NGN NCLEX PN Practice Questions/ Practice NCLEX PN Exam Updated 2023-2024 Latest Version, Exams of Nursing

Download NGN NCLEX PN Practice Questions/ Practice NCLEX PN Exam Updated 2023-2024 Latest Version and more Exams Nursing in PDF only on Docsity! NGN NCLEX PN Practice Questions/ Practice NCLEX PN Exam Updated 2023-2024 Latest Version The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal a pH of 7.36, CO2 at 45, O2 at 84, HCO3 at 28. The nurse would assess the client to be in: A. Uncompensated acidosis B. Compensated alkalosis C. Compensated respiratory acidosis D. Uncompensated metabolic acidosis ---------- Correct Answer --------- C. Compensated respiratory acidosis why? The client is experiencing compensated respiratory acidosis. The pH is within the normal range but is lower than 7.40, so it is on the acidic side. The CO2 level is elevated, the oxygen level is below normal, and the bicarb level is slightly elevated. In respiratory disorders, the pH will be in inverse of the CO2 and bicarb level. This means that if the pH is low, the CO2 and bicarb levels will be elevated. The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis? A. A weight loss of 10 pounds in 2 weeks. B. Complaints of numbness and tingling in the extremities. C. A red, beefy tongue. D. A hemoglobin level of 12.0 gm/dL ---------- Correct Answer --------- C. A red, beefy tongue why? A red, beefy tongue is characteristic of a client with pernicious anemia. A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for: A. Trendelenburg position B. Ice to the entire extremity C. Bucks traction D. An abduction pillow ---------- Correct Answer --------- C. Bucks traction why? The client with a fractured femur will be placed in Bucks traction to realign the leg and decrease spasms and pain. A client with caner is to undergo an intravenous pyelogram. The nurse should: A. Force fluids 24 hours before the procedure. B. Ask the client to void immediately before the study. C. Hold medication that affects the central nervous system for 12 hours pre- and post- test. D. Cover the client's reproductive organs with an x-ray shield. ---------- Correct Answer -- ------- B. Ask the client to void immediately before the study. why? The client having an intravenous pyelogram will have orders for laxatives of enemas so asking the client to void before the test is in order. A full bladder or bowel can obscure the visualization of the kidney, ureters, and urethra. The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor: A. That cannot be assessed B. That is in situ C. With increasing lymph node involvement D. With distant mestastasis ---------- Correct Answer --------- B. That is in situ. why? Cancer in situ means that the cancer is still localized in the primary site. Cancer is graded in terms of tumor, grade, node, involvement, and mestatasis. A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate? A. Reinsert the protruding organ and cover with 4x4s B. Cover the wound with a sterile 4x4 and ABD dressing C. Cover the wound with a sterile saline-soaked dressing D. Apply an abdominal binder and manual pressure to the wound ---------- Correct Answer --------- C. Cover the wound with a sterile saline-soaked dressing. why? If the client eviscerates, the abdominal content should be covered with a sterile saline- soaked dressing. why? Hypokalemia is evident from the lab values listed. The other laboratory findings are within normal limits. making answers A,C and D incorrect A 24 year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse? A. taking the vital signs B. obtaining the permit C. explaining the procedure D. Checking the lab work ---------- Correct Answer --------- A. taking the vital signs why? the primary responisblity of the nurse is to take the vital signs before any surgery. answers B,C and D are the responsibility of the doctor. The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. which action should receive priority? A. starting an IV? B. Applying oxygen C.Obtaining blood gas D. Medicating the client foe pain ---------- Correct Answer --------- B. Applying oxygen why? the client with burns to the neck needs airway assessments and supplemental oxygen, so applying oxygen is priority. the next action should be to start an IV and medicate for pain. The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instructions should be given to the client A. rest in bed after taking the medication for at least 30 mins B. Avoid rapid movements after taking the medication C. Take medication with water only D. Allow at least 1 hour between taking the medicine and taking other medications ------- --- Correct Answer --------- C. Take medication with water only why? Fosmax should be taken with water only. The client should also remain upright for at least 30 mins after taking the medication. The nurse is making initial rounds on a client with a C5 fracture and crutchfield thongs. Which equipment should be kept at the bedside? A. A pair of forceps B. A torque wrench C. A pair or wire cutters D. A screwdriver ---------- Correct Answer --------- B. A torque wrench why? A tourque wrench is kept at the bedside to tighten and loosen the screws of crutchfield tongs. This wrench controls the amount of pressure that is placed on the screws. An infant weighs 7 pounds at birth. The excpectd weight by 1 year should be: A. 10 pounds B.12 pounds C. 18 pounds D. 21 pounds ---------- Correct Answer --------- D. 21 pounds why? A birth weight of 7 pounds would indicate 21 pounds in 1 year or triple the his birth weight. A client is admitted with a Ewing's sacroma. which symptoms would be expected due to this tumor's location? A. Hemiplegia B. Aphasia C. Nausea D. Bone Pain ---------- Correct Answer --------- D. Bone Pain why? Sacroma is a type of bone cancer, therefor, bone pain would be expected The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which labatory value might be a indicate a serious side effect of this drug? A. Uric acid of 5mg/dL B. Hematoccrit of 33% C. WBC 2,000 per cubic millimeter D. Platelets 150,000 per cubic millimeter ---------- Correct Answer --------- C. WBC 2,000 per cubic millimeter why? Tegratol can suppress the bone marrow and decrease the white blood cells count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis? A. "tell me about the pain" B."what does his vomit look like?" C." Describe his usual diet." D. " have you noticed changes in his adominal size?" ---------- Correct Answer --------- C." Describe his usual diet." why? The least-helpful questions are those describing his usual diet. A, B, and D are useful in determining the extent of disease process and thus, are incorrect The nurse is assisting a client with diverticulosis to select appropiate foods. Which food should be avoided? A. Bran B. Fresh Peaches C. Cucumber salad D. Yeast Rolls ---------- Correct Answer --------- C. Cucumber salad why? the client with diverticulitis should avoid foods with seeds. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? A. Teaching how to irrigate the illeostomy B. Stopping electrolytes loss in the incisional area C. Encouraging a high fiber diet D. Facilitating perineal wound drainage ---------- Correct Answer --------- D. Facilitating perineal wound drainage why? the client with a perineal resection will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illestomy. as in answer A he will have some electrolyte loss, but A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure? A. Bradycardia B. Tachycardia C. Premature ventricular beats D. Heart block ---------- Correct Answer --------- A. Bradycardia why? Suctioning can cause a vagal response and bradycardia. The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period? A. Assessment of the client's level of anxiety. B. Evaluation of the client's exercise tolerance C. Identification of peripheral pulses. D. Assessment of bowel sounds and activity. ---------- Correct Answer --------- C. Identification of peripheral pulses why? The assessment that is most crucial to the client is identification of peripheral pulses because aorta is clammed during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities. A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session? A. "You will be sitting for the examination procedure." B. "Portions of the procedure will cause pain or discomfort." C. "You will be given some medication to anesthetize the area." D. "you will not be able to drink fluids for 24 hours before the study." ---------- Correct Answer --------- B. "Portions of the procedure will cause pain or discomfort." why? Portions of the exam are painful especially when the sample is being withdrawn so this should be included in the session with the client. A client visits the clinic after the death of a parent. Which statement made by the client's sister signifies abnormal grieving? A. "My sister still has episodes of crying and it's been 3 months since daddy died." B. "Sally seems to have forgotten the bad things that daddy did in his lifetime." C. "She really had a hard time after daddy's funeral. She said that she had a sense of longing." D. "Sally has not been sad at all by daddy's death. She acts like nothing has happened." ---------- Correct Answer --------- D. "Sally has not been sad at all by daddy's death. She acts like nothing has happened at all." why? Abnormal grieving is exhibited by a lack of feeling sad; if the client's sister appears not to grieve, it might be abnormal grieving. This family member might be suppressing feelings of grief. The nurse recognizes that which of the following would be most appropriate to wear when providing direct care to a client with a cough? A. Mask B. Gown C. Gloves D. Shoe covers ---------- Correct Answer --------- A. Mask why? If the nurse is exposed to the client with a cough, the best item to wear is a mask. If the answer had included a mask, gloves, and a gown, all would be appropriate. The nurse is caring for a client with a diagnosis of Hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention? A. Suggest that the client take warm showers b.i.d. B. Add baby oil to the client's bath water C. Apply powder to the client's skin D. Suggest a hot water rinse after bathing. ---------- Correct Answer --------- B. Add baby oil to the client's bath water why? Oil can be applied to help with the dry skin and to decrease itching, so adding baby oil to bath water is soothing to the skin. A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate? A. Blood pressure every 15 minutes B. Insertion of a levine tube C. Cardiac monitoring D. Dressing changes 2x per day ---------- Correct Answer --------- B. Insertion of a levine tube why? The client with pancreatitis frequently has nausea and vomiting. Lavage is often used to decompress the stomach and rest the bowel, so the insertion of a levine tube should be anticipated. The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because: A. The client is at risk for evisceration B. The client will require frequent dressing changes C. The straps provide support for drains that are inserted into the incision D. No sutures or clips are used to secure the incision. ---------- Correct Answer --------- B. The client will require frequent dressing changes why? Montgomery straps are used to secure dressing that require frequent dressing changes because the client with a cholescystectomy usually has a large amount of drainage on the dressing. Montgomery straps are also used for clients who are allergic to several types of tape. The physician has order that the client's medication be administered intrathecally. The nurse is aware that the medications will be administered by which method? A. Intravenously B. Rectally C. Intramuscularly D. Into the cerebrospinal fluid ---------- Correct Answer --------- D. Into the cerebrospinal fluid why? Intrathecal medications are administered into the cerebrospinal fluid. This method of administering medications is reserved for the client with metastases, the client with chronic pain, or the client with cerebrospinal infections. Which client can be best assigned to the newely licensed to the Practical Nurse? A. The client receiving chemotherapy B. The client post-coronary bypass The nurse who fails to wear gloves to remove a contaminated dressing needs further instruction The nurse is preparing the client for a mammogram. To prepare the client for a mammogram, the nurse should tell the client: A. Restrict her fat intake for one week before the test B. To omit creams, powders, or deodorants before the exam C. The mammography replaces the need for self breast exams D. That mammography requires higher does of radiation than an x-ray. ---------- Correct Answer --------- B. To omit creams, powders, or deodorants before the exam. why? The client having the mammogram should be instructed to omit deodorants or powders beforehand because powders and deodorants can be interpreted as abnormal. Which of the following roommates would be best for the client with gastric resection? A. A client with Chron's disease B. A client with pneuomia C. A client with gastritis D. A client with phlebitis ---------- Correct Answer --------- D. A client with phlebitis why? The most suitable roommate for the client with gastric resection is the client with phlebitis because phlebitis is an inflammation of the blood vessel and is not infectious. The licensed practical nurse is working with a RN and a patient care assistant. Which of the following clients should be cared for by the RN? A. A client two days post-appendectomy B. A client one week post-thyroidectomy C. A client 3 days post- splenectomy D. A client 2 days post- thoracotomy ---------- Correct Answer --------- D. A client 2 days post-thoracotomy why? The most critical client should be assigned to the RN; in this case, that is the client 2 days post-thoracotomy. The LPN is observing a graduate nurse as she assess the central venous pressure. Which observation indicates that the graduate needs further teaching? A. The graduate places the client in a supine position to read the manometer B. The graduate turns the stopcock to the off position from the IV fluid to the client C. The graduate instructs the client to perform the Valsalva manuever during the CVP reading D. The graduate notes the level at the top of the meniscus ---------- Correct Answer ------ --- C. The Graduate instructs the client to perform the Valsalva manuever during the CVP reading. why? The client should breathe normally during a central venous pressure monitor reading. Which of the following roommates would be most suitable for the client with myasthenia gravis? A. A client with hypothyroidism B. A client with Chron's disease C. A client with pylonephritis D. A client with bronchitis ---------- Correct Answer --------- A. A client with hypothyroidism why? The most suitable roommate for the client with myasthenia gravis is the client with hypothyroidism because he is quiet. The nurse employed in the ER is responsible for triage for 4 clients injured in a motor vehicle accident. Which of the following clients should receive priority in care? A. A 10 year old with lacerations to the face B. A 15 year old with sternal bruising C. A 34 year old with fractured femur D. A 50 year old with dislocation of the elbow ---------- Correct Answer --------- B. A 15 year old with sternal bruising why? The teenager with sternal bruising might be experiencing airway and oxygenation problems and, thus, should be seen first. The client is receiving peritoneal dialysis. If the dialysis returns cloudy the nurse should" A. Document the finding B. Send a specimen to the lab C. Strain the urine D. Obtain a complete blood count ---------- Correct Answer --------- B. Send a specimen to the lab why? If the dialysate returns cloudy, infection might be present and must be evaluated The client with cirrhosis of the liver is receiving lactulose. The nurse is aware that the ratio for the order of lactulose is : A. To lower the blood glucose level B. To lower the uric acid level C. To lower ammonia level D. To lower the creatinine level ---------- Correct Answer --------- C. To lower ammonia level why? Lactulose is administered to the client with cirrhosis to lower ammonia levels. The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client's ability to care for himself. Which statement by the client indicates a need for follow-up after discharge? A."I live by myself." B." I have trouble seeing." C. "I have a cat in the house with me." D. " I usually drive myself to the doctor." ---------- Correct Answer --------- B. "I have trouble seeing" why? A client with diabetes who has trouble seeing would require follow-up after discharge. The lack of visual acuity for the client preparing and injecting insulin might require help. The client is receiving total parenteral nutrition (TPN). Which lab should be evaluated while the client is receiving TPN? A. Hemoglobin B. Creatinine C. Blood glucose D. White blood cell count ---------- Correct Answer --------- C. Blood glucose why? A 25 year old male is brought to the ER with a piece of metal in his eye. Which action by the nurse is correct? A. Use a magnet to remove the object B. Rinse the eye thoroughly with saline C. Cover both eyes with paper cups D. Patch the affected eye only ---------- Correct Answer --------- C. Cover both eyes with paper cups why? Covering both eyes prevents consensual movement of the affected eye. The physician has order sodium warfrin ( Coumadin) for the client with thrombophlebitis. The order should be entered to administer the medication at: A. 0900 B. 1200 C. 1700 D. 2100 ---------- Correct Answer --------- C. 1700 why? Sodium warfarin is administered in the late afternoon, at approximately 1700 hours. this allows for accurate bleeding times to be drawn in the morning. The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion? A. Secrurity guard B. RN C. LPN D. The nursing assistant ---------- Correct Answer --------- B. RN why? The RN is the only one of these who can legally put the client in seclusion. The only other healthcare worker who is allowed to initiate seclusion is the doctor. The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to: A. Take blood pressure, pulse, and temp B. Ask the client to rate his pain from 1-5 C. Watch the client's facial expression D. Ask the client if he is in pain ---------- Correct Answer --------- B. Ask the client to rate his pain from 1-5 why? The best way to evaluate pain levels is to ask the client to rate his pain on a scale. The nursing is participating in a discharge teaching for the post-partal client. The nurse is aware that an effective means of managing discomfort associated with a episiotomy after discharge is: A. Promethazine B. Aspirin C. Sitz bath D. Ice bath ---------- Correct Answer --------- C. Sitz bath why? A sitz bath will help with swelling and improve healing Which of the following post-op diets are most appropriate for a client who has had a hemorroidectomy? A. High fiber B. Low-residue C. Bland D. Clear liquids ---------- Correct Answer --------- D. Clear liquids why? After surgery, the client will be placed o n a clear-liquid diet and progressed to a regular diet. stool softeners will be included in the plan of care, to avoid constipation. The physician has ordered a culture for the client with suspected Gonorrhea. The nurse should obtain what type of culture? A. Blood B. Nasopharyngeal secretions C. Stool D. Genital secretions ---------- Correct Answer --------- D. Genital secretions why? A culture for gonorrhea is taken from the genital secretions. The culture is placed in a warm environment, where it can grow nisseria gonorrhea The nurse is caring for a client with cerebral plasy. The nurse should provide frequent rest periods because: A: Grimacing and withering movements decrease with relaxation and rest. B. Hypoactive deep tendon reflexes become more active with rest C. Stretch reflexes become more increases with rest D. Fine motor movements are improved ---------- Correct Answer --------- A. Grimacing and withering movements decrease with relaxation and rest. why? Frequent rest periods help to relx tense muscles and preserve energy The nurse is making assignments for the day. Which client should be assigned to the nursing assistant? A. A client with Alzheimer's B. A client with pnuemonia C. A client with appendicitis D. A client with thrombophebitis ---------- Correct Answer --------- A. A client with Alzheimer's why? The client with Alzheimer's disease is the most stable of these clients and can be assigned to the nursing assistant, who can perform duties such as feeding and assisting the client with activities of daily living. A client with cancer develops xerostomia. The nurse can help alleviate the discomfort associated with xerostomia by: A. Offering a hard candy B. Administering an analgesic medication C. Splinting swollen joints D. Providing saliva substitue ---------- Correct Answer --------- D. Providing saliva substitute why? Xerostomia is dry mouth, and offering the client a saliva substitute will help the most. A home health nurse is making preparations for morning visits. Which of the following clients should the nurse visit first? A. A client with brain- attack (stroke) with tube feeding B. A client with congestive heart failure complaining of nighttime dyspnea why? Because the client is immune-suppressed, foods should be served in sealed containers, to avoid food contaminants. A 70 year old man who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggested of unilateral neglect? A. The client is observed by shaving only one side of his face B. The client is unable to distinguish between two tactile stimuli presented simultaneously C. The client is unable to complete a range a vision without turning his head side to side D. The client is unable to carry out cognitive and motor activity at the same time ---------- Correct Answer --------- A. The client is observed by shaving only one side of his face why? The client with unilateral neglect will neglect one side of the body The nurse is providing discharge teaching for a client who is taking dissulfiram (Antabuse). The nurse should instruct the client to avoid eating: A. Peanuts, dates, raisins B. Figs, chocolate, eggplant C. Pickles, salad with vinaigrette dressing, and beef D. Milk, cottage cheese, ice cream ---------- Correct Answer --------- C. Pickles, salad with vinaigrette dressing, beef why? The client taking antabuse should not eat or drink anything containing alcohol or vinegar A client has been receiving cyanocobalamine (B12) injections for the past 6 weeks. Which lab finding indicates that the medication is having the desired effect? A. Neutrophil count of 60% B. Basophil count of 0.5% C. Monocyte count of 2% D. Reticlocyte count of 1% ---------- Correct Answer --------- D. Reticlocyte count of 1 % why? Cyanocolamine is a B12 medication that is used for pernicious anemia, and a reticulocyte count of 1% indicates that it is having the desired effect. The nurse has just received a change of shift report. Which client should the nurse assess first? A. A client 2 hours post-lobectomy with 150 cc drainage B. A client 2 days post-gastrectomy with scant drainage C. A client with pnuemonia with a oral temp of 102 F D. A client with a fractured hip in Bucks traction ---------- Correct Answer --------- A. A client 2 hours post-lobectomy with 150 cc drainage why? The first client to be seen is the one who recently returned from surgery. Several clients are admitted to the ER following a three- car vehicle accident. Which clients can be assigned to share a room in the emergency department during the disaster? A. The schizophrenic client having visual and auditory hallucinations and the client with ulcerative collitis B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm C. A child whose pupils are fixed and dilated and his parents, and the client with a frontal head injury D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain ---------- Correct Answer --------- B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm why? Out of all these clients, it is best to hold the pregnant client and the client with a broken arm and facial lacerations in the same room. The home health nurse is planning for the day's visits. Which client should be seen first? A. The 78 year old who had a gastrectomy 3 weeks ago with a PEG tube B. The 5 month old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension C. The 50 year old with MRSA being treated with Vancomycin via a PICC line D. The 30 year old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter ---------- Correct Answer --------- D. The 30 year old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter why? The priority client is the one with multiple sclerosis who is being treated with cortisone via the central line. This client is at highest risk for complications. The nurse is found to be guilty of charting blood glucose results without actually performing the procedure. After talking to the nurse, the charge nurse should: A. Call the Board of Nursing B. File a formal reprimand C. Terminate the nurse D. Charge the nurse with a tort ---------- Correct Answer --------- B. File a formal reprimand why? The action after discussing the problem with the nurse is to document the incident and file a formal reprimand. If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but this is not the first step. Which information should be reported to the state Board of Nursing? A. The facility fails to provide literature in both Spanish and English B. The narcotic count has been incorrect on the unit for the past 3 days. C. The client fails to receive an itemized account of his bills and services received during his hospital stay D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath ---------- Correct Answer --------- B. The narcotic count has been incorrect on the unit for the past 3 days. why? The Joint Commission on Accreditation of Hospitals will probably be interested in the problems in answers A and C. The failure of the nursing assistant to assist the client with hepatitis should be reported to the charge nurse. If the behavior continues, termination may result. Which nurse should be assigned to care for the postpartal client with preeclampsia? A. The nurse with 2 weeks of experience on postpartum B. The nurse with 3 years of experience in labor and delivery C. The nurse with 10 years of experience in surgery D. The nurse with 1 year of experience in the neonatal intensive care unit ---------- Correct Answer --------- B. Th nurse with 3 years of experience in labor and delivery why? B. By hanging it IV piggyback C. With normal saline only D. By administering it through a venous access device ---------- Correct Answer --------- A. By giving it over 1-2 minutes why? Lasix should be given approximately 1mL per minute to prevent hypotesion The physician prescribes capropril (Capoten) 25 mg po tid for the client with hypertension. Which of the following adverse reactions can occur with administration of Capoten? A. Tinnitus B. Persistent coughing C. Muscle weakness D. Diarrhea ---------- Correct Answer --------- B. Persistent coughing why? A persistent cough might be related to an adverse reaction to Captoten. The doctor orders 2% nitroglycerin ointment on a 1-inch dose over 12 hours. Proper application of nitroglycerin ointment includes: A. Rotating application sites B. Limiting applications to the chest C. Rubbing it into the skin D. Covering it with a gauze dressing ---------- Correct Answer --------- A. Rotating application sites why? Sites for the application of nitroglycerin should be rotated, to prevent skin irritation. It can be applied to the back and upper arms, not to the lower extremities. Lidocaine is a medication frequently ordered for the client experiencing: A. Atrial tachycardia B. Ventricular tachycardia C. Heart block D. Ventricular brachycardia ---------- Correct Answer --------- B. Ventricular tachycardia why? Lidocaine is used to treat ventricular tachycardia. This medication slowly exerts an antiarrhythmic effect by increasing the electric stimulation threshold of the ventricle without depressing the force of ventricular contractions. The client is admitted to the ER with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. Te doctor orders quinidne sulfate. While he is receiving quinidine, the nurse should monitor his ECG for: A. Peaked P waves B. Elevated ST segment C. Inverted T wave D. Prolonged QT interval ---------- Correct Answer --------- D. Prolonged QT interval why? Quinidine can cause widened Q-T intervals and heart block. Other signs of myocardial toxicity are notched P waves and widened QRS complexes. The most common side effects are diarrhea, nausea, and vomiting. The client might experience tinnitus, veritgo, headache, visual disturbances, and confusion. The physician has prescibed tranylcypromine sulfate (Parnate) 10 mg bid. The nurse should teach the client to refrain from eating foods containing tyramine because it may cause: A. Hypertension B. Hyperthermia C. Melanoma D. Urinary retention ---------- Correct Answer --------- A. Hypertension why? If the client eats foods high in tyramine, he might experience malignant hypertension. Tyramine is found in cheese, sour cream, Chianti wine, sherry, beer, pickled herring, liver, canned figs, raisins, bananas, avocados, chocolate, soy sauce, fava beans, and yeast. These episodes are treated with Regitine, and alpha-adrenergic blocking agent. The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy? A. "She is very irritable lately." B. "She sleeps quite a bit of the time." C. "Her gums look too big for her teeth." D. "She has gained about 10 pounds in the last 6 months." ---------- Correct Answer ------ --- A 5 year old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery? A. Decreased appetite B. A low-grade fever C. Chest congestion D. Constant swallowing ---------- Correct Answer --------- A 6 year old with cerebral palsy functions at the level of an 18 month old. Which finding would support that assessment? A. She dresses herself B. She pulls a toy behind her C. She can build a tower of eight blocks D. She can copy a horizontal or vertical line. ---------- Correct Answer ---------