Hurst -NCLEX Test Taking Strategy Questions- with 100% verified answers & rationales-2024, Exams of Nursing

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Hurst -NCLEX Test Taking Strategy Questions- with

100% verified answers & rationales-2024-

WITH 75 Q&A

1. The nurse is providing post-operative care to a craniotomy client. Diabetes insipidus is suspected when the client’s urine output suddenly increases significantly. Which action takes highest priority? o 1. Monitoring urine output o 2. Checking pulse o 3. Checking blood pressure o 4. Assessing level of consciousness Rationale:
2. Correct: This is the best answer because we are “worried” this client is going into SHOCK. So…..you better be checking a BP. This is a time where checking the BP is appropriate. If we “assume the worst” I better check a blood pressure. It could have dropped out the bottom.
3. Incorrect: Continuing to monitor U/O is important but I need to find out if they are already shocky.
4. Incorrect: Checking the pulse is a good thing, but, not as important as checking the BP.
5. Incorrect: If my client is going into shock the highest priority is to assess the BP.
6. The client is being treated for fluid volume deficit. Which is an expected outcome of successful treatment? o 1. Resolution of orthostatic hypotension o 2. Maintenance of weight loss o 3. Compliance with sodium restricted diet o 4. Maintenance of serum Na above 148 mEq Rationale:
7. Correct: When you are in a fluid volume deficit your blood pressure goes down when you stand up and it’s called orthostatic hypotension. Successful treatment would resolve this.
8. Incorrect: When I have lost a lot of volume, my weight goes down, so if I am better, my weight should go up.
9. Incorrect: Who needs to adhere to dietary sodium restrictions? People who are in fluid volume excess.

4. Incorrect: If your serum sodium is above 148, hypernatremia is the same thing as dehydration, so this means that you are still sick.

3. The nurse in the intensive care unit is caring for a client receiving hemodynamic monitoring. When planning for a client’s care, which nursing diagnoses associated with hemodynamic monitoring may be utilized by the nurse? Select all that apply.  1. Decreased cardiac output  2. Fluid volume deficit  3. Fluid volume excess  4. Ineffective tissue perfusion  5. Ineffective airway Rationale: 1., 2., 3. & 4. Correct: Nursing diagnoses, associated with hemodynamic monitoring, that may be utilized by the nurse include decreased cardiac output, fluid volume deficit, fluid volume excess, and ineffective tissue perfusion. These nursing diagnoses relate to the pathophysiologic processes that alter one of the four hemodynamic mechanisms that support normal cardiovascular function: preload, afterload, heart rate, and contractility.
4. Incorrect: Ineffective Airway would not be associated with hemodynamic monitoring.
5. The nurse is caring for a client that has two IV access sites. One is a 20 gauge antecubital peripheral IV that was started yesterday for blood and has normal saline (NS) at keep vein open rate. The other is a double lumen central line catheter with one port for Total Parental Nutrition and the other is used for blood samples. Where is the best site for the nurse to administer 20 mEq of potassium chloride (KCL) in 100 mL of normal saline(NS) over 4 hours? o 1. Central line port that is being used for lab draws o 2. Same line with the Total Parental Nutrition o 3. Large bore antecubital o 4. Start another peripheral IV Rationale:
6. Correct: Yes- K is very hard on the veins, give it through the central line.
7. Incorrect: No, never put anything through a line with Total Parental Nutrition.
8. Incorrect: Second best choice- but it will burn.
9. Incorrect: No, a central line is needed.

5. The nurse is caring for a client that has metabolic acidosis secondary to acute renal failure. What is the initial client response to this problem? o 1. Respiratory rate increases to blow off acid. o 2. Respiratory rate decreases to conserve acid and buffer the kidneys response. o 3. Kidneys will excrete hydrogen and retain bicarb. o 4. Sodium will shift to cells and buffer the hydrogens. Rationale:
6. Correct: Yes, acute renal failure causes metabolic acidosis and the body is trying to breathe faster to blow off some acid. The respiratory response is fast.
7. Incorrect: No, the client’s respiratory rate is fast, not slow.
8. Incorrect: This will happen, later. Did not we say about 48 hours? Not initial response.
9. Incorrect: Sodium is extracellular electrolyte, not an intracellular electrolyte.
10. The client presents to the emergency department with nausea, vomiting and anorexia for the last few days. An EKG on admission reveals an arrhythmia. Which electrolytes imbalance is suspected? o 1. Hypercalcemia o 2. Hypokalemia o 3. Hypermagnesemia o 4. Hyponatremia Rationale:
11. Correct: The client has been vomiting so the electrolytes losses are potassium, hydrogen and chloride. The anorexia further complicates the condition because we get potassium from the foods we eat. The one electrolyte we worry about with arrhythmias is potassium.
12. Incorrect: What has calcium got to do with nausea and vomiting? Nothing
13. Incorrect: Magnesium is loss through the lower GI tract and Hypermagnesemia is not related to dysrhythmias.
14. Incorrect: The loss of sodium is related to diarrhea.

7. The nurse is caring for a client that is drowsy and has an elevated CO 2. What are some common drugs that cause retained CO 2? Select all that apply  1. Narcotics  2. Diuretics  3. Steroids  4. Antiemetics  5. Hypnotics Rationale: 1., 4. & 5. Correct: Yes! – Narcotics sedate and decrease the respiratory rate. Some antiemetics like promethazine (Phenergan) are very sedating. Hypnotics can cause sedation to point of hypoventilation.
8. Incorrect: No – Diuretics do not affect breathing patterns.
9. Incorrect: No –Steroids do not affect breathing patterns
10. A client was admitted 24 hours ago with sepsis. Treatment included IV therapy of lactated Ringers (LR) at 150 ml/hr, broad spectrum antibiotics, and steroid therapy. How will the nurse know that treatment has been successful? Select all that apply.  1. Blood pressure 96/68; HR- 98; RR- 20  2. Serum Glucose- 110  3. Hgb- 12; Hct- 38  4. pH- 7.30; pCO 2 - 48; HCO 3 - 24  5. Urinary output at 25 ml/hr  6. Awake, alert to person, place and time Rationale: 1., 2., 3. & 6. Correct: The systolic BP should be greater than 90. The other lab work is normal as well.
11. Incorrect: The client is still in respiratory acidosis, so is not better.
12. Incorrect: Urinary output should be at least 30 ml/hr.

9. The daytime charge nurse identifies that a client was treated for what condition during the night after reading the following chart entries? o 1. Respiratory Alkalosis o 2. Respiratory Acidosis o 3. Metabolic Alkalosis o 4. Metabolic Acidosis Rationale:
10. Correct: Look at pH? Acid and which other lab says acid….CO 2. Is CO 2 a respiratory or metabolic chemical? Respiratory. So the condition is Respiratory Acidosis.
11. Incorrect: Not alkalotic condition, the pH is acid.
12. Incorrect: Not metabolic condition, because HCO 3 is normal.
13. Incorrect: Not metabolic condition, because HCO 3 is normal. Progress Notes: 11/22/10- 0125 Restless, picking at sheets and pulling at IV tubing. Disoriented to place and time. Dyspnea on exertion noted. Dr. Timmons notified. Stat ABGs ordered.------- Mary Minee, RN 11/22/10- 0145 Oxygen started at 2 liters per nasal cannula. Incentive Spirometry and deep breathing exercises initiated. Head of bed elevated to 30 degreesMary Minee, RN Lab reports: pH- 7. pO 2 - 91mmHg pCO 2 - 50 mmHg HCO 3 - 24 mEq/L

10. The nurse is caring for a client, who is 8 hours post- op receiving 40% humidified oxygen. ABG results are: pO 2 = 91, pCO 2 = 50, pH= 7.30, HCO 3 = 24. Based on this information, which nursing action would be best? o 1. Turn client and encourage coughing and deep breathing. o 2. Request respiratory therapy to perform postural drainage and percussion. o 3. Report ABGs to physician and increase oxygen percentage. o 4. Administer anti-anxiety agent. Rationale:

1. Correct: If you had just a colectomy would you be taking nice deep breaths? No. So what would you be retaining? CO 2 which makes your pCO 2 go up, which makes your pH go down. I’m acidotic aren’t I?
2. Incorrect: Requesting postural drainage and percussion form respiratory therapy would not be the best nursing action to address the problem of retaining CO 2.
3. Incorrect: There’s nothing wrong with calling the physician and letting him know about the ABGs but the last part is just wrong. How is oxygen going to help this client? It’s not until they get rid of the what? CO 2. And the only way to rid of the CO 2 is coughing and deep breathing.
4. Incorrect: What are they going to say about you if you select #4? You’re a killer. Don’t give her a license, because if you give them an anti-anxiety agent what’s going to happen to the respiratory rate, decrease, and they are going to retain even more CO 2 and you’ve just made it worse.

11. After completing a round of chemotherapy, the client’s lab results revealed. Based on this data, what problem should the nurse anticipate? Select all that apply.  1. Anemia  2. Leukopenia  3. Thrombocytopenia  4. Hypernatremia  5. Hypokalemia Rationale: 1., 2. & 3. Correct: Chemotherapy decreases bone marrow production, resulting in reduced red blood cell counts (anemia), reduced white blood cell counts (leukopenia), and reduced platelet counts (thrombocytopenia).
12. Incorrect: The sodium level is normal.
13. Incorrect: The potassium level is also normal. Lab Results Hgb- 9.0g/dl Hct- 28% WBC- 3,000 mm Platelets- 94,000 mm Na- 142mEq/L K- 3. mEq/L

12. A client weighing 154 pounds is admitted to the burn unit with second and third degree burns covering 40% total body surface area. Normal Saline IV fluid resuscitation is ordered at 4 ml/kg per percentage of total body surface area burned over the first 24 hours. How much fluid does the nurse calculate the client will receive in 24 hours? Provide your answer in whole numbers ml Rationale: Correct: 11,200 ml in the first 24 hours 154 pounds/ 2.2 kg= 70 kg 4 ml x 70 kg= 280 280 ml x 40 tbsa= 11,200 ml in the first 24 hours
13. A client five days post electrical burn states, “I am feeling fine and would like to go home.” What is the rationale for this length of stay? o 1. Bone damage always occurs resulting in pathologic fractures. o 2. Vascular and nerve damage may cause organ failure. o 3. Continuous EKG monitoring is always required. o 4. Infection is sometimes a delayed response. Rationale:
14. Correct: The current of electrical burns damages the vascular system and the nerves nearby. This alteration in the vascular system can damage vital organs, and we worry about organ failure.
15. Incorrect: Bones are dense and not really affected by electrical current.
16. Incorrect: Cardiac monitoring is for the first 48 hours, not the reason for a prolonged stay.
17. Incorrect: Infection is not a priority in an electrical burn.

14. A client is hospitalized hundreds of miles from home for a bone marrow transplant. The client is in reverse isolation while undergoing total body irradiation and intense chemotherapy. The client’s sibling, who has driven a great distance, comes to visit and has obvious manifestations of an upper respiratory infection. Which nursing action would be most appropriate at this time? o 1. Do not allow the sibling to visit, and do not upset the client by mentioning the sibling’s visit. o 2. Allow the sibling to wave at the client through the window or door, then offer the use of the unit phone so they can talk. o 3. Allow the sibling to visit donning a sterile gown, mask, and gloves, but prohibit physical contact. o 4. Allow the sibling to visit after donning a sterile gown, mask, and gloves and have the client wear a mask. Rationale:
15. Correct: This is the only safe answer for the client.
16. Incorrect: No, allow client to see from distance and talk with client.
17. Incorrect: Sibling does not need to be allowed in the room regardless of protective clothing.
18. Incorrect: Sibling does not need to be allowed in the room regardless of protective clothing.
19. A client is admitted to the Emergency Department with burns to the chest and legs. Which assessment is the highest priority? o 1. Calculating the “Rule of Nines” o 2. Determining the time of the burn o 3. Ascertaining if the burn occurred in an enclosed area o 4. Calculating the Parkland formula Rationale:
20. Correct: A fire in an enclosed area brings on the concern for carbon monoxide poisoning. In addition with the burns to the chest there is the added potential for airway damage.
21. Incorrect: Important for surface area estimate but not airway.
22. Incorrect: Important for fluid replacement but not #1.
23. Incorrect: Determines the amount of fluid to be replaced, but not airway!

16. The client has returned to your unit after an escharotomy of the forearm. What is the priority nursing assessment? o 1. Infection o 2. Incision o 3. Pain o 4. Tissue perfusion Rationale:
17. Correct: Yes! They do the escharotomy for circulation problems, check circulation!
18. Incorrect: Not right away!
19. Incorrect: No, that incision is going to be bad and ugly.
20. Incorrect: Well this is the second best answer – the escharotomy for the lack of circulation and pain is one indicator of adequate circulation, so go with the real thing first.
21. A client had surgery for cancer of the colon and a colostomy was performed. Prior to discharge, the client states that he will no longer be able to swim. The nurse’s response would be based on which understanding? o 1. Swimming is not recommend, the client should begin looking for other areas of interest. o 2. Swimming is not restricted if the client wears a dressing over the stoma at all times. o 3. The client cannot go into water that is over the stoma area, he can only go into water up to the stoma area. o 4. There are no restrictions on the activity of a client with a colostomy; all previous activities may be resumed. Rationale:
22. Correct: With the colostomy bag providing an airtight seal they can take a shower, bath, and go swimming.
23. Incorrect: Swimming is allowed with the airtight seal that the colostomy bag provides.
24. Incorrect: Client will wear colostomy bag with airtight seal not a dressing over the stoma.
25. Incorrect: No, the client can swim with the airtight seal colostomy bag.

18. The nurse is evaluating whether a client understands the procedure for collecting a 24 hour urine sample. The nurse recognizes that teaching was successful when the client makes which statements? Select all that apply.  1. “I should start the 24 hour urine collection at the time of my first saved urine specimen.”  2. “If I forget to collect any urine, I will need to start over.”  3. “It is important to ensure that no feces or toilet tissue mixes with the urine.”  4. “When the 24 hours is up, I need to void and collect that specimen.”  5. “The urine specimen should be stored in my refrigerator during collection.” Rationale: 2., 3. & 4. Correct: Missed specimens make the collection inaccurate. The test should be started over. Contamination can alter the test. The last specimen should be obtained at the end of the 24 hour period.
19. Incorrect: The time begins with the first voiding, however that voiding is discarded.
20. Incorrect: Urine should be placed on ice or left at room temperature if an additive has been used. You do not want the client to store the specimen in their refrigerator.
21. After gathering supplies, explaining the procedure, putting the client in a high fowlers position, and washing hands, the nurse begins to clean a client’s tracheostomy. Place the steps in the proper order. All options must be used. Rationale: 6., 3., 4., 8., 1., 5., 2., 7. & 9. Correct: This is the proper procedure for trach care.
22. Soak inner cannula in peroxide.
23. Reinsert cannula with non-dominant hand and lock into place.
24. Prepare sterile supplies, hydrogen peroxide and normal saline.
25. Don sterile gloves.
26. Rinse and dry inner cannula with pipe cleaner.
27. Put on clean gloves to remove soiled dressing.
28. Secure tracheostomy with clean twill tape.
29. Cleanse the wound and plate of the tracheostomy tube with sterile cotton tipped applicator.
30. Remove old twill tape.

20. The client with Addison’s disease demonstrates an understanding of steroid therapy by which statement? o 1. “I’ll take my medicine at night to help me sleep.” o 2. “My medication dosage will be adjusted frequently.” o 3. “I will limit my sodium intake to 200 mg per day.” o 4. “I will weigh myself weekly to monitor medication effectiveness.” Rationale:
21. Correct: Steroid therapy is adjusted according to the client’s weight and signs of fluid volume status.
22. Incorrect: Steroids can cause insomnia.
23. Incorrect: This client needs a high sodium diet as they are losing sodium and retaining potassium.
24. Incorrect: Weights are done daily to adjust medication dosage not weekly.
25. The nurse is admitting a client with new onset Diabetes mellitus. Which findings does the nurse expect while completing the medical history and physical examination of this client? Select all that apply.  1. History of recurrent vaginal yeast infections  2. Complaints of intolerance to the cold  3. Slow, slurred speech noted  4. Prescription change for glasses needed twice in past year  5. Complaints of wanting to eat all the time  6. Amenorrhea Rationale: 1., 4. & 5. Correct: Polyuria, polyphagia, and polydipsia are classic symptoms of diabetes. With type II diabetes the manifestations are often nonspecific. Common manifestations include fatigue, recurrent infections, recurrent vaginal yeast or monilial infections, prolonged wound healing, and visual changes. Unfortunately, the clinical manifestations appear so gradually that an individual may blame the symptoms on another cause such as lack of sleep or increasing age, and before the person knows it, he or she may have complications.
26. Incorrect: This is a manifestation of hypothyroidism.

3. Incorrect: This is a manifestation of hypothyroidism.
4. Incorrect: This is a manifestation of hypothyroidism.
5. A nurse caring for a cancer client is teaching the client about precautions concerning the client’s risk for bleeding problems. The nurse identifies that teaching has been successful regarding bleeding precautions when the client makes which statement? Select all that apply.  1. “I cannot shave while I am at risk for bleeding.”  2. “It is important to gargle with a commercial mouthwash three times a day.”  3. “Stool softeners will help prevent rectal bleeding.”  4. “Prior to sexual intercourse, I will use a water-based lubricant.”  5. “I will use a soft toothbrush.” Rationale: 3., 4. & 5. Correct: Stool softeners prevent constipation and straining that may injure rectal tissue. Water-based lubricant will prevent friction and tissue trauma. Soft toothbrush will prevent trauma to gum tissue.
6. Incorrect: The client can shave with an electric razor. An electric razor will prevent trauma.
7. Incorrect: Commercial mouthwash should be avoided as they contain high alcohol content that will dry oral tissues and lead to bleeding.
8. The nurse is caring for a client that is paranoid in the locked psychiatric unit. It is time for the client’s individual session, but the client is very agitated with outburst of shouting. What would be the nurse’s best action at this time? o 1. Have the client sit with you and say a prayer. o 2. Explain that shouting is not allowed and send them to group session. o 3. Redirect the client to another activity. o 4. Call for assistance and put the client in seclusion. Rationale:
9. Correct: Yes! Get them active. Redirect their activity. This is too much for them right now.
10. Incorrect: They are agitated, shouting…Now you think it is reasonable to get them to sit and pray? Nope!
11. Incorrect: Setting limits is good, but here the client is disruptive.
12. Incorrect: Oh boy – it’s going to be a fight! NO! That’s not nice.

24. Which dietary consideration is the most important for the nurse to teach to a client with hypothyroidism? o 1. Increase carbohydrate intake. o 2. Increase fluid intake. o 3. Avoid shellfish. o 4. Increase fiber. Rationale:
25. Correct: YES! Low thyroid clients have constipation, so increased fiber.
26. Incorrect: No they need less calories, not more. Their metabolism is slowed.
27. Incorrect: What does increasing fluid have to do with it? Nothing
28. Incorrect: What does avoiding shellfish have to do with it? Nothing…that’s if they are allergic to iodine.
29. Following a thyroidectomy a client is complaining of shortness of breath and neck pressure. What should the nurse do? o 1. Stay with the client, remove the dressing, and elevate the head of bed. o 2. Call a code, open the trach set and position the client flat supine. o 3. Have the client say “EEE” to check for laryngeal integrity and assess Chvostek’s sign. o 4. Call the doctor and assess vital signs. Rationale:
30. Correct: Yes! Sounds like respiratory distress, Looks like respiratory distress, get that dressing off the neck and see if they can breathe any better.
31. Incorrect: Not yet! Do something first to see if it gets better.
32. Incorrect: Well just look and check and look and check – do something.
33. Incorrect: Don’t leave the client.

26. A client is admitted for evaluation of cardiac arrhythmias. What would be the most important information to obtain when assessing this client?  1. Ability to perform isometric exercises as ordered.  2. Changes in level of consciousness or behavior.  3. Recent blood sugar changes.  4. Compliance with dietary fat restrictions. Rationale:
27. Correct: The only answer that deals with cardiac output is #2. When the cardiac output drops, then the LOC will decrease.
28. Incorrect: What do isometrics have to do with cardiac output?
29. Incorrect: What does blood sugar have to do with cardiac output?
30. Incorrect: Arrhythmias have nothing to do with fat.

27. The nurse is caring for a client with deep vein thrombosis of the left leg. Which nursing goal

would be most appropriate for this client?  1. To decrease inflammatory response in the affected extremity.  2. To increase peripheral circulation.  3. To prepare client and family for anticipated vascular surgery.  4. To prevent hypoxia associated with the development of pulmonary emboli. Rationale:

1. Correct: When blood sets in one area it inflames the area, and a clot can form.
2. Incorrect: You do not need oxygen when you have a venous problem. The only time you need oxygen is when you have an arterial problem.
3. Incorrect: Getting ahead of yourself.
4. Incorrect: Getting ahead of yourself.

28. A six-year-old client has been receiving chemotherapy for two weeks. The laboratory results show a platelet count of 20,000. What is the priority nursing action? o 1. Encourage quiet play. o 2. Avoid persons with infections. o 3. Administer p.r.n. oxygen. o 4. Provide foods high in iron. Rationale:
29. Correct: With a low platelet count you are at risk for bleeding, and quiet play will decrease the risk of injury.
30. Incorrect: The priority is risk for bleeding with the low platelet count, not infection.
31. Incorrect: There is no indication that client has low RBC’s or anemia.
32. Incorrect: There is no indication that client has low iron.
33. A nurse is caring for a client diagnosed with heart failure (HF). The client currently takes furosemide (Lasix) 40mg every morning. Potassium 20mEq daily, digoxin (Lanoxin) 0.25mg every day. Which client comment should the nurse assess first in caring for this client? o 1. “My fingers and feet are swollen.” o 2. “My weight is up 1 pound.” o 3. “There is blood in my urine.” o 4. “I am having trouble with my vision.” Rationale:
34. Correct: Did you see the sign of Dig toxicity? Good Job!
35. Incorrect: History of heart failure, edema is common- may need bed rest or additional diuretic therapy- not usually life threatening.
36. Incorrect: No, weight should not vary more than 3-5 pounds.
37. Incorrect: Needs investigation, but digoxin toxicity comes first- more lethal.

30. After a left heart catheterization, a client complains of severe foot pain on the side of the femoral stick. The nurse notes pulselessness, pallor, and cold extremity. What should be the nurse’s next action? o 1. Administer an anticoagulant. o 2. Warm the room and re-assess. o 3. Increase IV fluids. o 4. Notify the physician stat. Rationale:
31. Correct: This is an emergency, and the doctor is the only one that can save this foot from ischemia – don’t delay.
32. Incorrect: Anticoagulants stabilize clots, not lyse – thrombolytics lyse clots..too aggressive – just report and get some help coming.
33. Incorrect: These symptoms are too severe for warming the room.
34. Incorrect: Well, in theory, increasing blood volume increases blood flow – but this client has an arterial obstruction.
35. A client is admitted to the medical unit with a diagnosis of Addison’s disease. What nursing interventions should the nurse implement for this client? Select all that apply.  1. Administer potassium supplements as ordered.  2. Assist the client to select food high in sodium.  3. Administer Fludrocortisone (Florinef) as ordered.  4. Monitor intake and output.  5. Record daily weight. Rationale: 2., 3., 4. & 5. Correct: The client with Addison’s disease needs sodium due to low levels of aldosterone. Florinef is a mineraocorticoid that the client will need to take lifelong. I&O and daily weights are needed to monitor fluid status.
36. Incorrect: Clients with Addison’s disease lose sodium and retain potassium, so this client does not need potassium.

32. In planning a menu for a client suffering from an acute manic episode, which meal would the nurse determine to be most appropriate? o 1. Spaghetti and meat balls, salad, banana o 2. Beef and vegetable stew, bread, vanilla pudding o 3. Fried chicken leg, ear of corn, apple o 4. Fish fillets, stewed tomatoes, cake Rationale:
33. Correct: Something they can hold in their hand and it is high calorie.
34. Incorrect: Spaghetti is too frustrating for anyone….Never give a manic client something frustrating to eat.
35. Incorrect: It’s hard to walk around and eat beef stew.
36. Incorrect: It’s hard to walk around and eat stewed tomatoes.
37. The manic client has just interrupted the counselor’s group session for the 4th time and states “I already know this information dealing with others when you are down.” What should the nurse do at this time? o 1. Engage the client to walk with you to make another pot of coffee. o 2. Ask the client to reflect on the client’s behavior to determine if it is appropriate. o 3. Ask the group to tell the client how they feel when she interrupts. o 4. Instruct the client to perform jumping jacks and counting aloud to get rid of some energy. Rationale:
38. Correct: Yes! Get them away and doing something purposeful.
39. Incorrect: That is embarrassing and humiliating to the client.
40. Incorrect: Sometimes this will be helpful during times of therapy – but the client is manic at this time, will she even believe them?
41. Incorrect: No, this is getting her active, but can the group continue with this attention seeking jumping, counting person? No. Get her away from the activity.

34. After examining the eyes of the following client, the nurse would expect which correlating lab work? o 1. Elevated cortisol level o 2. Elevated thyroxine levels o 3. Decreased parathormone levels o 4. Increased calcitonin level Rationale:
35. Correct: Exophthalmos is a classic finding in Graves’ disease. It is a protrusion of the eyeballs from the orbits due to impaired venous drainage from the orbit, which causes increased fat deposits and edema in the retro-orbital tissues. To diagnose hyperthyroid or Grave’s Disease you do a thyroxine level which when elevated indicates a hyperthyroid state.
36. Incorrect: This would indicate hyperfunctioning of the adrenal gland as in Cushing ’s syndrome.
37. Incorrect: This lab would indicate hypoparathyroidism.
38. Incorrect: Again, this level would tell you about the parathyroid.
39. A client with schizophrenic disorder begins to talk about fantasy material. What would be the most appropriate nursing action? o 1. Encourage the client to focus on reality-based issues. o 2. Allow the client to continue to talk so as not to interrupt the delusion. o 3. Ask the client to explain the meaning behind what he is saying. o 4. Persuade the client that his thoughts are not true. Rationale:
40. Correct: Get them out of the delusion to get into the real world.
41. Incorrect: Never allow clients to continue on in a delusion….this is reinforcing it.
42. Incorrect: Reinforcing the delusion.
43. Incorrect: Waste of time….produces anxiety.

36. A client has been admitted to the medical unit with hepatitis B. Identify what quadrant the nurse would assess for hepatomegaly. Place an “x” in the correct location. Rationale: Correct: The liver is located under the right lower rib cage. The liver may be palpable in the right upper quadrant.
37. Which client is at highest risk for suicide? o 1. Seventy-six year old widower with chronic renal failure o 2. Nineteen year old taking antidepressants o 3. Twenty-eight year old post-partum crying weekly o 4. Fifty year old with obsessive-compulsive disorder (OCD) Rationale:
38. Correct: Yes- elderly with chronic disease, especially men, are very high risk.
39. Incorrect: There is an increased incidence and risk in this population-but look for the highest risk.
40. Incorrect: Many post-partum clients cry weekly, this is not the red flag client.
41. Incorrect: Chronic disease, but the widower wins out as the higher risk.

38. A client with a T4 lesion is being cared for on the neuro rehabilitation unit. The client suddenly complains of a severe, pounding headache. Profuse diaphoresis is noted on the forehead. The blood pressure is 180/112 and the heart rate is 56. What interventions should the nurse initiate? Select all that apply.  1. Place the client supine with legs elevated.  2. Assess bladder and bowel for distention.  3. Examine skin for pressure areas.  4. Eliminate drafts.  5. Remove triggering stimulus.  6. Administer hydralazine (Apresoline) if BP does not return to normal. Rationale: 2., 3., 4., 5. & 6. Correct: All appropriate interventions for autonomic dysreflexia. This condition occurs in clients with a T6 or lower injury. The autonomic nervous system sends out a massive sympathetic response (epi and norepi) to stimuli. The stimuli is one that would not bother a healthy person but very dangerous to a spinal injury client, i.e. bladder or bowel distention, pressure areas in the bed, drafts, and other simple triggers.
39. Incorrect: The client should be placed immediately in a sitting position to lower blood pressure.
40. A client who is fourth day post-op cholecystectomy complains of severe abdominal pain. During the initial assessment he states, “I have had two almost black stools today.” Which nursing action is most important? o 1. Start an IV with D5W at 125 ml/hr. o 2. Insert a nasogastric tube. o 3. Notify the physician. o 4. Obtain a stool specimen. Rationale:
41. Correct: What’s going on inside? They are hemorrhaging. Assume the worst. The physician is the only one who can stop the bleeding.
42. Incorrect: There’s nothing wrong with starting an IV, but isn’t the client bleeding while you do this?
43. Incorrect: How does that help the bleeding stop? It doesn’t.
44. Incorrect: You are going to wait on a stool specimen and Hemoccult. Don’t delay care, notify the physician first.

40. A construction worker comes into the occupational health nurse’s clinic complaining of chest heaviness. What other signs and symptoms does the nurse expect to find if myocardial infarction is suspected? Select all that apply.  1. Headache  2. Indigestion  3. Lightheadedness  4. Dyspnea  5. Irregular pulse Rationale: 2., 3., 4. & 5. Correct: Chest pains or discomfort not relieved by rest or nitroglycerin. Palpitation. If heart failure occurs, BP maybe increases because of sympathetic stimulation or decreased because of decreased contractility, impending cardiogenic shock, medications. Irregular pulse due to artial fibrillation, shortness of breath, tachypnea, crackles due to pulmonary congestion, n/v, decreased UOP due to cardiogenic shock, as well as cool clammy skin. Anxiety, restlessness, lightheadedness.
41. Incorrect: Headaches do not commonly occur with MI.
42. The nurse is caring for a client complaining of intense headaches with increasing pain for the past month. A Magnetic Resonance Imaging (MRI) is ordered. In reviewing the client’s information, which piece of information is of concern? o 1. Allergic to shellfish o 2. Cardiac pacemaker o 3. Diabetic o 4. No IV access Rationale:
43. Correct: Yes! IF a client with a cardiac pacemaker has an MRI the pacemaker is turned off and the client could die.
44. Incorrect: No – there is not dye involved with MRI
45. Incorrect: No- The client does not need to be NPO or have any modifications of their medications
46. Incorrect: None needed

42. A newly diagnosed diabetic client is demonstrating to the nurse how to draw up regular insulin 15 units and NPH insulin 10 units into the same syringe. The nurse knows that the client successfully demonstrates this procedure if done in what order? Place in the correct order. All options must be used. Rationale: 4., 7., 2., 1., 6., 5. & 3. Correct: This is the correct procedure.
43. What must the nurse do while caring for a client with an eating disorder? o 1. Encourage client to cook for others. o 2. Weight the client daily and keep a journal. o 3. Restrict access to mirrors. o 4. Monitor food intake and behavior for one hour after meals. Rationale:
44. Correct: Yes! This is the primary problem and the most life threatening.
45. Incorrect: No – remember the focus is on control and attention to food – they need to eat.
46. Incorrect: No – we don’t let them know their weight, if they gain one ounce, they will try anything to lose it!
47. Incorrect: They still have to brush their hair and put on make-up – it’s the eating we just focus on to keep them alive.
48. Inject 15 units of air into regular insulin bottle.
49. Prepare skin site and inject insulin.
50. Draw up 10 units of NPH insulin into the insulin syringe.
51. Draw up 15 units of regular insulin into insulin syringe.
52. Wipe the top of insulin bottles.
53. Inject 10 units of air into NPH insulin bottle.
54. Roll insulin bottles between hands.

44. Which condition would warrant the nurse discontinuing the intravenous infusion of oxytocin (Pitocin)? o 1. Fetal heart rate baseline of 140-160 bpm o 2. Contractions every 1-1/2 minutes lasting 70-80 seconds o 3. Maternal temperature of 101.2 degrees o 4. Early decelerations in the fetal heart rate Rationale:
45. Correct: These contractions are too long and too often.
46. Incorrect: That heart rate is fine.
47. Incorrect: Temperature has nothing to do with Pitocin (uterine contractions).
48. Incorrect: Early decels are no big deal.
49. In preparing care for a client with Parkinson’s disease, which nursing diagnoses should the nurse include? Select all that apply.  1. Impaired physical mobility related to muscle rigidity  2. Imbalanced nutrition, greater than body requirements related to limited exercise  3. Self-care deficits related to motor disturbance  4. Impaired verbal communication related to inability to move facial muscles  5. Unilateral neglect related to muscle paralysis. Rationale: 1., 3. & 4. Correct: These are appropriate nursing diagnoses for a client with Parkinson’s disease.
50. Incorrect: The client is more likely to have imbalanced nutrition, less than body requirements, related to tremor, slowness in eating, difficulty in chewing and swallowing.