NCLEX-PN Test Prep: Practice Exam 1 with Explanations, Exams of Nursing

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NCLEX-PN Test Prep

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PRACTICE EXAM 1| LATEST

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NCLEX PN

1. The nurse is in the process of administering PO medications. Which of the following drugs should not be administered at the same time? A. Levofloxacin (Levaquin) and Mylanta B. Furosemide (Lasix) and Simethicone (Mylicon) C. Cyclobenzaprine (Flexeril) and Carbidopa (Sinemet) D. Sucralfate (Carafate) and docusate calcium (Surfak) Answer A: Administering Levofloxacin (Levaquin) and Mylanta at the same time will decrease the absorption of the fluoroquinolones. The drug combinations in answers B, C, and D are not contraindicated because the drugs in each combination do not affect one another.
2. The nurse caring for a client with hyperthyroidism would expect which group of clinical manifestations to be exhibited? A. Confusion, weakness, and increased weight B. Shortness of breath, dyspnea, and decreased libido C. Restlessness, fatigue, and weight loss D. Diuresis, hypokalemia, and tachycardia Answer C: A hyperactive thyroid causes hypermetabolism and increased sympathetic nervous system activity. Weight gain occurs with hypothyroidism, making answer A incorrect. Although tachycardia occurs with hyperthyroidism, diuresis and hypokalemia do not, so answer D is incorrect. Dyspnea can occur with this disorder, but clients exhibit increased libido, making answer B incorrect.
3. Which medication would the nurse expect to be prescribed for a client exhibiting tetany after thyroid surgery? A. Calcium B. Sodium C. Potassium D. Iodide Answer A: Tetany is caused by a decrease in calcium. Answers B, C, and D are not used in the treatment plan for clients with hypocalcemia.

4. The nurse should assess a client who has a peptic ulcer for signs of bleeding. Which symptom would best indicate this complication? A. Melena B. Hematuria C. Hemoptysis D. Ecchymosis Answer A: Melena is blood in the stools, which would occur with bleeding in the gastrointestinal tract due to a peptic ulcer. Answers B, C, and D are not specific to the GI system so are incorrect. Hematuria (blood in the urine) is not indicative of a peptic ulcer, blood from the lungs can occur as hemoptysis but is not related to this problem, and ecchymosis indicates bruising.
5. The nurse is preparing to administer insulin to a diabetic. Ten units regular and 35 units of NPH are ordered. Which of the following is the proper procedure for drawing up the medications? A. Draw up the insulin in two separate syringes, to prevent confusion. B. Draw up the NPH insulin before drawing up the regular. C. Inject air into the NPH vial, draw up 35 units, then inject air into the regular insulin vial and withdraw until insulin is at the 45 unit level. D. Inject 35 units of air into the NPH, inject 10 units of air into the regular, withdraw 10 units of regular, and then withdraw 35 units of NPH. Answer D: When mixing insulins, air should be injected into both vials before drawing up the dose, and clear (Regular) insulin should be drawn up before cloudy (NPH). Answer A would require two injections, which is not necessary. Answers B and C are incorrect procedures because regular insulin, not NPH, should be drawn up first.
6. What does the nurse recognize as the primary reason that food and fluids are withheld from clients with pancreatitis? A. Decrease blood flow to the pancreas B. Decrease stimulation of the pancreas C. Increase secretion of pancreatic enzymes D. Increase insulin production by the pancreas

Answer B: Pancreatic enzyme secretion is activated by food and fluid. Therefore, keeping the client NPO will prevent the pancreas from secreting, resulting in decreased pain and damage to the pancreas. Answers A and D would produce negative outcomes and would have no relationship to why food and fluids are withheld. Because pancreatic enzymes are decreased by withholding food and fluids, answer C is incorrect.

7. The nurse is administering digoxin (Lanoxin) to a client with congestive heart failure. What is the expected therapeutic effect of this drug? A. Increased force of heart contraction B. Increased heart rate C. Decreased perfusion of the heart muscle D. Decreased cardiac output Answer A: Digoxin (Lanoxin) increases the force of the contraction of the heart, thus increasing the cardiac output. Answer D is incorrect because Lanoxin increases cardiac output. Lanoxin slows the heart rate, making answer B incorrect. Answer C could result in a myocardial infarction and is not the effect of the drug.
8. A client has just returned from a bronchoscopy. Which safety measure is most important for the nurse to implement? A. Maintaining the client in the supine position B. Providing the client with saline gargles every 15 minutes for 2 hours C. Monitoring the client for return of the gag reflex before PO intake D. Splinting the abdomen when coughing Answer C: A loss of gag reflex can occur due to the anesthetizing agent used for the tube insertion. It is most important to ensure an intact reflex before administering food or fluids because of the danger of aspiration. The position in answer A would be contraindicated because of possible increased secretions. Answer B would be instituted at a later time. Answer D would be necessary for clients with abdominal surgery.
9. A 45-year-old client returned from a colon resection 2 hours ago. Which vital signs indicate possible hemorrhagic shock?

A. BP 120/80, heart rate 88 B. BP 170/100, heart rate 120 C. BP 160/98, heart rate 54 D. BP 96/60, heart rate 120 Answer D: Vital sign changes with hemorrhagic shock are decreasing blood pressure with an increased heart rate. Answer A is a normal BP and heart rate. Answers B and C are abnormal vital signs but do not correlate with hemorrhagic shock.

10. A client with newly diagnosed acquired immunodeficiency syndrome (AIDS) asks the nurse if it’s necessary to tell co-workers about the diagnosis. The nurse’s response is based on which correct understanding? A. Transmission of AIDS doesn’t occur through casual contact B. Employees have a right to choose with whom they will work C. Clients with an AIDS diagnosis should not work in public places D. The law requires that employers be informed of an AIDS diagnosis Answer A: AIDS is transmitted by transfer of blood and bodily fluids, not by casual contact. Answers B, C, and D are incorrect statements about AIDS. Some states require sexual contact notification; otherwise, confidentially is maintained.
11. A client is returning to the room after a thyroidectomy. Which piece of equipment should the nurse place at the bedside? A. A tracheotomy set B. A hemostat C. A chest tube system D. Wire cutters Answer A: A tracheotomy set is placed at the bedside as a safety measure in case the client has severe edema or respiratory distress. The pieces of equipment in answers B, C, and D are not required or helpful after a thyroidectomy.
12. A client with a hip fracture is receiving heparin sub-cutaneously. Which laboratory test should the nurse monitor when administering this medication?

A. Prothrombin time B. Vitamin K level C. Activated partial thromboplastin time D. Fibrin split levels Answer C: aPTTs should be monitored on clients receiving heparin. The goal is 1.5 to 2 times the control for prevention of deep vein thrombosis. Answer A is used for the monitoring of Coumadin therapy. Answer B is the antidote for too much Coumadin. Answer D is not a test used for heparin or Coumadin.

13. What teaching should the nurse reinforce to a young male adult regarding when he should perform testicular self-examinations? A. Weekly after becoming sexually active B. Monthly while in the shower C. Bimonthly after age 40 D. Annually on his birthday Answer B: This is the American Cancer Society’s recommendation for testicular examination. Answers A, C, and D are not the correct timing sequences for a testicular examination.
14. The nurse is reinforcing teaching to a client with a hiatal hernia. Which would be included in the teaching plan? A. Eat a puréed diet B. Avoid the intake of sweets C. Remain in an upright position after meals D. Limit protein to 3 oz. once a day Answer C: Remaining upright will decrease the chance of esophageal reflux. Clients should avoid fatty foods, coffee, tea, cola, chocolate, alcohol, and spicy and acidic foods, which makes answers B and D incorrect. Puréed diets, as in answer A, are not recommended.
15. A client who is in end-stage cirrhosis should restrict which of these foods? A. Apples

B. Broccoli C. Beef D. Rolls Answer C: With clients who are in end-stage cirrhosis, proteins are restricted because of the inability of the liver to convert the protein for excretion. This results in build-up of ammonia in the body. Answers A, B, and D are not restricted foods.

16. The nurse is providing initial first aid for a client with thermal burn injury in a community setting. Which action is appropriate? A. Apply betadine ointment over the area affected B. Cover the burn with an occlusive dressing C. Flush the burned area with cool water D. Remove any adhered clothing that is on the burn area Answer C: Cooling the burn stops the burn process, relieving pain and limiting edema. This is the initial action. Answers A and B are not initial actions to be performed in the field. Adherent clothing should remain in place after being cooled, so answer D is incorrect.
17. A client with suspected myasthenias gravis has been administered the drug edrophonium chloride (Tensilon). Which effect would the nurse expect the client to exhibit after administration? A. Decreased motor strength B. Decreased seizure activity C. Increased muscle strength D. Increased cognitive functioning Answer C: Clients with myasthenia gravis have a decrease in muscular strength because of a lack of acetylcholine. Tensilon administration halts the breakdown of acetylcholine, causing an increase in muscular strength that confirms the diagnosis. Answer A would indicate that the client does not have myasthenias gravis. Answers B and D are not an effect of the drug Tensilon.
18. A client is admitted with hypothyroidism. Which clinical manifestation

would the nurse expect the client to exhibit? A. Diarrhea B. Intolerance to cold C. Hyperactivity D. Diaphoresis Answer B: These clients have a subnormal temperature and pulse rate, causing them to have a decreased tolerance of cold. Answers A, C, and D are symptoms of hyperthyroidism, so they are incorrect.

19. The nurse caring for a client with Alzheimer’s disease should initiate which of the following when requesting an action by the client? A. Provide a detailed explanation B. Give one direction at a time C. Offer two choices for each activity D. Provide all instructions at one time Answer B: The nurse should give only one direction or step at a time when communicating to clients with Alzheimer’s disease. Clients cannot comprehend when too much detailed information or too many instructions are given at one time, making answers A and D incorrect. Answer C forces the Alzheimer’s client to make a choice and a decision, which is difficult for clients with this disorder.
20. A nurse would expect a newly diagnosed insulin-dependent diabetic to exhibit which clinical manifestations? A. Decreased appetite and constipation B. Weight gain and headache C. Nausea and hand tremors D. Increased urination and thirst Answer D: The three main symptoms of diabetes are increased urination, increased thirst, and increased appetite. Answer A is incorrect because the client’s appetite would be increased. Diabetics experience weight loss, which makes answer B incorrect. Answer C is not associated with diabetes.
21. Which medication is important to have available for clients who have

received Versed? A. Diazepam (Valium) B. Naloxone (Narcan) C. Flumazenil (Romazicon) D. Florinef (Fludrocortisone) Answer C: Versed is used for conscious sedation and is an antianxiety agent. The antidote for this drug is Romazicon, a benzodiazepine. Answers A, B, and D are not utilized as antagonists for Versed; however, answer B is the antagonist for narcotics.

22. The nurse is caring for a client who is nauseated and in danger of aspiration. Which action would the nurse take first? A. Administer an ordered antiemetic medication B. Obtain an ice bag and apply to the client’s throat C. Turn the client to one side D. Notify the physician Answer C: Turning the client to the side will allow any vomit to drain from the mouth and decrease the risk for aspiration. Answers A, B, and D are all appropriate as nursing interventions, but a patent airway and prevention of aspiration is the priority.
23. What is the action of the nurse who assesses dehiscence of a clients’ surgical wound? A. Place the client in the prone position B. Apply a sterile saline-moistened dressing to the wound C. Administer atropine to decrease abdominal secretions D. Wrap the abdomen with an ACE bandage Answer B: When dehiscence and/or evisceration of a wound occurs, the nurse should apply a sterile saline dressing before notifying the physician. Answer A is not the appropriate position because the client should be placed in low Fowler’s position. Answers C and D are not appropriate actions.
24. A client with hepatitis C is about to undergo a liver biopsy. Which of the following would the nurse expect to reiterate to this client?

A. The client should lie on the left side after the procedure. B. The client will have cleansing enemas the morning of the procedure. C. Blood coagulation studies might be done before the biopsy. D. The procedure is noninvasive and causes no pain. Answer C: There is a risk of bleeding with this procedure; therefore, laboratory tests are done to determine any problems with coagulation before the test. Answers A, B, and D are incorrect statements. The client lies on the right side, not the left; no enemas are given; and the test is invasive and can cause some pain.

25. The nurse is caring for a client after a tracheostomy procedure. The client is anxious, with a respiratory rate of 32 and an oxygen saturation of 88. The nurse’s first action should be to: A. Suction the client B. Turn the client to the left Sim’s position C. Notify the physician D. Recheck the O2 saturation Answer A: Obstruction of the tracheostomy can cause anxiety, increased respiratory rate, and a decrease in O2 saturation. The nurse should first suction the client. If this doesn’t work, she should notify the physician, as in answer C. Answer B would not help the client’s breathing. Answer D would be done to assess for improvement after the suctioning was performed.
26. The nurse has reinforced teaching to a client who is on isoniazid (INH). Which diet selection would let the nurse know that the teaching has been ineffective? A. Tuna casserole B. Ham salad C. Baked potato D. Broiled beef roast Answer A: Clients who are taking INH should avoid tuna, red wine, soy sauce, and yeast extracts because of the side effects that can occur, such as headaches and hypotension. Answers B, C, and D are all allowed with this drug.

27. A nurse is working in a nursing home and evaluating temperatures that have been recorded by the nurse’s assistant. A temperature of 100.4°F is noted. Which of these responses should the nurse take? A. Record the temperature on the client’s chart as the only action B. Retake the client’s temperature in 30 minutes to assess for an increase C. Have the client drink a glass of water and retake the temperature D. Call the doctor immediately and report the client’s temperature Answer B: Any abnormal temperature should be reassessed in 30 minutes. A temperature above 101°F requires that the physician be notified, which makes answer D incorrect. Answer A would be done, but it would not be the only action. Answer C is incorrect because the nurse should wait 5 minutes after food or liquids to retake the temperature, for an accurate recording.
28. A nurse is observing a student perform an assessment. When the student nurse asks the client to “stick out his tongue,” the student is assessing the function of which of the following cranial nerves? A. II optic B. I olfactory C. X vagus D. XII hypoglossal Answer D: This cranial nerve deals with the function of the tongue and its movement. Clients can exhibit weakness and deviation with impairment of this cranial nerve. Answers A, B, and C are not tested by this procedure. Cranial nerve I is smell, cranial nerve II is visual, and cranial nerve X deals with the gag reflex.
29. Which set of vital signs would best indicate an increase in intracranial pressure in a client with a head injury? A. BP 180/70, pulse 50, respirations 16, temperature 101°F B. BP 100/70, pulse 64, respirations 20, temperature 98.6°F C. BP 96/70, pulse 132, respirations 20, temperature 98.6°F D. BP 130/80, pulse 50, respirations 18, temperature 99.6°F Answer A: Increased intracranial pressure vital sign changes include an

elevated BP with a widening pulse pressure, decreased heart rate, and temperature elevation. Answer C could occur with shock or hypovolemia. Answer B does not correlate with increased ICP. Answer D shows increased intracranial pressure, but not as much as answer A.

30. The nurse is assessing the laboratory results of a client scheduled to receive phenytoin (Dilantin). The Dilantin level, drawn 2 hours ago, is 30mcg/mL. What is the appropriate nursing action? A. Administer the Dilantin as scheduled B. Hold the scheduled dose and notify the charge nurse C. Decrease the dosage of the Dilantin from 100mg to 50mg D. Increase the dosage to 200mg from 100mg Answer B: The normal Dilantin level is 10–20mcg/mL. The 30 level exceeds the normal. The appropriate action would be to notify the physician for orders. Answer A would be inappropriate because of the high level. Answers C and D would require an order from the physician.
31. A client with sickle cell disease is admitted with pneumonia. Which nursing intervention would be most helpful to prevent a sickling crisis? A. Obtaining blood pressures every 2 hours B. Administering pain medication every 3–4 hours as ordered C. Assessing breath sounds once a shift D. Monitoring IV fluids at ordered rate of 200mL/hr. Answer D: Hydration is needed to prevent slowing of blood flow and occlusion. It is important to perform assessments in answers A, B, and C, but answer D is the best intervention for preventing the crisis.
32. A client is admitted with a diagnosis of pernicious anemia. Which of the following signs or symptoms would indicate that the client has been noncompliant with ordered B12 injections? A. Hyperactivity in the evening hours B. Weight gain of 5 pounds in 1 week C. Paresthesia of hands and feet D. Diarrhea stools several times a day

Answer C: Vitamin B12 is an essential component for proper functioning of the peripheral nervous system. Clients without an adequate vitamin B12 level will have symptoms such as paresthesia due to the deficiency. Answers A and D don’t occur with pernicious anemia. The client would have weight loss rather than weight gain, as in answer B.

33. The nurse has given dietary instructions about food to be included in a low-purine diet. Which selection by the client with gout would indicate that teaching has been ineffective? A. Cabbage B. An apple C. Peach cobbler D. Spinach Answer D: Answers A, B, and C are all foods included on a low-purine diet. Spinach should be avoided on a low-purine diet. Other foods to avoid include poultry, liver, lobster, oysters, peas, fish, and oatmeal.
34. Which of these tasks would it be most appropriate to assign to a nursing assistant? A. Obtaining vital signs on a client with chest pain B. Obtaining blood sugars on a newly admitted client with diabetes C. Feeding a newly admitted stroke client D. Assisting a client 2 days post-operative abdominal surgery Answer D: It is appropriate for the nursing assistant to perform activity orders for stable clients. It is beyond the role of the nurse’s assistant to perform blood sugars and obtain vital signs on unstable clients, as in answers A and B. A client with a stroke might have dysphasia, which makes answer C inappropriate for the assistant, especially because the client is new and has not been evaluated.
35. The orthopedic nurse should be particularly alert for a fat embolus in which of the following clients having the greatest risk for this complication after a fracture? A. A 50-year-old with a fractured fibula

B. A 20-year-old female with a wrist fracture C. A 21-year-old male with a fractured femur D. An 8-year-old with a fractured arm Answer C: Fat emboli occur more frequently with long bone or pelvic fractures and usually in young adults ages 20 to 30. The answers in A, B, and D are not high-risk groups for this complication.

36. The nurse is reinforcing teaching to a client with iron-deficiency anemia about a high-iron diet. The nurse recognizes that teaching has been effective when the client selects which meal plan? A. Hamburger, French fries, orange juice B. Sliced veal, spinach salad, whole-wheat roll C. Vegetable lasagna, Caesar salad, toast D. Bacon, lettuce, and tomato sandwich; potato chips; tea Answer B: This selection is the one with the highest iron content. Other foods high in iron include cream of wheat, oatmeal, liver, collard greens and mustard greens, clams, chili with beans, brown rice, and dried apricots. Answers A, C, and D are not high in iron.
37. An elderly female is admitted with a fractured right femoral neck. Which clinical manifestation would the nurse expect to find? A. Free movement of the right leg B. Abduction of the right leg C. Internal rotation of the right hip D. Shortening of the right leg Answer D: Symptoms of a fractured right femoral neck include shortened, adducted, and external rotation. Answer A is incorrect because the patient usually is unable to move the leg because of pain. Answers B and C are incorrect because the fracture will cause adduction instead of abduction, and external rotation rather than internal rotation.
38. The nurse is observing a student perform the skill of intramuscular injection by the Z track method. Which technique would the student utilize to prevent tracking of the medication?

A. Inject the medication in the deltoid muscle B. Use a 22-gauge needle C. Omit aspirating for blood before injecting D. Draw up 0.2mL of air after the proper medication dose Answer D: The 0.2mL of air that would be administered after the medication with an intramuscular injection would allow the medication to be dispersed into the muscle. In answer A, the muscle is too small. Answer C is an incorrect procedure, and answer B doesn’t help prevent tracking.

39. Which action by the nurse would be most effective in relieving phantom limb pain on a client with an above-the-knee amputation? A. Acknowledging the presence of the pain B. Elevating the stump on a pillow C. Applying ordered transcutaneous nerve stimulator (TENS) unit D. Rewrapping the stump Answer C: The TENS unit is applied for pain relief. A TENS unit is a battery-operated unit applied to the skin that stimulates non–pain receptors in the same areas that transmit the pain. This is the only answer that actually does anything about the pain the client is experiencing. Answer A is a psychosocial acknowledgment. Answers B and D might help the pain, but answer C would help more.
40. The nurse caring for a client with anemia recognizes which clinical manifestation as the one that is specific for a hemolytic type of anemia? A. Jaundice B. Anorexia C. Tachycardia D. Fatigue Answer A: In hemolytic anemia, destruction of red blood cells causes the release of bilirubin, leading to the yellow hue of the skin. Answers C and D occur with several anemias, but they are not specific to hemolytic. Answer B does not relate to anemia.
41. A client has been given the drug Neulasta (pegfilgastrin). Which

laboratory value indicates that the drug is producing the desired effect? A. Hemoglobin of 13.5g/dL B. White blood cell count of 6,000/mm C. Platelet count of 300,000/mm D. HCT 39% Answer B: Neulasta is given to increase the white blood cell count in patients with leucopenia. This white blood cell count is within the normal range, showing an improvement. Answers A, C, and D are not specific to the drug’s desired effect.

42. The nurse is responding to questions from a client with polycythemia vera. Which would be included in the nurses explanations? The client should: A. Avoid large crowds B. Keep the head of the bed elevated at night C. Wear socks and gloves when going outside D. Recognize clinical manifestations of thrombosis Answer D: Clients with a diagnosis of polycythemia have an increased risk for thrombosis and must be aware of the symptoms. Answers A, B, and C do not relate to this disorder.
43. The physician has ordered a minimal bacteria diet for a client with cancer. Which seasoning is not permitted for this client? A. Salt B. Lemon juice C. Pepper D. Ketchup Answer C: Ground pepper is an unprocessed food and will not be allowed because of the possible bacteria. The nurse would also ensure that this client receives no uncooked fruits and vegetables. Answers A, B, and D have all been through processing.
44. The nurse is caring for a client with a hip fracture who is being discharged with a prescription for alendronate (Fosamax). Which statement would indicate a need for further teaching?

A. “I should take the medication immediately before bedtime.” B. “I should remain in an upright position for 30 minutes after taking the medication.” C. “The medication should be taken by mouth with water.” D. “I should not have any food intake with this medication.” Answer A: Alendronate (Fosamax) should be taken in the morning before food or other medications, with water as the only liquid. Answers B, C, and D are correct administrations. In answer B, remaining upright is important to prevent esophageal problems with Fosamax administration.

45. Acetaminophen (Tylenol) 240mg is ordered for an infant who weighs 12 pounds. The usual dose for an infant is 10–15mg per kilogram of body weight. A nurse should take which action? A. Give the medication as ordered B. Administer two-thirds of the prescribed dose C. Weigh the infant without clothes D. Discuss the order with the physician Answer D: The dose of medication is too high, so the nurse should contact the physician. The infant weighs 5.45kg; the dose should be between 54. and 81.75. Answer A would be an incorrect dose. Answer B would require a new prescription. The action in answer C is not necessary and inappropriate to the situation.
46. The nurse is caring for a client recovering from a bone fracture. Which diet selection would be best for this client? A. Loaded baked potato, fried chicken, and tea B. Dressed cheeseburger, French fries, and Coke C. Tuna fish salad on sourdough bread, potato chips, and skim milk D. Mandarin orange salad, broiled chicken, and milk Answer D: This diet selection is the most balanced and best promotes healing. Answers A, B, and C are not as inclusive of food groups that promote healing as answer D.
47. The nurse recognizes that it would be contraindicated to induce vomiting

if someone had ingested which of the following? A. Ibuprofen B. Aspirin C. Vitamins D. Gasoline Answer D: Vomiting would be contraindicated with an acid, alkaline, or petroleum product. Answers A, B, and C do not contain any of the solutions mentioned in the previous statement.

48. A client with ulcerative colitis has impaired nutrition due to diarrhea. Which diet selection by the client would indicate a need for further teaching about foods that can worsen the diarrhea? A. Tossed salad B. Baked chicken C. Broiled fish D. Steamed rice Answer A: Clients with ulcerative colitis experiencing diarrhea should avoid bowel irritants such as raw vegetables, nuts, and fatty and fried foods. Answers B, C, and D would not serve as irritants to the bowels.
49. The nurse has just received report from the RN. Which of the following clients should the nurse visit first? A. A 50-year-old COPD client with a PCO2 of 50 B. A 24-year-old admitted after an MVA complaining of shortness of breath C. A client with cancer requesting pain medication D. A 1-day post-operative cholecystectomy with a temperature of 100°F Answer B: The nurse should prioritize these clients and decide to see the client with the shortness of breath because this client is the least stable. Answer A has an abnormal PCO2 (normal 35–45), but this would be expected in a client with COPD. Answer C can be corrected by pain medication and does not require the priority visit. Answer D is incorrect because a temperature elevation of this level would not be a reason for great concern with a client after gallbladder surgery.

50. The nurse is performing a self-breast exam when she discovers a mass. Which characteristic of the mass would be most indicative of a malignancy? A. Tender to touch B. Regular shape C. Moves easily D. Firm to the touch Answer D: A malignant mass is usually firm and hard, usually located in one breast, and not movable with an irregular shape. Answers A, B, and C are not characteristics of a malignancy.
51. The nurse is caring for a client after a motor vehicle accident. The client has a fractured tibia, and bone is noted protruding through the skin. Which action would be the highest priority? A. Provide manual traction above and below the leg B. Cover the bone area with a sterile dressing C. Apply an ACE bandage around the entire lower limb D. Place the client in the prone position Answer B: The client has an open fracture. The priority would be to cover the wound and prevent further contamination. Swelling usually occurs with a fracture, making answer C incorrect. Manual traction, as in answer A, should not be attempted. In Answer D, the change in position would cause excessive movement and is an inappopriate action.
52. A child is to receive heparin sodium 5 units per kilogram of body weight by subcutaneous route every 4 hours. The child weighs 52.8 lb. How many units should the child receive in a 24-hour period? A. 300 B. 480 C. 720 D. 960 Answer C: The child weighs 24kg and should receive 5 units/kg, or 120 units every 4 hours. This would be 720 units in 24 hours. The answers in A, B, and D are incorrect calculations.

53. Which comment made by a client with congestive heart failure should cause a need for nursing follow-up? A. “My heart rate has been between 60 and 70 the past week.” B. “My oral temperature was 98°F yesterday.” C. “I have been urinating every 4 hours for the past 2 days.” D. “I have gained 3 pounds since yesterday.” Answer D: This statement indicates that the client is retaining fluid and the condition is deteriorating. Answers A and B are normal and require no need for follow-up. Answer C indicates that the client is diuresing, which is a positive outcome of treatment.
54. The nurse caring for a client diagnosed with bone cancer is exhibiting mental confusion and a BP of 150/100. Which laboratory value would correlate with the client’s symptoms reflecting a common complication with this diagnosis? A. Potassium 5.2mEq/L B. Calcium 13mg/dL C. Inorganic phosphorus 1.7mEq/L D. Sodium 138mEq/L Answer B: Hypercalcemia is a common occurrence with cancer of the bone. Clinical manifestations of hypercalcemia include mental confusion and an elevated blood pressure. The potassium level in answer A is elevated but does not relate to the diagnosis. Answers C and D are both normal levels.
55. The nurse is discussing pain from cholecystitis with a client. Which statement made by the client most accurately describes the typical pain of this disorder? A. “The pain is usually below my sternum.” B. “Eating food makes the pain better.” C. “The pain gets worse after I eat fatty foods.” D. “The pain is usually related to constipation.” Answer C: Clients with gallbladder (GB) disease complain of colicky pain usually after intake of fatty foods. The pain is located in the right upper

quadrant of the abdomen or the right shoulder, so answer A is incorrect. Food intake causes more pain because of GB stimulation, so answer B is incorrect. Answer D is an incorrect statement because the gallbladder function is not associated with diarrhea or constipation.

56. The nurse is preparing a client for cervical uterine radiation implant insertion. Which will be included in the nurse’s explanations? A. TV or telephone use will not be allowed while the implant is in place. B. A Foley catheter is usually inserted. C. A high-fiber diet is recommended. D. Excretions will be considered radioactive. Answer B: A catheter will allow urine elimination without possible disruption of the implant. There is usually no restriction on TV or phone use, as in answer A. The client is placed on a low-residue diet, not a high-fiber diet, as in answer C. The client’s radiation is not internal; therefore, there are no special precautions with excretions, as in answer D.
57. A client with end stage cirrhosis can sometimes develop mental changes. What is the most likely cause? A. Elevated blood ammonia B. Decreased serum proteins C. Leukocytosis D. Hyperglycemia Answer A: The liver fails to convert protein for excretion; therefore, protein converts to ammonia, which then builds up in the blood stream, causing mental changes and sometimes coma. An increased WBC and high blood sugar are not associated with liver cirrhosis, so answers C and D are incorrect. The protein levels are elevated, as evidenced by elevated ammonia in the serum, so answer B is incorrect.
58. The nurse is caring for a client after a liver biopsy. The nurse should carefully monitor the client for the development of which of the following? A. Respiratory alkalosis B. Metabolic acidosis

C. Pneumothorax D. Cardiac tamponade Answer C: The lung could be punctured inadvertently by the liver biopsy procedure, causing a pneumothorax. The nurse should also be alert for hemorrhage. Answers A, B, and D are not associated risks with a liver biopsy.

59. The LPN/LVN is assisting a client immediately after a paracentesis. Which of the following actions is the priority? A. Obtaining vital signs B. Positioning the client for comfort C. Detailed documentation of the procedure D. Reporting the amount removed to the client Answer A: The client is at risk for a loss of fluid volume and shock, so obtaining the vital signs to assess for complications would be the priority. Answers B, C, and D can all be implemented, but they are not the priority so they are incorrect.
60. A client has received platelet infusions. Which finding would indicate the most therapeutic effect from the transfusions? A. Hgb level increase from 8.9 to 10.6 B. Temperature reading of 99.4°F C. White blood cell count of 11,000 D. Decrease in oozing of blood from IV site Answer D: Platelets deal with the clotting of blood. Lack of platelets can cause bleeding. Answers A, B, and C do not directly relate to platelets.
61. A client is admitted with Parkinson’s disease. The client has been taking Carbidopa/levodopa (Sinemet) for 1 year. Which clinical manifestation would be most important to report? A. Dryness of the mouth B. Spasmodic eye winking C. Dark urine D. Dizziness

Answer B: Spasmodic eye winking could indicate a toxicity or overdose of the drug and should be reported to the physician. Other signs of toxicity include an involuntary twitching of muscles, facial grimaces, and severe tongue protrusion. Answers A, C, and D are side effects but do not indicate toxicity of the drug.

62. The nurse who is caring for a client with cancer notes a WBC of 1,000. Which intervention would be most appropriate to include when caring for this client? A. Assess temperature every 4 hours, due to risk for hypothermia B. Instruct the client to avoid large crowds and people who are sick C. Instruct in the use of a soft toothbrush D. Assess for hematuria Answer B: With neutropenia, the client is at risk for infection; therefore, the client must avoid crowds and people who are ill. Answer A would not be appropriate because there is no correlation between hypothermia and a WBC of 1000. Answers C and D would correlate with a risk for bleeding.
63. A client has a subtotal thyroidectomy. The nurse is observed requesting that the client state her name frequently. The primary reason for this assessment is to monitor for which of the following? A. Laryngeal nerve damage B. Hemorrhage C. Lower airway obstruction D. Tetany Answer A: The nurse would monitor the client for hoarseness or a voice change, which could indicate damage to the laryngeal nerve during the surgical procedure. Although the nurse would monitor for edema, bleeding, and tetany, assessment of these problems would not be performed by asking the client to speak.
64. The nurse is caring for a client with cancer of the cervix. What clinical data would the nurse expect to find in the client’s history? A. Post-coital vaginal bleeding

B. Nausea and vomiting C. Foul-smelling vaginal discharge D. Hyperthermia Answer A: Vaginal bleeding or spotting is a common symptom of cervical cancer. Answers B and C, the nausea and vomiting and foul-smelling discharge, are not specific or common to cervical cancer. Hyperthermia, in answer D, does not relate to the diagnosis.

65. The nurse is caring for a client with hyperthyroidism. Which clinical manifestation should be reported to the physician immediately? A. Urinary retention B. Heart failure C. Drowsiness D. Sedation Answer B: Heart failure can be life threatening and would be a priority for reporting. These clients are hyperactive and restless, making answers C and D incorrect. Urinary retention, as in answer A, is not a clinical manifestation of hyperthyroidism.
66. A client with suspected leukemia is about to undergo a bone marrow aspiration from the sternum. What position would the nurse assist the client into for this procedure? A. Dorsal recumbent B. Supine C. Fowler’s D. Lithotomy Answer C: This procedure is usually done by the physician with specimens obtained from the sternum or the iliac crest. The high Fowler’s position would be the best position of the ones listed to obtain a specimen from the client’s sternum. Answers A, B, and D would be inappropriate positions for getting a biopsy from the sites indicated.
67. The nurse is caring for a client with a head injury who has increased ICP. The physician plans to reduce the cerebral edema by constricting the cerebral

blood vessels. Which of the following would accomplish this action? A. Hyperventilation per mechanical ventilation B. Insertion of a ventricular shunt C. Furosemide (Lasix) D. Dexamethasone (Decadron) Answer A: Hyperventilation is utilized to decrease the PCO2 to 27–30, producing cerebral blood vessel constriction. Answers B, C, and D can decrease cerebral edema, but not by constricting cerebral blood vessels.

68. A client with a T6 injury 6 months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action? A. Notify the physician B. Assess the client for a distended bladder C. Apply oxygen at 3L/min D. Administer Procardia sublinqually Answer B: The client is experiencing autonomic hyperreflexia. This can be caused by a full bowel or bladder or a wrinkled sheet. Answer A is not the appropriate action before the assessment of the bladder. Answers C and D are not appropriate actions. There is no information to suggest a need for oxygen, and Procardia requires a doctor’s order and would not be done prior to assessment.
69. The nurse is reading an admission history for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug? A. Epistaxis B. Abdominal distention C. Nausea D. Hyperactivity Answer A: Plavix is an antiplatelet. Bleeding could indicate a severe effect. Answers B, C, and D are not associated with Plavix.
70. The nurse caring for a client with a head injury would recognize which