NCLEX-PN Test-Bank with 200 Questions with Answers and rationale-2024/2025 GUARANTEED PAS, Exams of Nursing

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NCLEX-PN Test-Bank with 200 Questions

with Answers and rationale- 202 4/

GUARANTEED PASS

1. The nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. The nurse should be particularly alert for: A. Nasal congestion B. Abdominal tenderness C. Muscle tetany D. Oliguria Answer A: Removal of the pituitary gland is usually done by a transsphenoidal approach, through the nose. Nasal congestion further interferes with the airway. Answers B, C, and D are not correct because they are not directly associated with the pituitary gland.
2. A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following? A. Hypernatremia B. Hypokalemia C. Myelosuppression D. Leukocytosis Answer B: Hypokalemia is evident from the lab values listed. The other laboratory findings are within normal limits, making answers A, C, and D incorrect.

3. A 24-year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse? A. Taking the vital signs B. Obtaining the permit C. Explaining the procedure D. Checking the lab work Answer A: The primary responsibility of the nurse is to take the vital signs before any surgery. The actions in answers B, C, and D are the responsibility of the doctor and, therefore, are incorrect for this question.
4. The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority? A. Starting an IV B. Applying oxygen C. Obtaining blood gases D. Medicating the client for pain Answer B: The client with burns to the neck needs airway assessment and supplemental oxygen, so applying oxygen is the priority. The next action should be to start an IV and medicate for pain, making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor.
5. The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client? A. Rest in bed after taking the medication for at least 30 minutes B. Avoid rapid movements after taking the medication C. Take the medication with water only

D. Allow at least 1 hour between taking the medicine and taking other medications Answer B: The client with burns to the neck needs airway assessment and supplemental oxygen, so applying oxygen is the priority. The next action should be to start an IV and medicate for pain, making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor.

6. The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside? A. A pair of forceps B. A torque wrench C. A pair of wire cutters D. A screwdriver Answer B: A torque wrench is kept at the bedside to tighten and loosen the screws of crutchfield tongs. This wrench controls the amount of pressure that is placed on the screws. A pair of forceps, wire cutters, and a screwdriver, in answers A, C, and D, would not be used and, thus, are incorrect.
7. An infant weighs 7 pounds at birth. The expected weight by 1 year should be: A. 10 pounds B. 12 pounds C. 18 pounds D. 21 pounds

Answer D: A birth weight of 7 pounds would indicate 21 pounds in 1 year, or triple his birth weight. Answers A, B, and C therefore are incorrect.

8. A client is admitted with a Ewing’s sarcoma. Which symptoms would be expected due to this tumor’s location? A. Hemiplegia B. Aphasia C. Nausea D. Bone pain Answer D: Sarcoma is a type of bone cancer; therefore, bone pain would be expected. Answers A, B, and C are not specific to this type of cancer and are incorrect.
9. The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug? A. Uric acid of 5mg/dL B. Hematocrit of 33% C. WBC 2,000 per cubic millimeter D. Platelets 150,000 per cubic millimeter Answer C: Tegretol can suppress the bone marrow and decrease the white blood cell count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers A and D are within normal limits, and answer B is a lower limit of normal; therefore, answers A, B, and D are incorrect.

10. A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis? A. “Tell me about his pain.” B. “What does his vomit look like?” C. “Describe his usual diet.” D. “Have you noticed changes in his abdominal size?” Answer C: The least-helpful questions are those describing his usual diet. A, B, and D are useful in determining the extent of disease process and, thus, are incorrect.
11. The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided? A. Bran B. Fresh peaches C. Cucumber salad D. Yeast rolls Answer C: The client with diverticulitis should avoid foods with seeds. The foods in answers A, B, and D are allowed; in fact, bran cereal and fruit will help prevent constipation.
12. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? A. Teaching how to irrigate the illeostomy B. Stopping electrolyte loss in the incisional area C. Encouraging a high-fiber diet

D. Facilitating perineal wound drainage Answer D: The client with a perineal resection will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illeostomy, as in answer A; he will have some electrolyte loss, but treatment is not focused on preventing the loss, so answer B is incorrect. A high-fiber diet, in answer C, is not ordered at this time.

13. The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client’s diet? A. Roasted chicken B. Noodles C. Cooked broccoli D. Custard Answer C: The client with diverticulitis should avoid eating foods that are gas forming and that increase abdominal discomfort, such as cooked broccoli. Foods such as those listed in answers A, B, and D are allowed.
14. The nurse is caring for a new mother. The mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is: A. The baby is dehydrated due to polyuria. B. The baby is hypoglycemic due to lack of glucose. C. The baby is allergic to the formula the mother is giving him. D. The baby can lose up to 10% of weight due to meconium stool, loss of extracellular fluid, and initiation of breast-feeding.

Answer D: After birth, meconium stool, loss of extracellular fluid, and initiation of breastfeeding cause the infant to lose body mass. There is no evidence to indicate dehydration, hypoglycemia, or allergy to the infant formula; thus, answers A, B, and C are incorrect.

15. The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis? A. Foul breath B. Dysphagia C. Diarrhea D. Chronic hiccups Answer C: Diarrhea is not common in clients with mouth and throat cancer. All the findings in answers A, B, and D are expected findings.
16. A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usually be included in the plan? A. Closed chest drainage B. A tracheostomy C. A mediastinal tube D. Percussion vibration and drainage Answer A: The client with a lung resection will have chest tubes and a drainage-collection device. He probably will not have a tracheostomy or mediastinal tube, and he will not have an order for percussion, vibration, or drainage. Therefore, answers B, C, and D are incorrect.

17. Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as: A. A cephalohematoma B. Molding C. Subdural hematoma D. Caput succedaneum Answer A: A swelling over the right parietal area is a cephalohematoma, an area of bleeding outside the cranium. This type of hematoma does not cross the suture line because it is outside the cranium but beneath the periosteum. Answer B, molding, is overlapping of the bones of the cranium and, thus, incorrect. In answer C, a subdural hematoma, or intracranial bleeding, is ominous and can be seen only on a CAT scan or x-ray. A caput succedaneum, in answer D, crosses the suture line and is edema.
18. The nurse is assisting the RN with discharge instructions for a client with an implantable defibrillator. What discharge instruction is essential? A. “You cannot eat food prepared in a microwave.” B. “You should avoid moving the shoulder on the side of the pacemaker site for 6 weeks.” C. “You should use your cellphone on your right side.” D. “You will not be able to fly on a commercial airliner with the defibrillator in place.” Answer C: The client with an internal defibrillator should learn to use any battery-operated machinery on the opposite side. He should also take his pulse rate and report dizziness or fainting. Answers A, B, and D are incorrect because the client can eat food prepared in the microwave, move his shoulder on the affected side, and fly in an airplane.
19. A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure?

A. Bradycardia B. Tachycardia C. Premature ventricular beats D. Heart block Answer A: Suctioning can cause a vagal response and bradycardia. Answer B is unlikely and, therefore, not most important, although it can occur. Answers C and D can occur as well, but they are less likely.

20. The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period? A. Assessment of the client’s level of anxiety B. Evaluation of the client’s exercise tolerance C. Identification of peripheral pulses D. Assessment of bowel sounds and activity Answer C: The assessment that is most crucial to the client is the identification of peripheral pulses because the aorta is clamped during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities. Answer A is of lesser concern, answer B is not advised at this time, and answer D is of lesser concern than answer A.
21. A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session? A. “You will be sitting for the examination procedure.” B. “Portions of the procedure will cause pain or discomfort.” C. “You will be given some medication to anesthetize the area.”

D. “You will not be able to drink fluids for 24 hours before the study.” Answer B: Portions of the exam are painful, especially when the sample is being withdrawn, so this should be included in the session with the client. Answer A is incorrect because the client will be positioned prone, not in a sitting position, for the exam. Anesthesia is not commonly given before this test, making answer C incorrect. Answer D is incorrect because the client can eat and drink following the test.

22. The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis? A. A weight loss of 10 pounds in 2 weeks B. Complaints of numbness and tingling in the extremities C. A red, beefy tongue D. A hemoglobin level of 12.0gm/dL Answer C: A red, beefy tongue is characteristic of the client with pernicious anemia. Answer A, a weight loss of 10 pounds in 2 weeks, is abnormal but is not seen in pernicious anemia. Numbness and tingling, in answer B, can be associated with anemia but are not particular to pernicious anemia. This is more likely associated with peripheral vascular diseases involving vasculature. In answer D, the hemoglobin is low normal.
23. A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for: A. Trendelenburg position B. Ice to the entire extremity C. Buck’s traction D. An abduction pillow

Answer C: The client with a fractured femur will be placed in Buck’s traction to realign the leg and to decrease spasms and pain. The Trendelenburg position is the wrong position for this client, so answer A is incorrect. Ice might be ordered after repair, but not for the entire extremity, so answer B is incorrect. An abduction pillow is ordered after a total hip replacement, not for a fractured femur; therefore, answer D is incorrect.

24. A client with cancer is to undergo an intravenous pyelogram. The nurse should: A. Force fluids 24 hours before the procedure B. Ask the client to void immediately before the study C. Hold medication that affects the central nervous system for 12 hours pre- and post-test D. Cover the client’s reproductive organs with an x-ray shield Answer B: The client having an intravenous pyelogram will have orders for laxatives or enemas, so asking the client to void before the test is in order. A full bladder or bowel can obscure the visualization of the kidney ureters and urethra. In answers A, C, and D, there is no need to force fluids before the procedure, to withhold medications, or to cover the reproductive organs.
25. The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor: A. That cannot be assessed B. That is in situ C. With increasing lymph node involvement D. With distant metastasis Answer B: Cancer in situ means that the cancer is still localized to the primary site. Cancer is graded in terms of tumor, grade, node involvement, and mestatasis. Answer A is incorrect because it is an untrue statement. Answer C is incorrect because T indicates tumor, not node involvement. Answer D is incorrect because a tumor that is in situ is not metastasized.

26. A client is 2 days post-operative colon resection. After a coughing episode, the client’s wound eviscerates. Which nursing action is most appropriate? A. Reinsert the protruding organ and cover with 4×4s B. Cover the wound with a sterile 4×4 and ABD dressing C. Cover the wound with a sterile saline-soaked dressing D. Apply an abdominal binder and manual pressure to the wound Answer C: If the client eviscerates, the abdominal content should be covered with a sterile saline-soaked dressing. Reinserting the content should not be the action and will require that the client return to surgery; thus, answer A is incorrect. Answers B and D are incorrect because they are not appropriate to this case.
27. The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery? A. Hearing aid B. Contact lenses C. Wedding ring D. Artificial eye Answer B: It is most important to remove the contact lenses because leaving them in can lead to corneal drying, particularly with contact lenses that are not extended-wear lenses. Leaving in the hearing aid or artificial eye will not harm the client. Leaving the wedding ring on is also allowed; usually, the ring is covered with tape. Therefore, answers A, C, and D are incorrect.
28. The nurse on the 3 – 11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?

A. Call the surgeon and ask him or her to see the client to clarify the information B. Explain the procedure and complications to the client C. Check in the physician’s progress notes to see if understanding has been documented D. Check with the client’s family to see if they understand the procedure fully Answer A: It is the responsibility of the physician to explain and clarify the procedure to the client. Answers B, C, and D are incorrect because they are not within the nurse’s purview.

29. When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain? A. A history of radiation treatment in the neck region B. A history of recent orthopedic surgery C. A history of minimal physical activity D. A history of the client’s food intake Answer A: Previous radiation to the neck might have damaged the parathyroid glands, which are located on the thyroid gland, and interfered with calcium and phosphorus regulation. Answer B has no significance to this case; answers C and D are more related to calcium only, not to phosphorus regulation.
30. A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170meq/L. What behavior changes would be most common for this client? A. Anger B. Mania C. Depression D. Psychosis

Answer B: The client with serum sodium of 170meq/L has hypernatremia and might exhibit manic behavior. Answers A, C, and D are not associated with hypernatremia and are, therefore, incorrect.

31. The nurse is obtaining a history of an 80 - year-old client. Which statement made by the client might indicate a possible fluid and electrolyte imbalance? A. “My skin is always so dry.” B. “I often use a laxative for constipation.” C. “I have always liked to drink a lot of ice tea.” D. “I sometimes have a problem with dribbling urine.” Answer B: Frequent use of laxatives can lead to diarrhea and electrolyte loss. Answers A, C, and D are not of particular significance in this case and, therefore, are incorrect.
32. A client visits the clinic after the death of a parent. Which statement made by the client’s sister signifies abnormal grieving? A. “My sister still has episodes of crying, and it’s been 3 months since Daddy died.” B. “Sally seems to have forgotten the bad things that Daddy did in his lifetime.” C. “She really had a hard time after Daddy’s funeral. She said that she had a sense of longing.” D. “Sally has not been sad at all by Daddy’s death. She acts like nothing has happened.”

Answer D: Abnormal grieving is exhibited by a lack of feeling sad; if the client’s sister appears not to grieve, it might be abnormal grieving. This family member might be suppressing feelings of grief. Answers A, B, and C are all normal expressions of grief and, therefore, incorrect.

33. The nurse recognizes that which of the following would be most appropriate to wear when providing direct care to a client with a cough? A. Mask B. Gown C. Gloves D. Shoe covers Answer A: If the nurse is exposed to the client with a cough, the best item to wear is a mask. If the answer had included a mask, gloves, and a gown, all would be appropriate, but in this case, only one item is listed; therefore, answers B and C are incorrect. Shoe covers are not necessary, so answer D is incorrect.
34. The nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention? A. Suggest that the client take warm showers B.I.D. B. Add baby oil to the client’s bath water C. Apply powder to the client’s skin D. Suggest a hot-water rinse after bathing Answer B: Oils can be applied to help with the dry skin and to decrease itching, so adding baby oil to bath water is soothing to the skin. Answer A is incorrect because bathing twice a day is too frequent and can cause more dryness. Answer C is incorrect because powder is also drying. Rinsing with hot water, as stated in answer D, dries out the skin as well.

35. A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate? A. Blood pressure every 15 minutes B. Insertion of a Levine tube C. Cardiac monitoring D. Dressing changes two times per day Answer B: The client with pancreatitis frequently has nausea and vomiting. Lavage is often used to decompress the stomach and rest the bowel, so the insertion of a Levine tube should be anticipated. Answers A and C are incorrect because blood pressures are not required every 15 minutes, and cardiac monitoring might be needed, but this is individualized to the client. Answer D is incorrect because there are no dressings to change on this client.
36. The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because: A. The client is at risk for evisceration. B. The client will require frequent dressing changes. C. The straps provide support for drains that are inserted in the incision. D. No sutures or clips are used to secure the incision. Answer B: Montgomery straps are used to secure dressings that require frequent dressing changes because the client with a cholecystectomy usually has a large amount of drainage on the dressing. Montgomery straps are also used for clients who are allergic to several types of tape. This client is not at higher risk of evisceration than other clients, so answer A is incorrect. Montgomery straps are not used to secure the drains, so answer C is incorrect. Sutures or clips are used to secure the wound of the client who has had gallbladder surgery, so answer D is incorrect.

37. The physician has ordered that the client’s medication be administered intrathecally. The nurse is aware that medications will be administered by which method? A. Intravenously B. Rectally C. Intramuscularly D. Into the cerebrospinal fluid Answer D: Intrathecal medications are administered into the cerebrospinal fluid. This method of administering medications is reserved for the client with metastases, the client with chronic pain, or the client with cerebrospinal infections. Answers A, B, and C are incorrect because intravenous, rectal, and intramuscular injections are entirely different procedures.
38. Which client can best be assigned to the newly licensed practical nurse? A. The client receiving chemotherapy B. The client post–coronary bypass C. The client with a TURP D. The client with diverticulitis Answer D: The best client to assign to the newly licensed nurse is the most stable client; in this case, it is the client with diverticulitis. The client receiving chemotherapy and the client with a coronary bypass both need nurses experienced in these areas, so answers A and B are incorrect. Answer D is incorrect because the client with a transurethral prostatectomy might bleed, so this client should be assigned to a nurse who knows how much bleeding is within normal limits.

39. The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the registered nurse? A. Notify the police department as a robbery B. Report this behavior to the charge nurse C. Monitor the situation and note whether any items are missing D. Ignore the situation until items are reported missing Answer B: The best action at this time is to report the incident to the charge nurse. Further action might be needed, but it should be determined by the charge nurse. Answers A, C, and D are incorrect because notifying the police is overreacting at this time, and monitoring or ignoring the situation is an inadequate response.
40. The nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should: A. Change the nursing assistant’s assignment B. Explore the interaction with the nursing assistant C. Discuss the matter with the client’s family D. Initiate a group session with the nursing assistant Answer B: The best action for the nurse to take is to explore the interaction with the nursing assistant. This will allow for clarification of the situation. Changing the assignment in answer A might need to be done, but talking to the nursing assistant is the first step. Answer C is incorrect because discussing the incident with the family is not necessary at this time; it might cause more problems. Answer C is not a first step, even though initiating a group session might be a plan for the future.
41. A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?

A. A client with AIDS being treated with Foscarnet B. A client with a fractured femur in a long leg cast C. A client with laryngeal cancer with a laryngetomy D. A client with diabetic ulcers to the left foot Answer C: The client with laryngeal cancer has a potential airway alteration and should be seen first. The clients in answers A, B, and D are not in immediate danger and can be seen later in the day.

42. The nurse is assigned to care for an infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin? A. Increasing the infant’s fluid intake B. Maintaining the infant’s body temperature at 98.6°F C. Minimizing tactile stimulation D. Decreasing caloric intake Answer A: Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temperature is important but will not assist in eliminating bilirubin; therefore, answer B is incorrect. Answers C and D are incorrect because they do not relate to the question.
43. The graduate licensed practical nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority? A. Maintain the client’s systolic blood pressure at 70mmHg or greater B. Maintain the client’s urinary output greater than 300cc per hour

C. Maintain the client’s body temperature of greater than 33°F rectal D. Maintain the client’s hematocrit less than 30% Answer A: When the cadaver client is being prepared to donate an organ, the systolic blood pressure should be maintained at 70mmHg or greater to ensure a blood supply to the donor organ. Answers B, C, and D are incorrect because they are unnecessary actions for organ donation.

44. Which action by the novice nurse indicates a need for further teaching? A. The nurse fails to wear gloves to remove a dressing. B. The nurse applies an oxygen saturation monitor to the ear lobe. C. The nurse elevates the head of the bed to check the blood pressure. D. The nurse places the extremity in a dependent position to acquire a peripheral blood sample. Answer A: The nurse who fails to wear gloves to remove a contaminated dressing needs further instruction. Answers B, C, and D are incorrect because they indicate an understanding of the correct method of completing these tasks.
45. The nurse is preparing a client for mammography. To prepare the client for a mammogram, the nurse should tell the client: A. To restrict her fat intake for 1 week before the test B. To omit creams, powders, or deodorants before the exam C. That mammography replaces the need for self-breast exams D. That mammography requires a higher dose of radiation than an x-ray

Answer B: The client having a mammogram should be instructed to omit deodorants or powders beforehand because powders and deodorants can be interpreted as abnormal. Answer A is incorrect because there is no need for dietary restrictions before a mammogram. Answer C is incorrect because the mammogram does not replace the need for self-breast exams. Answer D is incorrect because a mammogram does not require higher doses of radiation than an x-ray.

46. Which of the following roommates would be best for the client newly admitted with gastric resection? A. A client with Crohn’s disease B. A client with pneumonia C. A client with gastritis D. A client with phlebitis Answer D: The most suitable roommate for the client with gastric resection is the client with phlebitis because phlebitis is an inflammation of the blood vessel and is not infectious. Crohn’s disease clients, in answer A, have frequent stools that might spread infections to the surgical client. The client in answer B with pneumonia is coughing and will disturb the gastric client. The client with gastritis, in answer C, is vomiting and has diarrhea, which also will disturb the gastric client.
47. The licensed practical nurse is working with a registered nurse and a patient care assistant. Which of the following clients should be cared for by the registered nurse? A. A client 2 days post-appendectomy B. A client 1 week post-thyroidectomy C. A client 3 days post-splenectomy D. A client 2 days post-thoracotomy

Answer D: The most critical client should be assigned to the registered nurse; in this case, that is the client 2 days post-thoracotomy. The clients in answers A and B are ready for discharge, and the client in answer C who had a splenectomy 3 days ago is stable enough to be assigned to an LPN.

48. The licensed practical nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching? A. The graduate places the client in a supine position to read the manometer. B. The graduate turns the stop-cock to the off position from the IV fluid to the client. C. The graduate instructs the client to perform the Valsalva maneuver during the CVP reading. D. The graduate notes the level at the top of the meniscus. Answer C: The client should breathe normally during a central venous pressure monitor reading. Answer A indicates understanding because the client should be placed supine if he can tolerate being in that position. Answers B and D indicate understanding because the stop-cock should be turned off to the IV fluid, and the reading should be done at the top of the meniscus.
49. Which of the following roommates would be most suitable for the client with myasthenia gravis? A. A client with hypothyroidism B. A client with Crohn’s disease C. A client with pylonephritis

D. A client with bronchitis Answer A: The most suitable roommate for the client with myasthenia gravis is the client with hypothyroidism because he is quiet. The client with Crohn’s disease in answer B will be up to the bathroom frequently; the client with pylonephritis in answer C has a kidney infection and will be up to urinate frequently. The client in answer D with bronchitis will be coughing and will disturb any roommate.

50. The nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care? A. A 10 - year-old with lacerations of the face B. A 15 - year-old with sternal bruises C. A 34 - year-old with a fractured femur D. A 50 - year-old with dislocation of the elbow Answer B: The teenager with sternal bruising might be experiencing airway and oxygenation problems and, thus, should be seen first. In answer A, the 10 - year-old with lacerations might look bad but is not in distress. The client in answer C with a fractured femur should be immobilized but can be seen after the client with sternal bruising. The client in answer D with the dislocated elbow can be seen later as well.
51. The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should: A. Document the finding B. Send a specimen to the lab C. Strain the urine D. Obtain a complete blood count

Answer B: If the dialysate returns cloudy, infection might be present and must be evaluated. Documenting the finding, as stated in answer A, is not enough; straining the urine, in answer C, is incorrect; and dialysate, in answer D, is not urine at all. However, the physician might order a white blood cell count.

52. The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is: A. To lower the blood glucose level B. To lower the uric acid level C. To lower the ammonia level D. To lower the creatinine level Answer C: Lactulose is administered to the client with cirrhosis to lower ammonia levels. Answers A, B, and D are incorrect because this does not have an effect on the other lab values.
53. The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client’s ability to care for himself. Which statement made by the client would indicate a need for follow-up after discharge? A. “I live by myself.” B. “I have trouble seeing.” C. “I have a cat in the house with me.” D. “I usually drive myself to the doctor.” Answer B: A client with diabetes who has trouble seeing would require follow-up after discharge. The lack of visual acuity for the client preparing and injecting insulin might require help. Answers A, C, and D will not prevent the client from being able to care for himself and, thus, are incorrect.

54. The client is receiving total parenteral nutrition (TPN). Which lab test should be evaluated while the client is receiving TPN? A. Hemoglobin B. Creatinine C. Blood glucose D. White blood cell count Answer C: When the client is receiving TPN, the blood glucose level should be drawn. TPN is a solution that contains large amounts of glucose. Answers A, B, and D are not directly related to the question and are incorrect.
55. The client with a myocardial infarction comes to the nurse’s station stating that he is ready to go home because there is nothing wrong with him. Which defense mechanism is the client using? A. Rationalization B. Denial C. Projection D. Conversion reaction Answer B: The client who says he has nothing wrong is in denial about his myocardial infarction. Rationalization is making excuses for what happened, projection is projecting feeling or thoughts onto others, and conversion reaction is converting a psychological trauma into a physical illness; thus, answers A, C, and D are incorrect.