NCLEX PN REAL EXAM 150 QUESTIONS AND VERIFIED ANSWERS 2024-2025 LATEST UPDATE GRADED A+, Exams of Nursing

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NCLEX PN REAL EXAM 150 QUESTIONS AND

VERIFIED ANSWERS 2024-2025 LATEST

UPDATE GRADED A+

A client is shifted to the recovery unit after amputation of the left leg. Which of the following is the priority nursing action in the immediate postoperative period? A. Monitor Vital Signs B. Assess the proximal pulse at the amputated part C. Keep a surgical tourniquet t the bedside D. Administer IV fluids - answer-C. Keep a surgical tourniquet t the bedside Rationale: Hemorrhage is the most concerning primary immediate complication of amputation. Therefore, a surgical tourniquet is kept at the bedside in case of acute bleeding. The practical nurse knows that human papillomavirus infection (HPV) can lead to: A. Cervical cancer B. Infertility C. Pelvic inflammatory disease (PID) D. Rectal cancer - answer-A. Cervical cancer Rationale: HPV can lead to cervical cancer due to changes of the cervix from the genital warts. There is no known connection between HPV and infertility, PID, or rectal cancer. The nurse is to apply an Ace wrap to the client's right lower leg. Which action should the nurse take to ensure that the dressing is not too tight: A. Remove it every hour and reapply B. Check the pedal pulses C. Obtain a Doppler study to determine circulation D. Allow the wrap to remain in place for a minimum of 24 hours - answer-B. Check the pedal pulses

Rationale: To ensure that the Ace wrap is not too tight, the nurse should check the pulse, color, and temperature of the extremity. A doctor is preparing to remove a chest tube from a client. Before removing the tube, the nurse should instruct the client to: A. Breathe normally B. Hold breathe and bear down C. Take a deep breath D. Cough on demand - answer-B. Hold breathe and bear down Rationale: The client should be asked to hold breathe and bear down which prevents changes in pressure until an occlusive dressing is applied. A client admitted to the floor 3 days ago after a bowel resection suddenly develops chest pain and shortness of breath. Assessment of the client reveals rales, BP 160/40, and severe tachycardia. The nurse's first action should be to: A. Apply 02 at 2L/minute via mask B. Begin CPR C. Place the client in high Flower's position D. Administer a prescribed sedative - answer-C. Place the client in high Flower's position Rationale: The client during the post-operative period with a widening pulse pressure, SOB, and rales may have a pulmonary emboli. To facilitate breathing, he should be placed in high Flowler's position. Oxygen would the be applied. The nurse is caring for a pt. with a urinary catheter. The nurse should do which of the following to prevent a urinary tract infection? (select all that apply) A. Provide perineal care each day and after each bowel movement B. Change the catheter every day C. Encourage the pt. to drink fluids D. Ask the physician to prescribe prophylactic antibiotics E. Assess the pt. every shift for signs of infection - answer-A. Provide perineal care each day and after each bowel movement C. Encourage the pt. to drink fluids

E. Assess the pt. every shift for signs of infection The nurse is caring for a pt. with Raynaud's phenomenon. The nurse should emphasize that the pt. can reduce symptoms of this disease by: A. Increase coffee to three cups each day B. Keeping the house at 68 degrees F. C. Wearing gloves when handling frozen foods D. Running cold water over her hands during an episode - answer-C. Wearing gloves when handling frozen foods Rationale: Raynaud's phenomenon is characterized by vasospasm caused by extreme changes in temperature. Wearing gloves when handing cold caused by extreme changes in temperature. Wearing gloves when handing cold foods can help prevent the problem. This phenomenon is exacerbated by caffeine so the pt. should not increase caffeine intake. A house temperature of 68 degrees F is likely to increase vasospasm. During a vasospastic incident, the pt. can run warm water over her hands. A woman in labor has been pushing for one hour and is not making progress. Which of the following conditions could be hindering the descent of the fetus in the second stage of labor? A. A full bladder B. A paracervical block administered during the first stage of labor C. Mother lying in a side-lying position D. Fetus in left occiput anterior position - answer-A. A full bladder During a one-to-one conversation with a nurse, a client says, "I'm worried about my medication.'' The nurse replies, "Tell me more about that." The nurse's response is an example of: A. Focusing B. Clarifying C. Reflecting D. Refocusing - answer-A. Focusing You are caring for a child with cerebral palsy. You notice that the child's movements are very stiff, and it is very difficult for him to move his joints. What types of cerebral palsy does this child exhibit? A. Spastic cerebral palsy

B. Ataxic cerebral palsy C. Athetoid cerebral palsy D. Coritcate cerebral palsy - answer-A. Spastic cerebral palsy Rationale: Spastic cerebral palsy causes stiffness and movement difficulties. Athetoid cerebral palsy leads to involuntary and uncontrolled movements. Ataxic cerebral palsy causes a disturbed sense of balance and depth perception. The nurse is caring for a patient with multiple sclerosis. Which of the following symptoms is NOT indicative of the disease? A. Muscle weakness B. Trouble with coordination and balance C. Thinking and memory problems D. Hearing Loss - answer-D. Hearing Loss Rationale: Hearing Loss. Common symptoms of MS include fatigue, weakness, spasticity, balance problems, bladder and bowel problems, numbness, thinking/memoray problems, vision loss, tremors and depression. A patient is diagnosed with acute pancreatitis. Which of the following is the best choice for pain control? A. Morphine B. Ibuprofen C. Fentanyl D. Demerol - answer-D. Demerol Rationale: Pain in acute pancreatitis is caused by irritation and edema of the inflamed pancreas as well as spasm due to obstruction of the pancreatic ducts. Demerol is the drug of choice because it is less likely to cause spasm of the Sphincter of Oddi unlike Morphine which is spasmogenic. A patient has recently been diagnosed with a peptic ulcer. Upon reviewing lab data, the nurse notices that the patient's Helicobacter pylori titer is elevated. Which of the following would indicate the best understanding of the data? A. Treatment will be to continue to assess and monitor Helicobacter pylori titers B. Treatment involves educating the patient to avoid solid foods

C. Treatment will consist of Ranitidine and Antibiotics D. Treatment will involve surgical intervention - answer-C. Treatment will consist of Ranitidine and Antibiotics Rationale: One of the causes of peptic ulcer is H. Pylori infection. It releases toxin that destroys the gastric and duodenal mucosa which decreases the gastric epithelium's resistance to acid digestion. Giving antibiotics will control the infection and Ranitidine, which is a histamine-2 blocker, will reduce acid secretion that can lead to an ulcer. A client with congestive heart failure is being discharged home on a diet restricting sodium to 2000 milligrams per day. The client demonstrates adequate knowledge of the discharge instructions by avoiding which of the following foods? A. Plain nuts B. Canned sardines C. Spinach D. Whole milk - answer-B. Canned sardines Rationale: Canned sardines have the highest sodium content. A symptom that a client is developing a complication of heart failure is: A.Increased weight gain B. Development of ascites C. Restless and confusion D. Increased liver enzymes - answer-D. Increased liver enzymes Rationale: All of the symptoms mentioned are found in heart failure; however increased liver enzymes indicate congestion in the heart has reached the liver. A patient presents with complaints of generally not feeling well for 2 weeks, fatigue and occasional dizziness. The patient is placed on a cardiac monitor which shows a regular ventricular rate of 33 and more P waves than QRS complexes that do not seem to be associated. The patient is most likely experiencing: A. 1st degree heart block B. Sinus bradycardia C. 3rd degree heart block

D. Junctional rhythm - answer-C. 3rd degree heart block Rationale: In 3rd degree heart block there are more P waves than QRS complexes and there is no association between the P waves (atrial contraction) and QRS complexes (ventricular contraction). Which situation necessitates the use of restraints on a client? A. Insufficient staffing on the unit B. The client is confused and combative C. Family request to make sure client is safe D. Medical evaluation and written provider orders - answer-D. Medical evaluation and written provider orders Rationale: A medical evaluation and written healthcare provider orders that are timed and dated as per agency policy is required for the use of restraints. A client experiences an episode of pulmonary edema because the nurse forgot to administer the morning dose of furosemide (Lasix). Which legal element can the nurse be charged with? A. Assault B. Slander C. Negligence D. Tort - answer-C. Negligence Rationale: The nurse committed an act of omission (Breach of Duty) thereby constituting an act of negligence. Which finding should the nurse report to the provider prior to a magnetic resonance imaging MRI? A. History of cardiovascular disease B. Allergy to iodine and shellfish C. Permanent pacemaker in place D. Allergy to diary products - answer-C. Permanent pacemaker in place Rationale: In clients with implanted metallic devices such as pacemakers, an MRI is contraindicated.

A nurse is caring for a client admitted with left-sided heart failure. Which assessment finding supports the diagnosis? A. Dry mucous membranes B. Hypotension C. White frothy sputum D. Moist crackles - answer-Rationale: Most crackles are associated with client in fluid volume overload as a result of left-sided heart failure. A patient is started on dopamine (Inotropin) via peripheral intravenous access site. Which effect should the nurse monitor while on this therapy? A. Hypotension B. Tissue necrosis C. Pitting edema D. Petechiae - answer-B. Tissue necrosis Rationale: The infiltration of dopamine can cause extravasation and lead to tissue necrosis and sloughing. A patient tells the nurse that he enjoy eating garlic "to help lower his cholesterol level." Which drug has a potential interaction with the garlic? A. Acetaminophen (Tylenol) B.Warfarin (Coumadin) C.Digoxin (Lanoxin) D.Phenytoin (Dilantin) - answer-B.Warfarin (Coumadin) Rationale: When using garlic, it is recommended to avoid any other drugs that may interfere with platelet and clotting function. During teaching, the nurse discusses the major effects of beta-blockers during initial therapy. Which laboratory result should the nurse report? A. Blood sugar 60 mg/dL B. Potassium 4.0 mEq/L

C. Hemoglobin 14 mg/dL D.WBC 6000/mm3 - answer-A. Blood sugar 60 mg/dL Rationale: Beta-blockers can mask the signs and symptoms of hypo/hyperglycemia. Which lab value is abnormal? A. BUN 20 B. BUN 8 C. BUN 10 D. BUN 25 - answer-D. BUN 25 Rationale: normal lab value for BUN is 7-22. RBC 4.9 million, WBC 8,000, platelets 146,000, Hgb 16 g. Based on this lab report, which function of the blood is impaired? A. Oxygen carrying B. Infection fighting C. Blood clotting D. Size of RBC's - answer-C. Blood clotting Rationale: Normal platelet count is from 200,000 - 400,000. The rest of the lab work falls in normal range. Which lab value would you expect to be normal for a patient diagnosed with hyperparathyroidism? A. Calcium B. Parathyroid hormone C. Magnesium D.Phosphorus - answer-C. Magnesium Rationale: With hyperparathyroidism, parathyroid hormone and calcium levels are increased and phosphorous levels are decreased. Which of the following drug levels are not therapeutic?

A. Digoxin 1. B. Theophylline 15 C. Dilantin 25 D. Lithium 1.4 - answer-C. Dilantin 25 Rationale: The normal range for Dilantin is 10-20 mcg/dl. A nurse caring for a client diagnosed with a stroke is started on clopidrogrel (Plavix). Which adverse effect of the medication should the nurse monitor in the client? A. Hot flashes B. Confusion C. Tarry stools D. Abdominal pain - answer-C. Tarry stools Rationale: The nurse must monitor for signs of bleeding in a client taking the antiplatelet medication, clopidrogrel (Plavix). A nurse is teaching a client about stroke prevention. Which risk factors should the nurse include in the teaching plan as the most important factor contributing to a stroke? A. Active lifestyle B. Alcohol use C. Hypertension D. Smoking - answer-C. Hypertension Rationale: A complication of hypertension is a cerebral vascular accident and the client is at an increased risk for a stroke. During a neurologic examination, the notes the client's upper extremities are flexed, and internally rotated with plantar flexion of the lower extremities. What should the nurse document? A. Contractures B. Decorticate posturing C. Decerebrate posturing

D. Tetany - answer-B. Decorticate posturing Rationale: Decorticate posturing is a sign indicating that the client is neurologically decompensating. The client's upper extremities will be flexed, and internally rotated with plantar flexion of the lower extremities. During a neurologic assessment, a client demonstrates swaying with eyes closed. Based on this finding, which condition should the nurse suspect? A. Positive Babinski B. Positive Romberg sign C. Positive Weber test D. Negative Romberg - answer-B. Positive Romberg sign Rationale: Swaying with eyes closed is indicative of a positive Romberg sign indicating a condition known as proprioception. During the initial 24 hours after an above-the-knee amputation, the nurse performs which priority action to properly manage the surgical site? A. Elevate the residual limb B. Loosen the dressing every 4 hours C. Maintain the residual limb in a dependent position D. Change the dressing as often as needed - answer-A. Elevate the residual limb Rationale: Elevating the limb during the first 24 hours facilitates venous return, decreases swelling and promotes comfort. A client with a right arm cast for fractured humerus states, "I haven't been able to straighten the fingers on my right hand since this morning." What action should the nurse take? A. Assess neurovascular status to the hand B. Ask the client to massage the fingers C. Encourage the client to take the prescribed analgesic D. Elevate the right arm on a pillow to reduce edema - answer-A. Assess neurovascular status to the hand Rationale: This finding is suggestive of neurological injury as a result of pressure on nerves and soft tissue because of swelling.

Which is the most common cause of postoperative hypoxemia? A. Alveolar collapse B. Bronchospasm C. Aspiration D. Pulmonary Edema - answer-A. Alveolar collapse Rationale: The most common cause of hypoxemia after surgery is atelectasis. Which client has the highest risk for a bacteremia? A. Client with a peripherally inserted central catheter (PICC) line B. Client with a central venous catheter (CVC) C.Client with an implanted infusion port D. Client with a peripherally inserted intravenous line - answer-B. Client with a central venous catheter (CVC) Rationale: Central venous catheter insertion are placed into a vein in the neck or chest with the tip resting in the superior vena cava and carry the highest risk for bacterial infection of the bloodstream. What is the priority nursing action after a subtotal thyroidectomy? A. Airway obstruction B. Hemorrhage C. Tetany D. Edema - answer-A. Airway obstruction Rationale: A priority nursing action after a subtotal thyroidectomy is airway assessment because airway obstruction may occur postoperatively. It is a medical emergency and resuscitative equipment must be readily available in the client's room. A nurse caring for a client with a platelet count of 60,000 should observe for which initial finding indicative of bleeding? A. Heart rate 58 beats per minute

B. PaO2 80 mmHg C. Heart rate 118 beats per minute D. Blood pressure 110/60 - answer-C. Heart rate 118 beats per minute Rationale: In thrombocytopenia, the client will experience tachycardia because the heart has to beat faster to compensate for the drop in the amount of circulating volume and number of oxygen-carrying red blood cells. To facilitate drainage of oral secretions in a child who had cleft lip repair, the nurse should place the child in what position? A. Supine B. Side-lying C. Trendelenburg D. High-Fowler's - answer-B. Side-lying Rationale: After repair of a cleft palate, the child should be placed in a side-lying position. This position helps promote drainage and maintain an open airway. When communicating with children, what most important factor should the nurse take into consideration? A. Development level B. Physical development C. Nonverbal cues D. Parental involvement - answer-A. Development level Rationale: In order to engage in effective communication with children, nurses must take into consideration the developmental level of the child. A patient with suspected ulcers is scheduled for a diagnostic gastroscopy. During the insertion of the scope the patient experiences a vasovagal response. The nurse should expect all except: A. The pt. is given atropine before the procedure. B. The pt.'s pupils become dilated. C. A pt. has an increase in gastric secretions D. The pt. has a decrease in heart rate. - answer-B. The pt.'s pupils become dilated.

Rationale: Stimulation of the vagus nerve does not dilate the pupils. A patient presents to the emergency room with the following symptoms: Anxiety, dyspnea, rhonchi, fever, Oxygen saturation of 88%, and a pH of 7.21. The nurse realized that the patient suffering from: A. Respiratory Alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis - answer-C.Respiratory acidosis Rationale: One of the key symptoms of respiratory distress syndrome is the inability of the respiratory system to exchange gases, resulting in respiratory acidosis. A patient has a chest tube placement post right thoracotomy. During assessment the nurse expects all of the following findings except: A. Use of accessory muscles with respirations. B. Water level in the chamber rises and falls with each respiration. C. Chest drainage flows into the first chamber. D. Evaluate tidaling by disconnecting chest tube from wall suction. - answer-A. Use of accessory muscles with respirations. Use of the accessory muscles is an abnormal finding that could indicate air in the pleural sac. The AIDS virus can be transmitted under specific conditions and through infected bodily fluids except: A. Blood B. Feces C. Semen D. Breast Milk - answer-B. Feces Rationale: Feces is correct because it is the only answer mentioned in this question that is a bodily fluid but does not transmit the HIV virus. Which ethical principle is the nurse utilizing when supporting the decision of a client to terminate chemotherapy treatments?

A. Autonomy B. Confidentiality C. Fidelity D. Justice - answer-A. Autonomy Rationale: The ethical principle supported in this situation represents the client's autonomy or right to make his/her own decisions. Which element legally defines the nursing scope of practice for nursing? A. Healthcare providers B. Hospital standards of care C. Nurse practice Acts D. Professional nursing organizaetions - answer-C. Nurse practice Acts Rationale: The State Practice Acts help determine the legal nursing scope of practice for nurses in each state. A client has had an open reduction internal fixation (ORIF) of the right hip two days ago. There is a Jackson-Pratt (JP) suction device for drainage at the site and staple sutures which are open to air. Which assessment finding needs to be reported to the provider immediately? A. Absence of draining into the Jackson-Pratt B. Bright red drainage from the suture site C. A temperature of 98.0F D. pain scale rating of 6 out of 10 - answer-B. Bright red drainage from the suture site Rationale: Bright red drainage from the suture site indicates that hemorrhage is occurring and must be reported immediately to the surgeon. The charge nurse has assigned a client with an open burn wound to the licensed practical nurse (LPN). Which instruction should the charge nurse give to the licensed practical nurse (LPN)? A. Administer a tetanus toxoid vaccine as ordered B. Assess wounds for signs of infection C. Tell the client cough and breathe deeply

D. Perform hand washing upon entering room. - answer-D. Perform hand washing upon entering room Rationale: Hand washing is the most effective for preventing infection transmission especially with a burn client. A client develops a loud, brassy cough after a burn. What ordered intervention by the nurse is a priority? A. Administer oxygen as ordered B. Give the client small quantities of ice chips to suck on C. Request an order for an antitussive agent D. Tell the respiratory therapist to give the client humidified oxygen - answer-A. Administer oxygen as ordered Rationale: Brassy cough and wheezing signs seen of inhalation injury. The first action by the nurse is to administer oxygen. A patient who is receiving lovastatin [Mevacor] experiences chest pain. CK level is 580 units/mL (CK-MM 99%) and troponin T 0.02 g/mL. Which organ is a priority for the nurse to monitor? A. Brain B. Heart C. Lungs D. Kidney - answer-B. Heart Rationale: Troponin and CK-MM are specific to the heart. Which laboratory result would increase the risk of Torsades? A. Potassium 3.4 mEq/L B. Potassium 5.4 mEq/L C. Sodium 132 mEq/L D. Magnesium 1.0 mEq/L - answer-D. Magnesium 1.0 mEq/L Rationale: Normal Mg is 1.5-2.5 mEq/L. Low magnesium levels increases the risk of Torsades a ventricular dysrhythmia.

What effects of angiotensin-converting enzyme (ACE) inhibitors most often results in the provider changing the treatment plan to an angiotensin receptor blocker [ARB]? A. Orthostatic hypotension B. Nagging nonproductive cough C. Fatigue D. Hyokalemia - answer-B. Nagging nonproductive cough Rationale: Due to the release of bradykinin , ACE Inhibitors cause a nagging, dry, hacking nonproductive cough. The nurse is caring for a patient taking furosemide (Lasix). Which finding is most indicative of an adverse effect with this drug? A. Na 136 mEq/L B. Potassium 3.6 mEq/L C. Chloride 98 mEq/L D. Uric acid 15 mg/dL - answer-D. Uric acid 15 mg/dL Rationale: Hyperuricemia is an adverse effect of furosemide [Lasix]. Uric acid levels are extremely elevated. A patient arrives in the emergency department with severe chest pain. Which assessment finding would indicate the need for cautious use of nitrates and nitrites? A. Blood pressure of 96/66 mm Hg B. History of hepatitis C. History of congestive heart failure D. History of heart attack 1 year ago - answer-A. Blood pressure of 96/66 mm Hg Rationale: Hypotension is a possible contraindication to the use of nitrates because the medications may cause the blood pressure to decrease. Which medication use by the client with a history of chronic kidney disease (CKD) requires further teaching? A. Liquid iron B. Milk of magnesia (MOM)

C. Calcium phosphate (PhosLo) D. Ascorbic acid (Vitamin C) - answer-B. Milk of magnesia (MOM) Rationale: Pharmacokinetically, magnesium is excreted by the kidneys. A client with chronic kidney disease should not use any products containing magnesium. Which medication can be used in a client with chronic kidney disease (CKD) to help stimulate red blood cell production? A. Epoetin (Epogen) B. Filgrastim (Neupogen) C. Cobalamin (Vitamin B-12) D. Warfarin (Coumadin) - answer-Epoetin (Epogen) Rationale: Erythropoietin controls red blood cell production. It is used to treat anemia as a result of diminished endogenous production of erythropoietin in clients with chronic kidney disease. A client develops sudden onset dyspnea, a respiratory rate of 36 breaths per minute, and pink, frothy sputum. Which diuretic should the nurse anticipate administering as ordered? A. Acetazolaminde (Diamox) B. Furosemide (Lasix) C. Mannitol (Osmitrol) D. Spironolactone (Aldactone) - answer-B. Furosemide (Lasix) Rationale: The client is manifesting signs of pulmonary edema such as pink, frothy sputum, sudden onset difficulty breathing and rapid respiratory rate. The diuretic indicated is Furosemide (Lasix). Lasix is a potent loop diuretic used for rapid depletion of fluids. Which laboratory diagnostic is useful when evaluating improvement in kidney function for a client with acute kidney injury (AKI)? A. Blood urea nitrogen (BUN) level B. Glomerular filtration rate (GFR) C. Serum creatinine level D. Urine output - answer-B. Glomerular filtration rate (GFR)

Rationale: GFR is the preferred diagnostic method for evaluating renal function. Which menu items are good choices for a client on hemodialysis? A. Egg white omelet, toasted plain bagel, and apple juice B. Oatmeal with skim milk, half a banana, and coffee C. Lentil soup, whole-grain toast, and whole milk D. Swiss cheese sandwich, cream of broccoli soup, and orange juice - answer-A. Egg white omelet, toasted plain bagel, and apple juice Rationale: Egg white omelet provides high-quality protein, and the apple juice is very low in potassium. All of the following effects on cardiac output(CO) are true EXCEPT: A.If the heart rate is decreased the cardiac output is decreased B. If strove volume is increased the cardiac output is decreased C. If there is a decrease in preload the stroke volume will be decreased D.If the afterload is decreased there is an increase in cardiac output - answer-B. If strove volume is increased the cardiac output is decreased Rationale: When the stroke volume is increased, the cardiac output is increased. Cardiovascular drugs whose typical actions block the sympathetic stimulation to the heart and decrease the heart hate are called? A. Beta blockers B. Catecholamines C. Steroids D. Benzodiazepines - answer-A. Beta blockers Rationale: Beta blockers such as propranolol (Inderal) target the beta cells in the heart thereby slowing it down. The nurse notes spasms of the right hand while checking the client's morning blood pressure. Which action should the nurse take? A. Assess the blood pressure

B. Check the calcium level C. Perform a neurovascular assessment D. Notify the provider - answer-B. Check the calcium level Spasms of the hand during blood pressure read is indicative of a Trousseau sign which is manifested when the Calcium level is below 8.6 mEq/L. A client on digoxin [Lanoxin] reports nausea, vomiting, and seeing yellow halos. Which laboratory finding should the nurse report immediately? A. BUN 8 mg/dL B. Magnesium 1.4 mEq/L C. pH 7. 46 D. Potassium 3.2 mEq/L - answer-D. Potassium 3.2 mEq/L Rationale: The client on digoxin [Lanoxin] is at risk for digoxin toxicity as a result of hypokalemia. Toxicity is manifested by nausea, vomiting, abdominal cramps, anorexia and visual disturbances, such as halos. The nurse is caring for a client after receiving burns to more than 40% of the body. Which laboratory result is a priority to report in the first 24 hours? A. Serum glucose 115mg/dL B. Blood urea nitrogen 30 mg/dL C. Hematocrit 36% D. White blood count 10,000/mm3 - answer-B. Blood urea nitrogen 30 mg/dL Rationale: The rate at which the glomerular filters [GFT] will be diminished in the first 24 hour in response to extensive burns along with shift in fluid status. A nurse is taking the health history of a client. What information would she consider significant in regards to cardiovascular health? A. A history of metastatic cancer B. Frequent viral bronchitis C. Use of calcium supplements D. Use of recreational drugs - answer-D. Use of recreational drugs

Rationale: The use of recreational drugs, especially stimulants such as cocaine is a growing cause of heart irregularities. A client diagnosed with acute pericarditis has a nursing diagnosis of pain related to pericardial inflammation. The appropriate nurse involvement would include: A. Administering opioids every four hours as directed B. Encouraging relaxation exercises such as deep breathing C. Positioning the client on the left side with head elevated 20 degrees D. Positioning the client in a Fowler position with an over-the-bed table to lean on - answer-D. Positioning the client in a Fowler position with an over-the-bed table to lean on Rationale: Relief from pericardial pain is often obtained by sitting up and leaning forward. The American Nurses Association definition of nursing identifies which of the following activities that are in congruence with the Nurse Scope of Practice: A. Explaining the danger involved in a surgical procedure B. Discussing the risk of taking an investigational medication C. Determining the amount of IV fluid replacement needed for a patient admitted after a motor vehicle accident D. Contributing evidence to nursing research through nursing based studies on the effects of health policies on various cultural populations - answer-D. Contributing evidence to nursing research through nursing based studies on the effects of health policies on various cultural populations Rationale: All of the other options are not in the nurses' scope of practice. The nurse has made an error in documenting client care. Which appropriate action should the nurse take? A. Draw a line through error, initial, date and document correct information B. Document a late addendum to the nursing note in the client's chart C. Tear the documented note out of the chart D. Delete the error by using whiteout - answer-A. Draw a line through error, initial, date and document correct information

Rationale: An error in documentation requires that the nurse draw a single line through the error, initial and date the line, then document the factual and correct documentation in the medical record. The nurse on the day shift reports that the narcotic count is incorrect. What is the most appropriate nursing action? A.Report discrepancy to nurse manager and pharmacy immediately B. Report the incident to the local board of nursing C. Do a recount with another staff nurse D. Report the incident to the state nurses association - answer-A.Report discrepancy to nurse manager and pharmacy immediately Rationale: The nurse manager and pharmacy must be alerted immediately of any discrepancy in the narcotic count. These substances are regulated by the Drug Enforcement Agency. An incident report must also be completed. A patient with chronic low back pain is on extended release morphine twice a day for pain control. The patient has a pain contract in place. He requests a refill for his pain medication. Upon review of his request for pain medication refills you note that he has requested his pain medication at least 10 days later than expected the last three times. You have the patient come in to assess his use of the pain medication. He reports that he takes the pain medication once a day and he only uses the second dose if needed. What do you anticipate next? A. Authorization of a refill for his medication B.Instruction for use of extended release medication, review of the pain contract, decrease in dose to once a day C. Discontinuation of medication D. Change in the orders for one tablet of the extended release morphine daily with a second tablet daily as needed - answer-C. Discontinuation of medication Extended release narcotics for chronic pain are meant to be taken on schedule and not as needed. A pain contract typically indicates that the narcotic will be taken as prescribed. Among the reasons for a primary risk assessment for the development of cancer in women are all of the following EXCEPT: A. Detecting a trait or characteristic of cancer can be associated with the development of cancer B. Identifying the client who has started menses before age 12 as a risk factor in the development of cancer

C. Recognizing that living in certain areas of the United States have been found to be conclusive risk factors for developing cancer D. Understanding that the discovery of a family history that includes at least one family member who has been diagnosed with cancer as a risk factor - answer-C. Recognizing that living in certain areas of the United States have been found to be conclusive risk factors for developing cancer. Cancer occurrence in various parts of the USA is a risk factor due to various carcinogens, but it is by no means conclusive. Tests commonly incorporated in the diagnostic workup of women's cancer include all EXCEPT: A. Cancer-related checkups including examinations for thyroid, skin, lymph node and ovarian cancer B. Clinical breast exam (CBE), a manual breast examination performed by a trained clinician C. Mammography, an x-ray allowing visualization of a the internal structure of the breast D. Screening done on symptomatic clients to evaluate authenticity of disease process - answer-D. Screening done on symptomatic clients to evaluate authenticity of disease process Screening is done on asymptomatic clients in the diagnostic workup stage. A 38 year old female client has undergone a right modified radical mastectomy for breast cancer. Post operatively, she experiences incisional pain and swelling and limited movement of her right arm. The surgeon has informed her that four of the lymph nodes were positive for cancer and that she will have to undergo chemotherapy. As the nurse caregiver for this client, which of the following is an immediate problem related to potential health? A. Pain B. Impaired mobility of arm C. Disturbed body image D. Grieving - answer-A. Pain The pain postoperatively must be evaluated and treated prior to any of the other options. Nurses caring for the female cancer patient must be acquainted with a special perspective that focuses on the female. These perspectives include all EXCEPT: A. Coping skills supporting family interactions B. Emotional support regarding questions about changes in body image

C. Informational support regarding lifestyle changes D. Decision making support regarding the type of surgery that best suites the clients cancer - answer-D. Decision making support regarding the type of surgery that best suites the clients cancer. Helping the client make a decision about the type of surgery she must undergo is clearly not in the nurses' scope of practice. Knowledge of the breasts and their functions include: A. The breasts are supported by and attached to the chest wall, resting on the major scapular chest muscle B. The areolas deliver milk through the opening in the nipple C. Fibrosis, cysts, mastitis, contribute more than 70% added risk to developing breast cancer D. The major hormones affecting the breast are estrogen, progesterone, and prolactin - answer-D. The major hormones affecting the breast are estrogen, progesterone, and prolactin The other statements are false. Treatment of breast cancer involves many modalities. All of the answers below are correct EXCEPT: A.Staging which shows the size and spread of the malignancy B.Identifying the presence of the BRCA ½ factor predicting risk for optimum treatment C.Performing breast-sparing surgery (lumpectomy) D.incorporating chemotherapy as an adjunct to surgery - answer-B. Identifying the presence of the BRCA ½ factor predicting risk for optimum treatment. Identification of the BRCA ½ factor is used in the screening of breast cancer not in the treatment phase A 65 year old African American female has been diagnosed with lung cancer and is scheduled for a left thoracotomy. As the nurse caring for this client you understand that the major determining factor of this client's health is the fact that A. She is African American and lacks health insurance B. She chose to smoke all of her adult life C. Her mother died of lung cancer at about the same age D. She has limited ability to understand and act on health information post-operation - answer-B. She chose to smoke all of her adult life

She chose to smoke all of her life which influences the rest of her health going forward. Cancer can occur in the lining of the uterus, the endometrium. Women must be alert to the fact that these disorders of the endometrium can cause the same symptoms whether the disease is benign or malignant. A symptom that occurs in endometrial cancer that is different from endometriosis is: A.Irregular menstrual bleeding B. Lower back or pelvic pain C.Painful urination D. Vaginal bleeding between periods - answer-D. Vaginal bleeding between periods The most common symptom of endometrial cancer is vaginal bleeding between periods. A client explains to the nurse that they have been using a complementary medicine to control their cancer pain. As the caregiver to this client the nurse understands that all of the statements below regarding complimentary medicine are true EXCEPT: A. Complementary and alternative medicines are in direct contract to one another B. Complimentary therapies are adjuncts to conventional care C. Complimentary therapies are used by cancer patients with the belief that the therapies will control pain and improve physical or emotional well-being D. Complimentary medicine substitute conventional therapies - answer-D. Complimentary medicine substitute conventional therapies Complimentary medicinal therapies are used in conjunction with standard methods of cancer care. Which ethical principle is the nurse utilizing when supporting the decision of a client to terminate chemotherapy treatments? A. Autonomy B. Confidentiality C. Fidelity D. Justice - answer-A. Autonomy The ethical principle supported in this situation represents the client's autonomy or right to make his/her own decisions.

In which situation should the nurse accept an assignment but complete a protest of assignment? A. Floating to another unit B. Insufficient staffing C. Strike D. Mass disaster - answer-B. Insufficient staffing If an assignment is to care for clients than what is reasonable, it needs to be brought to the attention of nursing manager/and or supervisor. Protest of assignment do not relief a nurse of their responsibility but the nurse is attempting to act reasonable. A patient is ordered metformin 1000mg twice a day for his diabetes. While talking with the patient he states "I never eat breakfast so I take a ½ tablet at lunch and a whole tablet at supper because I don't want my blood sugar to drop." As his primary care nurse you: A. Tell him he has made a good decision and to continue B. Tell him to take a whole tablet with lunch and with supper C. Tell him to skip the morning dose and just take the dose at supper D.Tell him to take one tablet in the morning and one tablet in the evening as ordered - answer-D. Tell him to take one tablet in the morning and one tablet in the evening as ordered. The patient should take the metformin as ordered. Metformin does not cause low blood sugars due to the way it is metabolized. A patient calls his primary care physicians office requesting an appointment. While talking with the patient he reports that about 5 weeks ago he experienced a TIA. He reports that he was discharged from the hospital with plavix 75mg. He states he took one tablet daily as prescribed and completed all 30 tablets. You do the following: A. Schedule the patient ASAP to resume Plavix B. Inform the patient that a 30 day course of plavix is the usual course of treatment post TIA C.Schedule the patient for a 6 month follow up appointment D. Advise the patient that no follow up is needed unless he is having a problem - answer-A. Schedule the patient ASAP to resume Plavix. Plavix is an anti- platelet that is needed in order to prevent further TIAs or CVA and should be continued.