NCLEX-RN Practice Quiz Test Bank #4 (75 Questions), Exams of Biology

Download NCLEX-RN Practice Quiz Test Bank #4 (75 Questions) and more Exams Biology in PDF only on Docsity! NCLEX-RN Practice Quiz Test Bank #4 (75 Questions) NCLEXRN-04-001 Question Tag: delegation Question Category: Safe and Effective Care Environment, Management of Care Which action (s) should you delegate to the experienced nursing assistant when caring for a patient with a thrombotic stroke with residual left-sided weakness? Select all that apply.  A. Assist the patient to reposition every 2 hours.  B. Reapply pneumatic compression boots.  C. Remind the patient to perform active ROM.  D. Check extremities for redness and edema. Correct Answer: A, B, & C. The experienced nursing assistant would know how to reposition the patient and how to reapply compression boots, and would remind the patient to perform activities he has been taught to perform.  Option D: Assessing for redness and swelling (signs of deep venous thrombosis {DVT}) requires additional education and is still appropriate to the professional nurse. NCLEXRN-04-002 Question Tag: stroke Question Category: Safe and Effective Care Environment, Management of Care The patient who had a stroke needs to be fed. What instruction should you give to the nursing assistant who will feed the patient?  A. Position the patient sitting up in bed before you feed her.  B. Check the patient’s gag and swallowing reflexes.  C. Feed the patient quickly because there are three more waiting.  D. Suction the patient’s secretions between bites of food. Correct Answer: A. Position the patient sitting up in bed before you feed her. Positioning the patient in a sitting position decreases the risk of aspiration.  Option B: The nursing assistant is not trained to assess gag or swallowing reflexes.  Option C: The patient should not be rushed during feeding.  Option D: A patient who needs to be suctioned between bites of food is not handling secretions and is at risk for aspiration. This patient should be assessed further before feeding. NCLEXRN-04-003 Question Tag: bacterial meningitis Question Category: Physiological Integrity, Physiological Adaptation You have just admitted a patient with bacterial meningitis to the medical-surgical unit. The patient complains of a severe headache with photophobia and has a temperature of 102.60 F orally. Which collaborative intervention must be accomplished first? accomplished by an LPN/LVN who observes initial seizure activity. An LPN/LVN would know to call the supervising RN immediately if a patient started to seize.  Option A: Documentation is a nursing responsibility.  Option C: Patient education must be accomplished by the registered nurse because it is within their scope of practice.  Option D: Planning of care is a complex activity that requires RN level education and scope of practice. NCLEXRN-04-006 Question Tag: seizure disorder Question Category: Physiological Integrity, Physiological Adaptation While working in the ICU, you are assigned to care for a patient with a seizure disorder. Which of these nursing actions will you implement first if the patient has a seizure?  A. Place the patient on a non-rebreather mask will the oxygen at 15 L/minute.  B. Administer lorazepam (Ativan) 1 mg IV.  C. Turn the patient to the side and protect the airway.  D. Assess level of consciousness during and immediately after the seizure. Correct Answer: C. Turn the patient to the side and protect the airway. The priority action during a generalized tonic-clonic seizure is to protect the airway.  Option B: Administration of lorazepam should be the next action, since it will act rapidly to control the seizure.  Option A: Although oxygen may be useful during the postictal phase, the hypoxemia during tonic-clonic seizures is caused by apnea.  Option D: Checking the level of consciousness is not appropriate during the seizure, because generalized tonic-clonic seizures are associated with a loss of consciousness. NCLEXRN-04-007 Question Tag: phenytoin Question Category: Physiological Integrity, Pharmacological and Parenteral therapies A patient recently started on phenytoin (Dilantin) to control simple complex seizures is seen in the outpatient clinic. Which information obtained during his chart review and assessment will be of greatest concern?  A. The gums appear enlarged and inflamed.  B. The white blood cell count is 2300/mm3.  C. Patient occasionally forgets to take the phenytoin until after lunch.  D. Patient wants to renew his driver’s license next month. Correct Answer: B. The white blood cell count is 2300/mm3. Leukopenia is a serious adverse effect of phenytoin and would require discontinuation of the medication.  Option A: Inflammation of the gums should be reported to the physician, but it does not require immediate attention.  Option C: The nurse should include in the patient teaching the importance of taking medications on time to avoid episodes of seizure.  Option D: Driving is prohibited for a client with seizure disorder. This should be included in the patient’s teaching, but will not require a change in medical treatment for the seizures. NCLEXRN-04-008 Question Tag: prioritization Question Category: Safe and Effective Care Environment,Management of Care After receiving a change-of-shift report at 7:00 AM, which of these patients will you assess first?  A. A 23-year-old with a migraine headache who is complaining of severe nausea associated with retching.  B. A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching.  C. A 59-year-old with Parkinson’s disease who will need a swallowing assessment before breakfast.  D. A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank pain. Correct Answer: D. A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank pain. Urinary tract infections are a frequent complication in patients with multiple sclerosis because of the effect on bladder function. The elevated temperature and decreased breath sounds suggest that this patient may have pyelonephritis. The physician should be notified immediately so that antibiotic therapy can be started quickly.  Option A: This patient needs further assessment, but does not require immediate attention. A migraine can cause severe throbbing pain or a pulsing sensation, usually on one side of the head. It’s often accompanied by nausea, vomiting, and extreme sensitivity to light and sound. Migraine attacks can last for hours to days, and the pain can be so severe that it interferes with daily activities.  Option B: Preoperative teaching must be done but it is not the nurse’s priority. A craniotomy is the surgical removal of part of the bone from the skull to expose the brain. Specialized tools are used to remove the section of bone called the bone flap. The bone flap is temporarily removed, then replaced after the brain surgery has been done.  Option C: The patient should be assessed soon, but does not have an urgent need. In MS, the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problems between your brain and the rest of your body. Eventually, the disease can cause permanent damage or deterioration of the nerves. they are the same as the ones she takes at home. Based on this information, which nursing diagnosis is most appropriate for this patient?  A. Decreased Cardiac Output related to poor myocardial contractility  B. Caregiver Role Strain related to continuous need for providing care  C. Ineffective Therapeutic Regimen Management related to poor patient memory  D. Risk for Falls related to patient wandering behavior during the night Correct Answer: B. Caregiver Role Strain related to continuous need for providing care The husband’s statement about lack of sleep and anxiety over whether the patient is receiving the correct medications are behaviors that support this diagnosis.  Option A: There is no evidence that the patient’s cardiac output is decreased. Alzheimer′s disease and HF often occur together and thus increase the cost of care and health resource utilization; this highlights the need to investigate the relationship between these two conditions. Impaired cognition in HF patients leads to significantly more frequent hospital readmissions and increases mortality rates.  Option C: Ineffective Therapeutic Regimen Management is not a priority as based on the statement.  Option D: Risk for falls is not the priority at this time. Falls are a leading cause of broken hips and other serious injuries in the elderly, and those with Alzheimer’s are at particularly high risk of falling. Problems with vision, perception and balance increase as Alzheimer’s advances, making the risk of a fall more likely. NCLEXRN-04-012 Question Tag: glioblastoma Question Category: Physiological Integrity, Pharmacological and Parenteral therapies You are caring for a patient with a recurrent glioblastoma who is receiving dexamethasone (Decadron) 4 mg IV every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns you the most?  A. The patient does not recognize family members.  B. The blood glucose level is 234 mg/dL.  C. The patient complains of a continued headache.  D. The daily weight has increased by 1 kg. Correct Answer: A. The patient does not recognize family members. The inability to recognize a family member is a new neurologic deficit for this patient, and indicates a possible increase in intracranial pressure (ICP). This change should be communicated to the physician immediately so that treatment can be initiated.  Option B: Increased blood glucose levels is an expected side effect but not an emergency.  Option C: The continued headache also indicates that the ICP may be elevated, but it is not a new problem.  Option D: Weight gain is a common adverse effect of dexamethasone that may require treatment, but is not an emergency. NCLEXRN-04-013 Question Tag: lethargy Question Category: Safe and Effective Care Environment, Management of Care A 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence is admitted to the hospital ED. His wife tells you that he fell down the stairs about a month ago, but “he didn’t have a scratch afterward.” She feels that he has become gradually less active and sleepier over the last 10 days or so. Which of the following collaborative interventions will you implement first?  A. Place on the hospital alcohol withdrawal protocol.  B. Transfer to radiology for a CT scan.  C. Insert a retention catheter to straight drainage.  D. Give phenytoin (Dilantin) 100 mg PO. Correct Answer: B. Transfer to radiology for a CT scan. The patient’s history and assessment data indicate that he may have a chronic subdural hematoma. The priority goal is to obtain a rapid diagnosis and send the patient to surgery to have the hematoma evacuated.  Option A: This can be done after the treatment for any intracranial lesion has been implemented.  Option C: This intervention should be done but is not the priority.  Option D: Administration of phenytoin should be implemented as soon as possible, but the initial nursing activities should be directed toward treatment of any intracranial lesion. NCLEXRN-04-014 Question Tag: delegation Question Category: Safe and Effective Care Environment, Management of Care Which of these patients in the neurologic ICU will be best to assign to an RN who has floated from the medical unit?  A. A 26-year-old patient with a basilar skull structure who has clear drainage coming out of the nose.  B. A 42-year-old patient admitted several hours ago with a headache and diagnosed with a ruptured berry aneurysm.  C. A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due.  D. A 65-year-old patient with an astrocytoma who has just returned to the unit after having a craniotomy.  Option D: The stool from a colostomy can be thin or thick liquid, or semiformed. NCLEXRN-04-017 Question Tag: right-sided brain attack, hemianopsia Question Category: Physiological Integrity, Physiological Adaptation Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left homonymous hemianopsia?  A. On the client’s right side  B. On the client’s left side  C. Directly in front of the client  D. Where the client like Correct Answer: A. On the client’s right side The client has left visual field blindness. The client will see only from the right side. Homonymous hemianopsia is a condition in which a person sees only one side―right or left―of the visual world of each eye. The person may not be aware that the vision loss is happening in both eyes, not just one. An injury to the right part of the brain produces loss of the left side of the visual world of each eye.  Option B: The client would not be able to see the call light on his right side because he can only see the left side.  Option C: Only the right half of the visual world can be seen by the client.  Option D: The most ideal place to put the call light is on the client’s right side to avoid any injuries. NCLEXRN-04-018 Question Tag: accident Question Category: Physiological Integrity, Physiological Adaptation A male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse?  A. Check respiration, circulation, neurological response  B. Align the spine, check pupils, and check for hemorrhage  C. Check respirations, stabilize the spine and check the circulation  D. Assess level of consciousness and circulation Correct Answer: C. Check respirations, stabilize the spine and check the circulation Checking the airway would be the priority, and a neck injury should be suspected. Airway patency and adequate respiratory effort are both essential for normal oxygenation and ventilation within the body so that normal physiological processes can proceed without metabolic derangement.  Option A: These assessments should be made, but keeping the spine stable is also a priority since the patient has been in an accident.  Option B: The first priority is always to check the airway, then the rest of the assessments would follow. Patency is assessed through the presence/absence of obstructive symptoms or findings suggesting an airway that may become obstructed.  Option D: The level of consciousness and circulation can be assessed after securing a patent airway. NCLEXRN-04-019 Question Tag: nitroglycerin Question Category: Physiological Integrity, Pharmacological and Parenteral therapies In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and relieves angina by:  A. Increasing contractility and slowing heart rate  B. Increasing AV conduction and heart rate  C. Decreasing contractility and oxygen consumption  D. Decreasing venous return through vasodilation Correct Answer: D. Decreasing venous return through vasodilation. The significant effect of nitroglycerin is vasodilation and decreased venous return, so the heart does not have to work hard.  Option A: Nitroglycerin does not increase contractility. Cardiac work is decreased by venodilation, reducing anginal symptoms secondary to demand ischemia.  Option B: AV conduction is not increased through nitroglycerin, and an increased heart may increase the blood pressure, which is contrary to the desired effects of nitroglycerin,  Option C: Contractility is not significantly affected by nitroglycerin. The desired vasodilatory effect increases perfusion, and does not directly reduce oxygen consumption. NCLEXRN-04-020 Question Tag: myocardial infarction Question Category: Physiological Integrity, Physiological Adaptation Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse’s next action?  A. Call for help and note the time  B. Clear the airway  C. Give two sharp thumps to the precordium, and check the pulse  D. Administer two quick blows Correct Answer: A. Call for help and note the time.  Option D: The level is correct; increasing the dosage is unnecessary. Warfarin markedly affects PTT, for each increase of 1.0 in the international normalized ratio, the PTT increases 16 seconds. NCLEXRN-04-023 Question Tag: ileostomy, stoma Question Category: Physiological Integrity, Physiological Adaptation A client underwent an ileostomy, when should the drainage appliance be applied to the stoma?  A. 24 hours later, when edema has subsided  B. In the operating room  C. After the ileostomy begins to function  D. When the client is able to begin self-care procedures Correct Answer: B. In the operating room The stoma drainage bag is applied in the operating room. Drainage from the ileostomy contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short time becomes reddened, painful, and excoriated.  Option A: If the application of the drainage appliance is delayed after surgery, the skin around the stoma would be most likely irritated and damaged due to the digestive enzymes present in the secretions of the drainage.  Option C: An ileostomy needs a drainage bag before it starts to function so that the secretions from the drainage would be caught up by the bag, preventing contamination of the skin.  Option D: The client would have irritated, damaged skin once the drainage comes out from the stoma and comes into contact with the skin. NCLEXRN-04-024 Question Tag: spinal anesthesia Question Category: Physiological Integrity, Reduction of Risk Potential A client has undergone spinal anesthetic, it will be important that the nurse immediately position the client in:  A. On the side, to prevent obstruction of the airway by the tongue  B. Flat on back  C. On the back, with knees flexed 15 degrees  D. Flat on the stomach, with the head turned to the side Correct Answer: B. Flat on back To avoid the complication of a painful spinal headache that can last for several days, the client is kept in a flat supine position for approximately 4 to 12 hours postoperatively. Headaches are believed to be caused by the seepage of cerebrospinal fluid from the puncture site. By keeping the client flat, cerebral spinal fluid pressures are equalized, which avoids trauma to the neurons.  Option A: The client may experience a severe headache if kept in a side lying position. Spinal headaches are caused by leakage of spinal fluid through a puncture hole in the tough membrane (dura mater) that surrounds the spinal cord.  Option C: A supine position for 4 to 12 hours would prevent seepage of cerebrospinal fluid from the puncture site. There is no need to flex the knees.  Option D: Lying on his stomach would be uncomfortable to a postoperative patient, and would cause a painful spinal headache from the spinal anesthesia. . NCLEXRN-04-025 Question Tag: increased intracranial pressure Question Category: Physiological Integrity, Physiological Adaptation While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure?  A. Blood pressure has decreased from 160/90 to 110/70.  B. Pulse is increased from 87 to 95, with an occasional skipped beat.  C. The client is oriented when aroused from sleep and goes back to sleep immediately.  D. The client refuses dinner because of anorexia. Correct Answer: C. The client is oriented when aroused from sleep and goes back to sleep immediately. This finding suggests that the level of consciousness is decreasing.  Option A: A blood pressure level of 110/70 mmHg is within normal limits. Increased intracranial pressure is caused by an increase in blood pressure.  Option B: A pulse rate of 95 bpm is within the normal range. When arterial blood pressure exceeds the intracranial pressure, blood flow to the brain is restored. The increased arterial blood pressure caused by the CNS ischemic response stimulates the baroreceptors in the carotid bodies, thus slowing the heart rate drastically often to the point of bradycardia.  Option D: Anorexia is not related to increased intracranial pressure. Anorexia is an eating disorder characterized by an abnormally low body weight, an intense fear of gaining weight and a distorted perception of weight. NCLEXRN-04-026 Question Tag: pneumonia Question Category: Physiological Integrity, Physiological Adaptation Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first?  Option B: Bronchial pneumonia most often exhibits a productive cough. It is the type of pneumonia that affects the bronchi in the lungs. This condition commonly results from a bacterial infection, but viral and fungal infections can also cause it.  Option C: COPD commonly occurs in middle-aged people, mostly over the age of 40. Chronic obstructive pulmonary disease is a chronic inflammatory lung disease that causes obstructed airflow from the lungs.  Option D: Emphysema is most common in men between the ages of 50 and 70. It is a lung condition that causes shortness of breath. The air sacs in the lungs are damaged. Over time, the inner walls of the air sacs weaken and rupture-creating larger air spaces instead of many small ones. NCLEXRN-04-029 Question Tag: morphine Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might have which of the following reactions?  A. Asthma attack  B. Respiratory arrest  C. Seizure  D. Wake up on her own Correct Answer: B. Respiratory arrest Narcotics can cause respiratory arrest if given in large quantities.  Option A: The client’s respiratory system is most likely being suppressed, so an acute asthma attack would be unlikely. In an asthma attack, the airways become swollen and inflamed. The muscles around the airways contract and the airways produce extra mucus, causing the breathing (bronchial) tubes to narrow.  Option C: A seizure is not likely to occur in the situation. Seizures are mostly caused by paroxysmal discharges from groups of neurons, which arise as a result of excessive excitation or loss of inhibition.  Option D: The client’s respiratory rate is too low and she might be going into a respiratory arrest. Respiratory depression happens when the lungs fail to exchange carbon dioxide and oxygen efficiently. This dysfunction leads to a buildup of carbon dioxide in the body, which can result in health complications. NCLEXRN-04-030 Question Tag: elective knee surgery Question Category: Health Promotion and Maintenance A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging?  A. Increased elastic recoil of the lungs  B. Increased number of functional capillaries in the alveoli  C. Decreased residual volume  D. Decreased vital capacity Correct Answer: D. Decreased vital capacity Reduction in vital capacity is a normal physiologic change including decreased elastic recoil of the lungs, fewer functional capillaries in the alveoli, and an increase in residual volume.  Option A: Elastic recoil in the lungs of the elderly is decreased. There is homogenous degeneration of the elastic fibers around the alveolar duct starting around 0 years of age resulting in enlargement of air spaces.  Option B: There are fewer functional capillaries in the alveoli as one ages. The alveoli can lose their shape and become baggy.  Option C: Decreases in the measures of lung function such as the vital capacity occurs as part of the age-related changes. NCLEXRN-04-031 Question Tag: lidocaine Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies Nurse John is caring for a male client receiving lidocaine I.V. Which factor is the most relevant to the administration of this medication?  A. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter.  B. Increase in systemic blood pressure  C. Presence of premature ventricular contractions (PVCs) on a cardiac monitor  D. Increase in intracranial pressure (ICP) Correct Answer: C. Presence of premature ventricular contractions (PVCs) on a cardiac monitor. Lidocaine drips are commonly used to treat clients whose arrhythmias haven’t been controlled with oral medication and who are having PVCs that are visible on the cardiac monitor.  Option A: This should be reported to the physician but it is not the priority in this situation.  Option B: An increase in the blood pressure is also significant, but does not need immediate attention.  Option D: Increase in ICP is an important factor but isn’t as significant as PVCs in the situation.  Option D: Dowager’s hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature. NCLEXRN-04-035 Question Tag: BSE Question Category: Health Promotion and Maintenance Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the purpose of performing the examination is to discover:  A. Cancerous lumps  B. Areas of thickness or fullness  C. Changes from previous examinations  D. Fibrocystic masses Correct Answer: C. Changes from previous examinations. Women are instructed to examine themselves to discover changes that have occurred in the breast.  Option A: Lumps may be detected through BSE, but it does not diagnose whether it is benign or cancerous.  Option B: Only a physician can diagnose areas of thickness or fullness that signal the presence of a malignancy.  Option D: Only a physician can diagnose masses that are fibrocystic as opposed to malignant. NCLEXRN-04-036 Question Tag: hyperthyroidism Question Category: Physiological Integrity, Basic Care and Comfort When caring for a female client who is being treated for hyperthyroidism, it is important to:  A. Provide extra blankets and clothing to keep the client warm.  B. Monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy.  C. Balance the client’s periods of activity and rest.  D. Encourage the client to be active to prevent constipation. Correct Answer: C. Balance the client’s periods of activity and rest. A client with hyperthyroidism needs to be encouraged to balance periods of activity and rest. Many clients with hyperthyroidism are hyperactive and complain of feeling very warm.  Option A: One of the signs of hyperthyroidism is increased sensitivity to heat. So extra blankets and clothing would be unnecessary.  Option B: Restlessness, sweating, and unintentional weight loss are common signs of hyperthyroidism.  Option D: There should be equal moments of activity and rest for the client. NCLEXRN-04-037 Question Tag: atherosclerosis Question Category: Health Promotion and Maintenance Nurse Kris is teaching a client with a history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to:  A. Avoid focusing on his weight  B. Increase his activity level  C. Follow a regular diet  D. Continue leading a high-stress lifestyle. Correct Answer: B. Increase his activity level. The client should be encouraged to increase his activity level.  Option A: Clients with atherosclerosis should be vigilant about their weight and maintain the ideal number of kilograms/pounds.  Option C: The client should be following a low cholesterol, low sodium diet.  Option D: Avoiding stress is an important factor in decreasing the risk of atherosclerosis. NCLEXRN-04-038 Question Tag: logroll Question Category: Physiological Integrity, Physiological Adaptation Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client following a:  A. Laminectomy  B. Thoracotomy  C. Hemorrhoidectomy  D. Cystectomy Correct Answer: A. Laminectomy The client who has had spinal surgery, such as laminectomy, must be log rolled to keep the spinal column straight when turning.  Option B: Thoracotomy clients may turn themselves or may be assisted into a comfortable position.  Option C: Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery.  Option D: A client who has undergone cystectomy would be able to turn themselves or may need minimal assistance.  Option C: After notifying the physician, the nurse should take the client’s vital signs.  Option D: The dehiscence needs to be surgically closed, so the nurse should never try to close it. NCLEXRN-04-042 Question Tag: Cheyne-Stokes respirations Question Category: Physiological Integrity, Physiological Adaptation Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. During routine assessment, the nurse notices Cheyne- Stokes respirations. Cheyne-stokes respirations are:  A. Progressively deeper breath followed by shallower breaths with apneic periods.  B. Rapid, deep breathing with abrupt pauses between each breath.  C. Rapid, deep breathing and irregular breathing without pauses.  D. Shallow breathing with an increased respiratory rate. Correct Answer: A. Progressively deeper breaths followed by shallower breaths with apneic periods. Cheyne-Stokes respirations are breaths that become progressively deeper followed by more shallow respirations with apneic periods.  Option B: Biot’s respirations are rapid, deep breathing with abrupt pauses between each breath, and equal depth between each breath.  Option C: Kussmaul’s respirations are rapid, deep breathing without pauses.  Option D: Tachypnea is shallow breathing with increased respiratory rate. NCLEXRN-04-043 Question Tag: heart failure Question Category: Physiological Integrity, Physiological Adaptation Nurse Bea is assessing a male client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:  A. Tracheal  B. Fine crackles  C. Coarse crackles  D. Friction rubs Correct Answer: B. Fine crackles Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure.  Option A: Tracheal breath sounds are auscultated over the trachea.  Option C: Coarse crackles are caused by secretion accumulation in the airways.  Option D: Friction rubs occur with pleural inflammation. NCLEXRN-04-044 Question Tag: acute asthma Question Category: Physiological Integrity, Physiological Adaptation The nurse is caring for Kenneth experiencing an acute asthma attack. The client stops wheezing and breath sounds aren’t audible. The reason for this change is that:  A. The attack is over.  B. The airways are so swollen that no air cannot get through.  C. The swelling has decreased.  D. Crackles have replaced wheezes. Correct Answer: B. The airways are so swollen that no air cannot get through. During an acute attack, wheezing may stop and breath sounds become inaudible because the airways are so swollen that air can’t get through.  Option A: Breath sounds should still be audible even if the attack is over.  Option C: A decrease in swelling does not cause diminished breath sounds.  Option D: Crackles do not replace wheezes during an acute asthma attack. NCLEXRN-04-045 Question Tag: seizure Question Category: Safe & Effective Care Environment, Safety and infection Control Mike with epilepsy is having a seizure. During the active seizure phase, the nurse should:  A. Place the client on his back, remove dangerous objects, and insert a bite block.  B. Place the client on his side, remove dangerous objects, and insert a bite block.  C. Place the client on his back, remove dangerous objects, and hold down his arms.  D. Place the client on his side, remove dangerous objects, and protect his head. Correct Answer: D. Place the client on his side, remove dangerous objects, and protect his head. NCLEXRN-04-048 Question Tag: health history Question Category: Health Promotion and Maintenance Nurse Ron is taking the health history of an 84-year-old client. Which information will be most useful to the nurse for planning care?  A. General health for the last 10 years  B. Current health promotion activities  C. Family history of diseases  D. Marital status Correct Answer: B. Current health promotion activities Recognizing an individual’s positive health measures is very useful.  Option A: General health in the previous 10 years is important, however, the current activities of an 84-year-old client are most significant in planning care.  Option C: Family history of disease for a client in later years is of minor significance.  Option D: Marital status information may be important for discharge planning but is not as significant for addressing the immediate medical problem. NCLEXRN-04-049 Question Tag: oral care Question Category: Physiological Integrity, Physiological Adaptation When performing oral care on a comatose client, Nurse Krina should:  A. Apply lemon glycerin to the client’s lips at least every 2 hours.  B. Brush the teeth with a client lying supine.  C. Place the client in a side-lying position, with the head of the bed lowered.  D. Clean the client’s mouth with hydrogen peroxide. Correct Answer: C. Place the client in a side-lying position, with the head of the bed lowered. The client should be positioned in a side-lying position with the head of the bed lowered to prevent aspiration. A small amount of toothpaste should be used and the mouth swabbed or suctioned to remove pooled secretions.  Option A: Lemon glycerin can be drying if used for extended periods.  Option B: Brushing the teeth with the client lying supine may lead to aspiration.  Option D: Hydrogen peroxide is caustic to tissues and should not be used. NCLEXRN-04-050 Question Tag: pneumonia Question Category: Physiological Integrity, Physiological Adaptation A 77-year-old male client is admitted with a diagnosis of dehydration and change in mental status. He’s being hydrated with L.V. fluids. When the nurse takes his vital signs, she notes he has a fever of 103°F (39.4°C) , a cough producing yellow sputum and pleuritic chest pain. The nurse suspects this client may have which of the following conditions?  A. Adult respiratory distress syndrome (ARDS)  B. Myocardial infarction (MI)  C. Pneumonia  D. Tuberculosis Correct Answer: C. Pneumonia Fever, productive cough, and pleuritic chest pain are common signs and symptoms of pneumonia.  Option A: The client with ARDS has dyspnea and hypoxia with worsening hypoxia over time, if not treated aggressively.  Option B: Pleuritic chest pain varies with respiration, unlike the constant chest pain during an MI; so this client most likely isn’t having an MI.  Option D: The client with TB typically has a cough producing blood-tinged sputum. A sputum culture should be obtained to confirm the nurse’s suspicions. NCLEXRN-04-051 Question Tag: tuberculosis Question Category: Health Promotion and Maintenance Nurse Oliver is working in an outpatient clinic. He has been alerted that there is an outbreak of tuberculosis (TB). Which of the following clients entering the clinic today is most likely to have TB?  A. A 16-year-old female high school student  B. A 33-year-old daycare worker  C. A 43-year-old homeless man with a history of alcoholism  D. A 54-year-old businessman Correct Answer: C. A 43-year-old homeless man with a history of alcoholism Clients who are economically disadvantaged, malnourished, and have reduced immunity, such as a client with a history of alcoholism, are at extremely high risk for developing TB.  Option A: The high school student may be at low risk of developing TB, and she does not exhibit any signs and symptoms.  Option B: The daycare worker may have a lesser risk of developing TB than the homeless man with alcoholism. peripheral edema, and cyanotic nail beds. Based on this information, he most likely has which of the following conditions?  A. Adult respiratory distress syndrome (ARDS)  B. Asthma  C. Chronic obstructive bronchitis  D. Emphysema Correct Answer: C. Chronic obstructive bronchitis Because of this extensive smoking history and symptoms, the client most likely has chronic obstructive bronchitis.  Option A: Clients with ARDS have acute symptoms of hypoxia and typically need large amounts of oxygen.  Option B: Clients with asthma do not exhibit a chronic cough. Symptoms of asthma include shortness of breath, chest tightness or pain, wheezing when exhaling, and coughing or wheezing attacks.  Option D: Clients with emphysema tend not to have a chronic cough or peripheral edema. The main symptom of emphysema is shortness of breath, which usually begins gradually. NCLEXRN-04-055 Question Tag: chronic lymphocytic anemia Question Category: Physiological Integrity, Reduction of Risk Potential Situation: Francis, age 46 is admitted to the hospital with diagnosis of Chronic Lymphocytic Leukemia. The treatment for patients with leukemia is bone marrow transplantation. Which statement about bone marrow transplantation is not correct?  A. The patient is under local anesthesia during the procedure.  B. The aspirated bone marrow is mixed with heparin.  C. The aspiration site is the posterior or anterior iliac crest.  D. The recipient receives cyclophosphamide (Cytoxan) for 4 consecutive days before the procedure. Correct Answer: A. The patient is under local anesthesia during the procedure Before the procedure, the patient is administered with drugs that would help to prevent infection and rejection of the transplanted cells such as antibiotics, cytotoxic, and corticosteroids. During the transplant, the patient is placed under general anesthesia.  Option B: An anticoagulant is often added to prevent cell clumping.  Option C: The iliac crest is preferred for safety reasons, because there are no major blood vessels or organs located close to this area.  Option D: Cyclophosphamide is given to prevent incidence of graft- versus-host disease. NCLEXRN-04-056 Question Tag: disorientation Question Category: Safe and Effective Care Environemnt After several days of admission, Francis becomes disoriented and complains of frequent headaches. The nurse in-charge first action would be:  A. Call the physician  B. Document the patient’s status in his charts  C. Prepare oxygen treatment  D. Raise the side rails Correct Answer: D. Raise the side rails A patient who is disoriented is at risk of falling out of bed. The initial action of the nurse should be raising the side rails to ensure the patient’s safety.  Option A: Calling the physician would be unnecessary. These findings can be reported after ensuring the patient’s safety first.  Option B: After notifying the physician, the nurse should document these findings.  Option C: Oxygen treatment would be needed as ordered by the physician. NCLEXRN-04-057 Question Tag: WBC Question Category: Physiological Integrity, Physiological Adaptation During routine care, Francis asks the nurse, “How can I be anemic if this disease causes increased white blood cell production?” The nurse in-charge best response would be that the increased number of white blood cells (WBC) is:  A. Crowded red blood cells  B. Is not responsible for the anemia  C. Uses nutrients from other cells  D. Have an abnormally short lifespan of cells Correct Answer: A. Crowd red blood cells The excessive production of white blood cells crowds out red blood cells production which causes anemia to occur.  Option B: The increase in WBCs most likely caused the anemia.  Option C: The overcrowding of WBC pushes out the RBCs, thereby decreasing them and causing anemia.  Option D: The lifespan of WBCs is 13 to 20 days, while the RBCs live for approximately 115 days.  D. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. diltiazem (Cardizem). Correct Answer: D. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. diltiazem (Cardizem). The client with atrial fibrillation has the greatest potential to become unstable and is on L.V. medication that requires close monitoring.  Option A: After assessing the client with thrombophlebitis, the nurse should assess the 58- year-old client admitted 2 days ago with heart failure (his signs and symptoms are resolving and don’t require immediate attention).  Option B: The lowest priority is the 89-year-old with end-stage right-sided heart failure, who requires time-consuming supportive measures.  Option C: Assess this patient next because he is at high risk for developing an emboli, which is fatal. NCLEXRN-04-061 Question Tag: cocaine use Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies Honey, a 23-year old client complains of substernal chest pain and states that her heart feels like “it’s racing out of the chest”. She reports no history of cardiac disorders. The nurse attaches her to a cardiac monitor and notes sinus tachycardia with a rate of 136beats/minutes. Breath sounds are clear and the respiratory rate is 26 breaths/minutes. Which of the following drugs should the nurse question the client about using?  A. Barbiturates  B. Opioids  C. Cocaine  D. Benzodiazepines Correct Answer: C. Cocaine Because of the client’s age and negative medical history, the nurse should question her about cocaine use. Cocaine increases myocardial oxygen consumption and can cause coronary artery spasm, leading to tachycardia, ventricular fibrillation, myocardial ischemia, and myocardial infarction.  Option A: Barbiturate overdose may trigger respiratory depression and slow pulse.  Option B: Opioids can cause marked respiratory depression.  Option D: Benzodiazepines can cause drowsiness and confusion. NCLEXRN-04-062 Question Tag: breast lump Question Category: Health Promotion and Maintenance A 51-year-old female client tells the nurse-in-charge that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client’s lump is cancerous?  A. Eversion of the right nipple and mobile mass.  B. Nonmobile mass with irregular edges.  C. Mobile mass that is soft and easily delineated.  D. Nonpalpable right axillary lymph nodes. Correct Answer: B. Nonmobile mass with irregular edges Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges.  Option A: Nipple retraction — not eversion — may be a sign of cancer.  Option C: A mobile mass that is soft and easily delineated is most often a fluid-filled benign cyst.  Option D: Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass. NCLEXRN-04-063 Question Tag: vaginal cancer Question Category: Physiological Integrity, Physiological Adaptation A 35-year-old client with vaginal cancer asks the nurse, “What is the usual treatment for this type of cancer?” Which treatment should the nurse name?  A. Surgery  B. Chemotherapy  C. Radiation  D. Immunotherapy Correct Answer: C. Radiation The usual treatment for vaginal cancer is external or intravaginal radiation therapy.  Option A: Less often, surgery is performed. Surgery is usually only used for small stage I or II vaginal cancers and for cancers that were not cured with radiation.  Option B: Chemotherapy typically is prescribed only if vaginal cancer is diagnosed in an early stage, which is rare.  Option D: Immunotherapy isn’t used to treat vaginal cancer. It is a type of cancer treatment that helps the immune system fight cancer. Immunotherapy is a type of biological therapy. Biological therapy is a type of treatment that uses substances made from living organisms to treat cancer. NCLEXRN-04-064 Question Tag: TNM staging Question Category: Physiological Integrity, Reduction of Risk Potential  Option A: Breast cancer is the second most deadly type of cancer in women.  Option C: Brain cancer is the 10th most deadly type of cancer among women.  Option D: Colon and rectal cancer ranks third in women. NCLEXRN-04-067 Question Tag: Horner’s syndrome, lung cancer Question Category: Physiological Integrity, Physiological Adaptation Antonio, with lung cancer, develops Horner’s syndrome when the tumor invades the ribs and affects the sympathetic nerve ganglia. When assessing for signs and symptoms of this syndrome, the nurse should note:  A. Miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.  B. Chest pain, dyspnea, cough, weight loss, and fever.  C. Arm and shoulder pain and atrophy of arm and hand muscles, both on the affected side.  D. Hoarseness and dysphagia. Correct Answer: A. Miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. Horner’s syndrome, which occurs when a lung tumor invades the ribs and affects the sympathetic nerve ganglia, is characterized by miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.  Option B: Chest pain, dyspnea, cough, weight loss, and fever are associated with pleural tumors.  Option C: Arm and shoulder pain and atrophy of the arm and hand muscles on the affected side suggest Pancoast’s tumor, a lung tumor involving the first thoracic and eighth cervical nerves within the brachial plexus.  Option D: Hoarseness in a client with lung cancer suggests that the tumor has extended to the recurrent laryngeal nerve; dysphagia suggests that the lung tumor is compressing the esophagus. NCLEXRN-04-068 Question Tag: PSA Question Category: Physiological Integrity , Reduction of Risk Potential Vic asks the nurse what PSA is. The nurse should reply that it stands for:  A. Prostate-specific antigen, which is used to screen for prostate cancer.  B. Protein serum antigen, which is used to determine protein levels.  C. Pneumococcal strep antigen, which is a bacteria that causes pneumonia.  D. Papanicolaou-specific antigen, which is used to screen for cervical cancer. Correct Answer: A. Prostate-specific antigen, which is used to screen for prostate cancer. PSA stands for prostate-specific antigen, which is used to screen for prostate cancer.  Option B: There is no protein serum antigen test for protein levels.  Option C: There is no pneumococcal strep antigen test that tests for bacteria in pneumonia.  Option D: There is no Papanicolau-specific antigen test available for cervical cancer. NCLEXRN-04-069 Question Tag: subarachnoid block Question Category: Physiological Integrity, Reduction of Risk Potential What is the most important postoperative instruction that nurse Kate must give a client who has just returned from the operating room after receiving a subarachnoid block?  A. “Avoid drinking liquids until the gag reflex returns.”  B. “Avoid eating milk products for 24 hours.”  C. “Notify a nurse if you experience blood in your urine.”  D. “Remain supine for the time specified by the physician.” Correct Answer: D. “Remain supine for the time specified by the physician.” The nurse should instruct the client to remain supine for the time specified by the physician.  Option A: Local anesthetics used in a subarachnoid block don’t alter the gag reflex.  Option B: No interactions between local anesthetics and food occur.  Option C: Local anesthetics don’t cause hematuria. NCLEXRN-04-070 Question Tag: colorectal cancer Question Category: Physiological Integrity, Reduction of Risk Potential A male client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis?  A. Stool Hematest  B. Carcinoembryonic antigen (CEA)  C. Sigmoidoscopy  D. Abdominal computed tomography (CT) scan Correct Answer: C. Sigmoidoscopy NCLEXRN-04-073 Question Tag: MRI Question Category: Physiological Integrity,Reduction of Risk Potential Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client?  A. The client lies still  B. The client asks questions  C. The client hears thumping sounds  D. The client wears a watch and wedding band Correct Answer: D. The client wears a watch and wedding band. During an MRI, the client should wear no metal objects, such as jewelry, because the strong magnetic field can pull on them, causing injury to the client and (if they fly off) to others.  Option A: The client must lie still during the MRI. When clients move during an MRI, they create motion artifacts in magnetic resonance images that often appear as ghosting artifacts, obscuring clinical information.  Option B: The client may talk to those performing the test by way of the microphone inside the scanner tunnel.  Option C: The client should hear thumping sounds, which are caused by the sound waves thumping on the magnetic field. NCLEXRN-04-074 Question Tag: osteoporosis Question Category: Health Promotion and Maintenance Nurse Cecile is teaching a female client about preventing osteoporosis. Which of the following teaching points is correct?  A. Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss.  B. To avoid fractures, the client should avoid strenuous exercise.  C. The recommended daily allowance of calcium may be found in a wide variety of foods  D. Obtaining the recommended daily allowance of calcium requires taking a calcium supplement. Correct Answer: C. The recommended daily allowance of calcium may be found in a wide variety of foods. Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. It’s often, though not always, possible to get the recommended daily requirement in the foods we eat.  Option D: Supplements are available but not always necessary.  Option A: Osteoporosis doesn’t show up on ordinary X-rays until 30% of the bone loss has occurred. Bone densitometry can detect bone loss of 3% or less. This test is sometimes recommended routinely for women over 35 who are at risk.  Option B: Strenuous exercise won’t cause fractures. Weight-bearing aerobics exercises and resistance training are good for people with osteoporosis. NCLEXRN-04-075 Question Tag: arthroscopy Question Category: Physiological Integrity, Reduction of Risk Potential Before Jacob undergoes arthroscopy, the nurse reviews the assessment findings for contraindications for this procedure. Which finding is a contraindication?  A. Joint pain  B. Joint deformity  C. Joint flexion of less than 50%  D. Joint stiffness Correct Answer: C. Joint flexion of less than 50% Arthroscopy is contraindicated in clients with joint flexion of less than 50% because of technical problems in inserting the instrument into the joint to see it clearly. Other contraindications for this procedure include skin and wound infections.  Option A: Joint pain may be an indication, not a contraindication, for arthroscopy.  Option B: Joint deformity is not a contraindication for the procedure. Joint surgery can improve the appearance of deformed joints, especially in the hands.  Option D: Joint stiffness is not a contraindication for this procedure. Arthroscopic surgery usually results in less joint pain and stiffness.