NCLEX-RN Practice Quiz Test Bank #5 (75 Questions), Exams of Biology

Download NCLEX-RN Practice Quiz Test Bank #5 (75 Questions) and more Exams Biology in PDF only on Docsity! NCLEX-RN Practice Quiz Test Bank #5 (75 Questions) NCLEXRN-05-001 Question Tag: arthritis Question Category: Physiological Integrity, Mr. Rodriguez is admitted with severe pain in the knees. Which form of arthritis is characterized by urate deposits and joint pain, usually in the feet and legs, and occurs primarily in men over age 30?  A. Septic arthritis  B. Traumatic arthritis  C. Intermittent arthritis  D. Gouty arthritis Correct Answer: D. Gouty arthritis Gouty arthritis, a metabolic disease, is characterized by urate deposits and pain in the joints, especially those in the feet and legs. Urate deposits don’t occur in septic or traumatic arthritis.  Option A: Septic arthritis results from bacterial invasion of a joint and leads to inflammation of the synovial lining.  Option B: Traumatic arthritis results from blunt trauma to a joint or ligament.  Option C: Intermittent arthritis is a rare, benign condition marked by regular, recurrent joint effusions, especially in the knees. NCLEXRN-05-002 Question Tag: heparin Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies A heparin infusion at 1,500 units/hour is ordered for a 64-year-old client with stroke in evolution. The infusion contains 25,000 units of heparin in 500 ml of saline solution. How many milliliters per hour should be given?  A. 15 ml/hour  B. 30 ml/hour  C. 45 ml/hour  D. 50 ml/hour Correct Answer: B. 30 ml/hour An infusion prepared with 25,000 units of heparin in 500 ml of saline solution yields 50 units of heparin per milliliter of solution. The equation is set up as 50 units times X (the unknown quantity) equals 1,500 units/hour, X equals 30 ml/hour.  Option A: 15 ml/hr is incorrect based on the computation used.  Option C: 45 ml/hr is more than the correct milliliters to be infused based on the computation.  Option D: 50 ml/hr is incorrect because it is way more than the correct milliliter to be infused. NCLEXRN-05-003 Question Tag: stroke Question Category: Physiological Integrity, Physiological Adaptation A 76-year-old male client had a thromboembolic right stroke; his left arm is swollen. Which of the following conditions may cause swelling after a stroke? Mrs. Cruz uses a cane for assistance in walking. Which of the following statements is true about a cane or other assistive devices?  A. A walker is a better choice than a cane.  B. The cane should be used on the affected side.  C. The cane should be used on the unaffected side.  D. A client with osteoarthritis should be encouraged to ambulate without the cane. Correct Answer: C. The cane should be used on the unaffected side A cane should be used on the unaffected side. A client with osteoarthritis should be encouraged to ambulate with a cane, walker, or other assistive device as needed; their use takes weight and stress off joints.  Option A: If a single assisting hand helps to walk, then logically a cane might be of potential benefit.  Option B: A cane should be used on the unaffected side of the client.  Option D: The use of a cane is important to prevent further injury or falls. NCLEXRN-05-007 Question Tag: insulin Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies A male client with type 1 diabetes is scheduled to receive 30 U of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client:  A. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).  B. 21 U regular insulin and 9 U NPH.  C. 10 U regular insulin and 20 U NPH.  D. 20 U regular insulin and 10 U NPH. Correct Answer: A. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH). A 70/30 insulin preparation is 70% NPH and 30% regular insulin. Therefore, a correct substitution requires mixing 21 U of NPH and 9 U of regular insulin.  Option B: Using this dosage would be incorrect and may produce no effect on the client’s blood sugar level.  Option C: This is an incorrect insulin dose. Incorrect administration can result in transient and serious hypoglycemia and hyperglycemia, wide glycemic excursions, and diabetic ketoacidosis.  Option D: This is an incorrect dosage for the prescribed insulin. Glycemic control is poorer in those who lack confidence in their ability to choose correct doses. NCLEXRN-05-008 Question Tag: gout Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies Nurse Len should expect to administer which medication to a client with gout?  A. Aspirin  B. Furosemide (Lasix)  C. Colchicines  D. Calcium gluconate (Kalcinate) Correct Answer: C. Colchicines A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints. The physician prescribes colchicine to reduce these deposits and thus ease joint inflammation.  Option A: Although aspirin is used to reduce joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn’t indicated for gout because it has no effect on urate crystal formation.  Option B: Furosemide, a diuretic, doesn’t relieve gout. It is a loop diuretic that prevents the body from absorbing too much salt. This allows the salt to be passed in the urine.  Option D: Calcium gluconate is used to reverse a negative calcium balance and relieve muscle cramps, not to treat gout. NCLEXRN-05-009 Question Tag: hyperaldosteronism Question Category: Physiological Integrity, Physiological Adaptation Mr. Domingo with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client’s hypertension is caused by excessive hormone secretion from which of the following glands?  A. Adrenal cortex  B. Pancreas  C. Adrenal medulla  D. Parathyroid Correct Answer: A. Adrenal cortex Excessive secretion of aldosterone in the adrenal cortex is responsible for the client’s hypertension. This hormone acts on the renal tubule, where it promotes reabsorption of sodium and excretion of potassium and hydrogen ions.  Option B: The pancreas mainly secretes hormones involved in fuel metabolism.  Option C: The adrenal medulla secretes the catecholamines — epinephrine and norepinephrine.  Option D: The parathyroids secrete parathyroid hormone.  D. Administering glucose-containing I.V. fluids as ordered. Correct Answer: C. Restricting fluids. To reduce water retention in a client with SIADH, the nurse should restrict fluids.  Option A: Rapid infusion of IV fluids would further increase the client’s overload.  Option B: The client should be instructed to restrict his fluid intake. It is also important to restrict sodium intake because higher correction rates have been associated with osmotic demyelination.  Option D: Administering fluids by any route would further increase the client’s already heightened fluid load. NCLEXRN-05-013 Question Tag: diabetes mellitus Question Category: Physiological Integrity, Reduction of Risk Potential A female client tells nurse Nikki that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client’s efforts, the nurse should check:  A. Urine glucose level.  B. Fasting blood glucose level.  C. Serum fructosamine level.  D. Glycosylated hemoglobin level. Correct Answer: D. Glycosylated hemoglobin level. Because some of the glucose in the bloodstream attaches to some of the hemoglobin and stays attached during the 120-day lifespan of red blood cells, glycosylated hemoglobin levels provide information about blood glucose levels during the previous 3 months.  Option A: Urine glucose levels only show the glucose levels in the urine at that specific time.  Option B: Fasting blood glucose only gives information about glucose levels at the point in time when they were obtained.  Option C: Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks. NCLEXRN-05-014 Question Tag: insulin Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies Nurse Trinity administered neutral protamine Hagedorn (NPH) insulin to a diabetic client at 7 a.m. At what time would the nurse expect the client to be most at risk for a hypoglycemic reaction?  A. 10:00 am  B. Noon  C. 4:00 pm  D. 10:00 pm Correct Answer: C. 4:00 pm NPH is an intermediate-acting insulin that peaks 8 to 12 hours after administration. Because the nurse administered NPH insulin at 7 a.m., the client is at greatest risk for hypoglycemia from 3 p.m. to 7 p.m.  Option A: At 10:00 am, the insulin given would not have reached its peak.  Option B: During noontime, risk for hypoglycemia would still be low.  Option D: 10:00 pm is already a late time for the peak action of insulin. NCLEXRN-05-015 Question Tag: adrenal cortex Question Category: Physiological Integrity, Physiological Adaptation The adrenal cortex is responsible for producing which substances?  A. Glucocorticoids and androgens  B. Catecholamines and epinephrine  C. Mineralocorticoids and catecholamines  D. Norepinephrine and epinephrine Correct Answer: A. Glucocorticoids and androgens The adrenal glands have two divisions, the cortex, and medulla. The cortex produces three types of hormones: glucocorticoids, mineralocorticoids, and androgens.  Option B: Epinephrine, which is a catecholamines, is produced in the medulla. It causes smooth muscle relaxation in the airways or contraction of the smooth muscle in arterioles, which results in blood vessel constriction in kidneys, decreasing or inhibiting blood flow to the nephrons.  Option C: Catecholamines are produced in the medulla. They help the body respond to stress or fright and prepare the body for “fight-or-flight” reactions.  Option D: The medulla produces catecholamines — epinephrine and norepinephrine. NCLEXRN-05-016 Question Tag: partial thyroidectomy Question Category: Physiological Integrity, Physiological Adaptation On the third day after a partial thyroidectomy, Proserfina exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life- threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?  A. Hypocalcemia  Option C: Nausea, vomiting, and anorexia may be signs of hepatitis B.  Option D: Itching, rash, and jaundice may result from an allergic or hemolytic reaction. NCLEXRN-05-019 Question Tag: HIV, pregnancy Question Category: Health Promotion and Maintenance In teaching a female client who is HIV-positive about pregnancy, the nurse would know more teaching is necessary when the client says:  A. The baby can get the virus from my placenta.”  B. “I’m planning on starting on birth control pills.”  C. “Not everyone who has the virus gives birth to a baby who has the virus.”  D. “I’ll need to have a C-section if I become pregnant and have a baby.” Correct Answer: D. “I’ll need to have a C-section if I become pregnant and have a baby.” A Cesarean section delivery isn’t necessary when the mother is HIV-positive.  Option A: The human immunodeficiency virus (HIV) is transmitted from mother to child via the transplacental route.  Option B: The use of birth control will prevent the conception of a child who might have HIV.  Option C: It’s true that a mother whose HIV positive can give birth to a baby who’s HIV negative. NCLEXRN-05-020 Question Tag: AIDS Question Category: Health Promotion and Maintenance When preparing Judy with acquired immunodeficiency syndrome (AIDS) for discharge to the home, the nurse should be sure to include which instruction?  A. “Put on disposable gloves before bathing.”  B. “Sterilize all plates and utensils in boiling water.”  C. “Avoid sharing such articles as toothbrushes and razors.”  D. “Avoid eating foods from serving dishes shared by other family members.” Correct Answer: C. “Avoid sharing such articles as toothbrushes and razors.” The human immunodeficiency virus (HIV), which causes AIDS, is most concentrated in the blood. For this reason, the client shouldn’t share personal articles that may be blood-contaminated, such as toothbrushes and razors, with other family members.  Option A: There is no need to use gloves because HIV is not transmitted by bathing.  Option B: HIV cannot be transmitted through the utensils used by an infected person.  Option D: HIV isn’t transmitted by serving dishes used by a person with AIDS. NCLEXRN-05-021 Question Tag: pernicious anemia Question Category: Physiological Integrity, Physiological Adaptation Nurse Marie is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?  A. Pallor, bradycardia, and reduced pulse pressure  B. Pallor, tachycardia, and a sore tongue  C. Sore tongue, dyspnea, and weight gain  D. Angina, double vision, and anorexia Correct Answer: B. Pallor, tachycardia, and a sore tongue Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina; weakness; fatigue; and paresthesia of the hands and feet.  Option A: Tachycardia, instead of bradycardia, and reduced pulse pressure are present in a client with pernicious anemia. The heart may start to beat faster to make up for the reduced number of red blood cells in the body.  Option C: Weight loss, instead of weight gain, is a common symptom of pernicious anemia. A B12 deficiency can be counteracted with a dose of the vitamin, causing energy levels to regulate and the metabolism to work harder to burn up fuel. The result is weight loss when the deficiency is mitigated, but adding B12 to a body with sufficient levels doesn’t really increase natural effects.  Option D: Double vision isn’t a characteristic finding in pernicious anemia. However, vision loss associated with vitamin B12 deficiency can occur even in well-nourished individuals who can’t absorb enough B12 to support healthy vision. NCLEXRN-05-022 Question Tag: anaphylactic shock Question Category: Management of Care After receiving a dose of penicillin, a client develops dyspnea and hypotension. Nurse Celestina suspects the client is experiencing anaphylactic shock. What should the nurse do first?  A. Page an anesthesiologist immediately and prepare to intubate the client.  B. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.  C. Administer the antidote for penicillin, as prescribed, and continue to monitor the client’s vital signs.  D. Insert an indwelling urinary catheter and begin to infuse I.V. fluids as ordered.  Option A: The neutrophil is crucial to phagocytosis. Phagocytosis is a process by which certain living cells called phagocytes ingest or engulf other cells or particles.  Option B: The basophil plays an important role in the release of inflammatory mediators. Basophils play a role in preventing blood clotting because they contain heparin. This is a naturally occurring blood-thinning substance.  Option C: The monocyte functions in phagocytosis and monokine production. Monocytes are bone marrow-derived leukocytes that circulate in the blood and spleen. NCLEXRN-05-025 Question Tag: Sjögren’s syndrome Question Category: Physiological Integrity, Physiological Adaptation In an individual with Sjögren’s syndrome, nursing care should focus on:  A. Moisture replacement.  B. Electrolyte balance.  C. Nutritional supplementation.  D. Arrhythmia management. Correct Answer: A. Moisture replacement. Sjogren’s syndrome is an autoimmune disorder leading to progressive loss of lubrication of the skin, GI tract, ears, nose, and vagina. Moisture replacement is the mainstay of therapy.  Option B: Electrolyte balance is not the priority problem in Sjögren’s syndrome. Electrolyte abnormalities, particularly hypokalemia, must be considered in patients presenting with generalized weakness.  Option C: Though malnutrition may occur as a result of Sjogren’s syndrome effect on the GI tract, it isn’t the predominant problem. An estimated 90% of people with Sjogren’s syndrome have problems related to eating, enough to cause malnutrition.  Option D: Arrhythmias aren’t a problem associated with Sjogren’s syndrome. However, there is a new study that showed a significantly increased risk of heart attack in patients with Sjogren’s syndrome, particularly in the first year following diagnosis. NCLEXRN-05-026 Question Tag: chemotherapy Question Category: Physiological Integrity, Reduction of Risk Potential During chemotherapy for lymphocytic leukemia, Mathew develops abdominal pain, fever, and “horse barn” smelling diarrhea. It would be most important for the nurse to advise the physician to order:  A. Enzyme-linked immunosuppressant assay (ELISA) test.  B. Electrolyte panel and hemogram.  C. Stool for Clostridium difficile test.  D. Flat plate X-ray of the abdomen. Correct Answer: C. Stool for Clostridium difficile test. Immunosuppressed clients — for example, clients receiving chemotherapy, — are at risk for infection with C. difficile, which causes “horse barn” smelling diarrhea. Successful treatment begins with an accurate diagnosis, which includes a stool test.  Option A: The ELISA test is diagnostic for human immunodeficiency virus (HIV) and isn’t indicated in this case.  Option B: An electrolyte panel and hemogram may be useful in the overall evaluation of a client but aren’t diagnostic for specific causes of diarrhea.  Option D: A flat plate of the abdomen may provide useful information about bowel function but isn’t indicated in the case of “horse barn” smelling diarrhea. NCLEXRN-05-027 Question Tag: HIV Question Category: Physiological Integrity, Reduction of Risk Potential A male client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:  A. E-rosette immunofluorescence.  B. Quantification of T-lymphocytes.  C. Enzyme-linked immunosorbent assay (ELISA).  D. Western blot test with ELISA. Correct Answer: D. Western blot test with ELISA. HIV infection is detected by analyzing blood for antibodies to HIV, which form approximately 2 to 12 weeks after exposure to HIV and denote infection. The Western blot test — electrophoresis of antibody proteins — is more than 98% accurate in detecting HIV antibodies when used in conjunction with the ELISA. It isn’t specific when used alone.  Option A: E-rosette immunofluorescence is used to detect viruses in general; it doesn’t confirm HIV infection.  Option B: Quantification of T-lymphocytes is a useful monitoring test but isn’t diagnostic for HIV.  Option C: The ELISA test detects HIV antibody particles but may yield inaccurate results; a positive ELISA result must be confirmed by the Western blot test. NCLEXRN-05-028 Question Tag: blood count Question Category: Physiological Integrity, Reduction of Risk Potential  Option B: Carrots rarely cause allergies. An allergic reaction to carrots can be one element of oral allergy syndrome, which is also known as pollen- food allergy syndrome.  Option C: Oranges rarely cause allergic reactions. If they do, the reaction is mild. NCLEXRN-05-031 Question Tag: outpatient, prioritization Question Category: Safe and Effective Care Environment, Management of Care Nurse John is caring for clients in the outpatient clinic. Which of the following phone calls should the nurse return first?  A. A client with hepatitis A who states, “My arms and legs are itching.”  B. A client with a cast on the right leg who states, “I have a funny feeling in my right leg.”  C. A client with osteomyelitis of the spine who states, “I am so nauseous that I can’t eat.”  D. A client with rheumatoid arthritis who states, “I am having trouble sleeping.” Correct Answer: B. A client with a cast on the right leg who states, “I have a funny feeling in my right leg.” It may indicate neurovascular compromise, requiring immediate assessment.  Option A: Bilirubin levels in hepatitis A may increase, and itching is a common symptom.  Option C: A client feeling nauseous may require consultation but is not a priority.  Option D: Clients with rheumatoid arthritis may feel pain in the affected areas at night. They may need a prescription for painkillers but it is not urgent. NCLEXRN-05-032 Question Tag: prioritization Question Category: Safe and Effective Care Environment, Management of Care Nurse Sarah is caring for clients on the surgical floor and has just received a report from the previous shift. Which of the following clients should the nurse see first?  A. A 35-year-old admitted three hours ago with a gunshot wound; 1.5 cm area of dark drainage noted on the dressing.  B. A 43-year-old who had a mastectomy two days ago; 23 ml of serosanguinous fluid noted in the Jackson-Pratt drain.  C. A 59-year-old with a collapsed lung due to an accident; no drainage noted in the previous eight hours.  D. A 62-year-old who had an abdominal-perineal resection three days ago; client complains of chills. Correct Answer: D. A 62-year-old who had an abdominal-perineal resection three days ago; client complains of chills. The client is at risk for peritonitis; should be assessed for further symptoms and infection.  Option A: The client may be hemorrhaging on his wound; this needs further assessment but does not require urgent attention.  Option B: Serosanguinous fluid on the drain is a normal finding.  Option C: Absence of drainage on a client with collapsed lung is normal; the chest tube is for the removal of air inside the lung. NCLEXRN-05-033 Question Tag: thyroidectomy Question Category: Physiological Integrity, Physiological Adaptation Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago for treatment of Grave’s disease. The nurse would be most concerned if which of the following was observed?  A. Blood pressure 138/82, respirations 16, oral temperature 99 degrees Fahrenheit.  B. The client supports his head and neck when turning his head to the right.  C. The client spontaneously flexes his wrist when the blood pressure is obtained.  D. The client is drowsy and complains of sore throat. Correct Answer: C. The client spontaneously flexes his wrist when the blood pressure is obtained. Carpal spasms indicate hypocalcemia.  Option A: The vital signs are all within the normal range.  Option B: Supporting the head and neck while turning protects the surgical site from dehiscence.  Option D: Drowsiness may be a side effect of the anesthesia used during surgery and will fade away eventually; a sore throat is a normal finding after thyroid surgery. NCLEXRN-05-034 Question Tag: pain relief Question Category: Physiological Integrity, Physiological Adaptation Julius is admitted with complaints of severe pain in the lower right quadrant of the abdomen. To assist with pain relief, the nurse should take which of the following actions?  A. Encourage the client to change positions frequently in bed.  B. Administer Demerol 50 mg IM q 4 hours and PRN.  C. Apply warmth to the abdomen with a heating pad. An elderly client is admitted to the nursing home setting. The client is occasionally confused and her gait is often unsteady. Which of the following actions, if taken by the nurse, is most appropriate?  A. Ask the woman’s family to provide personal items such as photos or mementos.  B. Select a room with a bed by the door so the woman can look down the hall.  C. Suggest the woman eat her meals in the room with her roommate.  D. Encourage the woman to ambulate in the halls twice a day. Correct Answer: A. Ask the woman’s family to provide personal items such as photos or mementos. Photos and mementos provide visual stimulation to reduce sensory deprivation.  Option B: The client is often confused and may wander outside her room and easily get lost.  Option C: The client may take her meals with a roommate or in the dining hall.  Option D: This may lead to incidence of falls or injury because the client’s gait is unsteady. Assistance during ambulation is most appropriate. NCLEXRN-05-038 Question Tag: walker Question Category: Health Promotion and Maintenance Nurse Evangeline teaches an elderly client how to use a standard aluminum walker. Which of the following behaviors, if demonstrated by the client, indicates that the nurse’s teaching was effective?  A. The client slowly pushes the walker forward 12 inches, then takes small steps forward while leaning on the walker.  B. The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward.  C. The client supports his weight on the walker while advancing it forward, then takes small steps while balancing on the walker.  D. The client slides the walker 18 inches forward, then takes small steps while holding onto the walker for balance. Correct Answer: B. The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward. A walker needs to be picked up, placed down on all legs.  Option A: Teach the client to lift, not push, the walker forward and not to lean on it to avoid falls.  Option C: The client should not put his weight on the walker as it may lead to incidents of falls.  Option D: A walker should be lifted, not slide. NCLEXRN-05-039 Question Tag: sensory deprivation Question Category: Health Promotion and Maintenance Nurse Derek is supervising a group of elderly clients in a residential home setting. The nurse knows that the elderly are at greater risk of developing sensory deprivation for what reason?  A. Increased sensitivity to the side effects of medications.  B. Decreased visual, auditory, and gustatory abilities.  C. Isolation from their families and familiar surroundings.  D. Decrease musculoskeletal function and mobility. Correct Answer: B. Decreased visual, auditory, and gustatory abilities. Gradual loss of sight, hearing, and taste interferes with normal functioning.  Option A: The side effects of medications do not usually affect the senses in the elderly.  Option C: Isolation is not the reason for developing sensory deprivation.  Option D: Decrease in mobility and functioning does not cause sensory deprivation. NCLEXRN-05-040 Question Tag: emphysema Question Category: Physiological Integrity, Physiological Adaptation A male client with emphysema becomes restless and confused. What step should nurse Jasmine take next?  A. Encourage the client to perform pursed-lip breathing.  B. Check the client’s temperature.  C. Assess the client’s potassium level.  D. Increase the client’s oxygen flow rate. Correct Answer: A. Encourage the client to perform pursed-lip breathing. Pursed lip breathing prevents the collapse of the lung unit and helps client control the rate and depth of breathing.  Option B: Checking the temperature is unnecessary especially if the client is restless.  Option C: Emphysema does not significantly affect potassium levels.  Option D: Do not increase the oxygen levels in a client with emphysema. NCLEXRN-05-041 Question Tag: organ rejection Question Category: Physiological Integrity, Reduction of Risk Potential Randy has undergone a kidney transplant, what assessment would prompt Nurse Katrina to suspect organ rejection?  Option B: This solution does not maintain the function of parathyroid gland and it does not affect them; it prepares the thyroid gland for surgical removal.  Option C: Iodine is needed to make the thyroid hormones, of which thyroxine is the main hormone, but it does not affect small changes in free thyroxine. NCLEXRN-05-044 Question Tag: acute hypoglycemia Question Category: Physiological Integrity, Physiological Adaptation Ricardo was diagnosed with type I diabetes. The nurse is aware that acute hypoglycemia also can develop in the client who is diagnosed with:  A. Liver disease  B. Hypertension  C. Type 2 diabetes  D. Hyperthyroidism Correct Answer: A. Liver Disease The client with liver disease has a decreased ability to metabolize carbohydrates because of a decreased ability to form glycogen (glycogenesis) and to form glucose from glycogen.  Option B: The hemodynamic changes associated with hypoglycemia include an increase in heart rate and peripheral systolic blood pressure, a fall in the central blood pressure, reduced peripheral arterial resistance, and increased myocardial contractility, stroke volume, and cardiac output.  Option C: Type 2 diabetes is an islet paracrinopathy in which the reciprocal relationship between the glucagon-secreting alpha cell and the insulin- secreting beta-cell is lost, leading to hyperglucagonemia and hence the consequent hyperglycemia.  Option D: Hyperthyroidism is usually associated with poor blood glucose control and a need for additional insulin. An increased metabolism “clears” insulin from the system at a faster rate, and increased production and absorption of glucose can raise blood sugars.. NCLEXRN-05-045 Question Tag: carcinoma Question Category: Physiological Integrity, Physiological Adaptation Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby should monitor the client for the systemic side effect of:  A. Ascites  B. Nystagmus  C. Leukopenia  D. Polycythemia Correct Answer: C. Leukopenia Leukopenia, a reduction in WBCs, is a systemic effect of chemotherapy as a result of myelosuppression.  Option A: Ascites is common in some cancers that have reached the advanced stages and spread in the abdominal area. Sometimes chemotherapy might help manage ascites; it is not a side effect of chemotherapy.  Option B: Platinum-based chemotherapy is an effective antineoplastic intervention that is used for a variety of human malignancies. There were reports of spontaneous nystagmus in 7 out of 10 patients (70%) and positional nystagmus (60%).  Option D: While polycythemia vera is not a side effect of chemotherapy, it can become drug-induced with the excess use of rHuEPO or anabolic steroids. NCLEXRN-05-046 Question Tag: colostomy Question Category: Health Promotion and Maintenance Norma, with recent colostomy, expresses concern about the inability to control the passage of gas. Nurse Oliver should suggest that the client plan to:  A. Eliminate foods high in cellulose.  B. Decrease fluid intake at mealtimes.  C. Avoid foods that in the past caused flatus.  D. Adhere to a bland diet prior to social events. Correct Answer: C. Avoid foods that in the past caused flatus. Foods that bothered a person preoperatively will continue to do so after a colostomy.  Option A: Cellulose is just one of the several types of dietary fiber that naturally occur in food sources. Examples are green, leafy vegetables, Brussels sprouts, and green peas.  Option B: Increased fluid intake aids in the easy passage of stools and improves the consistency of colostomy stools.  Option D: Bland foods such as broccoli, cabbage, cauliflower, cucumber, green peppers, and corn increase passage of gas. NCLEXRN-05-047 Question Tag: colostomy Question Category: Health Promotion and Maintenance Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would evaluate that the instructions were understood when the client states, “I should:  Option C: 32 gtts/min is more than the prescribed gtts/min given.  Option D: This amount is incorrect according to the formula used to get the correct flow rate. NCLEXRN-05-050 Question Tag: burn injury Question Category: Physiological Integrity, Physiological Adaptation Terence suffered from burn injury. Using the rule of nines, which has the largest percent of burns?  A. Face and neck  B. Right upper arm and penis  C. Right thigh and penis  D. Upper trunk Correct Answer: D. Upper trunk The percentage designated for each burned part of the body using the rule of nines: Head and neck 9%; Right upper extremity 9%; Left upper extremity 9%; Anterior trunk 18%; Posterior trunk 18%; Right lower extremity 18%; Left lower extremity 18%; Perineum 1%.  Option A: The face and neck is 9%.  Option B: The right upper arm is 9% and the penis is only 1%.  Option C: The right thigh is 9% and the penis is 1%. NCLEXRN-05-051 Question Tag: fall Question Category: Physiological Integrity, Physiological Adaptation Herbert, a 45-year-old construction engineer, is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:  A. Reactive pupils  B. A depressed fontanel  C. Bleeding from ears  D. An elevated temperature Correct Answer: C. Bleeding from ears The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures, and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation.  Option A: The normal pupil size varies from 2 to 4 mm in diameter in bright light to 4 to 8 mm in the dark. The pupils are generally equal in size. They constrict to direct illumination and to illumination of the opposite eye. The pupil dilates in the dark. Both pupils constrict when the eye is focused on a near object.  Option B: The anterior fontanelle remains soft until about 18 months to 2 years of age. The posterior fontanelle usually closes first, during the first several months of an infant’s life.  Option D: Hypothermic trauma patients are less likely to survive their injuries when compared to similar patients who are normothermic. Hypothermia in conjunction with metabolic acidosis and impair coagulation creates a “lethal triad”, which significantly worsens the chances of recovery from a critical injury. NCLEXRN-05-052 Question Tag: pacemaker Question Category: Physiological Integrity, Physiological Adaptation Nurse Sherry is teaching male client regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker?  A. Take the pulse rate once a day, in the morning upon awakening.  B. May be allowed to use electrical appliances.  C. Have regular follow up care.  D. May engage in contact sports. Correct Answer: D. may engage in contact sports The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator.  Option A: The physician may advise to take and record the pulse rate often to gauge the heart rate. This allows comparison of the heart rate to the acceptable range to determine if the pacemaker is working effectively.  Option B: Use of electrical appliances is allowed, but the client must maintain a distance from the appliances. Devices such as anti-theft systems, metal detectors, cell phones, mp3 players/headphones, radios, power-generating equipment, magnets, etc may interfere with a pacemaker.  Option C: Modern pacemakers are built to last. Still, it needs to be checked periodically to assess the battery and find out how the wires are working, so it is a must to keep pacemaker checkup appointments. NCLEXRN-05-053 Question Tag: COPD Question Category: Physiological Integrity, Physiological Adaptation The nurse is aware that the most relevant knowledge about oxygen administration to a male client with COPD is:  A. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.  Option B: Warm saline gargles may help soothe the throat after bronchoscopy.  Option C: Coughing should not be done after bronchoscopy to avoid initiating bleeding.  Option D: The client should be on NPO status after bronchoscopy until gag reflex has returned. NCLEXRN-05-056 Question Tag: acute renal failure Question Category: Physiological Integrity, Physiological Adaptation Nurse Tristan is caring for a male client with acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:  A. Hypernatremia.  B. Hypokalemia.  C. Hyperkalemia.  D. Hypercalcemia. Correct Answer: C. Hyperkalemia. Hyperkalemia is a common complication of acute renal failure. It’s life- threatening if immediate action isn’t taken to reverse it. The administration of glucose and regular insulin, with sodium bicarbonate, if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels.  Option A: Hypernatremia is believed to be due to post-acute kidney injury diuresis in the face of inability to maximally concentrate the urine because of renal failure. The diuresis caused a disproportionate loss of water in excess of that of sodium in the absence of replenishment of the water loss.  Option B: Hypokalemia is related to increased use of diuretics, decreased use of RAS blockade, and malnutrition, all of which may impose additive deleterious effects on renal outcomes.  Option D: Hypocalcemia is a frequent accompaniment of acute renal failure, but paradoxically hypercalcemia also has been described in association with acute renal failure. This may be caused by dissolution of dystrophic calcifications in traumatized muscle and may lead to severe metastatic calcifications. NCLEXRN-05-057 Question Tag: genital warts Question Category: Physiological Integrity, Physiological Adaptation Ms. X has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?  A. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.  B. The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days.  C. The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse.  D. The human papillomavirus (HPV), which causes condylomata acuminata, can’t be transmitted during oral sex. Correct Answer: A. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually. Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap smears are very important for early detection. Because condylomata acuminata is a virus, there is no permanent cure.  Option B: Genital warts may be treated with imiquimod, podophyllin and podofilox, trichloroacetic acid, and sinecatechins. These are all topical treatments that the physician or even the client may apply.  Option C: Because condylomata acuminata can occur on the vulva, a condom won’t protect sexual partners.  Option D: HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx. NCLEXRN-05-058 Question Tag: palpation Question Category: Physiological Integrity, Physiological Adaptation Maritess was recently diagnosed with a genitourinary problem and is being examined in the emergency department. When palpating her kidneys, the nurse should keep which anatomical fact in mind?  A. The left kidney usually is slightly higher than the right one.  B. The kidneys are situated just above the adrenal glands.  C. The average kidney is approximately 5 cm (2 inches) long and 2 to 3 cm (¾ inch to 1 ⅛ inches) wide.  D. The kidneys lie between the 10th and 12th thoracic vertebrae. Correct Answer: A. The left kidney usually is slightly higher than the right one. The left kidney usually is slightly higher than the right one. An adrenal gland lies atop each kidney.  Option C: The average kidney measures approximately 11 cm (4-3/8″) long, 5 to 5.8 cm (2″ to 2 1/4”) wide, and 2.5 cm (1″) thick.  Option B: The kidneys are located retroperitoneally, in the posterior aspect of the abdomen, on either side of the vertebral column.  Option D: They lie between the 12th thoracic and 3rd lumbar vertebrae. NCLEXRN-05-059 Question Tag: chronic renal failure Question Category: Physiological Integrity, Reduction of Risk Potential  Option A: It is suggested that the immune-suppression results in co- infection with the papilloma virus. The immunosuppression causes reduction in the effectiveness of the immune surveillance system resulting in growth of the tumor.  Option B: Multiple myeloma is a very uncommon neoplasm complicating HIV infection but when it occurs, it is associated with an aggressive course and a worse prognosis.  Option C: Untreated HIV infection causes AIDS and this major impairment in the immune system is associated with an increased risk of cancer, including a number of “solid tumor” cancers and non-Hodgkin lymphoma, but also Hodgkin lymphoma, myeloma, and leukemia. NCLEXRN-05-062 Question Tag: prostatectomy, subarachnoid block Question Category: Physiological Integrity, Reduction of Risk Potential Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist’s instructions. Why does the client require special positioning for this type of anesthesia?  A. To prevent confusion.  B. To prevent seizures.  C. To prevent cerebrospinal fluid (CSF) leakage.  D. To prevent cardiac arrhythmias. Correct Answer: C. To prevent cerebrospinal fluid (CSF) leakage The client receiving a subarachnoid block requires special positioning to prevent CSF leakage and headache and to ensure proper anesthetic distribution.  Option A: Anesthetics are well known to cause confusion, but this typically decreases as the body processes the medications and removes them from circulation.  Option B: Generalized seizure as a complication following epidural anesthesia has been reported, but rarely following spinal anesthesia.  Option D: The incidence of arrhythmias, as well as hypotension during spinal anesthesia, is higher for Cesarean section mostly. NCLEXRN-05-063 Question Tag: nephrectomy Question Category: Physiological Integrity, Physiological Adaptation A male client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:  A. Auscultate bowel sounds.  B. Palpate the abdomen.  C. Change the client’s position.  D. Insert a rectal tube. Correct Answer: A. Auscultate bowel sounds. If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician.  Option B: Palpation is the examination of the abdomen for crepitus of the abdominal wall, for any abdominal tenderness, or for abdominal masses. It may be used to assess the client but this will not be the first choice following a nephrectomy.  Option C: Changing positions would not diminish the client’s nausea and abdominal pressure.  Option D: If peristalsis is absent, inserting a rectal tube won’t relieve the client’s discomfort. NCLEXRN-05-064 Question Tag: colonoscopy Question Category: Physiological Integrity, Reduction of Risk Potential Wilfredo with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse Patricia position the client for this test initially?  A. Lying on the right side with legs straight.  B. Lying on the left side with knees bent.  C. Prone with the torso elevated.  D. Bent over with hands touching the floor. Correct Answer: B. Lying on the left side with knees bent For a colonoscopy, the nurse initially should position the client on the left side with knees bent.  Option A: Lying on the right side with legs straight is not an appropriate position for this procedure. It would not allow proper visualization.  Option C: This position may not allow proper visualization of the large intestine.  Option D: Bent over with hands touching the floor wouldn’t allow proper visualization of the large intestine. NCLEXRN-05-065 Question Tag: ileostomy Question Category: Physiological Integrity, Reduction of Risk Potential A male client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, Nurse Oliver notes that the client’s stoma appears dusky. How should the nurse interpret this finding? NCLEXRN-05-068 Question Tag: cerebrovascular accident Question Category: Physiological Integrity, Basic Care and Comfort Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, Nurse Celia should:  A. Turn him frequently.  B. Perform passive range-of-motion (ROM) exercises.  C. Reduce the client’s fluid intake.  D. Encourage the client to use a footboard. Correct Answer: A. Turn him frequently. The most important intervention to prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn’t relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation.  Option B: During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn’t prevent pressure ulcers.  Option C: Adequate hydration is necessary to maintain healthy skin and ensure tissue repair.  Option D: A footboard prevents plantar flexion and foot drop by maintaining the foot in a dorsiflexed position. NCLEXRN-05-069 Question Tag: dermatitis Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies Nurse Maria plans to administer dexamethasone cream to a female client who has dermatitis over the anterior chest. How should the nurse apply this topical agent?  A. With a circular motion, to enhance absorption.  B. With an upward motion, to increase blood supply to the affected area.  C. In long, even, outward, and downward strokes in the direction of hair growth.  D. In long, even, outward, and upward strokes in the direction opposite hair growth. Correct Answer: C. In long, even, outward, and downward strokes in the direction of hair growth When applying a topical agent, the nurse should begin at the midline and use long, even, outward, and downward strokes in the direction of hair growth. This application pattern reduces the risk of follicle irritation and skin inflammation.  Option A: This type of application may contaminate the areas which are clean and irritate the skin.  Option B: An upward motion does not increase blood supply to the affected area; the goal is to reduce irritation of the skin and follicles.  Option D: The strokes should be downward in the direction of hair growth. NCLEXRN-05-070 Question Tag: beta-blockers Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies Nurse Kate is aware that one of the following classes of medication protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation is:  A. Beta-adrenergic blockers  B. Calcium channel blocker  C. Narcotics  D. Nitrates Correct Answer: A. Beta-adrenergic blockers Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infarction by decreasing myocardial oxygen demand.  Option B: Calcium channel blockers reduce the workload of the heart by decreasing the heart rate.  Option C: Narcotics reduce myocardial oxygen demand, promote vasodilation, and decrease anxiety.  Option D: Nitrates reduce myocardial oxygen consumption but decrease left ventricular end-diastolic pressure (preload) and systemic vascular resistance (afterload). NCLEXRN-05-071 Question Tag: jugular distention Question Category: Physiological Integrity, Physiological Adaptation A male client has jugular distention. In what position should the nurse place the head of the bed to obtain the most accurate reading of jugular vein distention?  A. High Fowler’s  B. Raised 10 degrees  C. Raised 30 degrees  D. Supine position Correct Answer: C. Raised 30 degrees Jugular venous pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation with the head of the bed inclined between 15 to 30 degrees.  A. The CCU nurse gives a verbal report to the nurse on the telemetry unit before transferring the client to that unit.  B. The CCU nurse notifies the on-call physician about a change in the client’s condition.  C. The emergency department nurse calls up the latest electrocardiogram results to check the client’s progress.  D. At the client’s request, the CCU nurse updates the client’s wife on his condition. Correct Answer: C. The emergency department nurse calls up the latest electrocardiogram results to check the client’s progress The emergency department nurse is no longer directly involved with the client’s care and thus has no legal right to information about his present condition.  Option A: Anyone directly involved in his care (such as the telemetry nurse) has the right to information about his condition.  Option B: The on-call physician should be updated about the client’s condition.  Option D: Because the client requested that the nurse update his wife on his condition, doing so doesn’t breach confidentiality. NCLEXRN-05-075 Question Tag: cardiopulmonary resuscitation Question Category: Physiological Integrity, Physiological Adaptation A male client arriving in the emergency department is receiving cardiopulmonary resuscitation from paramedics who are giving ventilation through an endotracheal (ET) tube that they placed in the client’s home. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of beats/minute with a palpable pulse. Which of the following actions should the nurse take first?  A. Start an L.V. line and administer amiodarone (Cordarone), 300 mg L.V. over 10 minutes.  B. Check endotracheal tube placement.  C. Obtain an arterial blood gas (ABG) sample.  D. Administer atropine, 1 mg L.V. Correct Answer: B. Check endotracheal tube placement. ET tube placement should be confirmed as soon as the client arrives in the emergency department. Once the airway is secured, oxygenation and ventilation should be confirmed using an end-tidal carbon dioxide monitor and pulse oximetry.  Option A: Next, the nurse should make sure L.V. access is established.  Option D: If the client experiences symptomatic bradycardia, atropine is administered as ordered 0.5 to 1 mg every 3 to 5 minutes to a total of 3 mg.  Option C: Then the nurse should try to find the cause of the client’s arrest by obtaining an ABG sample. Amiodarone is indicated for ventricular tachycardia, ventricular fibrillation, and atrial flutter – not symptomatic bradycardia.