • 22. Question A male client was on warfarin (Coumadin) before admission and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do? o A. Stop the I.V. infusion of heparin and notify the physician. o B. Continue treatment as ordered. o C. Expect the warfarin to increase the PTT. Option A: A blood pressure level of 110/70 mmHg is within normal limits. Increased intracranial pressure is caused by an increase in blood pressure. Option B: A pulse rate of 95 bpm is within the normal range. When arterial blood pressure exceeds the intracranial pressure, blood flow to the brain is restored. The increased arterial blood pressure caused by the CNS ischemic response stimulates the baroceptors in the carotid bodies, thus slowing the heart rate drastically often to the point of bradycardia. Option D: Anorexia is not related to increased intracranial pressure. Anorexia is an eating disorder characterized by abnormally low body weight, an intense fear of gaining weight, and a distorted perception of weight. Correct Answer: C. The client is oriented when aroused from sleep and goes back to sleep immediately. This finding suggests that the level of consciousness is decreasing. • 25. Question While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure? o A. Blood pressure has decreased from 160/90 to 110/70. o B. Pulse is increased from 87 to 95, with an occasional skipped beat. o C. The client is oriented when aroused from sleep and goes back to sleep immediately. o D. The client refuses dinner because of anorexia. o Option D: Lying on his stomach would be uncomfortable to a postoperative patient, and would cause a painful spinal headache from the spinal anesthesia. • 26. Question Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first? o A. Altered mental status and dehydration o B. Fever and chills o C. Hemoptysis and Dyspnea o D. Pleuritic chest pain and cough Correct Answer: A. Altered mental status and dehydration Elderly clients may first appear with only an altered mental status and dehydration due to a blunted immune response. o Option B: Fever and chills are classic signs of pneumonia that may appear later in the elderly. The inflammatory response results in a proliferation of neutrophils. This can damage lung tissue, leading to fibrosis and pulmonary edema, which also impairs lung expansion. o Option C: Hemoptysis is a late sign of pneumonia. Bleeding in the lungs may originate from bronchial arteries, pulmonary arteries, bronchial capillaries, and alveolar capillaries. Dyspnea may occur early, especially among the elderly. Swelling and mucus can make it harder to move air through the airways, making it harder to breathe. This leads to shortness of breath, difficulty of breathing, and feeling more tired than normal. o Option D: Cough and pleuritic chest pain are the common symptoms of pneumonia. The air sacs may fill with fluid or pus, causing cough with phlegm or ous, fever, chills, and difficulty breathing. • 27. Question A male client has active tuberculosis (TB). Which of the following symptoms will be exhibited? o A. Chest and lower back pain Option A: Chest pain may be present from coughing but isn’t usual. Pleurisy is a condition where there is inflammation or irritation of the lining of the lungs and chest. There is a sharp pain felt when breathing, coughing, or sneezing. Option C: Clients with TB typically have low-grade fevers, not higher than 102°F (38.9°C). Fever typically develops in the late afternoon or evening in 68% of the cases, and this typical fever is significantly more common in patients less 60 years of age. Option D: Nausea, headache, and photophobia aren’t usual TB symptoms. Typical symptoms include a cough that lasts for more than 3 weeks, loss of appetite and unintentional weight loss, fever, chills, and night sweats. Correct Answer: B. Chills, fever, night sweats, and hemoptysis Typical signs and symptoms are chills, fever, night sweats, and hemoptysis. o B. Chills, fever, night sweats, and hemoptysis o C. Fever of more than 104°F (40°C) and nausea o D. Headache and photophobia • 28. Question Mark, a 7-year-old client, is brought to the emergency department. He’s tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has a nonproductive cough. He recently had a cold. Form this history; the client may have which of the following conditions? o A. Acute asthma o B. Bronchial pneumonia o C. Chronic obstructive pulmonary disease (COPD) o D. Emphysema Correct Answer: B. Avoid foods high in vitamin Option A: This should be reported to the physician but it is not the priority in this situation. Option B: An increase in the blood pressure is also significant, but does not need immediate attention. Option D: Increase in ICP is an important factor but isn’t as significant as PVCs in the situation. Correct Answer: C. Presence of premature ventricular contractions (PVCs) on a cardiac monitor. Lidocaine drips are commonly used to treat clients whose arrhythmias haven’t been controlled with oral medication and who are having PVCs that are visible on the cardiac monitor. • 31. Question Nurse John is caring for a male client receiving lidocaine I.V. Which factor is the most relevant to the administration of this medication? o A. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter o B. Increase in systemic blood pressure o C. Presence of premature ventricular contractions (PVCs) on a cardiac monitor o D. Increase in intracranial pressure (ICP) • 32. Question Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to: o A. Report incidents of diarrhea o B. Avoid foods high in vitamin K o C. Use a straight razor when shaving o D. Take aspirin for pain relief Option A: The client may need to report diarrhea but it doesn’t have the effect of taking an anticoagulant. Option C: An electric razor-not a straight razor-should be used to prevent cuts that cause bleeding. Option D: Aspirin may increase the risk of bleeding; acetaminophen should be used for pain relief. The client should avoid consuming large amounts of vitamin K because vitamin K can interfere with anticoagulation. Option A: Leaving the hair intact can cause infections. Option B: Shaving the area can cause skin abrasions. Option D: Depilatories can irritate the skin. Correct Answer: C. Clipping the hair in the area Hair can be a source of infection and should be removed by clipping. • 33. Question Nurse Lynette is preparing a site for the insertion of an I.V. catheter. The nurse should treat excess hair at the site by: o A. Leaving the hair intact o B. Shaving the area o C. Clipping the hair in the area o D. Removing the hair with a depilatory • 34. Question Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication: o A. Bone fracture o B. Loss of estrogen o C. Negative calcium balance o D. Dowager’s hump Option B: Estrogen deficiencies result from menopause and not osteoporosis. Option C: Calcium and vitamin D supplements may be used to support normal bone metabolism, But a negative calcium balance isn’t a complication of osteoporosis. Option D: Dowager’s hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature. Correct Answer: A. Bone fracture Bone fracture is a major complication of osteoporosis that results when a loss of calcium and phosphate increases the fragility of bones. Option A: Lumps may be detected through BSE, but it does not diagnose whether it is benign or cancerous. Option B: Only a physician can diagnose areas of thickness or fullness that signal the presence of a malignancy. Option D: Only a physician can diagnose masses that are fibrocystic as opposed to malignant. Correct Answer: C. Changes from previous examinations Women are instructed to examine themselves to discover changes that have occurred in the breast. • 35. Question Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the purpose of performing the examination is to discover: o A. Cancerous lumps o B. Areas of thickness or fullness o C. Changes from previous examinations o D. Fibrocystic masses • 36. Question When caring for a female client who is being treated for hyperthyroidism, it is important to: Option A: Typically, the client is instructed to avoid lifting objects weighing more than 15 lb (7kg) – not 5lb. Option B: Instruct the client when lying in bed to lie on either the side or back. Option C: The client should avoid bright light by wearing sunglasses. Correct Answer: D. Avoiding straining during a bowel movement or bending at the waist. The client should avoid straining, lifting heavy objects, and coughing harshly because these activities increase intraocular pressure. Option A: Sexual activity is not an accurate indicator of when to start testicular exams. Option B: The age of 69 would be too old to start on testicular exams. Most elderly men may have testicular problems at this age. Correct Answer: D. Before age 20 Testicular cancer commonly occurs in men between ages 20 and 30. A male client should be taught how to perform testicular self- examination before age 20, preferably when he enters his teens. o B. Lie on your abdomen when in bed o C. Keep rooms brightly lit o D. Avoiding straining during a bowel movement or bending at the waist • 40. Question George should be taught about testicular examinations during: o A. When a sexual activity starts o B. After age 69 o C. After age 40 o D. Before age 20 Option A: After placing a saline-soaked gauze, the nurse should call the physician. Option C: After notifying the physician, the nurse should take the client’s vital signs. Option D: The dehiscence needs to be surgically closed, so the nurse should never try to close it Correct Answer: B. Place a saline-soaked sterile dressing on the wound. The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. • 41. Question A male client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. Nurse Trish first response is to: o A. Call the physician o B. Place a saline-soaked sterile dressing on the wound o C. Take blood pressure and pulse o D. Pull the dehiscence closed • 42. Question Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. During routine assessment, the nurse notices Cheyne- Stokes respirations. Cheyne-stokes respirations are: o A. Progressively deeper breath followed by shallower breaths with apneic periods. o B. Rapid, deep breathing with abrupt pauses between each breath. o Option C: The age of 40 is not an ideal age to start the testicular exams. It might be too late to detect a problem at this stage. Option B: Biot’s respirations are rapid, deep breathing with abrupt pauses between each breath, and equal depth between each breath. Option C: Kussmaul’s respirations are rapid, deep breathing without pauses. Option D: Tachypnea is shallow breathing with increased respiratory rate. Correct Answer: A. Progressively deeper breaths followed by shallower breaths with apneic periods. Cheyne-Stokes respirations are breaths that become progressively deeper followed by more shallow respirations with apneic periods. Option A: Tracheal breath sounds are auscultated over the trachea. Option C: Coarse crackles are caused by secretion accumulation in the airways. Option D: Friction rubs occur with pleural inflammation. Correct Answer: B. Fine crackles Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. o C. Rapid, deep breathing and irregular breathing without pauses. o D. Shallow breathing with an increased respiratory rate. • 43. Question Nurse Bea is assessing a male client with heart failure. The breath sounds commonly auscultated in clients with heart failure are: o A. Tracheal o B. Fine crackles o C. Coarse crackles o D. Friction rubs Option A: This would only be applicable if there is a complete obstruction, in which the client would not be able to cough anymore. Option B: If the client is unconscious, she should lay him down. Option C: A nurse should never leave a choking client alone. Correct Answer: D. Stay with him but not intervene at this time. If the client is coughing, he should be able to dislodge the object or cause complete obstruction. If a complete obstruction occurs, the nurse should perform the abdominal thrust maneuver with the client standing. • 47. Question Nurse Maureen is talking to a male client, the client begins choking on his lunch. He’s coughing forcefully. The nurse should: o A. Stand him up and perform the abdominal thrust maneuver from behind. o B. Lay him down, straddle him, and perform the abdominal thrust maneuver. o C. Leave him to get assistance. o D. Stay with him but not intervene at this time. o Option C: Excessive water won’t affect the chest tube drainage. The main purpose of the water seal is to allow air to exit from the pleural space on exhalation and prevent air from entering the pleural cavity or mediastinum on inhalation. o Option D: An excessive chest tube drainage cannot cause tension pneumothorax. Chest tubes drain blood, fluid, or air from around the lungs, heart, or esophagus. The tube around the lung is placed between the ribs and into the Option A: General health in the previous 10 years is important, however, the current activities of an 84- year-old client are most significant in planning care. Option C: Family history of disease for a client in later years is of minor significance. Option D: Marital status information may be important for discharge planning but is not as significant for addressing the immediate medical problem. Correct Answer: B. Current health promotion activities Recognizing an individual’s positive health measures is very useful. • 48. Question Nurse Ron is taking the health history of an 84-year-old client. Which information will be most useful to the nurse for planning care? o A. General health for the last 10 years o B. Current health promotion activities o C. Family history of diseases o D. Marital status • 49. Question When performing oral care on a comatose client, Nurse Krina should: o A. Apply lemon glycerin to the client’s lips at least every 2 hours. o B. Brush the teeth with a client lying supine. o C. Place the client in a side-lying position, with the head of the bed lowered. o D. Clean the client’s mouth with hydrogen peroxide. Option A: Lemon glycerin can be drying if used for extended periods. Option B: Brushing the teeth with the client lying supine may lead to aspiration. Option D: Hydrogen peroxide is caustic to tissues and should not be used. Correct Answer: C. Place the client in a side-lying position, with the head of the bed lowered. The client should be positioned in a side-lying position with the head of the bed lowered to prevent aspiration. A small amount of toothpaste should be used and the mouth swabbed or suctioned to remove pooled secretions. Option A: The client with ARDS has dyspnea and hypoxia with worsening hypoxia over time, if not treated aggressively. Option B: Pleuritic chest pain varies with respiration, unlike the constant chest pain during an MI; so this client most likely isn’t having an MI. Option D: The client with TB typically has a cough producing blood-tinged sputum. A sputum culture should be obtained to confirm the nurse’s suspicions. Correct Answer: C. Pneumonia Fever, productive cough, and pleuritic chest pain are common signs and symptoms of pneumonia. • 50. Question A 77-year-old male client is admitted with a diagnosis of dehydration and change in mental status. He’s being hydrated with I.V. fluids. When the nurse takes his vital signs, she notes he has a fever of 103°F (39.4°C) a cough producing yellow sputum and pleuritic chest pain. The nurse suspects this client may have which of the following conditions? o A. Adult respiratory distress syndrome (ARDS) o B. Myocardial infarction (MI) o C. Pneumonia o D. Tuberculosis Option A: Clients with ARDS have acute symptoms of hypoxia and typically need large amounts of oxygen. Option B: Clients with asthma do not exhibit a chronic cough. Symptoms of asthma include shortness of breath, chest tightness or pain, wheezing when exhaling, and coughing or wheezing attacks. Option D: Clients with emphysema tend not to have a chronic cough or peripheral edema. The main symptom of emphysema is shortness of breath, which usually begins gradually. Correct Answer: C. Chronic obstructive bronchitis Because of this extensive smoking history and symptoms, the client most likely has chronic obstructive bronchitis. • 54. Question Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two packs of cigarettes per day has a chronic cough producing thick sputum, peripheral edema, and cyanotic nail beds. Based on this information, he most likely has which of the following conditions? o A. Adult respiratory distress syndrome (ARDS) o B. Asthma o C. Chronic obstructive bronchitis o D. Emphysema • 55. Question Situation: Francis, age 46 is admitted to the hospital with a diagnosis of Chronic Lymphocytic Leukemia. The treatment for patients with leukemia is bone marrow transplantation. Which statement about bone marrow transplantation is not correct? o Option A: Beta-adrenergic blockers aren’t used to treat asthma and can cause bronchoconstriction. o Option C: Inhaled steroids are not ideal for emergency cases because of their slow onset. Correct Answer: D. Raise the side rails A patient who is disoriented is at risk of falling out of bed. The initial action of the nurse should be raising the side rails to ensure patients’ safety. Option B: An anticoagulant is often added to prevent cell clumping. Option C: The iliac crest is preferred for safety reasons, because there are no major blood vessels or organs located close to this area. Option D: Cyclophosphamide is given to prevent the incidence of graft-versus-host disease. Correct Answer: A. The patient is under local anesthesia during the procedure Before the procedure, the patient is administered with drugs that would help to prevent infection and rejection of the transplanted cells such as antibiotics, cytotoxic, and corticosteroids. During the transplant, the patient is placed under general anesthesia. o A. The patient is under local anesthesia during the procedure. o B. The aspirated bone marrow is mixed with heparin. o C. The aspiration site is the posterior or anterior iliac crest. o D. The recipient receives cyclophosphamide (Cytoxan) for 4 consecutive days before the procedure. • 56. Question After several days of admission, Francis becomes disoriented and complains of frequent headaches. The nurse in- charge first action would be: o A. Call the physician o B. Document the patient’s status in his charts o C. Prepare oxygen treatment o D. Raise the side rails Option B: The increase in WBCs most likely caused the anemia. Option C: The overcrowding of WBC pushes out the RBCs, thereby decreasing them and causing anemia. Option D: The lifespan of WBCs is 13 to 20 days, while the RBCs live for approximately 115 days. Correct Answer: A. Crowd red blood cells The excessive production of white blood cells crowds out red blood cells production which causes anemia to occur. • 57. Question During routine care, Francis asks the nurse, “How can I be anemic if this disease causes increased white blood cell production?” The nurse in-charge best response would be that the increased number of white blood cells (WBC) is: o A. Crowded red blood cells o B. Is not responsible for the anemia o C. Uses nutrients from other cells o D. Have an abnormally short lifespan of cells • 58. Question Diagnostic assessment of Francis would probably not reveal: o A. Predominance of lymphoblasts o B. Leukocytosis o C. Abnormal blast cells in the bone marrow o D. Elevated thrombocyte counts o Option A: Calling the physician would be unnecessary. These findings can be reported after ensuring the patient’s safety first. o Option B: After notifying the physician, the nurse should document these findings. o Option C: Oxygen treatment would be Option A: Barbiturate overdose may trigger respiratory depression and slow pulse. Option B: Opioids can cause marked respiratory depression. Option D: Benzodiazepines can cause drowsiness and confusion. Correct Answer: C. Cocaine Because of the client’s age and negative medical history, the nurse should question her about cocaine use. Cocaine increases myocardial oxygen consumption and can cause coronary artery spasm, leading to tachycardia, ventricular fibrillation, myocardial ischemia, and myocardial infarction. of 136beats/minutes. Breath sounds are clear and the respiratory rate is 26 breaths/minutes. Which of the following drugs should the nurse question the client about using? o A. Barbiturates o B. Opioids o C. Cocaine o D. Benzodiazepines • 62. Question A 51-year-old female client tells the nurse-in-charge that she has found a painless lump in her right breast during her monthly self- examination. Which assessment finding would strongly suggest that this client’s lump is cancerous? o A. Eversion of the right nipple and mobile mass o B. Nonmobile mass with irregular edges o C. Mobile mass that is soft and easily delineated o D. Nonpalpable right axillary lymph nodes Option A: Nipple retraction — not eversion — may be a sign of cancer. Option C: A mobile mass that is soft and easily delineated is most often a fluid-filled benign cyst. Option D: Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass. Correct Answer: B. Nonmobile mass with irregular edges Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. Option A: Less often, surgery is performed. Surgery is usually only used for small stage I or II vaginal cancers and for cancers that were not cured with radiation. Option B: Chemotherapy typically is prescribed only if vaginal cancer is diagnosed at an early stage, which is rare. Option D: Immunotherapy isn’t used to treat vaginal cancer. It is a type of cancer treatment that helps the immune system fight cancer. Immunotherapy is a type of biological therapy. Biological therapy is a type of treatment that uses substances made from living organisms to treat cancer. Correct Answer: C. Radiation The usual treatment for vaginal cancer is external or intravaginal radiation therapy. • 63. Question A 35-year-old client with vaginal cancer asks the nurse, “What is the usual treatment for this type of cancer?” Which treatment should the nurse name? o A. Surgery o B. Chemotherapy o C. Radiation o D. Immunotherapy Option A: No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis is classified as T0, N0, M0. Option C: If the tumor and regional lymph nodes can’t be assessed and no evidence of metastasis exists, the lesion is classified as TX, NX, M0. Option D: A progressive increase in tumor size, no demonstrable metastases of the regional lymph nodes, and ascending degrees of distant metastasis is classified as T1, T2, T3, or T4; N0; and M1, M2, or M3. Correct Answer: B. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis TIS, N0, M0 denotes carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis. • 64. Question Cristina undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, N0, M0. What does this classification mean? o A. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis. o B. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis. o C. Can’t assess tumor or regional lymph nodes and no evidence of metastasis. o D. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis. • 65. Question Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction? o A. “Keep the stoma uncovered.” Correct Answer: D. “Remain supine for the time specified by the physician.” The nurse should instruct the client to remain supine for the time specified by the physician. Option B: There is no protein serum antigen test for protein levels. Option C: There is no pneumococcal strep antigen test that tests for bacteria in pneumonia. Option D: There is no Papanicolau-specific antigen test available for cervical cancer. Correct Answer: A. Prostate-specific antigen, which is used to screen for prostate cancer. PSA stands for prostate-specific antigen, which is used to screen for prostate cancer. o A. Prostate-specific antigen, which is used to screen for prostate cancer. o B. Protein serum antigen, which is used to determine protein levels. o C. Pneumococcal strep antigen, which is a bacteria that causes pneumonia. o D. Papanicolaou-specific antigen, which is used to screen for cervical cancer. • 69. Question What is the most important postoperative instruction that nurse Kate must give a client who has just returned from the operating room after receiving a subarachnoid block? o A. “Avoid drinking liquids until the gag reflex returns.” o B. “Avoid eating milk products for 24 hours.” o C. “Notify a nurse if you experience blood in your urine.” o D. “Remain supine for the time specified by the physician.” Option A: Stool Hematest detects blood, which is a sign of colorectal cancer; however, the test doesn’t confirm the diagnosis. Option B: CEA may be elevated in colorectal cancer but isn’t considered a confirming test. Carcinoembryonic antigen is a protein normally found in very low levels in the blood of adults. It is most commonly used for colorectal cancer. Option D: An abdominal CT scan is used to stage the presence of colorectal cancer. Correct Answer: C. Sigmoidoscopy Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the detection of two-thirds of all colorectal cancers. • 70. Question A male client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis? o A. Stool Hematest o B. Carcinoembryonic antigen (CEA) o C. Sigmoidoscopy o D. Abdominal computed tomography (CT) scan • 71. Question During a breast examination, which finding most strongly suggests that the Luz has breast cancer? o A. Slight asymmetry of the breasts o B. A fixed nodular mass with dimpling of the overlying skin o Option A: Local anesthetics used in a subarachnoid block don’t alter the gag reflex. o Option B: No interactions between local anesthetics and food occur. Option A: Many women have slightly asymmetrical breasts. Option C: Bloody nipple discharge is a sign of intraductal papilloma, a benign condition. Option D: Multiple firm, round, freely movable masses that change with the menstrual cycle indicate fibrocystic breasts, a benign condition. Correct Answer: B. A fixed nodular mass with dimpling of the overlying skin A fixed nodular mass with dimpling of the overlying skin is common during the late stages of breast cancer. Option B: The colon is a rare cancer metastasis site. The most common pathway of metastatic spreading to the bowel is through peritoneal seeding, through hematogenous and lymphatic dissemination to the colon has also been reported. Option C: Metastasis rarely occurs in the reproductive tract. Ovary and vagina are the most frequent metastatic sites for extragenital and genital primaries. Correct Answer: A. Liver The liver is one of the five most common cancer metastasis sites. The others are the lymph nodes, lung, bone, and brain. o C. Bloody discharge from the nipple o D. Multiple firm, round, freely movable masses that change with the menstrual cycle • 72. Question A female client with cancer is being evaluated for possible metastasis. Which of the following is one of the most common metastasis sites for cancer cells? o A. Liver o B. Colon o C. Reproductive tract o D. White blood cells (WBCs)