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EXAM CRAM NCLEX-PN PRACTICE QUESTIONS AND ANSWERS 2024 VERSION GRADED A+ 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 - ansA. taking the vital signs
Typology: Exams
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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 - ansA. 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. 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 - ansC. Cover both eyes with paper cups why? Covering both eyes prevents consensual movement of the affected eye. 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 - ans 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. - ans 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?" - ansC." 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 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 - ansA. 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 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 - ansC. 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 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% - ansD. 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. 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 - ansD. 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 treatment is not focused on preventing the loss, so answer B is incorrect A high fiber diet in answer C is not ordered at this time. 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 - ansA. Bradycardia why?
Suctioning can cause a vagal response and bradycardia. 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 - ansC. 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. A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170 meq/L. What behavioral changes would be common for this client? A. Anger B. Mania C. Depression D. Pyschosis - ansB. Mania why? The client with serum sodium of 170 meq/L has hypernatrimia and might exhibit manic behvior.
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 - ansD. Bone Pain why? Sacroma is a type of bone cancer, therefor, bone pain would be expected 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." - ansD. "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. A client with acute leukemia develops a low white blood cell count. In addition to the institute of isolation the nurse should: A. Request that food be served with disposable utensils
B. Ask the client to wear a mask when visitors are present C. Prep IV with mild soap, water, and alcohol D. Provide foods in seal single serving packages - ansD. Provide foods in seal single serving packages why? Because the client is immune-suppressed, foods should be served in sealed containers, to avoid food contaminants. 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 - ansD. Providing saliva substitute why? Xerostomia is dry mouth, and offering the client a saliva substitute will help the most. A client with cancer is a, admitted to the oncology unit. Stat lab values revel Hgb 12.6, WBC 6500, K+1.9, uric acid 7.0, Na+136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following? A. Hypernatremia B. Hypokalemia C. Myelosuppression D. Leukocytosis - ansB. Hypokalemia
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 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. - ansB. 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. A client with glomerulonephritis is placed on a low sodium diet. Which of the following snacks is suitable for the client with low sodium restritctions? A. Peanut butter cookies B. Grilled cheese sandwich C. Cottage cheese and fruit D. Fresh peach - ansD. Fresh peach why? The fresh peach is the lowest in sodium of these choices
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 - ansB. 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. 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." - ansB. "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 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 C. A client with a thoracotomy 6 months ago D. A client with Parkinson disease - ansB. The client with congestive heart failure complaining of nighttime dyspnea why? The client with congestive heart failure who is complaining of nighttime dyspnea should be seen first because airway si number one in nursing care A home health nurse is planning for her daily visits. Which client should the home health nurse visit first? A. A client with AIDS being treated with Foscarnet B. A client with a fractured femur in a long leg cast C. A client with a laryngeal cancer with a laryngetomy D. A client with diabetic ulcers to the left foot - ansC. A client with a laryngeal cancer with a laryngetomy why? The client with laryngeal cancer has a potential airway alteration and should be seen first. A new nursing graduate indicates in charting enteries that he is a licensed practical nurse, although he has not received the results of the licensing exam. The graduate's actions can result in what type of charge? A. Fraud B. Tort
C. Malpractice D. Negligence - ansA. Fraud why? Identifying oneself as a nurse without a license defrauds the public and can be prosecuted. A tort is a wrongful; malpractice is failing to act appropriately as a nurse or acting in a way that harm comes to the client; and negligence is failing to perform care. A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post- operative measure would usually be included? A. Closed chest drainage B. A tracheostomy C. A mediastinal tube D. Percussion vibration and drainage - ansA. A closed chest drainage why? The client with a lung resection will have chest tubes and a drainage-collection device. He probably will not have a tracheoostomy or mediastinal tube, and he will not have an order for percussion, vibration, or drainage. 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 - ansD. 21 pounds
why? A birth weight of 7 pounds would indicate 21 pounds in 1 year or triple the his birth weight. Due to a high census, it had been necessary for a number of clients to be transferred to another unit within the hospital. Which client should be transferred to the post-partum unit? A. A 66 year old female with gastroenteritis B. A 40 year old female with a hysterectomy C. A 27 year old male with sever depression D. A 28 year old male with ulcerative colitis - ansB. A 40 year old female with a hysterectomy why? The best client to transport to the postpartum units it the 40 year old female with a hysterectomy. The nurses on the postpartum unit will be aware of moral amounts of bleeding and will be equipped to care for this client. During the change of the shift, the ongoing nurse notes a discrepancy in the number of Perocept (oxycodone) listed in the number present in the narcotics drawer. The nurse's first action should be to: A. Notify the hospital pharmacist B. Notify the nursing supervisor C. Notify the board of nursing D. Notify the director of nursing - ansB. Notify the nursing supervisor why? The first action the nurse should take is to report the finding to the nurse supervisor and follow the chain of command.
Lidocaine is a medication frequently ordered for the client experiencing: A. Atrial tachycardia B. Ventricular tachycardia C. Heart block D. Ventricular brachycardia - ansB. 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. 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 - ansB. 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. Six hours after birth, the infant is found to have an areas of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as:
A. A cephalohematoma B. Molding C. Subdural hematoma D. Caput succedaneum - ansA. A cephalohematoma why? The swelling over the right parietal area is a cephalohematoma, an area of bleeding outside the cranium. This type of hematoma does not cross the suture line because it's outside the cranium but beneath the periosteum. 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." - ans 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 - ansD. 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 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. - ansB. 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 client is admitted with a BP of 210/120. Her doctor orders furosemide (Lasix) 40 mg IV stat. How should the nurse administer the prescribed furosemide to this client? A. By giving it over 1-2 minutes B. By hanging it IV piggyback C. With normal saline only D. By administering it through a venous access device - ansA. By giving it over 1-2 minutes why?
Lasix should be given approximately 1mL per minute to prevent hypotesion The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal a pH of 7.36, CO 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 - ansC. 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 client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin? A. Cyanocoblalmine B. Protamine sulfate C. Streptokinase D. Sodium warfarin - ansB. Protamine sulfate why? The antidote for heparin is protamine sulfate. Cyanocolbalamine is B12, Strptokinase is a thrombolytic, and sodium warfarin is an anticoagulant.
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 - ansB. Send a specimen to the lab why? If the dialysate returns cloudy, infection might be present and must be evaluated 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 - ansC. Blood glucose why? When the client is receiving TPN, the blood glucose level should be drawn. TPN is a solution that contains large amounts of glucose. The client is scheduled for a pericentesis. Which instruction should be given to the client before the exam? A. "You will need to lay flat during the exam."
B. "You need to empty your bladder before the procedure." C. "You will be alseep during the procedure." D. "The doctor will injuect a medication to treat your illness during the procedure." - ansB. "You need to empty your bladder before the procedure." why? The client scheduled for a pericentesis should be told to empty the bladder, to prevent the risk of puncturing the bladder when the needle is inserted. A pericentesis is done to remove fluid from the peritoneal cavity. The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority? A. Continue to monitor the vital signs B. Contact the physician C. Ask the client how he feels D. Ask the LPN to continue the post-op care - ansB. Contact the physician why? The vital signs are abnormal and should be reported to the doctor immediately. The client with a myocardial farction comes to the nurse's station stating that he is ready to go come because there is nothing wrong with him. Which defense mechanism is the client using? A. Rationalization B. Denial C. Projection D. Conversion reaction - ansB. Denial
why? The client who says he has nothing wrong is in denial about his myocardial infarction. 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 - ansC. 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." - ansB. "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 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 - ansA. 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. The first exercise that should be performed by a client with a mastectomy is: A. Walking the hand up the wall B. Sweeping the floor C. Combing her hair D. Squeezing a ball - ansD. Squeezing a ball why? The first exercise that should be done by the client with a mastectomy is squeezing the ball The graduate licensed practical nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority?
A.Maintain the client's systolic blood pressure at 70 mm/Hg or greater B. Maintain the client's urinary output greater than 300 cc/hr C. Maintain the client's body temp of greater than 33 F rectal D. Maintain the client's hematocrit less than 30% - ansA. Maintain the client's systolic blood pressure at 70 mm/Hg or greater why? When the cadaver client is being prepared to donate and organ, the systolic blood pressure should be maintained at 70 mm/Hg or greater to ensure a blood supply to the donor organ. 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 - ansD. 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 licensed practical nurse assigned to the post-partal unit is preparing to administer Rhogam to a post- patrum client. Which of the women is not a candidate for the RhoGam?
A. A gravida IV para 3 that is Rh negative with a Rh postivie baby B. A gravida I para I that is Rh negative with a Rh positive baby C. A gravida II para 0 that is Rh negative attempted after a still birth delivery D. A gravida IV para II that is Rh negative with a Rh negative baby - ansD. A gravida IV para II that is Rh negative with a Rh negative baby why? The mother in answer D is the only one who does not require a RhoGam injection. 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 - ansD. 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 - ansC. 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. 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 - ansB. 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 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 - ansA. 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. The nurse if caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis? A. Foul breath B. Dysphagia C. Diarrhea D. Chronic hiccups - ansC. Diarrhea why? Diarrhea is not common in clients with mouth and throat cancer 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 - ansB. 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 nurse is assigned to care from infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin?
A. Increase the infant's fluid intake B. Maintain the infant's body temp at 98.6 F C. Minimize tactile stimulation D. Decrease caloric intake - ansA. Increase the infant's fluid intake why? Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temp is important but will not assist in eliminating bilirubin. The nurse is assigning staff for the day. Which assignment should be given to the nursing assistant? A. Taking the vital signs of the 5 month old with brochiolitis B. Taking the vital signs of a 10 year old with a 2 day post- appendectomy C. Administering medication to the 2 year old with periorbital cellulitis D. Adjusting the traction of a 1 year with a fractured tibia - ansB. Taking the vital signs of a 10 year old with a 2 day post-appendectomy why? The client with the appendectomy is the most stable of these clients and can be assigned to a nursing assistant. The client with bronchiolitis has an alteration in the airway, the client with periorbital cellulitis has an infection, and the client with a fracture might be an abused child. The nurse is assisting a client with diverticulosis to select appropiate foods. Which food should be avoided? A. Bran B. Fresh Peaches