NCLEX-RN EXAM (75 QUESTIONS & ANSWERS LATEST UPDATED 2024), Exams of Nursing

Download NCLEX-RN EXAM (75 QUESTIONS & ANSWERS LATEST UPDATED 2024) and more Exams Nursing in PDF only on Docsity! HOSMERIT NCLEX-RN EXAM (75 QUESTIONS & ANSWERS LATEST UPDATED 2024) 1. Question After cardiac surgery, a client’s blood pressure measures 126/80mm Hg. Nurse Katrina determines that mean arterial pressure (MAP) is which of the following? A. 46 mm Hg B. 80 mm Hg C. 95 mm Hg D. 90 mm Hg VCorrect Answer: C. 95 mm Hg Use the following formula to calculate MAP MAP = systolic + 2 (diastolic) MAP = 126 mm Hg + 2 (80 mm Hg) MAP = 286 mm Hg MAP = 95 mm Hg o Option A: 46 mmHg is according to the calculations. o Option B: 80 mmHg is inadequate according to the formula used in the computation. o Option D: 90 mmHg is according to the computation using the formula of mean arterial pressure. 2. Question A female client arrives at the emergency department with chestand stomach pain and a report of black tarry stool for several months. Which of the following orders should the nurse Oliver anticipate? A. Cardiac monitor, oxygen, creatine kinase and lactatedehydrogenase levels B. Prothrombin time, partial thromboplastin time,fibrinogen and fibrin split product values C. Electrocardiogram, complete blood count,testing for occult blood, comprehensive serum metabolic panel D. Electroencephalogram, alkaline phosphatase, and aspartate aminotransferase levels, basic serum metabolicpanel Correct Answer: C. Electrocardiogram, complete blood count, testing for occult blood, comprehensive serum metabolic panel. An electrocardiogram evaluates the complaints of chest pain, laboratory tests determine anemia, and the stool test for occult blood determines blood in the stool. o Option A: Cardiac monitoring, oxygen, and creatine kinase, and lactate dehydrogenase levels are appropriate for a cardiac primary problem. A basic metabolic panel and alkaline phosphatase and aspartate aminotransferase levels assess liver function. o Option B: Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split products are measured to verify bleeding dyscrasias. o Option D: An electroencephalogram evaluates brain electrical activity. 3. Question Olivia had coronary artery bypass graft (CABG) surgery 3 days ago. Which of the following conditions is suspected by the nursewhen a decrease in platelet count from 230,000 ul to 5,000 ul isnoted? A. Pancytopenia B. Idiopathic thrombocytopenic purpura (ITP) C. Disseminated intravascular coagulation (DIC) D. Heparin-associated thrombosis and thrombocytopenia (HATT) Correct Answer: D. Heparin-associated thrombosis and thrombocytopenia (HATT) HATT may occur after CABG surgery due to heparin use during surgery. Option B: ITP is a bleeding condition of unknown cause in which the blood fails to clot adequately because of a low circulating platelet count and a shortened platelet lifespan. o Option C: Although DIC causes platelet aggregation and bleeding, it is common in a client after revascularization surgery. o Option A: Pancytopenia is a reduction in all blood C. Essential thrombocytopenia D. Von Willebrand’s disease Correct Answer: C. Essential thrombocytopenia Essential thrombocytopenia is linked to immunologic disorders, such as SLE and the human immunodeficiency virus. o Option A: Dressler’s syndrome is pericarditis that occurs after myocardial infarction and isn’t linked to SLE. o Option B: Moderate to severe anemia is associated with SLE, not polycythemia. It is found in about 50% of patients, with anemia of chronic disease being the most common form. o Option D: Von Willebrand disease is a blood disorder in which the blood doesn’t clot properly. Blood contains many proteins that help the body stop bleeding. One of these proteins is called von Willebrand factor. 8. Question The nurse is aware that the following symptom is most commonly an early indication of stage 1 Hodgkin’sdisease? A. Pericarditis B. Night sweat C. Splenomegaly D. Persistent hypothermia Correct Answer: B. Night sweat In stage 1, symptoms include a single enlarged lymph node (usually), unexplained fever, night sweats, malaise, and generalized pruritus. o Option A: Pericarditis refers to the inflammation of the pericardium, two thin layers of a sac-like tissue that surround the heart, hold it in place, and help it work. Pericarditis isn’t associated with Hodgkin’s disease, nor is hypothermia. Moreover, splenomegaly and pericarditis aren’t symptoms. o Option C: The spleen is involved in 20%-30% of cases of Hodgkin’s disease. Patients are usually asymptomatic. o Option D: Persistent hypothermia is associated with Hodgkin’s but isn’t an early sign of the disease. 9. Question Francis with leukemia has neutropenia. Which of the followingfunctions must be frequently assessed? A. Blood pressure B. Bowel sounds C. Heart sounds D. Breath sounds Correct Answer: D. Breath sounds Pneumonia, both viral and fungal, is a common cause of death in clients with neutropenia, so frequent assessment of respiratory rate and breath sounds is required. o Option A: Blood pressure should be monitored regularly, but it is not a priority with neutropenia. o Option B: Assessing bowel sounds is not associated with neutropenia. Leukemia may affect the small and large bowel and they are usually hemorrhagic or infiltrative. o Option C: Although assessing heart sounds is important, it won’t help detect neutropenia. Patients with acute leukemia develop a higher rate of congestive heart failure than patients with other cancers. 10. Question The nurse knows that neurologic complications of multiple myeloma (MM) usually involve which of the following body systems? A. Brain B. Muscle spasm C. Renal dysfunction D. Myocardial irritability Correct Answer: B. Muscle spasm Back pain or paresthesia in the lower extremities may indicate impending spinal cord compression from a spinal tumor. This should be recognized and treated promptly as the progression of the tumor may result in paraplegia. o Option A: The reasons underlying the relative paucity of CNS invasion by multiple myeloma in comparison with other tumors, whether solid or hematological, remain unknown, but this phenomenon might be the result of underlying biological characteristics, or lack thereof, of malignant plasma cells. o Option C: In some cases, renal impairment is caused by the accumulation and precipitation of light chains,which form casts in the distal tubules, resulting in renal obstruction. o Option D: Some of the treatments used in MM may also affect cardiovascular health, however, with careful risk assessment, monitoring, and prophylactic therapy, many of these cardiovascular complications can be managed or treated successfully. 11. Question Nurse Patricia is aware that the average length of time from human immunodeficiency virus (HIV) infection to the development of acquired immunodeficiency syndrome (AIDS)? A. Less than 5 years B. 5 to 7 years C. 10 years D. More than 10 years D. O Rh-positive Correct Answer: C. A Rh-negative Human blood can sometimes contain an inherited D antigen. Persons with the D antigen have Rh-positive blood type; those lacking the antigen have Rh-negative blood. It’s important that a person with Rh-negative blood receives Rh-negative blood. o Option A: A person with Rh-negative blood should also receive Rh-negative blood. o Option B: If Rh-positive blood is administered to an Rh-negative person, the recipient develops anti-Rh agglutinins, and subsequent transfusions with Rhpositive blood may cause serious reactions with clumping and hemolysis of red blood cells. o Option D: This blood type is still not compatible because it is Rh-positive. 15. Question Stacy was diagnosed with acute lymphoid leukemia (ALL). Shewas discharged from the hospital following her chemotherapy treatments. Which statement of Stacy’s mother indicated thatshe understands when she will contact the physician? A. “I should contact the physician if Stacy has difficultyin sleeping”. B. “I will call my doctor if Stacy has persistentvomiting and diarrhea”. C. “My physician should be called if Stacy is irritable andunhappy”. D. “Should Stacy have continued hair loss, I need to callthe doctor”. Correct Answer: B. “I will call my doctor if Stacy has persistent vomiting and diarrhea”. Persistent (more than 24 hours) vomiting, anorexia, and diarrhea are signs of toxicity and the patient should stop the medication and notify the healthcare provider. o Option A: Oftentimes, chemotherapy drugs cause patients to feel tired and sleepy throughout the day. Therefore, patients on chemotherapy can end up napping or sleeping during the day and that leads to difficulty sleeping at night or through the night. o Option C: Chemotherapy medications can directly impact the way people feel emotionally and physically. o Option D: Chemotherapy drugs are powerful medications that attack rapidly growing cancer cells. Unfortunately, these drugs also attack other rapidly growing cells in the body, including those in the hair roots. 16. Question Molly Sue is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy. Her mother states to the nurse that it ishard to see Molly Sue with no hair. The best response for the nurse is: A. “Molly Sue looks very nice wearing a hat”. B. “You should not worry about her hair, just be glad thatshe is alive”. C. “Yes, it is upsetting. But try to cover up your feelingswhen you are with her or else she may be upset”. D. “This is only temporary; Molly Sue will re-grownew hair in 3-6 months but may be different in texture”. Correct Answer: D. “This is only temporary; Stacy will regrow new hair in 3-6 months but may be different in texture”. This is the appropriate response. The nurse should help the mother how to cope with her own feelings regarding the child’s disease so as not to affect the child negatively. When the hair grows back, it is still of the same color and texture. o Option A: It can be an option for the client to use a hat, but the nurse should be open about explanations regarding the side effects of chemotherapy. o Option B: Avoid reassuring the client. Statements of fact would be a good response. o Option C: The mother should be open and honest with the child, and providing an honest and true response would be a big help to both of them. 17. Question Brittany who is undergoing chemotherapy for her throat cancer isexperiencing stomatitis. To promote oral hygiene and comfort, the nurse-in-charge should: o Provide frequent mouthwash with normal saline. A. Provide frequent mouthwash with normal saline. B. Apply viscous Lidocaine to oral ulcers asneeded. C. Use lemon glycerine swabs every 2 hours. D. Rinse mouth with Hydrogen Peroxide. Correct Answer: B. Apply viscous Lidocaine to oral ulcers as needed. Stomatitis can cause pain and this can be relieved by applying topical anesthetics such as lidocaine before mouth care. o Option A: Before providing oral care, ensure that the patient is comfortable with the procedure first. o Option C: Use saline solution mixed with equal parts of water or hydrogen peroxide or oral care. o Option D: When the patient is already comfortable, the nurse can proceed with providing the patient with oral rinses of saline solution mixed with equal parts of water or hydrogen peroxide mixed water in 1:3 concentrations to promote oral hygiene. Every 2-4 hours. 18. Question During the administration of chemotherapy agents, Nurse Oliverobserved that the IV site is red and swollen when the IV is touched Stacy shouts in pain. The first nursing action to take is: A. Notify the physician. B. Flush the IV line with saline solution. C. Immediately discontinue the infusion. D. Apply an ice pack to the site, followed by warmcompress. Correct Answer: C. Immediately discontinue the infusion. Edema or swelling at the IV site is a sign that the needle has been dislodged and the IV solution is leaking into the tissues causing the edema. The patient feels pain as the nerves are irritated by pressure and the IV solution. The first action of the nurse would be to discontinue the infusion right away to prevent further edema and other complications. o Option A: After discontinuing the infusion, the nurse should notify the physician. A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis Correct Answer: C. Respiratory acidosis Because Paco2 is high at 80 mm Hg and the metabolic measure, HCO3- is normal, the client has respiratory acidosis. o Option A: If the HCO3- was below 22 mEq/L the client would have metabolic acidosis. o Option B: The result of the ABG is less than 7.35, which makes metabolic alkalosis . o Option D: The pH is less than 7.35, academic, which eliminates respiratory alkalosis as a possibility 23. Question Norma has started a new drug for hypertension. Thirty minutesafter she takes the drug, she develops chest tightness and becomes short of breath and tachypnea. She has a decreasedlevel of consciousness. These signs indicate which of the following conditions? A. Asthma attack B. Pulmonary embolism C. Respiratory failure D. Rheumatoid arthritis Correct Answer: C. Respiratory failure The client was reacting to the drug with respiratory signs of impending anaphylaxis, which could lead to eventually respiratory failure. o Option A: The symptoms may look like an asthma attack, but it may change because of the new drug ingested. o Option B: Although the signs are also related to a pulmonary embolism, consider the new drug first. o Option D: Rheumatoid arthritis is an autoimmune and inflammatory disease, which means that the immune system attacks healthy cells in the body by mistake, causing inflammation in the affected parts of the body. 24. Question Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver which laboratory testindicates liver cirrhosis? A. Decreased red blood cell count B. Decreased serum acid phosphatase level C. Elevated white blood cell count D. Elevated serum aminotransferase Correct Answer: D. Elevated serum aminotransferase Hepatic cell death causes the release of liver enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST), and lactate dehydrogenase (LDH) into the circulation. Liver cirrhosis is a chronic and irreversible disease of the liver characterized by generalized inflammation and fibrosis of the liver tissues. o Option A: Decreased red blood cell count may indicate anemia. o Option B: Serum acid phosphatase is an enzyme that acts to liberate phosphate under acidic conditions. Until now, low values cannot be determined with certainty. o Option C: A high white blood cell count usually indicates increased production of white blood cells to fight infection 25. Question After a motor vehicle accident, Armand, a 22-year-old client, is admitted with a pneumothorax. The surgeon inserts a chest tubeand attaches it to a chest drainage system. Bubbling soon appears in the water seal chamber. Which of the following is the most likely cause of the bubbling? A. Air leak B. Adequate suction C. Inadequate suction D. Kinked chest tube Correct Answer: A. Air leak Bubbling in the water seal chamber of a chest drainage system stems from an air leak. In pneumothorax, an air leak can occur as air is pulled from the pleural space. o Option B: Inadequate suction does not cause bubbling. o Option C: Bubbling doesn’t normally occur with adequate suction or any preexisting bubbling in the water seal chamber. o Option D: A kinked chest tube does not cause bubbling in the water seal chamber. 26. Question The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr.Gonzales is at increased risk for excessive bleeding primarily because of: A. Impaired clotting mechanism B. Varix formation C. Inadequate nutrition D. Trauma of invasive procedure Correct Answer: A. Impaired clotting mechanism Cirrhosis of the liver results in decreased Vitamin K absorption and formation of clotting factors resulting in impaired clotting mechanism. o Option B: Esophageal varices sometimes form when blood flow to the liver is blocked, most often by scar tissue in the liver caused by liver disease. o Option C: Inadequate nutrition alone cannot cause excessive bleeding in cirrhosis. o Option D: An invasive procedure may cause trauma that may result in bleeding, but the client has not yet undergone any invasive procedure. blood loss. o Option C: The increase in WBC count is due to the cells migrating to the site of the injury. o Option D: The pain in a ruptured aneurysm is constant and can only be alleviated if the aneurysm is repaired. 30. Question Nurse Sarah expects to note an elevated serum glucose level in aclient with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate? A. Elevated serum acetone level. B. Serum ketone bodies. C. Serum alkalosis. D. Below-normal serum potassium level. Correct Answer: D. Below-normal serum potassium level. A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency. o Option A: An elevated serum acetone level is a symptom of diabetic ketoacidosis. Hepatic metabolism of free fatty acids as an alternative energy source results in accumulation of acidic intermediate and end metabolites (ie, ketones). Ketone bodies have generally included acetone, a true ketone. o Option B: Serum ketone bodies are characteristic of diabetic ketoacidosis. Ketone bodies are produced from acetyl coenzyme A mainly in the mitochondria within hepatocytes when carbohydrate utilization is impaired because of relative or absolute insulin deficiency, such that energy must be obtained from fatty acid metabolism. o Option C: Metabolic acidosis, not serum alkalosis, may occur in HHNS. A wide anion gap can be observed in patients with HHNS. The mild acidosis in HHNS is often multifactorial and results, in part, from the accumulation of minimal ketoacids in the absence of effective insulin activity. 31. Question For a client with Graves’ disease, which nursing interventionpromotes comfort? A. Restricting intake of oral fluids. B. Placing extra blankets on the client’s bed. C. Limiting intake of high-carbohydrate foods. D. Maintaining room temperature in the low-normal range. Correct Answer: D. Maintaining room temperature in the low-normal range. Graves’ disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client’s room temperature in the low-normal range. o Option A: To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. o Option B: Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. o Option C: To provide needed energy and calories, the nurse should encourage the client to eat highcarbohydrate foods. 32. Question After undergoing a cardiac catheterization, Tracy has a large puddle of blood under his buttocks. Which of the following stepsshould the nurse take first? A. Call for help. B. Obtain vital signs. C. Ask the client to “lift up”. D. Apply gloves and assess the groin site. Correct Answer: D. Apply gloves and assess the groin site. Observing standard precautions is the first priority when dealing with any blood fluid. Assessment of the groin site is the second priority. This establishes where the blood is coming from and determines how much blood has been lost. The goal in this situation is to stop the bleeding. o Option A: The nurse would call for help if it were warranted after the assessment of the situation. o Option B: After determining the extent of the bleeding, vital signs assessment is important. o Option C: The nurse should never move the client, in case a clot has formed. Moving can disturb the clot and cause rebleeding. 33. Question A client who is admitted with an above-the-knee amputation tellsthe nurse that his foot hurts and itches. Which response by the nurse indicates an understanding of phantom limb pain? A. "The pain will go away in a few days." B. "The pain is due to peripheral nervous systeminterruptions. I will get you some pain medication." C. "The pain is psychological because your foot is nolonger there." D. "The pain and itching are due to the infection you hadbefore the surgery." Correct Answer: B. “The pain is due to peripheral nervoussystem interruptions. I will get you some pain medication.” Pain-related to phantom limb syndrome is due to a peripheral nervous system interruption. A recent study estimated that therewere about 1.6 million people with limb loss in the USA in 2005 and this number was projected to increase by more than double to 3.6 million by the year 2050. Vascular problems, trauma, cancer, and congenital limb deficiency are among the common causes of limb loss. • Option A: Phantom limb pain can last several monthsor indefinitely. The phantom pain and sensation may have its onset immediately or years after the amputation. There are reports of two peak periods of onset, the first within a month and the second a year after amputation. The prevalence is reported to decrease over time after amputation. • Option C: The explanation of phantom limb pain is not psychologically related. PLP was once thought to be primarily a psychiatric illness. With the accumulation of evidence from research over the pastdecades, the paradigm has shifted more towards changes at several levels of the neural axis, especiallythe cortex. Peripheral mechanisms and central neural mechanisms are among the hypotheses that have gained consensus as proposed mechanisms over the recent years. • Option D: Pain and itching are not symptoms of an infection due to surgery. During amputation, peripheral nerves are severed. This results in massivetissue and neuronal injury-causing disruption of the normal pattern of afferent nerve input to the spinal cord. This is followed by a process called C. It inhibits the angiotensin-converting enzymes. D. It inhibits the reabsorption of sodium andwater in the loop of Henle. Correct Answer: D. It inhibits the reabsorption of sodium and water in the loop of Henle. Furosemide is a loop diuretic that inhibits sodium and water reabsorption in the loop Henle, thereby causing a decrease in blood pressure. o Option A: Vasodilators cause dilation of peripheral blood vessels, directly relaxing vascular smooth muscle and decreasing blood pressure. o Option B: Adrenergic blockers decrease sympathetic cardio acceleration and decrease blood pressure. o Option C: Angiotensin-converting enzyme inhibitors decrease blood pressure due to their action on angiotensin. 38. Question Nurse Nikki knows that laboratory results supports the diagnosisof systemic lupus erythematosus (SLE) is: A. Elevated serum complement level B. Thrombocytosis, elevated sedimentation rate C. Pancytopenia, elevated antinuclear antibody(ANA) titer D. Leukocytosis, elevated blood urea nitrogen (BUN) andcreatinine levels Correct Answer: C. Pancytopenia, elevated antinuclear antibody (ANA) titer Laboratory findings for clients with SLE usually show pancytopenia, elevated ANA titer, and decreased serum complement levels. o Option A: Decreased levels of serum complement is usually associated with SLE. The cause of complement activation in SLE is the formation of immune complexes, which in turn activate complement, predominantly by means of the classical pathway. o Option B: Thrombocytopenia is one of the components of pancytopenia. It is a condition in which the platelet count is decreased. o Option D: Clients may have elevated BUN and creatinine levels from nephritis, but the increase does not indicate SLE. The part of the kidney most frequently troubled by SLE is part of the nephron called the glomerulus, a tuft of capillaries that functions to filter substances from the blood. For this reason, the type of kidney inflammation most commonly experienced in lupus is glomerulonephritis. 39. Question A client is discharged home with a prescription for Coumadin(sodium warfarin). The client should be instructed to: A. Have a Protime done monthly B. Eat more fruits and vegetables C. Drink more liquids D. Avoid crowds Correct Answer: A. Have a Protime done monthly Coumadin is an anticoagulant. One of the tests for bleeding time is a Protime. This test should be done monthly. The client will need to have his blood tested to tell how well the medication is working. The blood test, called prothrombin time (PT or protime), is used to calculate the International Normalized Ratio (INR). INR helps the healthcare provider determine how well warfarin is working to prevent blood clots and if the dose needs to be adjusted. o Option B: Eating more fruits and vegetables is not necessary, and dark-green vegetables contain vitamin K, which increases clotting. Vitamin K is needed for normal blood clotting. However, large changes in the amount of vitamin K in the diet can change the way warfarin works. If the client eats foods high in vitamin K, it’s important to keep a weekly intake of vitamin Kcontaining foods consistent. o Option C: Drinking more liquids could boost the platelet count and increase the body’s immunity. Do not start consuming the following herbal teas and supplements because they may affect the INR, causing it to be too high or too low. If the client drinks tea, black tea (such as orange pekoe tea) is acceptable because it is not high in Vitamin K. o Option D: Avoiding crowds is important for patients with decreased WBC. Stay away from people who are ill. Avoid contact with anyone who has recently been vaccinated, including infants and children. Avoid crowds as much as possible. When going to places where there are often a lot of people (i.e., church, shopping), try going at off-peak times, when they are not as crowded. 40. Question A client hospitalized with MRSA (methicillin-resistant staphaureus) is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact? A. The client should be placed in a room with negativepressure. B. Infection requires close contact; therefore, the doormay remain open. C. Transmission is highly likely, so the client should weara mask at all times. D. Infection requires skin-to-skin contact and isprevented by hand washing, gloves, and a gown. Correct Answer: D. Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown. The client with MRSA should be placed in isolation. Gloves, a gown, and a mask should be used when caring for the client and hand washing is very important. o Option A: The door should remain closed, but a negative-pressure room is not necessary. Whenever possible, patients with MRSA will have a single room or will share a room only with someone else who also has MRSA. o Option B: MRSA is spread by contact with blood or body fluid or by touching the skin of the client. Patients are asked to stay in their hospital rooms as much as possible. They should not go to common areas, such as the gift shop or cafeteria. They may go to other areas of the hospital for treatments and tests. o Option C: It is cultured from the nasal passages of the client, so the client should be instructed to cover his nose and mouth when he sneezes or coughs. It is not necessary for the client to wear the mask at all times; the nurse should wear the mask. 41. Question Arnold, a 19-year-old client with a mild concussion is discharged from the emergency department. Before discharge, he complainsof a headache. When offered acetaminophen, his mother tells thenurse the headache is severe and she would like her son to have something stronger. Which of the following responses by the nurse is appropriate? A. Replaces estrogen. B. Decreases infection. C. Decreases inflammation. D. Decreases bone demineralization. Correct Answer: C. Decreases inflammation. The action of colchicines is to decrease inflammation by reducing the migration of leukocytes to synovial fluid. o Option A: Colchicine does not replace estrogen. Colchicine works by reducing the inflammation caused by crystals of uric acid in the joints. o Option B: Decreasing infection is not a mechanism of action of colchicine. The primary mechanism of action of colchicine is tubulin disruption. This leads to subsequent downregulation of multiple inflammatory pathways and modulation of innate immunity. o Option D: Colchicine doesn’t decrease bone demineralization. The toxic effects of colchicine are related to this anti-mitotic activity within proliferating tissue such as skin, hair, and bone marrow. 45. Question Norma asks for information about osteoarthritis. Which of thefollowing statements about osteoarthritis is correct? A. Osteoarthritis is rarely debilitating. B. Osteoarthritis is a rare form of arthritis. C. Osteoarthritis is the most common form ofarthritis. D. Osteoarthritis affects people over 60. Correct Answer: C. Osteoarthritis is the most common form of arthritis Osteoarthritis is the most common form of arthritis and can be extremely debilitating. It can afflict people of any age, although most are elderly. o Option A: Osteoarthritis is an extremely debilitating disease. The cartilage within a joint begins to break down and the underlying bone begins to change. o Option B: It is the most common form of arthritis. It affects over 32.5 million US adults. o Option D: Osteoarthritis can affect people of any age, but are most common among the elderly. Women are more likely to develop QA than men, especially after the age of 50. 46. Question Johnny, a firefighter, was involved in extinguishing a house fire and is being treated for smoke inhalation. He developed severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. He most likely has developed which of the following conditions? A. Adult respiratory distress syndrome (ARDS) B. Atelectasis C. Bronchitis D. Pneumonia Correct Answer: A. Adult respiratory distress syndrome (ARDS) Severe hypoxia after smoke inhalation is typically related to ARDS. o Option B: Atelectasis is not associated with smoke inhalation. Inhaling harmful smoke can inflame the lungs and airway, causing them to swell and block oxygen. This can lead to acute respiratory distress syndrome and failure. o Option C: Bronchitis does not develop due to smoke inhalation. However, if the client already has bronchitis, inhalational injuries can worsen its condition. o Option D: Pneumonia isn’t typically associated with smoke inhalation and severe hypoxia. 47. Question A 67-year-old client develops acute shortness of breath and progressive hypoxia requiring right femur. The hypoxia was probably caused by which of the following conditions? A. Asthma attack B. Atelectasis C. Bronchitis D. Fat embolism Correct Answer: D. Fat embolism Long bone fractures are correlated with fat emboli, which cause shortness of breath and hypoxia. o Option A: Asthma attacks do not develop following a femoral fracture. o Option B: He could develop atelectasis but it typically doesn’t produce progressive hypoxia. o Option C: It’s unlikely the client has developed bronchitis without a previous history. 48. Question A client with cancer of the pancreas has undergone a Whipple procedure. The nurse is aware that during the Whipple procedure,the doctor will remove the: A. Head of the pancreas B. Proximal third section of the small intestines C. Stomach and duodenum D. Esophagus and jejunum Correct Answer: A. Head of the pancreas During a Whipple procedure the head of the pancreas, which is a part of the stomach, the jejunum, and a portion of the stomach is removed and anastomosed. It is the most often used surgery to treat pancreatic cancer that’s confined to the head of the pancreas. After performing the Whipple procedure, the surgeon reconnects the remaining organs to allow the client to digest food normally after surgery. o Option B: Small bowel resection is surgery to remove a part of the small bowel. It is done when part of the small bowel is blocked or diseased. o Option C: A gastrectomy is the surgical removal of all D. 4.2 ml Correct Answer: B. 2.4 ml .05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4 ml. o Option A: 1.2 ml is less than the correct dosage and may not produce the desired effects of the drug. o Option C: 3.5 ml is more than the correct dosage as calculated and may produce adverse effects. o Option D: 4.2 ml is an dosage according to the formula used. 52. Question Alvin with a massive pulmonary embolism will have an arterial blood gas analysis performed to determine the extent of hypoxia.The acid-base disorder that may be present is? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis Correct Answer: D. Respiratory alkalosis A client with massive pulmonary embolism will have a large region and blow off large amounts of carbon dioxide, which crosses the unaffected alveolar-capillary membrane more readily than does oxygen and results in respiratory alkalosis o Option A: Large amounts of carbon dioxide are blown off, removing the option of metabolic acidosis. o Option B: Respiratory, not metabolic, alkalosis is the result of a massive pulmonary embolism. o Option C: Acidosis does not occur with pulmonary embolism. Hypocapnia usually is present with an embolism. 53. Question Ruby is receiving thyroid replacement therapy, develops the flu, and forgets to take her thyroid replacement medicine. The nurseunderstands that skipping this medication will put the client at risk for developing which of the following life-threatening complications? A. Exophthalmos B. Thyroid storm C. Myxedema coma D. Tibial myxedema Correct Answer: C. Myxedema coma Myxedema coma, severe hypothyroidism, is a life-threatening condition that may develop if thyroid replacement medication isn’t taken. o Option A: Exophthalmos, protrusion of the eyeballs, is seen with hyperthyroidism. If a person’s immune system attacks the thyroid gland, it may react by producing extra hormones. The autoimmune antibodies can attack the muscles and soft tissue surrounding the eyes, which can cause them to protrude from the sockets. o Option B: Thyroid storm is life-threatening but is caused by severe hyperthyroidism. It is also referred to as thyrotoxic crisis, an acute, life-threatening hypermetabolic state induced by excessive release of thyroid hormones. o Option D: Tibial myxedema, peripheral mucinous edema involving the lower leg, is associated with hypothyroidism but isn’t life-threatening 54. Question Nurse Sugar is assessing a client with Cushing’s syndrome. Whichobservation should the nurse report to the physician immediately? A. Pitting edema of the legs B. An irregular apical pulse C. Dry mucous membranes D. Frequent urination Correct Answer: B. An irregular apical pulse Because Cushing’s syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician. o Option A: Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention. o Option C: Dry mucous membranes is not a symptom of Cushing’s syndrome. Thinning of the skin and mucous membranes occur because cortisol causes the breakdown of some dermal proteins along with the weakening of small blood vessels. o Option D: Frequent urination signals dehydration, which isn’t associated with Cushing’s syndrome. Short term administration of adrenocorticotropic hormone or glucocorticoids causes an increased glomerular filtration rate. Glomerular dysfunction leads to proteinuria and albuminuria. 55. Question Cyrill with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later, the client’s urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse’s suspicion of diabetes insipidus? A. Above-normal urine and serum osmolality levels. B. Below-normal urine and serum osmolality levels. C. Above-normal urine osmolality level, below-normalserum osmolality level. D. Below-normal urine osmolality level, above-normal serum osmolality level. Correct Answer: D. Below-normal urine osmolality level, above-normal serum osmolality level In diabetes insipidus, excessive polyuria causes dilute urine, resulting in a below-normal urine osmolality level. At the same time, polyuria depletes the body of water, causing dehydration that leads to an above-normal serum osmolality level. o Option A: Urine osmolality level should be below stasis by increasing the blood flow volume and decrease of the caliber of venous blood vessels by compression of the lower limbs. o Option C: The stockings should be worn the whole day and removed before going to sleep. 59. Question If a client requires a pneumonectomy, what fills the area of thethoracic cavity? A. The space remains filled with air only. B. The surgeon fills the space with a gel. C. Serous fluids fill the space and consolidate theregion. D. The tissue from the other lung grows over to the otherside. Correct Answer: C. Serous fluids fill the space and consolidate the region Serous fluid fills the space and eventually consolidates, preventing extensive mediastinal shift of the heart and remaining lung. o Option A: Air can’t be left in space. Air in the chest cavity is called a pneumothorax, and it may cause the lungs to collapse. o Option B: There’s no gel that can be placed in the pleural space. The pleural cavity is the space that lies between the pleura, the two thin membranes that line and surround the lungs. It contains a small amount of liquid known as pleural fluid. o Option D: The tissue from the other lung can’t cross the mediastinum, although a temporary mediastinal shift exists until space is filled. 60. Question Hemoptysis may be present in the client with a pulmonaryembolism because of which of the following reasons? A. Alveolar damage in the infarcted area. B. Involvement of major blood vessels in the occludedarea. C. Loss of lung parenchyma. D. Loss of lung tissue. Correct Answer: A. Alveolar damage in the infarcted area. The infarcted area produces alveolar damage that can lead to the production of bloody sputum, sometimes in massive amounts. o Option B: Clot formation usually occurs in the legs. This is called deep vein thrombosis, which occurs in one or more of the deep veins in the legs. o Option C: Loss of lung parenchyma is not found with hemoptysis in pulmonary embolism. The lung parenchyma comprises a large number of thin-walled alveoli, forming an enormous surface area, which serves to maintain proper gas exchange. o Option D: A regional loss of surfactant is one of the consequences in pulmonary embolism. 61. Question A client with shortness of breath has decreased to absent breath sounds on the right side, from the apex to the base. Which of the following conditions would best explain this? A. Acute asthma B. Chronic bronchitis C. Pneumonia D. Spontaneous pneumothorax Correct Answer: D. Spontaneous pneumothorax A spontaneous pneumothorax occurs when the client’s lung collapses, causing an acute decrease in the amount of functional lung used in oxygenation. The sudden collapse was the cause of his chest pain and shortness of breath. o Option A: An asthma attack would show wheezing breath sounds. o Option B: Bronchitis would have rhonchi. o Option C: Pneumonia would have bronchial breath sounds over the area of consolidation. 62. Question A 62-year-old male client was in a motor vehicle accident as an unrestrained driver. He’s now in the emergency department complaining of difficulty of breathing and chest pain. On auscultation of his lung field, no breath sounds are present in theupper lobe. This client may have which of the following conditions? A. Bronchitis B. Pneumonia C. Pneumothorax D. Tuberculosis (TB) Correct Answer: C. Pneumothorax Pneumothorax is defined as the presence of air or gas in the pleural cavity, which can impair oxygenation and/or ventilation. o Option A: Rhonchi is heard with bronchitis. o Option B: From the trauma the client experienced, it’s unlikely he has pneumonia. Pneumonia may produce crackling, bubbling, and rumbling sounds when inhaling upon auscultation. o Option D: Bronchial breath sounds with TB would be heard. 63. Question Patrick is treated in the emergency department for a Colles’fracture sustained during a fall. What is a Colles’ fracture? A. Fracture of the distal radius. B. Fracture of the olecranon. A. High corticotropin and low cortisol levels B. Low corticotropin and high cortisol levels C. High corticotropin and high cortisol levels D. Low corticotropin and low cortisol levels Correct Answer: C. High corticotropin and high cortisol levels A corticotropin-secreting pituitary tumor would cause high corticotropin and high cortisol levels. o Option A: Cortisol levels should also be elevated in corticotropin-secreting pituitary adenoma. o Option B: Low corticotropin and high cortisol levels would be seen if there was a primary defect in the adrenal glands. o Option D: A low corticotropin level with a low cortisol level would be associated with hypocortisolism 67. Question A male client is scheduled for a transsphenoidal hypophysectomyto remove a pituitary tumor. Preoperatively, the nurse should assess for potential complications by doing which of the following? A. Testing for ketones in the urine. B. Testing urine specific gravity. C. Checking temperature every 4 hours. D. Performing capillary glucose testing every 4hours. Correct Answer: D. Performing capillary glucose testing every 4 hours. The nurse should perform capillary glucose testing every 4 hours because excess cortisol may cause insulin resistance, placing the client at risk for hyperglycemia. o Option A: Urine ketone testing isn’t indicated because the client does secrete insulin and, therefore, isn’t at risk for ketosis. o Option B: Urine specific gravity isn’t indicated because although fluid balance can be compromised, it usually isn’t dangerously imbalanced. 68. Question Capillary glucose monitoring is being performed every 4 hours fora client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucoseresults. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Nurse Mariner should expect the dose’s: A. Onset to be at 2 p.m. and its peak to be at 3 p.m. B. Onset to be at 2:15 p.m. and its peak to be at 3 p.m. C. Onset to be at 2:30 p.m. and its peak to be at 4p.m. D. Onset to be at 4 p.m. and its peak to be at 6 p.m. Correct Answer: C. Onset to be at 2:30 p.m. and its peak to be at 4 p.m. Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m. o Option A: 2 p.m. is when the insulin was given; onset does not occur at the same time as the medication was given o Option B: The peak starts 2 to 4 hours after the insulin was given, which will be at 4 p.m. o Option D: Onset of 4 p.m. is very late; 15 to 30 minutes is the expected onset of insulin. Peak shoud start at 4 p.m. 69. Question The physician orders laboratory tests to confirm hyperthyroidismin a female client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis? A. No increase in the thyroid-stimulating hormone(TSH) level after 30 minutes during the TSH stimulation test. B. A decreased TSH level. C. An increase in the TSH level after 30 minutes duringthe TSH stimulation test. D. Below-normal levels of serum triiodothyronine (T3)and serum thyroxine (T4) as detected by radioimmunoassay. Correct Answer: A. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism. o Option B: A decreased TSH level indicates a pituitary deficiency of this hormone. o Option C: If the TSH level rises after 30 minutes, then the client has no hyperthyroidism. o Option D: Below-normal levels of T3 and T4, as detected by radioimmunoassay, signal hypothyroidism. A below-normal T4 level also occurs in malnutrition and liver disease and may result from the administration of phenytoin and certain other drugs. 70. Question The nurse is assisting the physician with the removal of a centralvenous catheter. To facilitate removal, the nurse should instruct the client to: A. Perform the Valsalva maneuver as the catheteris advanced B. Turn his head to the left side and hyperextend theneck C. Take slow, deep breaths as the catheter is removed D. Turn his head to the right while maintaining a sniffingposition Correct Answer: A. Perform the Valsalva maneuver as the catheter is advanced The client who is having a central venous catheter removed should be told to hold his breath and bear down. This prevents air from entering the line. o Option B: Although there are many steps in the process of CVC removal, essential elements of the procedure include (for internal jugular and subclavian CVCs), positioning of the patient in the head down (Trendelenburg) position, having the patient perform a Valsalva maneuver as the catheter is being withdrawn, application of pressure to the catheter-entry site as the catheter is being withdrawn, placement of an air-occlusive dressing over the site after removal, and a C. Promote movement D. Prevent pain and discomfort Correct Answer: A. Lessen the amount of cellular damage Rapid continuous rewarming of frostbite primarily lessens cellular damage. Rapid rewarming is the single most effective therapy for frostbite. Heat conduction and radiation from deeper tissue circulation prevent freezing and ice crystallization until the skin temperature drops below 0°C o Option B: Blisters contain high amounts of thromboxane and prostaglandins. They contract and dry within 2-3 weeks, forming a dark eschar that sloughs off in 4 weeks. o Option C: Before movement can be improved, the cell injury should be resolved first. o Option D: It does not prevent the formation of blisters. It does promote movement, but this is not the primary reason for rapid rewarming. It might increase pain for a short period of time as the feeling comes back into the extremity. 74. Question Rico with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10 U of U-100 regular insulinand 35 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction? A. “Inject insulin into healthy tissue with large bloodvessels and nerves.” B. “Rotate injection sites within the same anatomic region, not among different regions.” C. “Administer insulin into areas of scar tissue orhypertrophy whenever possible.” D. “Administer insulin into sites above muscles that youplan to exercise heavily later that day.” Correct Answer: B. “Rotate injection sites within the same anatomic region, not among different regions.” The nurse should instruct the client to rotate injection sites within the same anatomic region. Rotating sites among different regions may cause excessive day-to-day variations in the blood glucose level; also, insulin absorption differs from one region to the next. o Option A: Insulin should be injected only into healthy tissue lacking large blood vessels, nerves, or scar tissue, or other deviations. o Option C: Injecting insulin into areas of hypertrophy may delay absorption. The client shouldn’t inject insulin into areas of lipodystrophy (such as hypertrophy or atrophy); to prevent lipodystrophy, the client should rotate injection sites systematically. o Option D: Exercise speeds drug absorption, so the client shouldn’t inject insulin into sites above muscles that will be exercised heavily. 75. Question A client has an order for streptokinase. Before administering themedication, the nurse should assess the client for: A. A history of streptococcal infections B. Allergies to pineapples and bananas C. Prior therapy with phenytoin D. A history of alcohol abuse Correct Answer: A history of streptococcal infections Clients with a history of streptococcal infections could have antibodies that render the streptokinase ineffective. Due to streptokinase’s thrombolytic mechanisms of action, patients need monitoring for bleeding. The patient’s thrombin time, prothrombin time, partial thromboplastin time, complete blood count, and any signs of bleeding demand careful surveillance. Patients also need monitoring for signs and symptoms of reinfarction or vessel occlusion. o Option B: There is no reason to assess the client for allergies to pineapples or bananas. Streptokinase can precipitate an allergic reaction. Symptoms include fever, shivering, and rash. Patients in rare instances have developed nonfatal anaphylactic reactions. In cases of anaphylaxis, patients should be administered epinephrine immediately and discontinue streptokinase therapy. The toxicity of streptokinase is believed to be because it is a polypeptide derivative of beta-hemolytic streptococci bacteria. o Option C: There is no correlation to the use of phenytoin and streptokinase. The thrombolytic nature of streptokinase makes it contraindicated in patients with active internal bleeding, as it can worsen bleeding in some patients. It is also contraindicated in patients with severe uncontrolled hypertension, intracranial neoplasms, surgery within two months, recent stroke, and intraspinal surgery. o Option D: A history of alcohol abuse is also not a factor in the order for streptokinase. Streptokinase administered with extreme caution to those who have experienced recent trauma, coagulopathies or hematologic diseases, gastrointestinal bleeding, infective endocarditis, obstetric deliveries, diabetic hemorrhagic retinopathy, organ biopsies, or previous puncture of a non-compressible vessel. Streptokinase is a pregnancy Category C medication. The effects of streptokinase on a fetus are unknown, and patients who are pregnant should only receive streptokinase to prevent life-threatening injury.