Download MN 576 PRACTICE TEST 2026 FULL SOLUTION VIEW AHEAD and more Exams Reasoning in PDF only on Docsity!
MN 576 PRACTICE TEST 2026 FULL SOLUTION
VIEW AHEAD
▶ A client receiving intravenous chemotherapy asks the nurse the reason for wearing a mask, gloves, and gown while administering drugs to the client. What is the nurse's best response? A) "I am preventing the spread of infection from you to me or any other client here." B) "The clothing protects me from accidentally absorbing these drugs." C) "The policy is for any nurse giving these drugs to wear a gown, gloves, and mask." D) "These coverings protect you from getting an infection from me." Answer: B Most chemotherapy drugs are absorbed through the skin and mucous membranes. As a result, health care workers who prepare or give these drugs, especially nurses and pharmacists, are at risk for absorbing them. Even at low doses, chronic exposure to chemotherapy drugs can affect health. The Oncology Nursing Society and the Occupational Safety and Health Administration (OSHA) have specific guidelines for using caution and wearing protective clothing whenever preparing, giving, or disposing of chemotherapy drugs. ▶ The earliest and most sensitive assessment finding that would indicate an alteration in intracranial regulation would be: A) change in level of consciousness. B) unequal pupil size. C) loss of primitive reflexes. D) inability to focus visually. Answer: A A change in level of consciousness is the earliest and most sensitive indication of a change in intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which assesses eye opening and verbal and motor response. The inability to focus may indicate a change, but it is not one of the earliest indicators or a component of the GCS. Primitive reflexes refers to those reflexes found in a normal infant that disappear with
maturation. These reflexes may reappear with frontal lobe dysfunction and may be tested for with a suspected brain injury, so it would be the reappearance of primitive reflexes. A change in pupil size or unequal pupils may indicate a change, but they are not one of the earliest indicators or a component of the GCS. ▶ Which client statement indicates a good understanding regarding antibiotic therapy for recurrent urinary tract infections? A) "Even if I feel completely well, I should take the medication until it is gone." B) "When my urine no longer burns, I will no longer need to take the antibiotics." C) "If my urine becomes lighter and clearer, I can stop taking my medicine." D) "If I have a fever higher than 100° F (37.8° C), I should take twice as much medicine." Answer: A Antibiotic therapy is most effective, especially for recurrent urinary tract infections, when the client takes the prescribed medication for the entire course, not just when symptoms are present. The other statements demonstrate that additional teaching is needed for the client. ▶ A client presents with a pressure ulcer on the ankle. Which is the first intervention that the nurse implements? A) Place the client in bed and instruct him or her to elevate the foot. B) Prepare for and assist with obtaining a wound culture. C) Assess the affected leg for pulses, skin color, and temperature. D) Draw blood for albumin, prealbumin, and total protein. Answer: C A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler if unable to palpate with his or her fingers. Elevation of the foot would impair the ability of arterial blood to flow to the area. Wound cultures are done after it has been determined drainage, odor, and other risks for infection are present. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done.
D) Dantrolene sodium (Dantrium) Answer: C Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other medications are not appropriate. ▶ The nurse is assessing a client's understanding of his hypertension therapy. What client statement indicates a need for further teaching? A) "When my blood pressure is normal, I will no longer need to take medication." B) "If my blood pressure stays under control, I will reduce my risk for a heart attack." C) "If I lose weight, I might be able to reduce my blood pressure medication." D) "When getting out of bed in the morning, I will sit for a few moments then stand." Answer: A Compliance with antihypertensive therapy is difficult for two reasons. First, often clients have no distressing symptoms associated with hypertension and may not believe that they have a problem. Second, many clients believe that once blood pressure is brought back into the normal range, they are "cured" and no longer need to take medication. Losing weight might allow the client to reduce medications. Lowering blood pressure does lower risk for heart attack. Because blood pressure medications often lead to orthostatic hypotension, clients should be taught to change position slowly, sitting first before standing after lying flat. ▶ Which of the following would be included in the assessment of a patient with diabetes mellitus who is experiencing a hypoglycemic reaction? (Select all that apply.) A) Constricted pupils B) Flushed skin C) Tremors D) Nervousness E) Extreme thirst F) Profuse perspiration Answer: C,D,F When hypoglycemia occurs, blood glucose levels fall, resulting in sympathetic nervous system responses such as tremors, nervousness, and
profuse perspiration. Dilated pupils would also occur, not constricted pupils. Extreme thirst, flushed skin, and constricted pupils are consistent with hyperglycemia. ▶ A client who has had a stroke with left-sided hemiparesis has been referred to a rehabilitation center. The client asks, "Why do I need rehabilitation?" How does the nurse respond? A) "Rehabilitation will reverse any physical deficits caused by the stroke." B) "Rehabilitation will help you function at the highest level possible." C) "If you do not have rehabilitation, you may never walk again." D) "Your doctor knows best and has ordered this treatment for you." Answer: B The goal of rehabilitation is to maximize the client's abilities in all aspects of life. The other responses do not answer the client's question appropriately. ▶ The nurse is monitoring a client with hypoglycemia. Glucagon provides which function? A) It enhances the activity of insulin, restoring blood glucose levels to normal more quickly after a high-calorie meal. B) It prevents hypoglycemia by promoting release of glucose from liver storage sites. C) It is a storage form of glucose and can be broken down for energy when blood glucose levels are low. D) It converts excess glucose into glycogen, lowering blood glucose levels in times of excess. Answer: B Glycogen is a counterregulatory hormone secreted by the alpha cells of the pancreas when blood glucose levels are low. The actions of glycogen that raise blood glucose levels include stimulating the liver to break down glycogen (glycogenolysis) and forming new glucose from protein breakdown (gluconeogenesis). The other statements are not accurate descriptions of the actions of glucagon. ▶ A client has a deep wound covered with a wet-to-damp dressing. Which intervention does the nurse include on this client's care plan? A) Apply a new dressing when the seal breaks and the dressing leaks.
▶ When reviewing an older client's medical record, which findings lead the nurse to perform a nutrition assessment? (Select all that apply.) A) Widow/widower status B) Chronic constipation C) Cholecystectomy 4 years ago D) Random blood sugar level of 198 mg/dL E) History of depression F) Inability to afford a new pair of glasses Answer: A,B,E,F Many factors contribute to malnutrition in older clients. Depression and loneliness from the loss of a spouse; constipation; poor eyesight; chronic medical problems, including depression; and taking prescription and/or over-the-counter medications can contribute to malnutrition. Blood glucose levels and a previous cholecystectomy would not necessarily contribute. ▶ The nurse is caring for a female client who is 5 feet, 7 inches tall and weighs 115 pounds. The client asks the nurse if she needs to lose weight. Which response by the nurse is best? A) "No. In fact, your body mass index suggests that you are already underweight." B) "Yes. Your body mass index suggests you are slightly overweight." C) "Your weight is just fine. Don't worry about it." D) "Maybe. Let's look at your risks for cardiovascular disease." Answer: A The client's body mass index (BMI) is 18.0, so she is already underweight. It is inaccurate to tell the client she is overweight, and it is unnecessary to consider her weight in light of any cardiovascular risk factors. The nurse should not reassure the client that her weight is just fine because she is underweight. ▶ A client who has type 2 diabetes is prescribed glipizide (Glucotrol). Which precautions does the nurse include in the teaching plan related to this medication? A) "Avoid taking nonsteroidal anti-inflammatory drugs." B) "Change positions slowly when you get up." C) "If you miss a dose of this drug, you can double the next dose." D) "Discontinue the medication if you develop an infection." Answer: A
Nonsteroidal anti-inflammatory drugs potentiate the hypoglycemic effects of sulfonylurea agents. Glipizide is a sulfonylurea. The other statements are not applicable to glipizide. ▶ The nurse is caring for a client who had a stroke. Which nursing intervention does the nurse implement during the first 72 hours to prevent complications? A) Position with the head of the bed flat to enhance cerebral perfusion. B) Monitor neurologic and vital signs closely to identify early changes in status. C) Administer prescribed analgesics to promote pain relief. D) Cluster nursing procedures together to avoid fatiguing the client. Answer: B Early detection of neurologic, blood pressure, and heart rhythm changes offers an opportunity to intervene in a timely fashion. Evidence is not yet sufficient to recommend a specific back rest elevation after stroke. Analgesics are often held during the first 72 hours to ensure that the client's neurologic status is not altered by pain medications. Preventing fatigue is not a priority in the first 72 hours. ▶ A client with diabetes is prescribed insulin glargine once daily and regular insulin four times daily. One dose of regular insulin is scheduled at the same time as the glargine. How does the nurse instruct the client to administer the two doses of insulin? A) "Draw up and inject the insulin glargine first, then draw up and inject the regular insulin." B) "First draw up the dose of regular insulin, then draw up the dose of insulin glargine in the same syringe, mix, and inject the two insulins together." C) "First draw up the dose of insulin glargine, then draw up the dose of regular insulin in the same syringe, mix, and inject the two insulins together." D) "Draw up and inject the insulin glargine first, wait 20 minutes, then draw up and inject the regular insulin." Answer: A
▶ Which is the highest priority goal to set for a client with pneumonia? A) Maintenance of SaO2 of 95% B) Walking 20 feet three times daily C) Absence of cyanosis D) Absence of confusion Answer: A Maintenance of an SaO2 of at least 95% is a clear goal that indicates that the client has adequate oxygenation. Absence of cyanosis and the presence of confusion are assessment factors that contribute to evaluation of oxygen; however, they are not absolute measures. Likewise, walking three times a day does not directly address oxygenation. ▶ The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure? A) "I sleep with four pillows at night." B) "I wake up coughing every night." C) "My shoes fit really tight lately." D) "I have trouble catching my breath." Answer: C Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left- sided heart failure. ▶ The nurse is caring for a client with Crohn's disease and colonic strictures. Which assessment finding requires the nurse to consult the health care provider immediately? A) Traces of blood in the stool B) Distended abdomen C) Temperature of 100.0° F (37.8° C) D) Crampy lower abdominal pain Answer: B The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an
obstruction of the large bowel, and the client's provider should be notified right away. Low-grade fever, bloody diarrhea, and crampy abdominal pain are common symptoms of Crohn's disease. ▶ What is my favorite football team? A) I hate football!! B) the Fightin' Irish C) GO BUCKS!!!! D) that team up north Answer: C Seriously, if you don't know the instructor's favorite football by this time, you need to listen to your recordings from the first lecture. Just sayin' ▶ The nurse is caring for a client who is receiving heparin therapy for a venous thromboembolism (VTE). The client's activated partial thromboplastin time (aPTT) before heparin therapy was 30 seconds. Which aPTT result indicates that anticoagulation is adequate at this time? A) 30 seconds B) 150 seconds C) 60 seconds D) 15 seconds Answer: C Therapeutic aPTT values for clients receiving heparin should range from 1.5 to 2.5 times the control value. ▶ The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patient's discharge planning? A) Limiting contact with the general population B) The importance of wearing a face mask in public C) The mechanisms of the inflammatory response D) Basic infection control techniques Answer: D The spleen is one of the major organs of the immune system. Without the spleen, the patient is at higher risk for infection; so, the nurse must be sure that the patient understands basic principles of infection control. The patient with a splenectomy does not need to understand the mechanisms
A) High cost of medications B) Inadequate nutrition C) Easy access to health screenings D) Uninsured or underinsured status Answer: A, B, D Individuals of low socioeconomic status tend to be part of the underinsured or uninsured population. Lack of insurance decreases accessibility to health care in general and health screening services specifically. High costs of medication and nutritious food also make this population at higher risk for infection. ▶ The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating a: A) portal of entry. B) host. C) mode of transmission. D) reservoir. Answer: A Broken or impaired skin creates a portal of entry for pathogens. By maintaining intact tissue, the patient and the nurse have broken the chain of infection by eliminating a portal of entry. Host is incorrect because you are not eliminating the person or organism. Intact tissue does not eliminate the mode of transmission. Skin can still be used to transfer pathogens regardless of it being intact or broken. Intact skin does not eliminate the location for pathogens to live and grow. ▶ The nurse is preparing to administer a prescribed IV antibiotic to a client admitted with a serious infection. Which action by the nurse is most important? A) Double check the "five rights." B) Assess the client for allergies. C) Teach the client about the drug. D) Check the IV for patency. Answer: B All actions are appropriate and important before administering any medications. However, client safety is the priority. The nurse should first
assess the client for medication allergies by asking the client or checking the chart (or both). Ensuring a patent IV and checking the five rights will not protect the client from an allergic reaction. ▶ The nurse assesses a cut that is 24 hours old and finds that the site is swollen, red, and tender to the touch. Which cell types are responsible for these assessment findings? A) Natural killer cells B) Basophils and eosinophils C) Erythrocytes and platelets D) Plasma cells and B-lymphocytes Answer: B Basophils and eosinophils release histamine, kinins, and other substances that cause the manifestations of inflammation. Erythrocytes carry oxygen, and platelets help stop bleeding. Plasma cells and B-lymphocytes produce antibodies to help fight infection, and natural killer cells destroy invading bacteria. ▶ A female client is admitted with an exacerbation of ulcerative colitis. Which laboratory value does the nurse correlate with this condition? A) Erythrocyte sedimentation rate (ESR), 55 mm/hr B) Potassium, 5.5 mEq/L C) Sodium, 144 mEq/L D) Hemoglobin, 14.2 g/dL Answer: A The erythrocyte sedimentation rate (ESR) is an indicator of inflammation, which is elevated during an exacerbation of ulcerative colitis. The normal range for the ESR is 0 to 33 mm/hr. Diarrhea caused by ulcerative colitis will result in loss of potassium and hypokalemia with levels lower than 3. mEq/L. Bloody diarrhea will lead to anemia, with hemoglobin levels lower than 12 g/dL in females. The sodium level is normal. ▶ O-H- A) who cares! B) I cannot pick this so I will lose points (this is for the Michigan Fans!!) C) I-O D) O-No!! Answer: C
D) Check oxygen saturation and notify the health care provider. Answer: D Decreased lung sounds and decreased lung expansion could indicate the development of a complication such as empyema or pus in the pleural space. The nurse should check the client's oxygen saturation and notify the provider. Infection can also move into the bloodstream and result in sepsis, so quick treatment is needed. ▶ The nurse is assigned a group of patients. Which patient would the nurse identify as being at increased risk for impaired gas exchange? A patient: A) with a hemoglobin of 8.5 g/dL B) with a blood glucose of 350 mg/dL C) who has been on anticoagulants for 10 days D) with a heart rate of 100 beats/min and blood pressure of 100/60 Answer: A The hemoglobin is low (anemia), therefore the ability of the blood to carry oxygen is decreased. High blood glucose and/or anticoagulants do not alter the oxygen carrying capacity of the blood. A heart rate of 100 beats/min and blood pressure of 100/60 are not indicative of oxygen carrying capacity of the blood. ▶ The nurse is starting a client on digoxin (Lanoxin) therapy. What intervention is essential to teach this client? A) "Increase your intake of foods high in potassium." B) "Avoid taking aspirin or aspirin-containing products." C) "Hold this medication if your pulse rate is below 80 beats/min." D) "Do not take this medication within 1 hour of taking an antacid." Answer: D Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 is too high for this cutoff. ▶ The nurse is caring for a client with Crohn's disease who has developed a fistula. Which nursing intervention is the highest priority? A) Position the client to allow gravity drainage of the fistula.
B) Check and record blood glucose levels every 6 hours. C) Encourage the client to consume a diet high in protein and calories. D) Monitor the client's hematocrit and hemoglobin. Answer: C The client with Crohn's disease is already at risk for malabsorption and malnutrition. Malnutrition impairs healing of the fistula and immune responses. Therefore, maintaining adequate nutrition is a priority for this client. The client will require 3000 calories per day to promote healing of the fistula. Monitoring the client's blood sugar and hemoglobin levels is important, but less so than encouraging nutritional intake. The client need not be positioned to facilitate gravity drainage of the fistula, because fistulas often are found in the abdominal cavity. ▶ The nurse is teaching a client who has recently given birth about immunity that has been passed to the newborn. Which statement by the client indicates that additional teaching is needed? A) "My baby received some antibodies from me before birth, and I will give him more when I breast-feed." B) "I had the measles, so my baby will be protected against it until he is old enough to receive the MMR vaccine." C) "Only certain antibodies were able to cross the placenta to protect my baby." D) "I had chickenpox and am immune to it, so my baby will not need to have the chickenpox vaccine." Answer: D The baby receives passive immunity from antibodies that are passed through the placenta in utero. Maternal passive immunity is temporary and will last for only a short time after birth. ▶ The nurse notes a venous ulcer on the client's left ankle. What additional assessment finding does the nurse expect in this client? A) Absence of hair on the left lower extremity B) Skin surrounding the ulcer mottled but blanchable C) Brownish discoloration of the lower extremity D) Cold and gray-blue lower extremity Answer: C
Older adult clients often do not demonstrate typical signs and symptoms of infection because of the diminished immune function seen with aging. Often, the first sign of infection is mental status changes. Any change in mental status in the older postoperative client should lead the nurse to assess for a wound infection. ▶ The nurse is assessing a client's skin for local signs of infection. Which signs does the nurse assess for? (Select all that apply.) A) Redness B) Fever C) Increased erythrocyte sedimentation rate (ESR) D) Pain E) Swelling F) Warmth Answer: A,D,E,F Localized signs of infection include redness, warmth, pain, swelling, heat, and pus. Fever and increased ESR are systemic signs of infection. ▶ Which client is at highest risk of compromised immunity? A) Client with extreme anxiety B) Client who is awaiting surgery C) Client who has just had surgery D) Client who just delivered a baby Answer: C Intact skin is a defense to prevent infection; however, a client who has recently had surgery has a portal for organisms to enter the body and cause infection. ▶ A client is admitted with left lower lung pneumonia. Which assessment finding does the nurse correlate with this condition? A) Expiratory wheeze on the right side B) Crackles heard on expiration bilaterally C) Dullness to percussion on the lower left side D) Crepitus of the skin around the left lung Answer: C The client with pneumonia may have dullness to percussion on the affected side. The other options are all inconsistent with pneumonia.
▶ The nurse auscultates the following lung sound in the client with pneumonia. What is the best intervention? Audio Clip A) Administer IV fluids. B) Have the client use an incentive spirometer. C) Have the client cough and deep breathe. D) Prepare to administer a bronchodilator. Answer: B The sound heard is crackles. Crackles often indicate atelectasis, which can be reversed by using an incentive spirometer. If no spirometer is available, coughing and deep breathing is the next best option. This client does not have wheezing, so bronchodilators are not indicated. IV fluids would not help atelectasis. ▶ A client with a history of heart failure is being discharged. Which priority instruction will assist the client in the prevention of complications associated with heart failure? A) "Eat six small meals daily instead of three larger meals." B) "When you feel short of breath, take an additional diuretic." C) "Avoid drinking more than 3 quarts of liquids each day." D) "Weigh yourself daily while wearing the same amount of clothing." Answer: D Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. ▶ The nurse assesses a client's legs. Which assessment finding indicates arterial insufficiency? A) Pain with activity but not while resting B) Dependent mottling and absence of hair C) Full veins present in dependent extremity D) Ankle discoloration and pitting edema Answer: B
