NCLEX PN Test Bank, Exams of Nursing

Download NCLEX PN Test Bank and more Exams Nursing in PDF only on Docsity! NCLEX PN TEST BANK 1 NCLEX PN TEST BANK GRADED A Latest version 2021 download to score A QUESTION 1 Which of the following is an appropriate nursing goal for a client at risk for nutritional problems? A. provide oxygen B. promote healthy nutritional practices C. treat complications of malnutrition D. increase weight Answer: B Explanation: Promoting healthy nutritional practices is an appropriate nursing goal for a client at risk for nutritional problems. Choice 1 is incorrect because it is a nursing intervention, not a goal statement. Choice 3 is incorrect because it is a therapeutic treatment. Choice 4 is incorrect because weight gain is an appropriate goal only if the client is underweight.Basic Care and Comfort QUESTION 2 Major competencies for the nurse giving end-oflife care include: A. demonstrating respect and compassion, and applying knowledge and skills in care of the family and the client. B. assessing and intervening to support total management of the family and client. C. setting goals, expectations, and dynamic changes to care for the client. D. keeping all sad news away from the family and client. NCLEX PN TEST BANK 2 Answer: A Explanation: There are many competencies that the nurse must have to care for families and clients at the end of life. Demonstration of respect and compassion as well as using knowledge and skills in the care of the client and family are major competencies.Basic Care and Comfort QUESTION 3 Which of the following lab values is associated with a decreased risk of cardiovascular disease? NCLEX PN TEST BANK 5 C. withdrawal D. problem-solving Answer: B Explanation: Somatizing means one experiences an emotional conflict as a physical symptom. Ashley manifests several physical symptoms associated with severe anxiety. Acting out refers to behaviors such as anger, crying, laughter, and physical or verbal abuse. Withdrawal is a reaction in which psychic energy is withdrawn from the environment and focused on the self in response to anxiety. Problem-solving takes place when anxiety is identified and the unmet need is met.Psychosocial Integrity NCLEX PN TEST BANK 6 QUESTION 7 A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered? A. Advil B. Anasaid C. Clinocil D. Colace Answer: D Explanation: Colace is a stool softener that acts by pulling more water into the bowel lumen, making the stool soft and easier to evacuate.Basic Care and Comfort QUESTION 8 A client is taking hydrocodone (Vicodin) for chronic back pain. The client has required an increase in the dose and asks whether this means he is addicted to Vicodin. The nurse should base her reply on the knowledge that: A. the client’s body has developed tolerance, requiring more drug to produce the same effect. B. the client is preoccupied with getting the drug and is experiencing loss of control, indicating drug dependence. C. addiction is the term used to describe physical dependence with withdrawal symptoms and tolerance. D. the client has a dual diagnosis of substance abuse and chronic back pain. Answer: A Explanation: Drug tolerance is characterized by the ability to ingest a larger dose without adverse effect and decreased sensitivity to the substance. Substance dependence is a severe condition indicating physical problems and disruption of the person’s social, family, and work life. The psychological behaviors related to substance use are termed addiction. Dual diagnosis is the coexistence of substance abuse and psychiatric disorders.Psychosocial Integrity NCLEX PN TEST BANK 7 QUESTION 9 A client has been taking alprazolam (Xanax) for four years to manage anxiety. The client reports taking 0.5 mg four times a day. Which statement indicates that the client understands the nurse’s teaching about discontinuing the medication? A. “I can drink alcohol now that I am decreasing my Xanax.” B. “I should not take another Xanax pill. Here is what is left of my last prescription.” C. “I should take three pills per day next week, then two pills for one week, then one pill for one week.” D. “I can expect to be sleepy for several days after stopping the medicine.” Answer: C Explanation: Xanax, like other benzodiazepines, can cause withdrawal symptoms that include agitation, insomnia, NCLEX PN TEST BANK 10 A. standing the client and walking him or her to the wheelchair. B. moving the wheelchair close to client’s bed and standing and pivoting the client on his unaffected extremity to the wheelchair. C. moving the wheelchair close to client’s bed and standing and pivoting the client on his affected extremity to the wheelchair. D. having the client stand and push his body to the wheelchair. Answer: B Explanation: Moving the wheelchair close to client’s bed and having him stand and pivot on his unaffected extremity to the wheelchair is safer because it provides support with the unaffected limb.Basic Care and Comfort QUESTION 13 Which of the following terms refers to soft-tissue injury caused by blunt force? NCLEX PN TEST BANK 11 A. contusion B. strain C. sprain D. dislocation Answer: A Explanation: A contusion is a soft-tissue injury caused by blunt force. It is an injury that does not break the skin, is caused by a blow and is characterized by swelling, discoloration, and pain. The immediate application of cold might limit the development of a contusion. A strain is a muscle pull from overuse, overstretching, or excessive stress. A sprain is caused by a wrenching or twisting motion. A dislocation is a condition in which the articular surfaces of the bones forming a joint are no longer in anatomic contact.Physiological Adaptation QUESTION 14 Why might breast implants interfere with mammography? A. They might cause additional discomfort. B. They are contraindications to mammography. C. They are likely to be dislodged. D. They might prevent detection of masses. Answer: D Explanation: Breast implants can prevent detection of masses. Choices 1, 2, and 3 are not ways in which breast implants interfere with mammography.Reduction of Risk Potential QUESTION 15 The nurse teaching about preventable diseases should emphasize the importance of getting the following vaccines: A. human papilloma virus, genital herpes, measles. B. pneumonia, HIV, mumps. C. syphilis, gonorrhea, pneumonia. D. polio, pertussis, measles. NCLEX PN TEST BANK 12 Answer: D Explanation: Vaccines are one of the most effective methods of preventing and controlling certain communicable diseases. The smallpox vaccine is not currently in use because the smallpox virus has been declared eradicated from the world’s population. Diseases such as polio, diphtheria, pertussis, and measles are mostly controlled by routine childhood immunization. They have not, however, been eradicated, so children need to be immunized against these diseases.Physiological Adaptation QUESTION 16 Assessment of a client with a cast should include: A. capillary refill, warm toes, no discomfort. NCLEX PN TEST BANK 15 Vitamin B12 is the primary nutritional deficiency of concern for a strict vegetarian.Health Promotion and Maintenance QUESTION 20 A client who is experiencing infertility says to the nurse, “I feel I will be incomplete as a man/woman if I cannot have a child.” Which of the following nursing diagnoses is likely to be appropriate for this client? A. Risk for Self Harm B. Body Image Disturbance C. Ineffective Role Performance D. Powerlessness Answer: B Explanation: Of the nursing diagnoses listed, the client’s statement most represents Body Image Disturbance because it directly refers to loss of the function of having a child. Nothing in the statement indicates that the client is at risk for harming herself. Ineffective Role Performance could be correct but is not the best choice because the statement does not reflect a disruption of the parent’s role. Powerlessness could be an appropriate nursing diagnosis if the client described feeling powerless about the infertility.Health Promotion and Maintenance QUESTION 21 When the nurse is determining the appropriate size of an oropharyngeal airway to insert, what part of a client’s body should she measure? A. corner of the mouth to the tragus of the ear B. corner of the eye to the top of the ear C. tip of the chin to the sternum D. tip of the nose to the earlobe Answer: A Explanation: An oropharyngeal airway is measured from the corner of the client’s mouth, to the tragus of the ear. Reduction of Risk Potential NCLEX PN TEST BANK 16 QUESTION 22 A client with stress incontinence should be advised: A. to purchase absorbent undergarments. B. that Kegel exercises might help. C. that effective surgical treatments are nonexistent. D. that behavioral therapy is ineffective. Answer: B Explanation: Kegel exercises, tightening and releasing the pelvic floor muscles, might improve stress incontinence. Choice 1 is not an appropriate treatment for stress incontinence. Several effective surgical treatments exist. Lifestyle and dietary modifications can also be helpful.Physiological Adaptation NCLEX PN TEST BANK 17 QUESTION 23 To remove hard contact lenses from an unresponsive client, the nurse should: A. gently irrigate the eye with an irrigating solution from the inner canthus outward. B. grasp the lens with a gentle pinching motion. C. don sterile gloves before attempting the procedure. D. ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens. Answer: D Explanation: To remove hard contact lenses, the upper and lower eyelids are gently maneuvered to help loosen the lens and slide it out of the eye. The lens must be situated on the cornea, not the sclera, before removal. An attempt to grasp a hard lens might result in a scratch on the cornea. Clean gloves are an option if drainage is present.Basic Care and Comfort QUESTION 24 Which is the proper hand position for performing chest percussion? A. cup the hands B. use the side of the hands C. flatten the hands D. spread the fingers of both hands Answer: A Explanation: The hands are cupped for performing percussion, producing a vibration that helps loosen respiratory secretions. The other hand positions do not accomplish this task.Reduction of Risk Potential QUESTION 25 For a client with suspected appendicitis, the nurse should expect to find abdominal tenderness in which quadrant? NCLEX PN TEST BANK 20 QUESTION 29 A batterer is usually someone who: A. grew up in a loving, secure home. B. was an only child. C. was physically or psychologically abused. D. admits he has a problem with anger. Answer: C Explanation: Many batterers report having been abused as children.Psychosocial Integrity QUESTION 30 Which fetal heart monitor pattern can indicate cord compression? NCLEX PN TEST BANK NCLEX PN TEST BANK A. variable decelerations B. early decelerations C. bradycardia D. tachycardia Answer: A Explanation: Variable decelerations can be related to cord compression. The other patterns are not. Reduction of Risk Potential QUESTION 31 Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care? A. “I should put alcohol on my baby’s cord 3–4 times a day.” B. “I should put the baby’s diaper on so that it covers the cord.” C. “I should call the physician if the cord becomes dark.” D. “I should wash my hands before and after I take care of the cord.” Answer: D Explanation: Parents should be taught to wash their hands before and after providing cord care. This prevents transferring pathogens to and from the cord. Folding the diaper below the cord exposes the cord to air and allows for drying. It also prevents wet or soiled diapers from coming into contact with the cord. Current recommendations include cleaning the area around the cord 3–4 times a day with a cotton swab but do not include putting alcohol or other antimicrobials on the cord. It is normal for the cord to turn dark as it dries.Health Promotion and Maintenance QUESTION 32 Teaching about the need to avoid foods high in potassium is most important for which client? A. a client receiving diuretic therapy B. a client with an ileostomy C. a client with metabolic alkalosis D. a client with renal disease NCLEX PN TEST BANK NCLEX PN TEST BANK Answer: D Explanation: Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. Choices 1, 2, and 3 are incorrect because clients receiving diuretics with ileostomy or with metabolic alkalosis are at risk for hypokalemia and should be encouraged to eat foods high in potassium. Physiological Adaptation QUESTION 33 A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client’s weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as: NCLEX PN TEST BANK NCLEX PN TEST BANK Promotion and Maintenance NCLEX PN TEST BANK NCLEX PN TEST BANK QUESTION 36 When making an occupied bed, it is important for the nurse to: A. keep the bed in the low position. B. use a bath blanket or top sheet for warmth and privacy. C. constantly keep side rails raised on both sides. D. move back and forth from one side to the other when adjusting the linens. Answer: B Explanation: Using a bath blanket or top sheet keeps the client warm and provides privacy. Keeping the bed in the low position and working above raised side rails might strain the nurse’s back. Continually moving back and forth to tuck and arrange linen is time-consuming and disorganized.Basic Care and Comfort QUESTION 37 Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority? A. open leg fracture B. open head injury C. stab wound to the chest D. traumatic amputation of a thumb Answer: C Explanation: A stab wound to the chest might result in lung collapse and mediastinal shift that, if untreated, could lead to death. Treatment of an obstructed airway or a chest wound is a higher priority than hemorrhage. The principle of ABC (airway, breathing, and circulation) prioritizes care decisions.Physiological Adaptation QUESTION 38 Which of the following medications is a serotonin antagonist that might be used to relieve nausea and vomiting? NCLEX PN TEST BANK NCLEX PN TEST BANK A. metoclopramide (Reglan) B. onedansetron (Zofran) C. hydroxyzine (Vistaril) D. prochlorperazine (Compazine) Answer: B Explanation: Zofran is a serotonin antagonist that can be used to relieve nausea and vomiting. The other medications can be used for nausea and vomiting, but they have different mechanisms of action. Physiological Adaptation QUESTION 39 Erythropoietin used to treat anemia in clients with renal failure should be given in conjunction with: NCLEX PN TEST BANK NCLEX PN TEST BANK QUESTION 42 Which of the following instructions should the nurse give a client who will be undergoing mammography? A. Be sure to use underarm deodorant. B. Do not use underarm deodorant. C. Do not eat or drink after midnight. D. Have a friend drive you home. Answer: B Explanation: Underarm deodorant should not be used because it might cause confusing shadows on the X-ray film. There are no restrictions on food or fluid intake. No sedation is used, so the client can drive herself home.Reduction of Risk Potential QUESTION 43 Which of the following is an inappropriate item to include in planning care for a severely neutropenic client? A. Transfuse netrophils (granulocytes) to prevent infection. B. Exclude raw vegetables from the diet. C. Avoid administering rectal suppositories. D. Prohibit vases of fresh flowers and plants in the client’s room. Answer: A Explanation: Granulocyte transfusion is not indicated to prevent infection. Produced in the bone marrow, granulocytes normally comprise 70% of all WBCs. They are subdivided into three types based on staining properties: neutrophils, eosinophils, and basophils. They can be beneficial in a selected population of infected, severely granulocytopenic clients (less than 500/mm3) who do not respond to antibiotic therapy and who are expected to experience prolonged suppression of granulocyte production.Physiological Adaptation QUESTION 44 To remove a client’s gown when she has an intravenous line, the nurse should: A. temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown. NCLEX PN TEST BANK NCLEX PN TEST BANK B. cut the gown with scissors. C. thread the bag and tubing through the gown sleeve, keeping the line intact. D. temporarily disconnect the tubing from the intravenous container and thread it through the gown. Answer: C Explanation: Threading the bag and tubing through the gown sleeve keeps the system intact. Opening an intravenous line causes a break in a sterile system and introduces the potential for infection. Cutting a gown off is not an alternative except in an emergency. IV gowns, which open along sleeves, are widely available.Basic Care and Comfort QUESTION 45 Which of the following nursing diagnoses might be appropriate as Parkinson’s disease progresses and complications develop? NCLEX PN TEST BANK NCLEX PN TEST BANK A. Impaired Physical Mobility B. Dysreflexia C. Hypothermia D. Impaired Dentition Answer: A Explanation: The client with Parkinson’s disease can develop a shuffling gait and rigidity, causing impaired physical mobility. The other diagnoses do not necessarily relate to a client with Parkinson’s disease. Reduction of Risk Potential QUESTION 46 Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma? A. The clothing is the property of another and must be treated with care. B. Such care facilitates repair and salvage of the clothing. C. The clothing of a trauma victim is potential evidence with legal implications. D. Such care decreases trauma to the family members receiving the clothing. Answer: C Explanation: Trauma in any client, living or dead, has potential legal and/or forensic implications. Clothing, patterns of stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death, and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health care facilities have policies governing the collection of forensic evidence. The chain of evidence custody must be followed to ensure the integrity and credibility of the evidence. The chain of evidence custody is the pathway that evidence follows from the time it is collected until is has served its purpose in the legal investigation of an incident.Physiological Adaptation NCLEX PN TEST BANK NCLEX PN TEST BANK because potassium, mixed in the pharmacy per physician order, is mixed at a concentration no higher than 60 mEq/L. Physiological Adaptation QUESTION 48 A 10-month-old child is brought to the Emergency Department because he is difficult to awaken. The nurse notes bruises on both upper arms. These findings are most consistent with: A. wearing clothing that is too small for the child. B. the child being shaken. C. falling while learning to walk. D. parents trying to awaken the child. Answer: B Explanation: Children who are shaken are frequently grasped by both upper arms. Symptoms of brain injury associated with shaking include decreased level of consciousness.Psychosocial Integrity QUESTION 49 Which of the following might be an appropriate nursing diagnosis for an epileptic client? A. Dysreflexia B. Risk for Injury C. Urinary Retention D. Unbalanced Nutrition Answer: B Explanation: The epileptic client is at risk for injury due to the complications of seizure activity, such as possible head trauma associated with a fall. The other choices are not related to the question.Reduction of Risk Potential NCLEX PN TEST BANK NCLEX PN TEST BANK QUESTION 50 The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to examine? A. 6 B. 8 C. 12 D. 16 Answer: C Explanation: In general, children begin dentition around 6 months of age. During the first 2 years of life, a quick guide to the number of teeth a child should have is as follows: Subtract the number 6 from the number of months in the age of the child. In this example, the child is 18 months old, so the formula is 18 – 6 = 12. An 18-month-old child should have approximately 12 teeth.Health Promotion and Maintenance NCLEX PN TEST BANK NCLEX PN TEST BANK QUESTION 51 When helping a client gain insight into anxiety, the nurse should: A. help relate anxiety to specific behaviors. B. ask the client to describe events that precede increased anxiety. C. instruct the client to practice relaxation techniques. D. confront the client’s resistive behavior. Answer: B Explanation: To gain insight, the client needs to recognize causal events. The other activities focus on recognition of anxiety.Psychosocial Integrity QUESTION 52 A middle-aged woman tells the nurse that she has been experiencing irregular menses for the past six months. The nurse should assess the woman for other symptoms of: A. climacteric. B. menopause. C. perimenopause. D. postmenopause. Answer: C Explanation: Perimenopause refers to a period of time in which hormonal changes occur gradually, ovarian function diminishes, and menses become irregular. Perimenopause lasts approximately five years. Climacteric is a term applied to the period of life in which physiologic changes occur and result in cessation of a woman’s reproductive ability and lessened sexual activity in males. The term applies to both genders. Climacteric and menopause are interchangeable terms when used for females. Menopause is the period when permanent cessation of menses has occurred. Postmenopause refers to the period after the changes accompanying menopause are complete.Health Promotion and Maintenance NCLEX PN TEST BANK NCLEX PN TEST BANK A. nutrition, ROM exercises. B. ROM exercises, transportation. C. nutrition, elimination, comfort, safety. D. elimination, safety, isotonic exercises. Answer: C Explanation: Nutrition, elimination, comfort, and safety are the major areas of importance. The diet should be high in protein with adequate fluids.Basic Care and Comfort QUESTION 57 Which of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophgeal reflux disease (GERD)? A. lettuce NCLEX PN TEST BANK NCLEX PN TEST BANK B. eggs C. chocolate D. butterscotch Answer: C Explanation: Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure leading to reflux and clinical symptoms of GERD. The other foods do not affect LES pressure.Basic Care and Comfort QUESTION 58 A health care worker is concerned about a new mother being overwhelmed by caring for her infant. The health care worker should: A. immediately contact child protective services. B. provide the mother with literature about child care. C. consult a therapist to help the mother work out her fears. D. refer the mother to parenting classes. Answer: D Explanation: Prevention of child abuse is centered on teaching the parents how to care for their child and cope with the demands of infant care. Parenting classes can help build self-confidence, self-esteem, and coping skills. Parents benefit by understanding the developmental needs of their children, while learning how to manage their home environment more effectively. The classes also increase the parents’ social contacts and teach about community resources.Psychosocial Integrity QUESTION 59 While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse? A. “I will assist you in arranging to have a medicine woman present.” B. “We do not allow medicine women in exam rooms.” C. “That does not make any difference in the outcome.” D. “It is old-fashioned to believe in that.” NCLEX PN TEST BANK NCLEX PN TEST BANK Answer: A Explanation: This statement reflects cultural awareness and acceptance that receiving support from a medicine woman is important to the client. The other statements are culturally insensitive and unprofessional. Reduction of Risk Potential QUESTION 60 A client with which of the following conditions is at risk for developing a high ammonia level? A. renal failure B. psoriasis C. lupus NCLEX PN TEST BANK NCLEX PN TEST BANK QUESTION 64 Which of the following conditions is mammography used to detect? A. pain B. tumor C. edema D. epilepsy Answer: B Explanation: Mammography is used to detect tumors or cysts in the breasts, not the other conditions. Reduction of Risk Potential QUESTION 65 Nurses caring for clients who have cancer and are taking opioids need to assess for all of the following except: A. tolerance. B. constipation. C. sedation. D. addiction. Answer: D Explanation: Addiction is not of primary concern when treating the pain of terminally ill clients. Clients with cancer who are taking opioid analgesics can develop tolerance, constipation, and sedation.Basic Care and Comfort QUESTION 66 An appropriate intervention for the client with suspected genitourinary trauma and visible blood at the urethral meatus is: A. insertion of a Foley catheter. B. in and out catheter specimen for urinalysis. C. a voided urine specimen for urinalysis. NCLEX PN TEST BANK NCLEX PN TEST BANK D. a urologist consult. Answer: D Explanation: A urologist consult is appropriate for a client with visible blood at the urethral meatus and suspected trauma. Choices 1 and 2 are contraindicated. A urinalysis might be ordered by the physician, but the question does not provide enough information to make Choice 3 the correct answer.Physiological Adaptation QUESTION 67 Which of the following foods is a complete protein? A. corn B. eggs C. peanuts Dsunflower seeds NCLEX PN TEST BANK NCLEX PN TEST BANK Answer: B Explanation: Eggs are a complete protein. The remaining options are incomplete proteins.Health Promotion and Maintenance QUESTION 68 When obtaining a health history on a menopausal woman, which information should a nurse recognize as a contraindication for hormone replacement therapy? A. family history of stroke B. ovaries removed before age 45 C. frequent hot flashes and/or night sweats D. unexplained vaginal bleeding Answer: D Explanation: Unexplained vaginal bleeding is a contraindication for hormone replacement therapy. Family history of stroke is not a contraindication for hormone replacement therapy. If the woman herself had a history of stroke or other blood-clotting events, hormone therapy could be contraindicated. Frequent hot flashes and/or night sweats can be relieved by hormone replacement therapy.Health Promotion and Maintenance QUESTION 69 Which of the following methods of contraception is able to reduce the transmission of HIV and other STDs? A. intrauterine device (IUD) B. Norplant C. oral contraceptives D. vaginal sponge Answer: D Explanation: NCLEX PN TEST BANK NCLEX PN TEST BANK QUESTION 73 What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36mmHg, and HCO3 24 mEq/L? A. metabolic alkalosis B. homeostasis C. respiratory acidosis D. respiratory alkalosis Answer: B Explanation: These ABG values are within normal limits. Choices 1, 3, and 4 are incorrect because the ABG values indicate none of these acid-base disturbances.Physiological Adaptation NCLEX PN TEST BANK NCLEX PN TEST BANK QUESTION 74 Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley’s level of anxiety as: A. mild. B. moderate. C. severe. D. panic. Answer: C Explanation: The person whose anxiety is assessed as severe is unable to solve problems and has a poor grasp of what’s happening in his or her environment. Somatic symptoms such as those described by Ashley are usually present. Vital sign changes are observed. The individual with mild anxiety might report being mildly uncomfortable and might even find performance enhanced. The individual with moderate anxiety grasps less information about the situation, has some difficulty problem-solving, and might have mild changes in vital signs. The individual in panic demonstrates markedly disturbed behavior and might lose touch with reality. Psychosocial Integrity QUESTION 75 Which is the proper hand position for performing chest vibration? A. cup the hands B. use the side of the hands C. flatten the hands D. spread the fingers of both hands Answer: C Explanation: The hands are flattened over the area of the body where chest percussion is used to conduct vibration through to the chest and loosen secretions. The other hand positions do not accomplish this task. NCLEX PN TEST BANK NCLEX PN TEST BANK Reduction of Risk Potential QUESTION 76 A client turns her ankle. She is diagnosed as having a Pulled Ligament. This should be documented as a: A. sprain. B. strain. C. subluxation. D. distoration. Answer: B Explanation: NCLEX PN TEST BANK NCLEX PN TEST BANK QUESTION 80 A client, age 28, was recently diagnosed with Hodgkin’s disease. After staging, therapy is planned to include combination radiation therapy and systemic chemotherapy with MOPP— nitrogen mustard, vincristine (Onconvin), prednisone, and procarbazine. In planning care for this client, the nurse should anticipate which of the following side effects to contribute to a sense of altered body image? A. cushingoid appearance B. alopecia C. temporary or permanent sterility D. pathologic fractures Answer: D Explanation: Pathologic fractures are not common to the disease process. Its treatment through osteoporosis is a potential complication of steroid use. Hodgkin’s disease most commonly affects young adults (males), is spread through lymphatic channels to contiguous nodes, and also might spread via the hematogenous route to extradal sites (GI, bone marrow, skin, and other organs). A working staging classification is performed for clinical use and care. Physiological Adaptation QUESTION 81 When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula? A. 2 liters/minute B. 4 liters/minute C. 6 liters/minute D. 8 liters/minute Answer: C Explanation: The highest flow rate that oxygen can be delivered via nasal cannula is 6 liters/minute. Higher flow rates must be delivered by mask.Reduction of Risk Potential NCLEX PN TEST BANK NCLEX PN TEST BANK QUESTION 82 Which condition is associated with inadequate intake of vitamin C? A. rickets B. marasmus C. kwashiorkor D. scurvy Answer: D Explanation: Scurvy is associated with inadequate intake of vitamin C. The remaining choices refer to other nutritional deficiencies.Health Promotion and Maintenance NCLEX PN TEST BANK NCLEX PN TEST BANK QUESTION 83 Which of the following physical findings indicates that an 11–12-month-old child is at risk for developmental dysplasia of the hip? A. refusal to walk B. not pulling to a standing position C. negative Trendelenburg sign D. negative Ortolani sign Answer: B Explanation: The nurse might be concerned about developmental dysplasia of the hip if an 11–12-month-old child doesn’t pull to a standing position. An infant who does not walk by 15 months of age should be evaluated. Children should start walking between 11–15 months of age. Trendelenberg sign is related to weakness of the gluteus medius muscle, not hip dysplasia. Ortolani sign is used to identify congenital subluxation or dislocation of the hip in infants.Health Promotion and Maintenance QUESTION 84 Which of the following is likely to increase the risk of sexually transmitted disease? A. alcohol use B. certain types of sexual practices C. oral contraception use D. all of the above Answer: D Explanation: STDs affect certain groups in groups in greater numbers. Factors associated with risk include being younger than 25 years of age, being a member of a minority group, residing in an urban setting, being impoverished, and using crack cocaine.Physiological Adaptation QUESTION 85 Which of the following values should the nurse monitor closely while a client is on total parenteral nutrition? NCLEX PN TEST BANK NCLEX PN TEST BANK Answer: A Explanation: Parents must be careful when warming bottles in a microwave oven because the milk can become superheated. When a microwave oven is used, the defrost setting should be chosen, and the temperature of the formula should be checked before giving it to the baby. Refrigerated, partially used bottles should be discarded after 4 hours because the baby might have introduced some pathogens into the formula. Returning the bottle to the refrigerator does not destroy pathogens. Formula concentrate and water are usually mixed in a 1:1 ratio of one part concentrate and one part water. Infants should be offered fresh formula at each feeding. Partially used bottles should not have NCLEX PN TEST BANK NCLEX PN TEST BANK fresh formula added to them. Pathogens can grow in partially used bottles of formula and be transferred to the NCLEX PN TEST BANK NCLEX PN TEST BANK new formula.Health Promotion and Maintenance QUESTION 89 A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes. Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image? A. administering immune globulin intravenously B. assessing the extremities for edema, redness and desquamation every 8 hours C. explaining progression of the disease to the client and his or her family D. assessing heart sounds and rhythm Answer: C Explanation: Teaching the client and family about progression of the disease includes explaining when symptoms can be expected to improve and resolve. Knowledge of the course of the disease can help them understand that no permanent disruption in physical appearance will occur that could negatively affect body image. Clients with Kawasaki disease might receive immune globulin intravenously to reduce the incidence of coronary artery lesions and aneurysms. Cardiac effects could be linked to body image, but Choice 3 is the most direct link to body image. The nurse assesses symptoms to assist in evaluation of treatment and progression of the disease.Health Promotion and Maintenance QUESTION 90 Which of the following is the primary force in sex education in a child’s life? A. school nurse B. peers C. parents D. media NCLEX PN TEST BANK NCLEX PN TEST BANK Answer: D Explanation: Morton’s neuroma is a small mass or tumor in a digital nerve of the foot. Hallux valgus is referred to in lay terms as abunion.Hammertoe is where one toe is cocked up over another toe. Plantar fasciitis is an inflammation of, or pain in, the arch of the foot.Basic Care and Comfort QUESTION 94 Diagnostic genetic counseling, for procedures such as amniocentesis and chorionic villus sampling, allows clients to make all of the following choices except: A. terminating the pregnancy. B. preparing for the birth of a child with special needs. C. accessing support services before the birth. NCLEX PN TEST BANK NCLEX PN TEST BANK D. completing the grieving process before the birth. Answer: D Explanation: If findings are ominous, the grieving process will not be completed before birth. If the couple elects to terminate a pregnancy based on diagnostic tests, there will be grief and concerns for future pregnancies. Couples might choose to access support services and prepare for the birth of an infant with special needs. Some fetal conditions can be treated in utero.Health Promotion and Maintenance QUESTION 95 Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes a serosanguious drainage on the dressing. The most appropriate intervention is to: A. notify the physician of the drainage. B. change the dressing. C. reinforce the dressing. D. apply an abdominal binder. Answer: C Explanation: Serosanguious drainage is expected at this time. The dressing should be reinforced. Changing a new postop dressing increases the risk of infection. An abdominal binder interferes with visualization of the dressing.Basic Care and Comfort QUESTION 96 A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy’s mother indicates a need for further teaching by the nurse? A. “I should make sure he gets plenty of rest.” B. “I should get him a medic alert bracelet.” C. “I should lay him on his back during a seizure.” D. “I should loosen his clothing during a seizure.” NCLEX PN TEST BANK NCLEX PN TEST BANK Answer: C Explanation: A client having a seizure should be turned to the side to prevent aspiration of secretions. The other statements are correct and indicate adequate understanding of teaching.Reduction of Risk Potential QUESTION 97 Which of the following neurological disorders is characterized by writhing, twisting movements of the face and limbs? A. epilepsy B. Parkinson’s C. muscular sclerosis D. Huntington’s chorea NCLEX PN TEST BANK NCLEX PN TEST BANK QUESTION 101 A client begins a regimen of chemotherapy. Her platelet counts falls to 98,000. Which action is least likely to increase the risk of hemorrhage? A. Test all excreta for occult blood. B. Use a soft toothbrush or foam cleaner for oral hygiene. C. Implement reverse isolation. D. Avoid IM injections. Answer: C Explanation: Reverse isolation does not affect the risk of hemorrhage.Physiological Adaptation QUESTION 102 Signs of impaired breathing in infants and children include all of the following except: A. nasal flaring. B. grunting. C. seesaw breathing. D. quivering lips. Answer: D Explanation: Lip quivering is a distracter. Signs of impaired breathing in infants and children include all the other options. Physiological Adaptation QUESTION 103 An elderly client denies that abuse is occurring. Which of the following factors could be a barrier for the client to admit being a victim? A. knowledge that elder abuse is rare B. personal belief that abuse is deserved C. lack of developmentally appropriate screening tools D. fear of reprisal or further violence if the incident is reported NCLEX PN TEST BANK NCLEX PN TEST BANK Answer: D Explanation: Barriers to reporting elder abuse include victim shame, fear of reprisals, fear of loss of caregiver, and lack of knowledge of agencies that provide services. Many elders fear that reporting abuse results in their placement in long-term care because the current caregiver is the abuser. Choices 1 and 3 are incorrect. Choice 2 might be true but is not the best choice.Psychosocial Integrity QUESTION 104 An assessment of the skull of a normal 10-monthold baby should identify which of the following? A. closure of the posterior fontanel. B. closure of the anterior fontanel. C. overlap of cranial bones. NCLEX PN TEST BANK NCLEX PN TEST BANK D. ossification of the sutures. Answer: A Explanation: The posterior fontanel should close by the age of 2 months.Health Promotion and Maintenance QUESTION 105 A client has chronic respiratory acidosis caused by end-stage chronic obstructive pulmonary disease (COPD). Oxygen is delivered at 1 L/min per nasal cannula. The nurse teaches the family that the reason for this is to avoid respiratory depression, based on which of the following explanations? A. COPD clients are stimulated to breathe by hypoxia. B. COPD clients depend on a low carbon dioxide level. C. COPD clients tend to retain hydrogen ions if they are given high doses of oxygen. D. COPD clients thrive on a high oxygen level. Answer: A Explanation: COPD clients are compensating for low oxygen and high carbon dioxide levels. Hypoxia is the main stimulus to breathe in persons with chronic hypercapnia. Increasing the level of oxygen decreases the stimulus to breathe. Physiological Adaptation QUESTION 106 A wrong committed by one person against another (or against the property of another) that might result in a civil trial is: A. a tort. B. a crime. C. a misdemeanor. D. a felony. Answer: A Explanation: NCLEX PN TEST BANK NCLEX PN TEST BANK QUESTION 110 A client with asthma develops respiratory acidosis. Based on this diagnosis, what should the nurse expect the client’s serum potassium level to be? A. normal B. elevated C. low D. unrelated to the pH Answer: B Explanation: Hyperkalemia occurs in a state of acidosis because potassium moves from injured cells into the bloodstream. Physiological Adaptation NCLEX PN TEST BANK NCLEX PN TEST BANK QUESTION 111 What significant event occurs in the orientation phase of a nurse-client relationship? A. establishment of roles B. identification of transference phenomenon C. placement of the client within the client’s family structure D. client agreement that the nurse has the authority in the relationship Answer: B Explanation: Transference phenomena are intensified in relationships with authority, such as physicians and nurses. Common positive transferences include desire for affection and gratification of dependency needs. Common negative transferences include hostility and competitiveness. These transferences must be recognized and resolved before growth and positive change can be undertaken in the working stage. Psychosocial Integrity QUESTION 112 The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should: A. administer both medications simultaneously. B. give the medications sequentially, and flush well between them. C. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug. D. start one medication now and begin the other medication in 2–4 hours. Answer: B Explanation: A client with an infection needs both antibiotics as soon a possible. However, the pH of ampicillin is 8–10, and the pH of gentamicin is 3–5.5 (making them incompatible when given together). Flushing well between drugs is necessary. Choice 3 is incorrect because the PN determines the correct steps and consults with the pharmacist and the physician as necessary. Choice 4 is incorrect because delaying the second medication by several hours slows the treatment of the client’s infection.Pharmacological Therapies NCLEX PN TEST BANK NCLEX PN TEST BANK QUESTION 113 The vast majority of deaths resulting from unintentional poisoning occur in: A. infants. B. toddlers. C. teens. D. adults. Answer: B Explanation: The vast majority of deaths resulting from unintentional poisoning occur in toddlers.Safety and Infection Control NCLEX PN TEST BANK NCLEX PN TEST BANK and Infection Control NCLEX PN TEST BANK NCLEX PN TEST BANK QUESTION 117 Quality is defined as a combination of all of the following except: A. conforming to standards. B. performing at the minimally acceptable level. C. meeting or exceeding customer requirements. D. exceeding customer expectations. Answer: B Explanation: Compliance or performance at the minimally acceptable level is not considered quality care.Coordinated Care QUESTION 118 A client is diagnosed with HIV. Which of the following are antiviral drug classes used in the treatment of HIV/AIDS? A. nucleoside reverse transcriptase inhibitors B. protease inhibitors C. HIV fusion inhibitors D. all of the above. Answer: D Explanation: All of the choices are anti-HIV drugs.Safety and Infection Control QUESTION 119 A nurse observes a client sitting alone and talking. When asked, the client reports that he is “talking to the voices.” The nurse’s next action should be: A. touching the client to help him return to reality. B. leaving the client alone until reality returns. C. asking the client to describe what is happening. D. telling the client there are no voices. NCLEX PN TEST BANK NCLEX PN TEST BANK Answer: C Explanation: Nurses might observe behavioral cues that can indicate the presence of hallucinations. Talking about the hallucinations is reassuring and validating to the client who has them. Focusing on the symptoms and asking about the hallucinations helps the client gain control.Psychosocial Integrity QUESTION 120 The drug of choice to decrease uric acid levels is: A. prednisone (Colisone). B. allopurinol (Zyloprim). C. indomethacin (Indocin). D. hydrochlorothiazide (HydroDiuril). NCLEX PN TEST BANK NCLEX PN TEST BANK Answer: C Explanation: Toddlers are possessive and struggle for independence. The other play activities are too advanced for a 2-year-old child.Health Promotion and Maintenance QUESTION 124 Someone who has received a recent tattoo should be screened for: A. tuberculosis. B. herpes. C. hepatitis. D. syphilis. Answer: C Explanation: Tattooing puts a client at risk for blood-borne hepatitis B or C if strict sterile procedures are not followed. Tuberculosis is an airborne pathogen, while herpes and syphilis are spread directly (such as through sexual contact).Safety and Infection Control QUESTION 125 A nurse is planning a brief treatment program for a client who was raped. A realistic, short-term goal is to: A. identify all psychosocial problems. B. eliminate the client’s enticing behaviors. C. resolve feelings of trauma and fear. D. verbalize feeling about the event. Answer: D Explanation: A realistic short-term goal is for the client to verbalize feelings about the event. A brief treatment program is not designed to identify or resolve problems. The focus is on managing acute symptoms. If in-depth psychological problems are identified, the nurse might make referrals for treatment.Psychosocial Integrity NCLEX PN TEST BANK NCLEX PN TEST BANK QUESTION 126 The focus of a nurse case manager is: A. nursing care needs at discharge. B. the comprehensive care needs of the client for continuity of care. C. client education needs upon discharge. D. financial resources for needed care. Answer: B Explanation: By definition, case management is a process of providing for the comprehensive care needs of a client for continuity of care throughout the health care experience.Coordinated Care NCLEX PN TEST BANK NCLEX PN TEST BANK QUESTION 127 The family carries out its health care functions in which of the following ways? A. Family provides very little preventive health care to its members at home. B. Family provides sick care to its members. C. Family pays for most health services. D. Family decides when and where to hospitalize its members. Answer: B Explanation: The family provides sick care to its members. The other options are incorrect.Prevention and Early Detection of Disease QUESTION 128 A 12-year-old male is brought to his primary care provider to determine whether sexual abuse has occurred. The mother states, “Because there is no permanent physical damage, he does not need any more treatment.” The nurse’s response should be based on which of the following pieces of information? A. Male victims of sexual abuse seldom have long-term psychological problems. B. Survivors of male sexual abuse might become confused about their sexual identity. C. Unless treated, all male sex abuse survivors grow up to abuse other children. D. All children who have been sexually abused have the same needs, regardless of gender. Answer: B Explanation: Male children are sexually abused nearly as often as female children. Perpetrators are usually men but can be women. Needs of male children who have been sexually abused might be different from the needs of female survivors. Male survivors might respond in anger, question their sexuality, use alcohol and other drugs, and might try to prove their masculinity by performing daring acts.Psychosocial Integrity QUESTION 129 Legal protection of confidentiality: NCLEX PN TEST BANK NCLEX PN TEST BANK Answer: C Explanation: The client has a right to know the parameters of the nurse-client relationship. If the relationship is to be time limited, the client should be informed of the number of sessions. If it is open-ended, the termination date is not known at the outset, and the client should know that this is an issue that is negotiated at a later date.Coordinated Care QUESTION 133 A 35-year-old Latin-American client wishes to lose weight to reduce her chances of developing heart disease and diabetes. The client states, “I do not know how to make my diet work with the kind of foods that my family eats.” What should the nurse do first to help the client determine a suitable diet for disease prevention? A. Provide her with copies of the approved dietary guidelines for the American Diabetic Association and the American Heart Association. NCLEX PN TEST BANK NCLEX PN TEST BANK B. Ask the client to provide a list of the types of foods she eats to determine how to best meet her needs. C. Provide a high-protein diet plan for the client. D. Provide the client with information related to risk factors for heart disease and diabetes. Answer: B Explanation: Assessment is the first step. Assessing what the client eats helps the nurse determine a plan for dietary recommendations based on the ADA and AHA guidelines. Providing the client with a copy of the guidelines is important but is not the first priority. Based on the client’s wish to reduce her chances of heart disease and diabetes, a high-protein diet plan might not be appropriate. Providing information to the client related to risk factors for heart disease and diabetes is important but is not the first step.Health Promotion and Management QUESTION 134 A concern regarding maternal and infant mortality and morbidity is that: A. a segment of the population is not receiving prenatal care. B. families appear unconcerned about quality health care. C. the personnel shortage in the maternity field will increase. D. maternal-child health workers are not adequately prepared. Answer: A Explanation: There is a concern that a segment of the population is not accessing prenatal care, affecting infant and maternal mortality and morbidity.Health Promotion and Maintenance QUESTION 135 Narrow therapeutic index medications: A. are drug formulations with limited pharmacokinetic variability. B. have limited value and require no monitoring of blood levels. C. have less than a twofold difference in minimum toxic levels and minimum effective concentration in the blood. D. have limited potency and side effects. NCLEX PN TEST BANK NCLEX PN TEST BANK Answer: C Explanation: The therapeutic index is the ratio between the median lethal dose and median effective dose of a drug. It provides a general indication of the margin of safety of a drug. Choice 1 is incorrect because pharmacokinetics is the process of adsorption, distribution, metabolism, and elimination. Choice 2 is incorrect because narrow therapeutic index drugs require close monitoring since there is often little difference between the desired drug effect and toxicity. Choice 4 is incorrect because narrow therapeutic index drugs have the potential for severe toxic effects with only slight increases in the dose or slight decreases in elimination. Pharmacological Therapies QUESTION 136 What is the primary theory that explains a family’s concept of health and illness? A. Health Belief Model NCLEX PN TEST BANK NCLEX PN TEST BANK intolerance for individual differences in style, and inability to delegate all interfere with team building and overall effectiveness.Coordinated Care QUESTION 140 The client’s lab culture report is negative for a suspected infection. A test that can correctly identify those who do not have a given disease is: A. specific. B. sensitive. C. negative culture. D. marginal finding. Answer: A Explanation: Testing that identifies clients without a disease is said to be specific, while testing that identifies clients with a disease is said to be sensitive. Safety and Infection Control QUESTION 141 The nurse wishes to decrease a client’s use of denial and increase the client’s expression of feelings. To do this the nurse should: A. tell the client to stop using the defense mechanism of denial. B. positively reinforce each expression of feelings. C. instruct the client to express feelings. D. challenge the client each time denial is used. Answer: B Explanation: The nurse should positively reinforce each expression of feelings.Psychosocial Integrity QUESTION 142 NCLEX PN TEST BANK NCLEX PN TEST BANK A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child’s scratching. Which of the following advisory comments should be given? A. The history and presentation might indicate chickenpox, a highly contagious disease. B. The lesions might indicate a noncontagious infection that does not require isolation. C. The history and presentation might indicate an infectious illness called impetigo. D. The lesions are not contagious unless others have open wounds or lesions themselves. Answer: C Explanation: The scenario describes classic impetigo for which the physician is likely to order antibiotic therapy. Chickenpox is highly contagious but presents with a history of high fever followed by a vesicular rash.Safety and Infection Control NCLEX PN TEST BANK NCLEX PN TEST BANK QUESTION 143 Client self-determination is the primary focus of: A. malpractice insurance. B. nursing’s advocacy for clients. C. confidentiality. D. health care. Answer: B Explanation: Advocacy for clients by nurses is the primary focus of the client’s right to autonomy and self-determination. Confidentiality involves the maintenance of the privacy of the client and information regarding him or her. Malpractice insurance is a type of insurance for professionals.Coordinated Care QUESTION 144 A client can receive the mumps, measles, rubella (MMR) vaccine if he or she: A. is pregnant. B. is immunocompromised. C. is allergic to neomycin. D. has a cold. Answer: D Explanation: A simple cold without fever does not preclude vaccination. Choices 1 and 2 are incorrect because pregnant women and immunocompromised individuals cannot have the MMR vaccine because the rubella component is a live virus and might cause birth defects and/or disease. Choice 3 is incorrect because the American Academy of Pediatrics states, “Persons who have experienced anaphylactic reactions to topically or systemically administered neomycin should not receive measles vaccine.”Pharmacological Therapies QUESTION 145