NCLEX-RN Exam Pack Set 6 (75 Questions & Answers Latest Updated 2023), Exams of Nursing

Download NCLEX-RN Exam Pack Set 6 (75 Questions & Answers Latest Updated 2023) and more Exams Nursing in PDF only on Docsity! [Date] 1 NCLEX-RN EXAM PACK SET 6 (75 QUESTIONS & ANSWERS LATEST UPDATED 2023) 1. 1. Question After cardiac surgery, a client’s blood pressure measures 126/80 mm Hg. Nurse Katrina determines that mean arterial pressure (MAP) is which of the following? o A. 46 mm Hg o B. 80 mm Hg o C. 95 mm Hg o D. 90 mm Hg Correct Answer: C. 95 mm Hg Use the following formula to calculate MAP MAP = systolic + 2 (diastolic) MAP = 126 mm Hg + 2 (80 mm Hg) MAP = 286 mm Hg MAP = 95 mm Hg o Option A: 46 mmHg is according to the calculations. o Option B: 80 mmHg is inadequate according to the formula used in the computation. o Option D: 90 mmHg is according to the computation using the formula of mean arterial pressure. • 2. Question [Date] 2 A female client arrives at the emergency department with chest and stomach pain and a report of black tarry stool for several months. Which of the following orders should the nurse Oliver anticipate? o A. Cardiac monitor, oxygen, creatine kinase and lactate dehydrogenase levels o B. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split product values o C. Electrocardiogram, complete blood count, testing for occult blood, comprehensive serum metabolic panel o D. Electroencephalogram, alkaline phosphatase, and aspartate aminotransferase levels, basic serum metabolic panel Correct Answer: C. Electrocardiogram, complete blood count, testing for occult blood, comprehensive serum metabolic panel. An electrocardiogram evaluates the complaints of chest pain, laboratory tests determine anemia, and the stool test for occult blood determines blood in the stool. o Option A: Cardiac monitoring, oxygen, and creatine kinase, and lactate dehydrogenase levels are appropriate for a cardiac primary problem. A basic metabolic panel and alkaline phosphatase and aspartate aminotransferase levels assess liver function. o Option B: Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split products are [Date] 5 o A. Allogeneic o B. Autologous o C. Syngeneic o D. Xenogeneic Correct Answer: D. Xenogeneic A xenogeneic transplant is between a human and another species. o Option A: Allogeneic transplant is between two humans, o Option B: Autologous is a transplant from the same individual. o Option C: A syngeneic transplant is between identical twins. • 6. Question Marco falls off his bicycle and injures his ankle. Which of the following actions shows the initial response to the injury in the extrinsic pathway? Correct Answer: B. Release of tissue thromboplastin Tissue thromboplastin is released when damaged tissue comes in contact with clotting factors. o Option A: Calcium is released to assist the conversion of factors X to Xa. o Option C: Conversion of factors XII to XIIa are part of the intrinsic pathway. o Option D: Conversion factors VIII to VIIIa are part of the intrinsic pathway. o A. Release of Calcium o B. Release of tissue thromboplastin o C. Conversion of factors XII to factor XIIa o D. Conversion of factor VIII to factor VIIIa [Date] 6 • 7. Question Instructions for a client with systemic lupus erythematosus (SLE) would include information about which of the following blood dyscrasias? o A. Dressler’s syndrome o B. Polycythemia o C. Essential thrombocytopenia o D. Von Willebrand’s disease Correct Answer: C. Essential thrombocytopenia Essential thrombocytopenia is linked to immunologic disorders, such as SLE and the human immunodeficiency virus. o Option A: Dressler’s syndrome is pericarditis that occurs after myocardial infarction and isn’t linked to SLE. o Option B: Moderate to severe anemia is associated with SLE, not polycythemia. It is found in about 50% of patients, with anemia of chronic disease being the most common form. o Option D: Von Willebrand disease is a blood disorder in which the blood doesn’t clot properly. Blood contains many proteins that help the body stop bleeding. One of these proteins is called von Willebrand factor. • 8. Question The nurse is aware that the following symptom is most commonly an early indication of stage 1 Hodgkin’s disease? o A. Pericarditis o B. Night sweat o C. Splenomegaly o D. Persistent hypothermia [Date] 7 Correct Answer: B. Night sweat In stage 1, symptoms include a single enlarged lymph node (usually), unexplained fever, night sweats, malaise, and generalized pruritus. o Option A: Pericarditis refers to the inflammation of the pericardium, two thin layers of a sac-like tissue that surround the heart, hold it in place, and help it work. Pericarditis isn’t associated with Hodgkin’s disease, nor is hypothermia. Moreover, splenomegaly and pericarditis aren’t symptoms. o Option C: The spleen is involved in 20%-30% of cases of Hodgkin’s disease. Patients are usually asymptomatic. o Option D: Persistent hypothermia is associated with Hodgkin’s but isn’t an early sign of the disease. • 9. Question Francis with leukemia has neutropenia. Which of the following functions must be frequently assessed? Correct Answer: D. Breath sounds Pneumonia, both viral and fungal, is a common cause of death in clients with neutropenia, so frequent assessment of respiratory rate and breath sounds is required. o Option A: Blood pressure should be monitored regularly, but it is not a priority with neutropenia. o A. Blood pressure o B. Bowel sounds o C. Heart sounds o D. Breath sounds [Date] 10 An 18-year-old male client admitted with heat stroke begins to show signs of disseminated intravascular coagulation (DIC). Which of the following laboratory findings is most consistent with DIC? o A. Low platelet count o B. Elevated fibrinogen levels o C. Low levels of fibrin degradation products o D. Reduced prothrombin time Correct Answer: A. Low platelet count In DIC, platelets and clotting factors are consumed, resulting in microthrombi and excessive bleeding. As clots form, fibrinogen levels decrease and the prothrombin time increases. o Option B: Severe, rapidly evolving DIC is diagnosed by demonstrating thrombocytopenia, an elevated partial thromboplastin time and prothrombin time, increased levels of plasma D-dimers, and a decreasing plasma fibrinogen level. o Option C: Fibrin degradation products increase as fibrinolysis takes place. o Option D: Both PT and aPTT seem prolonged in about 50% of DIC cases which is attributed to the consumption of coagulation factors but can also be prolonged in impaired synthesis of coagulation factors and in massive bleeding. • 13. Question Mario comes to the clinic complaining of fever, drenching night sweats, and unexplained weight loss over the past 3 months. Physical examination reveals a [Date] 11 single enlarged supraclavicular lymph node. Which of the following is the most probable diagnosis? o A. Influenza o B. Sickle cell anemia o C. Leukemia o D. Hodgkin’s disease Correct Answer: D. Hodgkin’s disease Hodgkin’s disease typically causes fever night sweats, weight loss, and lymph node enlargement. o Option A: The incubation period ranges from 1 to 4 days. Peak virus shedding usually occurs from 1 day before the onset of symptoms to 3 days after. o Option B: Clients with sickle cell anemia manifest signs and symptoms of chronic anemia with pallor of the mucous membrane, fatigue, and decreased tolerance for exercise; they don’t show fever, night sweats, weight loss or lymph node enlargement. o Option C: In some cases, the signs of leukemia may include noticeable swelling of the neck, armpit, or groin. This occurs when leukemia has spread to the lymph nodes. • 14. Question A male client with a gunshot wound requires an emergency blood transfusion. His blood type is AB negative. Which blood type would be the safest for him to receive? [Date] 12 o A. AB Rh-positive o B. A Rh-positive o C. A Rh-negative o D. O Rh-positive Correct Answer: C. A Rh-negative Human blood can sometimes contain an inherited D antigen. Persons with the D antigen have Rh-positive blood type; those lacking the antigen have Rh-negative blood. It’s important that a person with Rh-negative blood receives Rh-negative blood. o Option A: A person with Rh-negative blood should also receive Rh-negative blood. o Option B: If Rh-positive blood is administered to an Rh-negative person, the recipient develops anti-Rh agglutinins, and subsequent transfusions with Rh- positive blood may cause serious reactions with clumping and hemolysis of red blood cells. o Option D: This blood type is still not compatible because it is Rh-positive. • 15. Question Stacy was diagnosed with acute lymphoid leukemia (ALL). She was discharged from the hospital following her chemotherapy treatments. Which statement of Stacy’s mother indicated that she understands when she will contact the physician? o A. “I should contact the physician if Stacy has difficulty in sleeping”. o B. “I will call my doctor if Stacy has persistent vomiting and diarrhea”. [Date] 15 oA. Provide frequent mouthwash with normal saline. oB. Apply viscous Lidocaine to oral ulcers as needed. o C. Use lemon glycerine swabs every 2 hours. o D. Rinse mouth with Hydrogen Peroxide. Correct Answer: B. Apply viscous Lidocaine to oral ulcers as needed. Stomatitis can cause pain and this can be relieved by applying topical anesthetics such as lidocaine before mouth care. o Option A: Before providing oral care, ensure that the patient is comfortable with the procedure first. o Option C: Use saline solution mixed with equal parts of water or hydrogen peroxide or oral care. o Option D: When the patient is already comfortable, the nurse can proceed with providing the patient with oral rinses of saline solution mixed with equal parts of water or hydrogen peroxide mixed water in 1:3 concentrations to promote oral hygiene. Every 2-4 hours. • 18. Question During the administration of chemotherapy agents, Nurse Oliver observed that the IV site is red and swollen when the IV is touched Stacy shouts in pain. The first nursing action to take is: o A. Notify the physician. o B. Flush the IV line with saline solution. o C. Immediately discontinue the infusion. o D. Apply an ice pack to the site, followed by warm compress. [Date] 16 Correct Answer: C. Immediately discontinue the infusion. Edema or swelling at the IV site is a sign that the needle has been dislodged and the IV solution is leaking into the tissues causing the edema. The patient feels pain as the nerves are irritated by pressure and the IV solution. The first action of the nurse would be to discontinue the infusion right away to prevent further edema and other complications. o Option A: After discontinuing the infusion, the nurse should notify the physician. o Option B: Flushing may aggravate the edema since the IV cannula might be dislodged. o Option D: Compresses may be given as indicated by the physician. • 19. Question The term “blue bloater” refers to a male client which of the following conditions? o A. Adult respiratory distress syndrome (ARDS) o B. Asthma o C. Chronic obstructive bronchitis o D. Emphysema Correct Answer: C. Chronic obstructive bronchitis Clients with chronic obstructive bronchitis appear bloated; they have large barrel chest and peripheral edema, cyanotic nail beds, and at times, [Date] 17 circumoral cyanosis. o Option A: Clients with ARDS are acutely short of breath and frequently need intubation for mechanical ventilation and large amounts of oxygen. o Option B: Clients with asthma don’t exhibit characteristics of chronic disease. o Option D: Clients with emphysema appear pink and cachectic. • 20. Question The term “pink puffer” refers to the female client with which ofthe following conditions? o A. Adult respiratory distress syndrome (ARDS) o B. Asthma o C. Chronic obstructive bronchitis o D. Emphysema Correct Answer: D. Emphysema Because of the large amount of energy it takes to breathe, clients with emphysema are usually cachectic. They’re pink and usually breathe through pursed lips, hence the term “puffer.” o Option A: Clients with ARDS are usually acutely short of breath. o Option B: Clients with asthma don’t have any particular characteristics. o Option C: Clients with chronic obstructive [Date] 20 o Option D: Rheumatoid arthritis is an autoimmune and inflammatory disease, which means that the immune system attacks healthy cells in the body by mistake, causing inflammation in the affected parts of the body. • 24. Question Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver which laboratory test indicates liver cirrhosis? o A. Decreased red blood cell count o B. Decreased serum acid phosphatase level o C. Elevated white blood cell count o D. Elevated serum aminotransferase Correct Answer: D. Elevated serum aminotransferase Hepatic cell death causes the release of liver enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST), and lactate dehydrogenase (LDH) into the circulation. Liver cirrhosis is a chronic and irreversible disease of the liver characterized by generalized inflammation and fibrosis of the liver tissues. o Option A: Decreased red blood cell count may indicate anemia. o Option B: Serum acid phosphatase is an enzyme that acts to liberate phosphate under acidic conditions. Until now, low values cannot be determined with certainty. o Option C: A high white blood cell count usually indicates increased production of white blood cells to fight infection. • 25. Question The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales is at increased risk for excessive bleeding primarily because of: [Date] 21 o A. Impaired clotting mechanism o B. Varix formation o C. Inadequate nutrition o D. Trauma of invasive procedure Correct Answer: A. Impaired clotting mechanism Cirrhosis of the liver results in decreased Vitamin K absorption and formation of clotting factors resulting in impaired clotting mechanism. o Option B: Esophageal varices sometimes form when blood flow to the liver is blocked, most often by scar tissue in the liver caused by liver disease. o Option C: Inadequate nutrition alone cannot cause excessive bleeding in cirrhosis. o Option D: An invasive procedure may cause trauma that may result in bleeding, but the client has not yet undergone any invasive procedure. • 26. Question Mr. Jay develops hepatic encephalopathy. Which clinical manifestation is most common with this condition? o A. Increased urine output o B. Altered level of consciousness o C. Decreased tendon reflex o D. Hypotension [Date] 22 Correct Answer: B. Altered level of consciousness Changes in behavior and level of consciousness are the first signs of hepatic encephalopathy. Hepatic encephalopathy is caused by liver failure and develops when the liver is unable to convert protein metabolic product ammonia to urea. This results in accumulation of ammonia and other toxic in the blood that damages the cells. o Option A: The main cause of renal dysfunction in inpatients with liver disease is prerenal failure; specifically, the cause is a reduction in perfusion of the kidneys. o Option C: It must be emphasized that the flapping tremor of the extremities is also observed in patients with uremia, pulmonary insufficiency, and barbiturate toxicity. o Option D: A diseased liver can cause portal hypertension, which is high blood pressure in the portal vein. The portal vein supplies the liver with blood. Over time, this pressure causes blood vessels to grow, called collateral blood vessels. These vessels act as channels to divert the blood under high pressure. • 27. Question Patrick who is diagnosed with liver cirrhosis is experiencing symptoms of hepatic encephalopathy. The physician ordered 50ml of Lactulose p.o. every 2 hours. Patrick suddenly develops diarrhea. The nurse best action would be: o A. “I’ll see if your physician is in the hospital”. o B. “Maybe you’re reacting to the drug; I will withhold the next dose”. o C. “I’ll lower the dosage as ordered so the drug causes only 2 to 4 stools a day”. o D. “Frequently, bowel movements are needed to reduce sodium level”. [Date] 25 o A. Call for help. o B. Obtain vital signs. o C. Ask the client to “lift up”. o D. Apply gloves and assess the groin site. Correct Answer: D. Apply gloves and assess the groin site. Observing standard precautions is the first priority when dealing with any blood fluid. Assessment of the groin site is the second priority. This establishes where the blood is coming from and determines how much blood has been lost. The goal in this situation is to stop the bleeding. o Option A: The nurse would call for help if it were warranted after the assessment of the situation. o Option B: After determining the extent of the bleeding, vital signs assessment is important. o Option C: The nurse should never move the client, in case a clot has formed. Moving can disturb the clot and cause rebleeding. • 30. Question Which of the following treatments is a suitable surgical intervention for a client with unstable angina? o A. Cardiac catheterization o B. Echocardiogram o C. Nitroglycerin o D. Percutaneous transluminal coronary angioplasty (PTCA) [Date] 26 Correct Answer: D. Percutaneous transluminal coronary angioplasty (PTCA) PTCA can alleviate the blockage and restore blood flow and oxygenation. o Option A: Cardiac catheterization is a diagnostic tool – not a treatment. It is a procedure used to diagnose and treat certain cardiovascular conditions. o Option B: An echocardiogram is a non-invasive diagnostic test. It is a graphic outline of the heart’s movement. o Option C: Nitroglycerin is an oral sublingual medication. It is a vasodilatory drug used primarily to provide relief from anginal chest pain. • 31. Question The nurse is aware that the following terms used to describe reduced cardiac output and perfusion impairment due to ineffective pumping of the heart is: o A. Anaphylactic shock o B. Cardiogenic shock o C. Distributive shock o D. Myocardial infarction (MI) Correct Answer: B. Cardiogenic shock Cardiogenic shock is shock related to ineffective pumping of the heart. o Option A: Anaphylactic shock results from an allergic reaction. This severe reaction happens when an over- release of chemicals puts the person into shock. o Option C: Distributive shock results from changes in the intravascular volume distribution and is usually associated [Date] 27 with increased cardiac output. o Option D: MI isn’t a shock state, though in most cases, a lack of oxygen to the heart, usually from a heart attack, damages its main pumping chamber. Without oxygen-rich blood circulating to that area of the heart, the heart muscle can weaken and go into cardiogenic shock. • 32. Question A client with hypertension asks the nurse which factors can causeblood pressure to drop to normal levels? o A. Kidneys’ excretion to sodium only. o B. Kidneys’ retention of sodium and water. o C. Kidneys’ excretion of sodium and water. o D. Kidneys’ retention of sodium and excretion of water. Correct Answer: C. Kidneys’ excretion of sodium and water. The kidneys respond to rise in blood pressure by excreting sodium and excess water. This response ultimately affects systolic blood pressure by regulating blood volume. o Option A: As the kidneys excrete sodium, water also goes along with it. o Option B: Sodium or water retention would only further increase blood pressure. o Option D: Sodium and water travel together across the membrane in the kidneys; one can’t travel without the other. • 33. Question [Date] 30 Arnold, a 19-year-old client with a mild concussion is discharged from the emergency department. Before discharge, he complains of a headache. When offered acetaminophen, his mother tells the nurse the headache is severe and she would like her son to have something stronger. Which of the following responses by the nurse is appropriate? o A. “Your son had a mild concussion, acetaminophen isstrong enough.” o B. “Aspirin is avoided because of the danger of Reye’s syndrome in children or young adults.” o C. “Narcotics are avoided after a head injury because they may hide a worsening condition.” o D. Stronger medications may lead to vomiting, whichincreases the intracranial pressure (ICP).” Correct Answer: C. Narcotics are avoided after a head injury because they may hide a worsening condition. Narcotics may mask changes in the level of consciousness that indicate increased ICP. o Option A: Acetaminophen is strong enough ignores the mother’s question and therefore isn’t appropriate. o Option B: Aspirin is contraindicated in conditions that may have bleeding, such as trauma, and for children or young [Date] 31 adults with viral illnesses due to the danger of Reye’s syndrome. o Option D: Stronger medications may not necessarily lead to vomiting but will sedate the client, thereby masking changes in his level of consciousness. • 36. Question When evaluating an arterial blood gas from a male client with a subdural hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following responses best describes the result? o A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). o B. Emergent; the client is poorly oxygenated. o C. Normal. o D. Significant; the client has alveolar hypoventilation. Correct Answer: A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP) A normal Paco2 value is 35 to 45 mm Hg CO2 has vasodilating properties; therefore, lowering Paco2 through hyperventilation will lower ICP caused by dilated cerebral vessels. o Option B: Oxygenation is evaluated through Pao2 and oxygen saturation. o Option C: The normal PaCO2 level is between 35 to 45 mmHg. PaCO2 or the partial pressure of carbon dioxide is the measure of carbon dioxide within arterial or venous blood. o Option D: Alveolar hypoventilation would be reflected in an [Date] 32 increased Paco2. Alveolar hypoventilation is defined as insufficient ventilation leading to hypercapnia, which is an increase in the partial pressure of carbon dioxide as measured by arterial blood gas analysis. • 37. Question When prioritizing care, which of the following clients should the nurse Olivia assess first? o A. A 17-year-old client 24-hours post appendectomy. o B. A 33-year-old client with a recent diagnosis of Guillain- Barre syndrome. o C. A 50-year-old client 3 days post myocardial infarction. o D. A 50-year-old client with diverticulitis. Correct Answer: B. A 33-year-old client with a recent diagnosis of GuillainBarre syndrome Guillain-Barre syndrome is characterized by ascending paralysis and potential respiratory failure. The order of client assessment should follow client priorities, with disorder of airways, breathing, and then circulation. o Option A: The client who is post appendectomy has no signs of hemorrhage or unstable vital signs. Possible complications of appendectomy are bleeding, wound infection, peritonitis, blocked bowels, [Date] 35 over 32.5 million US adults. o Option D: Osteoarthritis can affect people of any age, but are most common among the elderly. Women are more likely to develop QA than men, especially after the age of 50. • 40. Question Ruby is receiving thyroid replacement therapy, develops the flu, and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication will put the client at risk for developing which of the following life- threatening complications? o A. Exophthalmos o B. Thyroid storm o C. Myxedema coma o D. Tibial myxedema Correct Answer: C. Myxedema coma Myxedema coma, severe hypothyroidism, is a life-threatening condition that may develop if thyroid replacement medication isn’t taken. o Option A: Exophthalmos, protrusion of the eyeballs, is seen with hyperthyroidism. If a person’s immune system attacks the thyroid gland, it may react by producing extra hormones. The autoimmune antibodies can attack the muscles and soft tissue surrounding the eyes, which can cause them to protrude from the sockets. o Option B: Thyroid storm is life-threatening but is caused by severe hyperthyroidism. It is also referred to as thyrotoxic crisis, an acute, life-threatening hypermetabolic state induced by excessive release of thyroid hormones. o Option D: Tibial myxedema, peripheral mucinous edema involving the lower leg, is associated with hypothyroidism but isn’t life-threatening [Date] 36 • 41. Question Nurse Sugar is assessing a client with Cushing’s syndrome. Which observation should the nurse report to the physician immediately? o A. Pitting edema of the legs o B. An irregular apical pulse o C. Dry mucous membranes o D. Frequent urination Correct Answer: B. An irregular apical pulse Because Cushing’s syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician. o Option A: Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention. o Option C: Dry mucous membranes is not a symptom of Cushing’s syndrome. Thinning of the skin and mucous membranes occur because cortisol causes the breakdown of some dermal proteins along with the weakening of small blood vessels. o Option D: Frequent urination signals dehydration, which isn’t associated with Cushing’s syndrome. Short term administration of adrenocorticotropic hormone or glucocorticoids causes an increased glomerular filtration rate. Glomerular dysfunction leads to proteinuria and albuminuria. • 42. Question Cyrill with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later, the client’s urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse’s suspicion of diabetes insipidus? [Date] 37 o A. Above-normal urine and serum osmolality levels. o B. Below- normal urine and serum osmolality levels. o C. Above-normal urine osmolality level, below-normal serum osmolality level. o D. Below-normal urine osmolality level, above- normal serum osmolality level. Correct Answer: D. Below-normal urine osmolality level, above-normal serum osmolality level In diabetes insipidus, excessive polyuria causes dilute urine, resulting in a below-normal urine osmolality level. At the same time, polyuria depletes the body of water, causing dehydration that leads to an above-normal serum osmolality level. o Option A: Urine osmolality level should be below normal because of excessive polyuria. o Option B: Serum osmolality levels should be above normal because of dehydration. o Option C: For the same reasons, diabetes insipidus doesn’t cause above-normal urine osmolality or below- normal serum osmolality levels. • 43. Question Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which of the following statements indicates that the client understands her condition and how to control it? [Date] 40 o A. “I’ll take my hydrocortisone in the late afternoon, before dinner.” o B. “I’ll take all of my hydrocortisone in the morning, right after I wake up.” o C. “I’ll take two-thirds of the dose when I wake up and one- third in the late afternoon.” o D. “I’ll take the entire dose at bedtime.” Correct Answer: C. “I’ll take two-thirds of the dose when I wake up and one-third in the late afternoon.” Hydrocortisone, a glucocorticoid, should be administered according to a schedule that closely reflects the body’s own secretion of this hormone; therefore, two-thirds of the dose of hydrocortisone should be taken in the morning and one-third in the late afternoon. This dosage schedule reduces adverse effects. o Option A: Taking the medicine at this schedule may cause adverse effects. o Option B: The dosage should be according to the imitation of when the body secretes glucocorticoids. o Option D: Taking an entire dose might cause severe adverse effects. • 46. Question Which of the following laboratory test results would suggest to the nurse Len that a client has a corticotropin-secreting pituitary adenoma? o A. High corticotropin and low cortisol levels o B. Low corticotropin and high cortisol levels o C. High corticotropin and high cortisol levels [Date] 41 o D. Low corticotropin and low cortisol levels Correct Answer: C. High corticotropin and high cortisol levels A corticotropin-secreting pituitary tumor would cause high corticotropin and high cortisol levels. o Option A: Cortisol levels should also be elevated in corticotropin-secreting pituitary adenoma. o Option B: Low corticotropin and high cortisol levels would be seen if there was a primary defect in the adrenal glands. o Option D: A low corticotropin level with a low cortisol level would be associated with hypocortisolism. • 47. Question A male client is scheduled for a transsphenoidal hypophysectomy to remove a pituitary tumor. Preoperatively, the nurse should assess for potential complications by doing which of the following? o A. Testing for ketones in the urine. o B. Testing urine specific gravity. o C. Checking temperature every 4 hours. o D. Performing capillary glucose testing every 4 hours. Correct Answer: D. Performing capillary glucose testing every 4 hours. The nurse should perform capillary glucose testing every 4 hours because excess cortisol may cause insulin resistance, placing the client at risk for hyperglycemia. [Date] 42 o Option A: Urine ketone testing isn’t indicated because the client does secrete insulin and, therefore, isn’t at risk for ketosis. o Option B: Urine specific gravity isn’t indicated because although fluid balance can be compromised, it usually isn’t dangerously imbalanced. o Option C: Temperature regulation may be affected by excess cortisol and isn’t an accurate indicator of infection. • 48. Question Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Nurse Mariner should expect the dose’s: o A. Onset to be at 2 p.m. and its peak to be at 3 p.m. o B. Onset to be at 2:15 p.m. and its peak to be at 3 p.m. o C. Onset to be at 2:30 p.m. and its peak to be at 4 p.m. o D. Onset to be at 4 p.m. and its peak to be at 6 p.m. Correct Answer: C. Onset to be at 2:30 p.m. and its peak to be at 4 p.m. Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m. [Date] 45 Correct Answer: B. “Rotate injection sites within the same anatomic region, not among different regions.” The nurse should instruct the client to rotate injection sites within the same anatomic region. Rotating sites among different regions may cause excessive day-to-day variations in the blood glucose level; also, insulin absorption differs from one region to the next. o Option A: Insulin should be injected only into healthy tissue lacking large blood vessels, nerves, or scar tissue, or other deviations. o Option C: Injecting insulin into areas of hypertrophy may delay absorption. The client shouldn’t inject insulin into areas of lipodystrophy (such as hypertrophy or atrophy); to prevent lipodystrophy, the client should rotate injection sites systematically. o Option D: Exercise speeds drug absorption, so the client shouldn’t inject insulin into sites above muscles that will be exercised heavily. • 51. Question Nurse Sarah expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate? o A. Elevated serum acetone level. o B. Serum ketone bodies. o C. Serum alkalosis. o D. Below-normal serum potassium level. [Date] 46 Correct Answer: D. Below-normal serum potassium level. A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency. o Option A: An elevated serum acetone level is a symptom of diabetic ketoacidosis. Hepatic metabolism of free fatty acids as an alternative energy source results in accumulation of acidic intermediate and end metabolites (ie, ketones). Ketone bodies have generally included acetone, a true ketone. o Option B: Serum ketone bodies are characteristic of diabetic ketoacidosis. Ketone bodies are produced from acetyl coenzyme A mainly in the mitochondria within hepatocytes when carbohydrate utilization is impaired because of relative or absolute insulin deficiency, such that energy must be obtained from fatty acid metabolism. o Option C: Metabolic acidosis, not serum alkalosis, may occur in HHNS. A wide anion gap can be observed in patients with HHNS. The mild acidosis in HHNS is often multifactorial and results, in part, from the accumulation of minimal ketoacids in the absence of effective insulin activity. • 52. Question For a client with Graves’ disease, which nursing intervention promotes comfort? o A. Restricting intake of oral fluids. o B. Placing extra blankets on the client’s bed. o C. Limiting intake of high-carbohydrate foods. o D. Maintaining room temperature in the low- normal range. [Date] 47 Correct Answer: D. Maintaining room temperature in the low-normal range. Graves’ disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client’s room temperature in the low-normal range. o Option A: To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. o Option B: Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. o Option C: To provide needed energy and calories, the nurse should encourage the client to eat high- carbohydrate foods. • 53. Question Patrick is treated in the emergency department for a Colles’ fracture sustained during a fall. What is a Colles’ fracture? o A. Fracture of the distal radius. o B. Fracture of the olecranon. o C. Fracture of the humerus. o D. Fracture of the carpal scaphoid. Correct Answer: A. Fracture of the distal radius. Colles’ fracture is a fracture of the distal radius, such as from a fall on an outstretched hand. It’s most common in women. o Option B: Colles’ fracture does not involve the olecranon. Most Colles fractures are secondary to a fall on an outstretched hand with a pronated forearm in dorsiflexion. [Date] 50 • 56. Question A 67-year-old client develops acute shortness of breath and progressive hypoxia requiring right femur. The hypoxia was probably caused by which of the following conditions? o A. Asthma attack o B. Atelectasis o C. Bronchitis o D. Fat embolism Correct Answer: D. Fat embolism Long bone fractures are correlated with fat emboli, which cause shortness of breath and hypoxia. o Option A: Asthma attacks do not develop following a femoral fracture. o Option B: He could develop atelectasis but it typically doesn’t produce progressive hypoxia. o Option C: It’s unlikely the client has developed bronchitis without a previous history. • 57. Question A client with shortness of breath has decreased to absent breath sounds on the right side, from the apex to the base. Which of the following conditions would best explain this? o A. Acute asthma o B. Chronic bronchitis o C. Pneumonia o D. Spontaneous pneumothorax [Date] 51 Correct Answer: D. Spontaneous pneumothorax A spontaneous pneumothorax occurs when the client’s lung collapses, causing an acute decrease in the amount of functional lung used in oxygenation. The sudden collapse was the cause of his chest pain and shortness of breath. o Option A: An asthma attack would show wheezing breath sounds. o Option B: Bronchitis would have rhonchi. o Option C: Pneumonia would have bronchial breath sounds over the area of consolidation. • 58. Question A 62-year-old male client was in a motor vehicle accident as an unrestrained driver. He’s now in the emergency department complaining of difficulty of breathing and chest pain. On auscultation of his lung field, no breath sounds are present in the upper lobe. This client may have which of the following conditions? o A. Bronchitis o B. Pneumonia o C. Pneumothorax o D. Tuberculosis (TB) Correct Answer: C. Pneumothorax Pneumothorax is defined as the presence of air or gas in the pleural cavity, which can impair oxygenation and/or ventilation. o Option A: Rhonchi is heard with bronchitis. o Option B: From the trauma the client experienced, it’s unlikely he has pneumonia. [Date] 52 Pneumonia may produce crackling, bubbling, and rumbling sounds when inhaling upon auscultation. o Option D: Bronchial breath sounds with TB would be heard. • 59. Question If a client requires a pneumonectomy, what fills the area of the thoracic cavity? o A. The space remains filled with air only. o B. The surgeon fills the space with a gel. o C. Serous fluids fill the space and consolidate the region. o D. The tissue from the other lung grows over to the other side. Correct Answer: C. Serous fluids fill the space and consolidate the region Serous fluid fills the space and eventually consolidates, preventing extensive mediastinal shift of the heart and remaining lung. o Option A: Air can’t be left in space. Air in the chest cavity is called a pneumothorax, and it may cause the lungs to collapse. o Option B: There’s no gel that can be placed in the pleural space. The pleural cavity is the space that lies between the pleura, the two thin membranes that line and surround the lungs. It contains a small amount of liquid known as pleural fluid. o Option D: The tissue from the other lung can’t cross the mediastinum, although a temporary mediastinal shift exists until space is filled. • 60. Question [Date] 55 • 63. Question Nurse Michelle calculates the IV flow rate for a postoperative client. The client receives 3,000 ml of Ringer’s lactate solution IV to run over 24 hours. The IV infusion set has a drop factor of 10 drops per milliliter. The nurse should regulate the client’s IV to deliver how many drops per minute? o A. 18 o B. 21 o C. 35 o D. 40 Correct Answer: B. 21 3000 x 10 divided by 24 x 60. o Option A: 18 is according to the formula used. o Option C: 35 is more than the prescribed gtts/minute as calculated. o Option D: 40 is more than the correct gtts/minute as calculated. • 64. Question Mickey, a 6-year-old child with a congenital heart disorder is admitted with congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The bottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amount should the nurse administer to the child? o A. 1.2 ml o B. 2.4 ml o C. 3.5 ml o D. 4.2 ml Correct Answer: B. 2.4 ml .05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4 ml. [Date] 56 o Option A: 1.2 ml is less than the correct dosage and may not produce the desired effects of the drug. o Option C: 3.5 ml is more than the correct dosage as calculated and may produce adverse effects. o Option D: 4.2 ml is an dosage according to the formula used. • 65. Question Nurse Alexandra teaches a client about elastic stockings. Which of the following statements, if made by the client, indicates to the nurse that the teaching was successful? o A. “I will wear the stockings until the physician tells me to remove them.” o B. “I should wear the stockings even when I am asleep.” o C. “Every four hours I should remove the stockings for a half hour.” o D. “I should put on the stockings before getting out of bed in the morning.” Correct Answer: D. “I should put on the stockings before getting out of bed in the morning. Promote venous return by applying external pressure on veins. o Option A: The stockings may be removed before going to bed and worn again before getting out of bed. o Option B: Wearing stockings while sleeping is unnecessary. The mechanisms by which wearing elastic stockings prevent DVT are prevention of blood stasis by increasing the blood flow volume and decrease of the caliber of venous blood vessels by compression of the lower limbs. o Option C: The stockings should be worn the whole day and removed before going to sleep. [Date] 57 • 66. Question The primary reason for rapid continuous rewarming of the area affected by frostbite is to: o A. Lessen the amount of cellular damage o B. Prevent the formation of blisters o C. Promote movement o D. Prevent pain and discomfort Correct Answer: A. Lessen the amount of cellular damage Rapid continuous rewarming of frostbite primarily lessens cellular damage. Rapid rewarming is the single most effective therapy for frostbite. Heat conduction and radiation from deeper tissue circulation prevent freezing and ice crystallization until the skin temperature drops below 0°C. o Option B: Blisters contain high amounts of thromboxane and prostaglandins. They contract and dry within 2-3 weeks, forming a dark eschar that sloughs off in 4 weeks. o Option C: Before movement can be improved, the cell injury should be resolved first. o Option D: It does not prevent the formation of blisters. It does promote movement, but this is not the primary reason for rapid rewarming. It might increase pain for a short period of time as the feeling comes back into the extremity. • 67. Question [Date] 60 o D. Tell the client that he should remain in isolation for 2 weeks Correct Answer: B. Contact the physician for an order for immune globulin The client who is immunosuppressed and is exposed to measles should be treated with medications to boost his immunity to the virus. If the patient knows that he has been exposed to measles and his CD4 count is less than 200, he should talk to his doctor about whether post-exposure prophylaxis (PEP) with immunoglobulin may be an option. PEP may provide some protection or lessen the severity of infection if it occurs. If the CD4 count is 200 or greater, PEP can also include getting the MMR vaccine. Ideally, PEP should be administered within 72 hours of exposure to measles. o Option A: Antibiotics may not be an effective treatment. One important characteristic of measles infection is that it produces more serious illness and increased mortality among immunocompromised individuals, primarily those with defects in T-cell immunity. Because >90% of the human immunodeficiency virus (HIV)–infected children live in regions where measles is still endemic, achieving high rates of measles vaccine coverage is especially important among these populations to suppress excess measles-associated morbidity and mortality. o Option C: Antivirals would not be as effective as immunoglobulins for the client with AIDS. Early identification and antiretroviral treatment of HIV- infected infants and children are critical to maximizing measles vaccine immunogenicity and providing protection against other HIV- related complications. o Option D: The patient should remain in isolation, but the administration of immunoglobulin is a priority. The impact of HIVrelated immunocompromise and subsequent effects of antiretroviral therapy (ART) on immune reconstitution and, [Date] 61 ultimately, on vaccine immunogenicity is unclear. • 69. Question A client ho spitalized with MRSA (methicillin-resistant staph aureus) is placed on contact pre cautions. Which statement is true reg arding precautions for infections spread by contact? o A. The client should be placed in a room with negative pressure. o B. Infection requires close contact; therefore, the door may remain open. o C. Transmission is highly likely, so the client should wear a mask at all times. o D. Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown. [Date] 62 Correct Answer: D. Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown. The client with MRSA should be placed in isolation. Gloves, a gown, and a mask should be used when caring for the client and hand washing is very important. o Option A: The door should remain closed, but a negative- pressure room is not necessary. Whenever possible, patients with MRSA will have a single room or will share a room only with someone else who also has MRSA. o Option B: MRSA is spread by contact with blood or body fluid or by touching the skin of the client. Patients are asked to stay in their hospital rooms as much as possible. They should not go to common areas, such as the gift shop or cafeteria. They may go to other areas of the hospital for treatments and tests. o Option C: It is cultured from the nasal passages of the client, so the client should be instructed to cover his nose and mouth when he sneezes or coughs. It is not necessary for the client to wear the mask at all times; the nurse should wear the mask. • 70. Question A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates an understanding of phantom limb pain? o A. "The pain will go away in a few days." [Date] 65 that’s confined to the head of the pancreas. After performing the Whipple procedure, the surgeon reconnects the remaining organs to allow the client to digest food normally after surgery. o Option B: Small bowel resection is surgery to remove a part of the small bowel. It is done when part of the small bowel is blocked or diseased. o Option C: A gastrectomy is the surgical removal of all or part of the stomach. The stomach is a J-shaped organ in the upper abdomen. It is part of the digestive system, which processes nutrients ( vitamins, minerals, carbohydrates, fats, proteins, and water) in foods that are eaten and help pass waste material out of the body. A partial gastrectomy is the removal of only part of the stomach. The remaining portion then continues with its digestive role. If the entire stomach is removed, the esophagus is connected directly to the small intestine, where digestion now begins. Patients must make significant dietary changes when a gastrectomy is performed. o Option D: Jejunal interposition is a procedure in which surgeons replace the missing section of a child’s esophagus with a section of the jejunum (the middle part of the small intestine). It is used to treat children who have already undergone failed repair of long-gap esophageal atresia and for whom the Foker process isn’t an option. • 72. Question The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to avoid eating: o A. Packed fruits o B. Salt o C. Fresh raw pepper o D. Ketchup [Date] 66 Correct Answer: C. Fresh raw pepper Fresh raw or whole pepper is not allowed unless thoroughly cooked in food. A low-bacteria diet is designed to reduce exposure to bacteria and other pathogens that can make one sick. It’s often prescribed for people who are at a greater risk of infection because they’re currently not making enough white blood cells due to certain illnesses or medical treatments. o Option A: Canned fruits are allowed since they are processed and pasteurized. Fresh fruits and vegetables are fine as long as they are washed first or cooked thoroughly. Meat, fish, and eggs should also be fully cooked. Commercially prepared and packaged foods are acceptable but avoid buying foods indented and swollen cans or damaged packaging. o Option B: Salt is allowed. The keys to a low-bacteria diet are choosing foods that are less likely to carry bacteria while avoiding the foods that do. Frequent hand washing and paying particular attention to food safety practices are also essential. o Option D: Ketchup is also allowed. Bread, ready-to- eat cereals, pancakes, waffles, and crackers are safe to eat. Bottled beverages, hot beverages, and pasteurized fruit and vegetable juices are good as well. Cream cheese, sour cream, mayonnaise, margarine, commercial peanut butter, and chocolate are okay, too. • 73. Question A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to: o A. Have a Protime done monthly o B. Eat more fruits and vegetables o C. Drink more liquids o D. Avoid crowds [Date] 67 Correct Answer: A. Have a Protime done monthly Coumadin is an anticoagulant. One of the tests for bleeding time is a Protime. This test should be done monthly. The client will need to have his blood tested to tell how well the medication is working. The blood test, called prothrombin time (PT or protime), is used to calculate the International Normalized Ratio (INR). INR helps the healthcare provider determine how well warfarin is working to prevent blood clots and if the dose needs to be adjusted. o Option B: Eating more fruits and vegetables is not necessary, and dark-green vegetables contain vitamin K, which increases clotting. Vitamin K is needed for normal blood clotting. However, large changes in the amount of vitamin K in the diet can change the way warfarin works. If the client eats foods high in vitamin K, it’s important to keep a weekly intake of vitamin K- containing foods consistent. o Option C: Drinking more liquids could boost the platelet count and increase the body’s immunity. Do not start consuming the following herbal teas and supplements because they may affect the INR, causing it to be too high or too low. If the client drinks tea, black tea (such as orange pekoe tea) is acceptable because it is not high in Vitamin K. o Option D: Avoiding crowds is important for patients with decreased WBC. Stay away from people who are ill. Avoid contact with anyone who has recently been vaccinated, including infants and children. Avoid crowds as much as possible. When going to places where there are often a lot of people (i.e., church, shopping), try going at off-peak times, when they are not as crowded. • 74. Question