NCLEX TEST BANK FOR NCLEX-RN 2024-2025 300 QUESTIONS AND ANSWERS WITH RATIONALES, Exams of Nursing

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lOMoARcPSD| 40206794

NCLEX TEST BANK FOR NCLEX-RN 2024-2025 300 QUESTIONS

AND ANSWERS WITH RATIONALES

1. A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every two hours. Which of the following outcome criteria? would the nurse use? ❍ A. Body temperature of 99°F or less ❍ B. Toes moved in active range of motion ❍ C. Sensation reported when soles of feet are touched ❍ D. Capillary refill of < 3 seconds
2. A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client? ❍ A. Side-lying with knees flexed ❍ B. Knee-chest ❍ C. High Fowler’s with knees flexed ❍ D. Semi-Fowler’s with legs extended on the bed
3. A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client? ❍ A. Taking hourly blood pressures with mechanical cuff ❍ B. Encouraging fluid intake of at least 200mL per hour ❍ C. Position in high Fowler’s with knee gatch raised ❍ D. Administering Tylenol as ordered
4. Which of the following foods would the nurse encourage the client in sickle cell crisis to eat? ❍ A. Steak ❍ B. Cottage cheese

lOMoARcPSD| 40206794 ❍ C. Popsicle ❍ D. Lima beans Quick Answer: 223 Detailed Answer: 225 Quick Answer: 223 Detailed Answer: 225 Quick Answer: 223 Detailed Answer: 225 Quick Answer: 223 Detailed Answer: 225 Quick Check ✓ 170 Chapter 3

5. A newly admitted client has sickle cell crisis. He is complaining of pain in his feet and hands. The nurse’s assessment findings include a pulse oximetry of 92. Assuming that all the following interventions are ordered, which should be done first? ❍ A. Adjust the room temperature ❍ B. Give a bolus of IV fluids ❍ C. Start O 2 ❍ D. Administer meperidine (Demerol) 75mg IV push
6. The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select? ❍ A. Roast beef, gelatin salad, green beans, and peach pie ❍ B. Chicken salad sandwich, coleslaw, French fries, ice cream

lOMoARcPSD| 40206794 C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie ❍ D. Pork chop, creamed potatoes, corn, and coconut cake

7. Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend? ❍ A. A family vacation in the Rocky Mountains ❍ B. Chaperoning the local boys club on a snow-skiing trip ❍ C. Traveling by airplane for business trips ❍ D. A bus trip to the Museum of Natural History
8. The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which finding reinforces the diagnosis of B12 deficiency? ❍ A. Enlarged spleen ❍ B. Elevated blood pressure ❍ C. Bradycardia ❍ D. Beefy tongue
9. The body part that would most likely display jaundice in the darkskinned individual is the: ❍ A. Conjunctiva of the eye ❍ B. Soles of the feet ❍ C. Roof of the mouth ❍ D. Shins Quick Check ✓ Quick Answer: 223 Detailed Answer: 225

lOMoARcPSD| 40206794 Quick Answer: 223 Detailed Answer: 225 Quick Answer: 223 Detailed Answer: 225 Quick Answer: 223 Detailed Answer: 225 Quick Answer: 223 Detailed Answer: 225Practice Exam 3 and Rationales 171

10. The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia? ❍ A. BP 146/ ❍ B. Respirations 28 shallow ❍ C. Weight gain of 10 pounds in six months ❍ D. Pink complexion
11. The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching? ❍ A. “I will drink 500mL of fluid or less each day.” ❍ B. “I will wear support hose.” ❍ C. “I will check my blood pressure regularly.” ❍ D. “I will report ankle edema.”
12. A 33-year-old male is being evaluated for possible acute leukemia. Which of the following findings is most likely related to the diagnosis of leukemia? ❍ A. The client collects stamps as a hobby. ❍ B. The client recently lost his job as a postal worker.

lOMoARcPSD| 40206794 ❍ C. The client had radiation for treatment of Hodgkin’s disease as a teenager. ❍ D. The client’s brother had leukemia as a child.

13. Where is the best site for examining for the presence of petechiae in an African American client? ❍ A. The abdomen B. The thorax ❍ C. The earlobes ❍ D. The soles of the feet
14. The client is being evaluated for possible acute leukemia. Which inquiry by the nurse is most important? ❍ A. “Have you noticed a change in sleeping habits recently?” ❍ B. “Have you had a respiratory infection in the last six months?” ❍ C. “Have you lost weight recently?” ❍ D. “Have you noticed changes in your alertness?” Quick Check ✓ Quick Answer: 223 Detailed Answer: 226 Quick Answer: 223 Detailed Answer: 226 Quick Answer: 223 Detailed Answer: 226 Quick Answer: 223 Detailed Answer: 226 Quick Answer: 223

lOMoARcPSD| 40206794 Detailed Answer: 226172 Chapter 3

15. Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia? ❍ A. Oral mucous membrane, altered related to chemotherapy ❍ B. Risk for injury related to thrombocytopenia ❍ C. Fatigue related to the disease process ❍ D. Interrupted family processes related to life- threatening illness of a family member
16. A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client? ❍ A. Sexual dysfunction related to radiation therapy ❍ B. Anticipatory grieving related to terminal illness ❍ C. Tissue integrity related to prolonged bed rest ❍ D. Fatigue related to chemotherapy
17. A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor: ❍ A. Platelet count ❍ B. White blood cell count ❍ C. Potassium levels ❍ D. Partial prothrombin time (PTT)
18. The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client’s platelet count currently is 80,000. It will be most important to teach the client and family about: ❍ A. Bleeding precautions

lOMoARcPSD| 40206794 ❍ B. Prevention of falls ❍ C. Oxygen therapy ❍ D. Conservation of energy

19. The client has surgery for removal of a Prolactinoma. Which of the following interventions would be appropriate for this client? ❍ A. Place the client in Trendelenburg position for postural drainage. ❍ B. Encourage coughing and deep breathing every two hours. C. Elevate the head of the bed 30°. ❍ D. Encourage the Valsalva maneuver for bowel movements. Quick Check ✓ Quick Answer: 223 Detailed Answer: 226 Quick Answer: 223 Detailed Answer: 226 Quick Answer: 223 Detailed Answer: 226 Quick Answer: 223 Detailed Answer: 226 Quick Answer: 223 Detailed Answer: 226Practice Exam 3 and Rationales 173
20. The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is: ❍ A. Measure the urinary output. ❍ B. Check the vital signs. ❍ C. Encourage increased fluid intake.

lOMoARcPSD| 40206794 ❍ D. Weigh the client.

21. A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding? ❍ A. Place the client in a sitting position. ❍ B. Administer acetaminophen (Tylenol). ❍ C. Pinch the soft lower part of the nose. ❍ D. Apply ice packs to the forehead.
22. A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in the immediate post-operative period for the nurse to take is: ❍ A. The blood pressure ❍ B. The temperature ❍ C. The urinary output ❍ D. The specific gravity of the urine
23. A client with Addison’s disease has been admitted with a history of nausea and vomiting for the past three days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement? ❍ A. Glucometer readings as ordered ❍ B. Intake/output measurements ❍ C. Evaluating the sodium and potassium levels ❍ D. Daily weights
24. A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses’ next action be? ❍ A. Obtain a crash cart.

lOMoARcPSD| 40206794 ❍ B. Check the calcium level. ❍ C. Assess the dressing for drainage. ❍ D. Assess the blood pressure for hypertension. Quick Check ✓ Quick Answer: 223 Detailed Answer: 227 Quick Answer: 223 Detailed Answer: 227 Quick Answer: 223 Detailed Answer: 227 Quick Answer: 223 Detailed Answer: 227

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25. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in four months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority? ❍ A. Impaired physical mobility related to decreased endurance ❍ B. Hypothermia r/t decreased metabolic rate ❍ C. Disturbed thought processes r/t interstitial edema ❍ D. Decreased cardiac output r/t bradycardia
26. The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client taking rosuvastatin (Crestor)? ❍ A. Report muscle weakness to the physician. ❍ B. Allow six months for the drug to take effect. ❍ C. Take the medication with fruit juice. ❍ D. Report difficulty sleeping.
27. The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should: ❍ A. Utilize an infusion pump. ❍ B. Check the blood glucose level. ❍ C. Place the client in Trendelenburg position. ❍ D. Cover the solution with foil.
28. The six-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor? ❍ A. Blood pressure of 126/

Downloaded by DOCMERIT DOCMERIT ❍ B. Blood glucose of 110mg/dL ❍ C. Heart rate of 60bpm ❍ D. Respiratory rate of 30 per minute

29. The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to: ❍ A. Replenish his supply every three months. ❍ B. Take one every 15 minutes if pain occurs. ❍ C. Leave the medication in the brown bottle. ❍ D. Crush the medication and take with water. Quick Check ✓ Quick Answer: 223 Detailed Answer: 227 Quick Answer: 223 Detailed Answer: 227 Quick Answer: 223 Detailed Answer: 227 Quick Answer: 223 Detailed Answer: 227 Quick Answer: 223 Detailed Answer: 228Practice Exam 3 and Rationales 175
30. The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats? ❍ A. Macaroni and cheese ❍ B. Shrimp with rice ❍ C. Turkey breast ❍ D. Spaghetti with meat sauce

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31. The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the: ❍ A. Feet ❍ B. Neck ❍ C. Hands ❍ D. Sacrum
32. The nurse is checking the client’s central venous pressure. The nurse should place the zero of the manometer at the: ❍ A. Phlebostatic axis ❍ B. PMI ❍ C. Erb’s point ❍ D. Tail of Spence
33. The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should: ❍ A. Question the order. ❍ B. Administer the medications. ❍ C. Administer separately. ❍ D. Contact the pharmacy.
34. The best method of evaluating the amount of peripheral edema is: ❍ A. Weighing the client daily ❍ B. Measuring the extremity ❍ C. Measuring the intake and output ❍ D. Checking for pitting Quick Check ✓

Downloaded by DOCMERIT DOCMERIT Quick Answer: 223 Detailed Answer: 228 Quick Answer: 223 Detailed Answer: 228 Quick Answer: 223 Detailed Answer: 228 Quick Answer: 223 Detailed Answer: 228 Quick Answer: 223 Detailed Answer: 228176 Chapter 3

35. A client with vaginal cancer is being treated with a radioactive vaginal implant. The client’s husband asks the nurse if he can spend the night with his wife. The nurse should explain that: ❍ A. Overnight stays by family members is against hospital policy. ❍ B. There is no need for him to stay because staffing is adequate. ❍ C. His wife will rest much better knowing that he is at home. ❍ D. Visitation is limited to 30 minutes when the implant is in place.
36. The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client? ❍ A. Roast beef sandwich, potato chips, pickle spear, iced tea ❍ B. Split pea soup, mashed potatoes, pudding, milk ❍ C. Tomato soup, cheese toast, Jello, coffee ❍ D. Hamburger, baked beans, fruit cup, iced tea
37. The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?

Downloaded by DOCMERIT DOCMERIT ❍ A. “I will make sure I eat breakfast within 10 minutes of taking my insulin.” ❍ B. “I will need to carry candy or some form of sugar with me all the time.” ❍ C. “I will eat a snack around three o’clock each afternoon.” ❍ D. “I can save my dessert from supper for a bedtime snack.”

38. The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first two weeks of life because: ❍ A. New parents need time to learn how to hold the baby. ❍ B. The umbilical cord needs time to separate. ❍ C. Newborn skin is easily traumatized by washing. ❍ D. The chance of chilling the baby outweighs the benefits of bathing. Quick Check ✓ Quick Answer: 223 Detailed Answer: 228 Quick Answer: 223 Detailed Answer: 228 Quick Answer: 223 Detailed Answer: 229 Quick Answer: 223 Detailed Answer: 229Practice Exam 3 and Rationales 177
39. A client with leukemia is receiving Trimetrexate. After reviewing the client’s chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:

Downloaded by DOCMERIT DOCMERIT ❍ A. Treat iron-deficiency anemia caused by chemotherapeutic agents ❍ B. Create a synergistic effect that shortens treatment time ❍ C. Increase the number of circulating neutrophils ❍ D. Reverse drug toxicity and prevent tissue damage

40. A four-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive: ❍ A. Hib titer ❍ B. Mumps vaccine ❍ C. Hepatitis B vaccine ❍ D. MMR
41. The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication: ❍ A. 30 minutes before a meal ❍ B. With each meal ❍ C. In a single dose at bedtime ❍ D. 30 minutes after meals
42. A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take? ❍ A. Call security for assistance and prepare to sedate the client. ❍ B. Tell the client to calm down and ask him if he would like to play cards. ❍ C. Tell the client that if he continues his behavior he will be punished. ❍ D. Leave the client alone until he calms down. Quick Check ✓ Quick Answer: 223

Downloaded by DOCMERIT DOCMERIT Detailed Answer: 229 Quick Answer: 223 Detailed Answer: 229 Quick Answer: 223 Detailed Answer: 229 Quick Answer: 223 Detailed Answer: 229178 Chapter 3

43. When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to: ❍ A. Check the client for bladder distention. ❍ B. Assess the blood pressure for hypotension. ❍ C. Determine whether an oxytocic drug was given. ❍ D. Check for the expulsion of small clots.
44. A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood- tinged hemoptysis, fatigue, and night sweats. The client’s symptoms are consistent with a diagnosis of: ❍ A. Pneumonia ❍ B. Reaction to antiviral medication ❍ C. Tuberculosis ❍ D. Superinfection due to low CD4 count
45. The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client’s history should be reported to the doctor? ❍ A. Diabetes ❍ B. Prinzmetal’s angina ❍ C. Cancer

Downloaded by DOCMERIT DOCMERIT ❍ D. Cluster headaches

46. The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig’s sign is charted if the nurse notes: ❍ A. Pain on flexion of the hip and knee ❍ B. Nuchal rigidity on flexion of the neck ❍ C. Pain when the head is turned to the left side ❍ D. Dizziness when changing positions Quick Check ✓ Quick Answer: 223 Detailed Answer: 229 Quick Answer: 223 Detailed Answer: 229 Quick Answer: 223 Detailed Answer: 229 Quick Answer: 223 Detailed Answer: 229Practice Exam 3 and Rationales 179
47. The client with Alzheimer’s disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting: ❍ A. Agnosia ❍ B. Apraxia ❍ C. Anomia ❍ D. Aphasia
48. The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as: ❍ A. Chronic fatigue syndrome

Downloaded by DOCMERIT DOCMERIT ❍ B. Normal aging ❍ C. Sundowning ❍ D. Delusions

49. The client with confusion says to the nurse, “I haven’t had anything to eat all day long. When are they going to bring breakfast?” The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make? ❍ A. “You know you had breakfast 30 minutes ago.” ❍ B. “I am so sorry that they didn’t get you breakfast. I’ll report it to the charge nurse.” ❍ C. “I’ll get you some juice and toast. Would you like something else?” ❍ D. “You will have to wait a while; lunch will be here in a little while.”
50. The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer’s disease. Which side effect is most often associated with this drug? ❍ A. Urinary incontinence ❍ B. Headaches ❍ C. Confusion ❍ D. Nausea Quick Check ✓ Quick Answer: 223 Detailed Answer: 229 Quick Answer: 223 Detailed Answer: 230

Downloaded by DOCMERIT DOCMERIT Quick Answer: 223 Detailed Answer: 230 Quick Answer: 223 Detailed Answer: 230180 Chapter 3

51. A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate? ❍ A. Document the finding. ❍ B. Report the finding to the doctor. ❍ C. Prepare the client for a C-section. ❍ D. Continue primary care as prescribed.
52. A client with a diagnosis of HPV is at risk for which of the following? ❍ A. Hodgkin’s lymphoma ❍ B. Cervical cancer ❍ C. Multiple myeloma ❍ D. Ovarian cancer
53. During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is: ❍ A. Syphilis ❍ B. Herpes ❍ C. Gonorrhea ❍ D. Condylomata
54. A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:

Downloaded by DOCMERIT DOCMERIT ❍ A. Venereal Disease Research Lab (VDRL) ❍ B. Rapid plasma reagin (RPR) ❍ C. Fluorescent treponemal antibody (FTA) ❍ D. Thayer-Martin culture (TMC)

55. A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome? ❍ A. Elevated blood glucose ❍ B. Elevated platelet count ❍ C. Elevated creatinine clearance ❍ D. Elevated hepatic enzymes Quick Check ✓ Quick Answer: 223 Detailed Answer: 230 Quick Answer: 223 Detailed Answer: 230 Quick Answer: 223 Detailed Answer: 230 Quick Answer: 223 Detailed Answer: 230 Quick Answer: 223 Detailed Answer: 230Practice Exam 3 and Rationales 181
56. The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex? ❍ A. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer. B. The nurse loosely suspends the client’s arm in an

Downloaded by DOCMERIT DOCMERIT open hand while tapping the back of the client’s elbow. ❍ C. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer. ❍ D. The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.

57. A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor’s order should the nurse question? ❍ A. Magnesium sulfate 4gm (25%) IV ❍ B. Brethine 10mcg IV ❍ C. Stadol 1mg IV push every 4 hours as needed prn for pain ❍ D. Ancef 2gm IVPB every 6 hours
58. A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse’s assessment of this data is: ❍ A. The infant is at low risk for congenital anomalies. ❍ B. The infant is at high risk for intrauterine growth retardation. ❍ C. The infant is at high risk for respiratory distress syndrome. ❍ D. The infant is at high risk for birth trauma.
59. Which observation in the newborn of a diabetic mother would require immediate nursing intervention? ❍ A. Crying ❍ B. Wakefulness ❍ C. Jitteriness

Downloaded by DOCMERIT DOCMERIT ❍ D. Yawning Quick Check ✓ Quick Answer: 223 Detailed Answer: 230 Quick Answer: 223 Detailed Answer: 230 Quick Answer: 223 Detailed Answer: 231 Quick Answer: 223 Detailed Answer: 231182 Chapter 3

60. The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is: ❍ A. Decreased urinary output ❍ B. Hypersomnolence ❍ C. Absence of knee jerk reflex ❍ D. Decreased respiratory rate
61. The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would: ❍ A. Place her in Trendelenburg position. ❍ B. Decrease the rate of IV infusion. ❍ C. Administer oxygen per nasal cannula. ❍ D. Increase the rate of the IV infusion.
62. A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis? ❍ A. Alteration in nutrition ❍ B. Alteration in bowel elimination

Downloaded by DOCMERIT DOCMERIT ❍ C. Alteration in skin integrity D. Ineffective individual coping

63. The nurse is caring for a client with uremic frost. The nurse is aware that uremic frost is often seen in clients with: ❍ A. Severe anemia ❍ B. Arteriosclerosis ❍ C. Liver failure ❍ D. Parathyroid disorder
64. The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing diagnosis? ❍ A. Alteration in cerebral tissue perfusion ❍ B. Fluid volume deficit ❍ C. Ineffective airway clearance ❍ D. Alteration in sensory perception Quick Check ✓ Quick Answer: 223 Detailed Answer: 231 Quick Answer: 223 Detailed Answer: 231 Quick Answer: 223 Detailed Answer: 231 Quick Answer: 223 Detailed Answer: 231 Quick Answer: 223 Detailed Answer: 231Practice Exam 3 and Rationales 183

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65. The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client: ❍ A. Likes to play football ❍ B. Drinks carbonated drinks ❍ C. Has two sisters ❍ D. Is taking acetaminophen for pain
66. The nurse working the organ transplant unit is caring for a client with a white blood cell count of 450. During evening visitation, a visitor brings a basket of fruit. What action should the nurse take? ❍ A. Allow the client to keep the fruit. ❍ B. Place the fruit next to the bed for easy access by the client. ❍ C. Offer to wash the fruit for the client. ❍ D. Ask the family members to take the fruit home.
67. The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40. The initial nurse’s action should be to: ❍ A. Place the client in Trendelenburg position. ❍ B. Increase the infusion of normal saline. ❍ C. Administer atropine intravenously. ❍ D. Move the emergency cart to the bedside.
68. The client admitted two days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes? ❍ A. Order a chest x-ray. ❍ B. Reinsert the tube.

Downloaded by DOCMERIT DOCMERIT ❍ C. Cover the insertion site with a Vaseline gauze. ❍ D. Call the doctor.

69. A client being treated with sodium warfarin (Coumadin) has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan? A. Assess for signs of abnormal bleeding. ❍ B. Anticipate an increase in the Coumadin dosage. ❍ C. Instruct the client regarding the drug therapy. ❍ D. Increase the frequency of neurological assessments. Quick Check ✓ Quick Answer: 223 Detailed Answer: 231 Quick Answer: 223 Detailed Answer: 231 Quick Answer: 223 Detailed Answer: 231 Quick Answer: 223 Detailed Answer: 231 Quick Answer: 223 Detailed Answer: 231184 Chapter 3
70. Which selection would provide the most calcium for the client who is four months pregnant? ❍ A. A granola bar ❍ B. A bran muffin ❍ C. A cup of yogurt ❍ D. A glass of fruit juice