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

Download NCLEX-RN Exam Pack Set 6 (75 Questions & Answers Updated 2023)NCLEX-RN Exam Pack Set 6 (75 and more Exams Nursing in PDF only on Docsity! NCLEX-RN Exam Pack Set 6 (75 Questions & Answers Updated 2022) 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 • 2. Question 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 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. 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 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 • 3. Question Olivia had coronary artery bypass graft (CABG) surgery 3 days ago. Which of the following conditions is suspected by the nurse when a decrease in platelet count from 230,000 ul to 5,000 ul is noted? o A. Pancytopenia o B. Idiopathic thrombocytopenic purpura (ITP) o C. Disseminated intravascular coagulation (DIC) 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 measured to verify bleeding dyscrasias. o Option D: An electroencephalogram evaluates brain electrical activity. 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. • 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 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. Correct Answer: B. Release of tissue thromboplastin Tissue thromboplastin is released when damaged tissue comes in contact with clotting factors. 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. Correct Answer: C. Essential thrombocytopenia Essential thrombocytopenia is linked to immunologic disorders, such as SLE and the human immunodeficiency virus. • 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 • 9. Question Francis with leukemia has neutropenia. Which of the following functions must be frequently assessed? o A. Blood pressure o B. Bowel sounds o C. Heart sounds o D. Breath sounds 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. Correct Answer: B. Night sweat In stage 1, symptoms include a single enlarged lymph node (usually), unexplained fever, night sweats, malaise, and generalized pruritus. • 10. Question The nurse knows that neurologic complications of multiple myeloma (MM) usually involve which of the following body systems? o A. Brain o B. Muscle spasm o C. Renal dysfunction o D. Myocardial irritability o Option A: Blood pressure should be monitored regularly, but it is not a priority with neutropenia. o Option B: Assessing bowel sounds is not associated with neutropenia. Leukemia may affect the small and large bowel and they are usually hemorrhagic or infiltrative. o Option C: Although assessing heart sounds is important, it won’t help detect neutropenia. Patients with acute leukemia develop a higher rate of congestive heart failure than patients with other cancers. 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: The reasons underlying the relative paucity of CNS invasion by multiple myeloma in comparison with other tumors, whether solid or hematological, remain unknown, but this phenomenon might be the result of underlying biological characteristics, or lack thereof, of malignant plasma cells. o Option C: In some cases, renal impairment is caused by the accumulation and precipitation of light chains, Correct Answer: B. Muscle spasm Back pain or paresthesia in the lower extremities may indicate impending spinal cord compression from a spinal tumor. This should be recognized and treated promptly as the progression of the tumor may result in paraplegia. • 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? o A. AB Rh-positive o B. A Rh-positive o C. A Rh-negative o D. O Rh-positive 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. 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. 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. • 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”. o C. “My physician should be called if Stacy is irritable and unhappy”. o D. “Should Stacy have continued hair loss, I need to call the doctor”. • 16. Question Molly Sue is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy. Her mother states to the nurse that it is hard to see Molly Sue with no hair. The best response for the nurse is: o Option A: Oftentimes, chemotherapy drugs cause patients to feel tired and sleepy throughout the day. Therefore, patients on chemotherapy can end up napping or sleeping during the day and that leads to difficulty sleeping at night or through the night. o Option C: Chemotherapy medications can directly impact the way people feel emotionally and physically. o Option D: Chemotherapy drugs are powerful medications that attack rapidly growing cancer cells. Unfortunately, these drugs also attack other rapidly growing cells in the body, including those in the hair roots. Correct Answer: B. “I will call my doctor if Stacy has persistent vomiting and diarrhea”. Persistent (more than 24 hours) vomiting, anorexia, and diarrhea are signs of toxicity and the patient should stop the medication and notify the healthcare provider. o A. “Molly Sue looks very nice wearing a hat”. o B. “You should not worry about her hair, just be glad that she is alive”. o C. “Yes, it is upsetting. But try to cover up your feelings when you are with her or else she may be upset”. o D. “This is only temporary; Molly Sue will re-grow new hair in 3-6 months but may be different in texture”. • 17. Question Brittany who is undergoing chemotherapy for her throat cancer is experiencing stomatitis. To promote oral hygiene and comfort, the nurse-in-charge should: o Provide frequent mouthwash with normal saline. o A. Provide frequent mouthwash with normal saline. o B. Apply viscous Lidocaine to oral ulcers as needed. o C. Use lemon glycerine swabs every 2 hours. o D. Rinse mouth with Hydrogen Peroxide. o Option A: It can be an option for the client to use a hat, but the nurse should be open about explanations regarding the side effects of chemotherapy. o Option B: Avoid reassuring the client. Statements of fact would be a good response. o Option C: The mother should be open and honest with the child, and providing an honest and true response would be a big help to both of them. Correct Answer: D. “This is only temporary; Stacy will re- grow new hair in 3-6 months but may be different in texture”. This is the appropriate response. The nurse should help the mother how to cope with her own feelings regarding the child’s disease so as not to affect the child negatively. When the hair grows back, it is still of the same color and texture. • 21. Question Jose is in danger of respiratory arrest following the administration of a narcotic analgesic. An arterial blood gas value is obtained. Nurse Oliver would expect the paco2 to be which of the following values? o A. 15 mm Hg o B. 30 mm Hg o C. 40 mm Hg o D. 80 mm Hg • 22. Question Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80 mm Hg; Pao2 46 mm Hg; HCO3- 24 mEq/L; Sao2 81%. This ABG result represents which of the following conditions? 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 bronchitis are bloated and cyanotic in appearance. 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: 15 mmHg is a low value for a client about to go into respiratory arrest. o Option B: 30 mmHg is lower than the expected value because of inefficient ventilation. o Option C: 40 mmHg is still less than the expected value for a client who is about to go into respiratory arrest. Correct Answer: D. 80 mm Hg A client about to go into respiratory arrest will have inefficient ventilation and will be retaining carbon dioxide. The value expected would be around 80 mm Hg. All other values are lower than expected. o A. Metabolic acidosis o B. Metabolic alkalosis o C. Respiratory acidosis o D. Respiratory alkalosis • 23. Question Norma has started a new drug for hypertension. Thirty minutes after she takes the drug, she develops chest tightness and becomes short of breath and tachypnea. She has a decreased level of consciousness. These signs indicate which of the following conditions? o A. Asthma attack o B. Pulmonary embolism o C. Respiratory failure o D. Rheumatoid arthritis o Option A: If the HCO3- was below 22 mEq/L the client would have metabolic acidosis. o Option B: The result of the ABG is less than 7.35, which makes metabolic alkalosis . o Option D: The pH is less than 7.35, academic, which eliminates respiratory alkalosis as a possibility. Correct Answer: C. Respiratory acidosis Because Paco2 is high at 80 mm Hg and the metabolic measure, HCO3- is normal, the client has respiratory acidosis. o Option A: The symptoms may look like an asthma attack, but it may change because of the new drug ingested. o Option B: Although the signs are also related to a pulmonary embolism, consider the new drug first. Correct Answer: C. Respiratory failure The client was reacting to the drug with respiratory signs of impending anaphylaxis, which could lead to eventually respiratory failure. • 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 • 25. Question The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales is at increased risk for excessive bleeding primarily because of: o A. Impaired clotting mechanism 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. 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. 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. • 28. Question Which of the following groups of symptoms indicates a ruptured abdominal aortic aneurysm? o A. Lower back pain, increased blood pressure, decreased red blood cell (RBC) count, increased white blood (WBC) count. o B. Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC count. o C. Severe lower back pain, decreased blood pressure, decreased RBC count, decreased RBC count, decreased WBC count. o D. Intermittent lower back pain, decreased blood pressure, decreased RBC count, increased WBC count. o Option B: Withholding the next dose is unnecessary; the nurse may lower the dosage as ordered. o Option D: Lactulose, in this case, is given to reduce absorption of ammonia in the intestines. Correct Answer: B. Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC count. Severe lower back pain indicates an aneurysm rupture, secondary to pressure being applied within the abdominal cavity. When rupture occurs, the pain is constant because it can’t be alleviated until the aneurysm is repaired. Blood pressure decreases due to the loss of blood. After the aneurysm ruptures, the vasculature is interrupted and blood volume is lost, so blood pressure wouldn’t increase. For the same reason, the RBC count has decreased – not increased. The WBC count increases as cells migrate to the site of injury. o Option A: The pain is severe due to the ruptured aneurysm; the blood pressure is decreased due to blood loss. o Option C: The increase in WBC count is due to the cells migrating to the site of the injury. • 29. Question After undergoing a cardiac catheterization, Tracy has a large puddle of blood under his buttocks. Which of the following steps should the nurse take first? 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. • 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 Option D: The pain in a ruptured aneurysm is constant and can only be alleviated if the aneurysm is repaired. 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. 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 D. Percutaneous transluminal coronary angioplasty (PTCA) • 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) 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. Correct Answer: D. Percutaneous transluminal coronary angioplasty (PTCA) PTCA can alleviate the blockage and restore blood flow and oxygenation. 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 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 Correct Answer: B. Cardiogenic shock Cardiogenic shock is shock related to ineffective pumping of the heart. • 35. Question 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 is strong 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, which increases the intracranial pressure (ICP).” o Option D: Clients may have elevated BUN and creatinine levels from nephritis, but the increase does not indicate SLE. The part of the kidney most frequently troubled by SLE is part of the nephron called the glomerulus, a tuft of capillaries that functions to filter substances from the blood. For this reason, the type of kidney inflammation most commonly experienced in lupus is glomerulonephritis. 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 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. 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. • 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. • 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 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 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. 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 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 Guillain-Barre 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, and injury to nearby organs. o Option C: There’s no information to suggest the postmyocardial infarction client has an arrhythmia or other complication. About 90% of patients who have an acute MI develop some form of cardiac arrhythmia during or immediately after the event. o Option D: There’s no evidence to suggest perforation for the client with diverticulitis as a priority of care. Diverticula are small, bulging pouches that can form in the lining of the digestive system.when one or more of the pouches become inflamed, and in some cases infected, that condition is known as diverticulitis. • 38. Question JP has been diagnosed with gout and wants to know why colchicine is used in the treatment of gout. Which of the following actions of colchicines explains why it’s effective for gout? o A. Replaces estrogen. o B. Decreases infection. o C. Decreases inflammation. o D. Decreases bone demineralization. Correct Answer: C. Decreases inflammation. o A. Pitting edema of the legs o B. An irregular apical pulse o C. Dry mucous membranes o D. Frequent urination • 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? 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 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. 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 D. Below-normal urine osmolality level, above- normal serum osmolality level. • 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? o A. “I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual.” o B. “If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar.” o C. “I will have to monitor my blood glucose level closely and notify the physician if it’s constantly elevated.” o D. “If I begin to feel especially hungry and thirsty, I’ll eat a snack high in carbohydrates.” 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. 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. Correct Answer: A. “I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual.” • 44. Question A 66-year-old client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, the nurse would suspect which of the following disorders? o A. Diabetes mellitus o B. Diabetes insipidus o C. Hypoparathyroidism o D. Hyperparathyroidism o Option B: Drinking a glass of non-diet soda would be appropriate for hypoglycemia. o Option C: A client whose diabetes is controlled with oral antidiabetic agents usually doesn’t need to monitor blood glucose levels. o Option D: A high carbohydrate diet would exacerbate the client’s condition, particularly if fluid intake is low. Inadequate fluid intake during hyperglycemic episodes often leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS. o Option A: Common symptoms of diabetes mellitus include polyuria, polydipsia, and polyphagia o Option B: While clients with diabetes insipidus also have polyuria, they don’t have bone pain and increased sleeping. o Option C: Hypoparathyroidism is characterized by urinary frequency rather than polyuria. Correct Answer: D. Hyperparathyroidism Hyperparathyroidism is most common in older women and is characterized by bone pain and weakness from excess parathyroid hormone (PTH). Clients also exhibit hypercalciuria- causing polyuria. • 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. • 49. Question The physician orders laboratory tests to confirm hyperthyroidism in a female client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis? o Option C: Temperature regulation may be affected by excess cortisol and isn’t an accurate indicator of infection. o Option A: 2 p.m. is when the insulin was given; onset does not occur at the same time as the medication was given o Option B: The peak starts 2 to 4 hours after the insulin was given, which will be at 4 p.m. o Option D: Onset of 4 p.m. is very late; 15 to 30 minutes is the expected onset of insulin. Peak shoud start at 4 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. o A. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test. o B. A decreased TSH level. o C. An increase in the TSH level after 30 minutes during the TSH stimulation test. o D. Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by radioimmunoassay. • 50. Question Rico with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10 U of U-100 regular insulin and 35 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction? o A. “Inject insulin into healthy tissue with large blood vessels and nerves.” o B. “Rotate injection sites within the same anatomic region, not among different regions.” o Option B: A decreased TSH level indicates a pituitary deficiency of this hormone. o Option C: If the TSH level rises after 30 minutes, then the client has no hyperthyroidism. o Option D: Below-normal levels of T3 and T4, as detected by radioimmunoassay, signal hypothyroidism. A below-normal T4 level also occurs in malnutrition and liver disease and may result from the administration of phenytoin and certain other drugs. Correct Answer: A. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism. o C. “Administer insulin into areas of scar tissue or hypertrophy whenever possible.” o D. “Administer insulin into sites above muscles that you plan to exercise heavily later that day.” • 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. 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. 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. 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 o B. Calcium and phosphorous o C. Phosphorus and potassium o D. Potassium and sodium • 55. Question Johnny, a firefighter, was involved in extinguishing a house fire and is being treated for smoke inhalation. He developed severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. He most likely has developed which of the following conditions? o A. Adult respiratory distress syndrome (ARDS) o B. Atelectasis o C. Bronchitis o D. Pneumonia o Option A: Sodium increases calcium excretion and higher calcium excretion is associated with lower bone mineral density, a predictor of osteoporotic fractures. o Option C: Potassium is not involved in osteoporosis. Potassium salts aid in bone health. A study, published in the journal Osteoporosis International, also revealed that high intake of potassium salts significantly reduces the excretion of calcium and acid in urine. o Option D: Sodium, in the form of sodium chloride, elevates urinary calcium excretion and, at prevailing calcium intakes, evokes compensatory responses that may lead to increased bone remodeling and bone loss. However, potassium was inversely associated with both urinary calcium excretion and intestinal calcium absorption, yielding no significant net change in calcium balance. Correct Answer: B. Calcium and phosphorous In osteoporosis, bones lose calcium and phosphate salts, becoming porous, brittle, and abnormally vulnerable to fracture. • 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 o Option B: Atelectasis is not associated with smoke inhalation. Inhaling harmful smoke can inflame the lungs and airway, causing them to swell and block oxygen. This can lead to acute respiratory distress syndrome and failure. o Option C: Bronchitis does not develop due to smoke inhalation. However, if the client already has bronchitis, inhalational injuries can worsen its condition. o Option D: Pneumonia isn’t typically associated with smoke inhalation and severe hypoxia. Correct Answer: A. Adult respiratory distress syndrome (ARDS) Severe hypoxia after smoke inhalation is typically related to ARDS. 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. Correct Answer: D. Fat embolism Long bone fractures are correlated with fat emboli, which cause shortness of breath and hypoxia. • 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 • 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) 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. 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. Correct Answer: C. Pneumothorax • 62. Question After a motor vehicle accident, Armand, a 22-year-old client, is admitted with a pneumothorax. The surgeon inserts a chest tube and attaches it to a chest drainage system. Bubbling soon appears in the water seal chamber. Which of the following is the most likely cause of the bubbling? o A. Air leak o B. Adequate suction o C. Inadequate suction o D. Kinked chest tube • 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 o Option A: Large amounts of carbon dioxide are blown off, removing the option of metabolic acidosis. o Option B: Respiratory, not metabolic, alkalosis is the result of a massive pulmonary embolism. o Option C: Acidosis does not occur with pulmonary embolism. Hypocapnia usually is present with an embolism. A client with massive pulmonary embolism will have a large region and blow off large amounts of carbon dioxide, which crosses the unaffected alveolar-capillary membrane more readily than does oxygen and results in respiratory alkalosis. o Option B: Inadequate suction does not cause bubbling. o Option C: Bubbling doesn’t normally occur with adequate suction or any preexisting bubbling in the water seal chamber. o Option D: A kinked chest tube does not cause bubbling in the water seal chamber. Correct Answer: A. Air leak Bubbling in the water seal chamber of a chest drainage system stems from an air leak. In pneumothorax, an air leak can occur as air is pulled from the pleural space. 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 • 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 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. Correct Answer: B. 21 3000 x 10 divided by 24 x 60. 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. Correct Answer: B. 2.4 ml .05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4 ml. • 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.” • 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 Option D: 4.2 ml is an dosage according to the formula used. 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. 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. 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 HIV-related immunocompromise and subsequent effects of antiretroviral therapy (ART) on immune reconstitution and, ultimately, on vaccine immunogenicity is unclear. • 69. Question A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on contact precautions. Which statement is true regarding 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. • 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." 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. 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 B. "The pain is due to peripheral nervous system interruptions. I will get you some pain medication." o C. "The pain is psychological because your foot is no longer there." o D. "The pain and itching are due to the infection you had before the surgery." Correct Answer: B. “The pain is due to peripheral nervous system interruptions. I will get you some pain medication.” Pain-related to phantom limb syndrome is due to a peripheral nervous system interruption. A recent study estimated that there were about 1.6 million people with limb loss in the USA in 2005 and this number was projected to increase by more than double to 3.6 million by the year 2050. Vascular problems, trauma, cancer, and congenital limb deficiency are among the common causes of limb loss. o Option A: Phantom limb pain can last several months or indefinitely. The phantom pain and sensation may have its onset immediately or years after the amputation. There are reports of two peak periods of onset, the first within a month and the second a year after amputation. The prevalence is reported to decrease over time after amputation. o Option C: The explanation of phantom limb pain is not psychologically related. PLP was once thought to be primarily a psychiatric illness. With the accumulation of evidence from research over the past decades, the paradigm has shifted more towards changes at several levels of the neural axis, especially the cortex. Peripheral mechanisms and central neural mechanisms are among the hypotheses that have gained consensus as proposed mechanisms over the recent years. o Option D: Pain and itching are not symptoms of an infection due to surgery. During amputation, peripheral nerves are severed. This results in massive tissue and neuronal injury-causing disruption of the normal pattern of afferent nerve input to the spinal cord. This is followed by a process called • 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 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. 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 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. • 74. Question The nurse is assisting the physician with the removal of a central venous catheter. To facilitate removal, the nurse should instruct the client to: o A. Perform the Valsalva maneuver as the catheter is advanced o B. Turn his head to the left side and hyperextend the neck o C. Take slow, deep breaths as the catheter is removed o D. Turn his head to the right while maintaining a sniffing position 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. o Option B: Although there are many steps in the process of CVC removal, essential elements of the procedure include (for internal jugular and subclavian CVCs), positioning of the patient in the head down (Trendelenburg) position, having the patient perform a Valsalva maneuver as the catheter is being withdrawn, application of pressure to the catheter-entry site as the catheter is being withdrawn, placement of an air- Correct Answer: A. Perform the Valsalva maneuver as the catheter is advanced The client who is having a central venous catheter removed should be told to hold his breath and bear down. This prevents air from entering the line. • 75. Question A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for: o A. A history of streptococcal infections o B. Allergies to pineapples and bananas o C. Prior therapy with phenytoin o D. A history of alcohol abuse occlusive dressing over the site after removal, and a period of post-procedure monitoring. o Option C: The patient is asked to take a deep breath, hold it, and bear down during the removal to avoid introduction of an air embolism. Breath-holding or Valsalva maneuver will increase intracardiac pressures. Immediate occlusion is required to prevent air embolism. Option D: The patient’s head should be placed in a supine position with the head of the bed flat to reduce the risk of air embolism. Risk for air embolism increases when the catheter insertion site is above heart level (e.g., in a sitting position), if the patient is hypovolemic or during spontaneous inspiration. Correct Answer: A history of streptococcal infections Clients with a history of streptococcal infections could have antibodies that render the streptokinase ineffective. Due to streptokinase’s thrombolytic mechanisms of action, patients need monitoring for bleeding. The patient’s thrombin time, prothrombin time, partial thromboplastin time, complete blood count, and any signs of bleeding demand careful surveillance. Patients also need monitoring for signs and symptoms of reinfarction or vessel occlusion. o Option B: There is no reason to assess the client for allergies to pineapples or bananas. Streptokinase can precipitate an allergic reaction. Symptoms include fever, shivering, and rash. Patients in rare instances have developed nonfatal anaphylactic reactions. In cases of anaphylaxis, patients should be administered