NCLEX-RN & NCLEX-PN Test Bank: Nursing Questions and Answers, Exams of Nursing

Download NCLEX-RN & NCLEX-PN Test Bank: Nursing Questions and Answers and more Exams Nursing in PDF only on Docsity! NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Pretest Question 1 A c. What document should be in guiding the care of this client? A) Client Self Determination Act B) Physician's treatment orders C) Advance Directives. D) Clinical Pathway protocols Review Information: The correct answer is: C) Advance Directives. This document specifies the client's wishes Question 2 You are the of a health care team that consists of one licensed practical/vocational nurse, one nursing assistant , a nursing student and yourself. To whom is it appropriate to assign complete care for A) Yourself B) The nursing student C) The licensed vocational nurse D) The nursing assistant Review Information: The correct answer is:A) Yourself. While the nurse may delegate a bed bath for a stable client, this care should be performed by an RN for a new admission. Only tasks that do not require independent judgment should be delegated. 3Question 3 A mother brings her the clinic, complaining that the child seems to be The nurse expects to find which of the following on the initial history and physical assessment? A) Increased temperature and lethargy B) Rash and restlessness C) Increased sleeping and listlessness D) Diarrhea and poor skin turgor NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Review Information: The correct answer is:B) Rash and restlessness. NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Question 9 A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action A) May result in charges of unlawful seclusion and restraint B) Leaves the nurse vulnerable for charges of assault and battery C) Was appropriate in view of the client's history of violence D) Was necessary to maintain the therapeutic milieu of the unit Review Information: The correct answer is:A) May result in charges of unlawful seclusion and restraint. Seclusion should only be used when there is an immediate threat of violence or threatening behavior. Question 10 A client has been admitted to the Coronary Care Unit with a Myocardial Infarction. Which of the following nursing diagnosis should have PRIORITY? A) Pain related to ischemia B) Risk for altered elimination: constipation C) Risk for complication: dysrhythmias D) Anxiety Review Information: The correct answer is:A) Pain related to ischemia. Pain is related to ischemia, and relief of pain will decrease myocardial oxygen demands, reduce blood pressure and heart rate and relieve anxiety. Pain also stimulates the sympathetic nervous system and increased preload, further increasing myocardial demands. Question 11 The nurse manager who is responsible for hiring professional nursing staff is required to comply with the Americans with Disabilities Act. The provisions of the law require the nurse manager to A) Maintain an environment free from hazards B) Provide reasonable accommodations for disabled individuals C) Make all necessary accommodations for disabled individuals NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale D) Consider only physical disabilities in making employment decisions Review Information: The correct answer is:B) Provide reasonable accommodations for disabled individuals. The law is designed to permit persons with disabilities access to job opportunities. Employers must evaluate an applicant's ability to perform the job and not discriminate on the basis of a disability. Employers also must make "reasonable accommodations. Question 12 The mother of a school-aged child in a long leg cast asks the nurse how to relieve itching inside the cast. Which of the following is appropriate for the nurse to suggest as a remedy? A) Scratching the outside of the cast vigorously, applying pressure over the area B) Blowing a hair dryer or heat lamp on the cast over the area that is itching C) Using a long, smooth piece of wood to gently scratch the affected area D) Applying an ice pack over the area of the cast that is affected Review Information: The correct answer is:D) Applying an ice pack over the area of the cast that is affected. Applying ice is a safe method of relieving the itching. Question 13 Which of the following BEST describes the application of time management strategies in the role of the nurse manager? A) Scheduling staff efficiently to cover client needs B) Assuming a fair share of the client care as a role model C) Setting daily goals to prioritize work D) Delegating tasks to reduce work load Review Information: The correct answer is:C) Setting daily goals to prioritize work. Time management strategies must include setting priorities and meeting goals. Question 14 The clinic nurse assesses a toddler with a tentative diagnosis of neuroblastoma. Symptoms the nurse observes that suggest this problem include A) Lymphedema and nerve palsy NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale B) Hearing loss and ataxia C) Headaches and vomiting D) Abdominal mass and weakness Review Information: The correct answer is:D) Abdominal mass and weakness. Clinical manifestations of neuroblastoma include an irregular abdominal mass that crosses the midline, weakness, pallor, anorexia, weight loss and irritability. Question 15 A fifteen year-old client has been placed in a Milwaukee Brace. Which one of the following statements from the client indicates the need for additional teaching? A) "I will only have to wear this for six months." B) "I should inspect my skin daily." C) "The brace will be worn day and night." D) "I can take it off when I shower." Review Information: The correct answer is:A) "I will only have to wear this for six months.". The brace must be worn long-term, usually for 1-2 years. Question 16 The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that A) Quality of care will improve B) Staff turnover should decrease C) Flexible scheduling will occur D) Team morale will improve Review Information: The correct answer is:D) Team morale will improve. Nurses are more satisfied with autonomy and control. The nurse manager becomes the facilitator of scheduling rather than the decision-maker of the schedule. Question 17 A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? A) Diffuse expiratory wheezing NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Review Information: The correct answer is: C) Respiratory function. Spinal injury at the C-2 level results in quadriplegia. While the client will experience all of the problems identified, respiratory assessment is a priority. Question 23 The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care? A) Hourly urine output B) White blood count C) Blood glucose every four hours D) Temperature every two hours Review Information: The correct answer is:A) Hourly urine output. Clients who have had an episode of decreased glomerular perfusion are at risk for pre-renal failure. This is caused by any abnormal decline in kidney perfusion that reduces glomerular perfusion. Pre-renal failure occurs when the effective arterial blood volume falls. Examples of this phenomena include a drop in circulating blood volume as in a cardiac arrest state or in low cardiac perfusion states such as congestive heart failure associated with a cardiomyopathy. Close observation of hourly urinary output is necessary for early detection of this condition. Question 24 The nurse admitting a 5 month-old who vomited nine times in the past six hours should observe for signs of A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis Review Information: The correct answer is:B) Metabolic alkalosis. Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss and lead to metabolic alkalosis. Question 25 A child is injured on the school playground and appears to have a fractured leg. The FIRST action the school nurse should take is NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale A) Call for emergency transport to the hospital B) Immobilize the limb and joints above and below the injury C) Assess the child and the extent of the injury D) Apply cold compresses to the injured area Review Information: The correct answer is:C) Assess the child and the extent of the injury. When applying the nursing process, assessment is the first step in providing care. The 5 "Ps" of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis). Question 26 As the nurse interviews the parents of a child with asthma, it is a PRIORITY to ask about A) Household pets B) New furniture C) Lead based paint D) Plants such as cactus Review Information: The correct answer is:A) Household pets. Animal dander is a very common allergen affecting persons with asthma. Other triggers may include pollens, carpeting and household dust. Question 27 An 80 year-old client was admitted with a diagnosis of possible cerebral vascular accident. Blood pressure has ranged from 180/110 to 160/100. Over the past several hours, the nurse noted increasing lethargy. Which of the following assessments should the nurse report IMMEDIATELY to the physician? A) Slurred speech B) Incontinence C) Muscle weakness D) Rapid pulse Review Information: The correct answer is:A) Slurred speech. Changes in speech patterns and level of conscious can be indicators of continued intercranial bleeding. Treatment options may change based on further diagnostic tests. NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Question 28 A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night." Based on these complaints, the nurse would INITIALLY assess for A) Allergies B) Hyperactivity C) Regression D) Pinworms Review Information: The correct answer is:D) Pinworms. Signs of pinworm infection include intense perianal itching, poor sleep patterns, general irritability, restlessness, bed-wetting, distractibility and short attention span. Question 29 A 72 year-old client with osteomyelitis requires a six week course of intravenous antibiotics. In planning for home care, the MOST important action by the nurse is A) Investigating the client's insurance coverage for home IV antibiotic therapy B) Determining if there are adequate hand washing facilities in the home C) Assessing the client's ability to participate in self care and/or the reliability of a caregiver D) Selecting the appropriate venous access device Review Information: The correct answer is:C) Assessing the client''s ability to participate in self care and/or the reliability of a caregiver. The cognitive ability of the client as well as the availability and reliability of a caregiver must be assessed to determine if home care is a feasible option. Question 30 The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. The BEST response by the nurse is A) "Folic acid should be taken before and after conception." B) "Multivitamin supplements are recommended during pregnancy." C) "A well balanced diet promotes normal fetal development." D) "Increased dietary iron improves the health of mother and fetus." Review Information: The correct answer is:A) "Folic acid should be taken before and after conception.". NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale A) Promote the client's comfort B) Reduce the drying time C) Decrease irritation to the skin D) Improve venous return Review Information: The correct answer is:D) Improve venous return. Elevating the leg both improves venous return and reduces swelling. Question 37 A nurse is working with family members of a newly diagnosed client with Alzheimer's disease. Which of the following interventions is MOST helpful? A) Teaching relaxation techniques B) Implementing a daily exercise routine C) Improving daily nutritional intake D) Suggesting communication strategies Review Information: The correct answer is:D) Suggesting communication strategies. Since Alzheimer''s disease is a progressive chronic illness that greatly challenges caregivers, the nurse can be of greatest assistance in helping family to identify language changes, and select verbal and nonverbal communication strategies to minimize aberrant behavior. Question 38 The nurse is teaching a client with non-insulin dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to A) Maintain previous calorie intake B) Keep a candy bar available at all times C) Reduce carbohydrates intake to 25% of total calories D) Keep a regular schedule of meals and snacks Review Information: The correct answer is:D) Keep a regular schedule of meals and snacks. Currently, calorie-controlled diets with strict mealplans are rarely suggested for clients who have diabetes. Try to incorporate schedule or food changes into clients'' existing dietary patterns. Help clients learn to read labels and identify specific canned foods, frozen entrees, or other foods which are acceptable and those which should be avoided. Question 39 NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale The mother of a two month-old baby calls the nurse at a well-baby clinic two days after the first DTaP immunization. She reports that the baby feels very warm, has cried inconsolably for as long as three hours, and has had several shaking spells. The response of the nurse should be to A) instruct the mother to call 911 for an ambulance to transport the infant B) suggest that these are expected reactions and to begin every 4 hour antipyretics C) tell the mother to take the infant immediately to the nearest emergency room D) give instructions to bring the infant to the clinic now Review Information: The correct answer is:A)instruct the mother to call 911 for an ambulance to transport the infant The exhibited findings of the infant indicate a severe reaction to the immunizations. Immediate attention is needed & an ambulance with trained staff needs to transport because of the risk of grand mal seizures from potential encephalopathy which is a critical reaction. The mother would need to be instructed after this acute reaction to inform the provider of this reaction to the first dose of DTaP. Based on the need and risk involved to the infant, the health care provider may decide that further DTaP immunizations are contraindicated for life. The clinic nurse would need to document in the notes for this infant: the instructions given, findings reported by the mother and specific follow-up needs for the next clinic visit in relation to teaching and evaluation of the outcome of this event. Question 40 The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk? A) Donating blood B) Using public bathrooms C) Unprotected sex D) Touching a person with AIDS Review Information: The correct answer is:C) Unprotected sex. Because HIV is spread through exposure to bodily fluids, unprotected intercourse and shared drug paraphernalia remain the highest risk for infection. Question 41 A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has short palpebral fissures, thinned upper lip, and hypoplastic philtrum of the upper lip. The mother states that the child seems to have problems in learning to count and recognizing basic colors. Based on this data, the nurse suspects that the child is MOST likely showing the effects of A) Congenital abnormalities B) Chronic toxoplasmosis C) Fetal alcohol syndrome D) Lead poisoning NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Review Information: The correct answer is:C) Fetal alcohol syndrome. Major features of fetal alcohol syndrome consist of facial and associated physical features, such as short palpebral fissure, hypoplastic philtrum, thinned upper lip, short, upturned nose. Behavioral problems, cognitive impairment and psychosocial deficits are also associated with this syndrome. Question 42 The nurse is performing the admission assessment of a client with an acute episode of asthma. Which of the following assessments would the nurse anticipate finding? A) Prolonged inspiration B) Expiratory wheezes C) Expectorating large amounts of purulent mucous D) Lethargy Review Information: The correct answer is:B) Expiratory wheezes. Asthma is characterized by expiratory wheezes caused by obstruction of the airways. Wheezes are a high pitched musical sounds produced by air moving through narrowed airways. Clients often associate wheezes with the feeling of tightness in the chest. Question 43 The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which of the following dinner menus would be BEST? A) Fish sticks, french fries, banana, cookies, milk B) Ground beef patty, lima beans, wheat roll, raisins, milk C) Chicken nuggets, macaroni, peas, cantaloupe, milk D) Peanut butter and jelly sandwich, apple slices, milk Review Information: The correct answer is:B) Ground beef patty, lima beans, wheat roll, raisins, milk. Iron rich foods include red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, dried fruits such as raisins. This dinner is the best choice, high in iron and is appropriate for a toddler. Question 44 A ten year-old client is recovering from a splenectomy following a traumatic injury. The clients laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Question 47 The nurse is giving instructions to the parents of a child with Cystic Fibrosis. The nurse would emphasize that pancreatic enzymes should be taken A) Once each day B) Three times daily after meals C) With each meal or snack D) Each time carbohydrates are eaten Review Information: The correct answer is:C) With each meal or snack. Pancreatic enzymes should be taken with each meal and every snack to allow for digestion of all foods that are eaten. Question 48 The nurse is assessing an eight month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be MOST likely to exhibit? A) Lethargy B) Irritability C) Negative Moro D) Depressed fontanel Review Information: The correct answer is:B) Irritability. Signs of IICP (increased intracranial pressure) in infants include bulging fontanel, instability, high-pitched cry, and cries when held. Vital sign changes include pulse that is variable, i.e., rapid, slow and bounding, or feeble. Respirations are more often slow, deep, and irregular. Question 49 The nurse is performing a physical assessment on a toddler. Which of the following should be the FIRST action? A) Perform traumatic procedures B) Use minimal physical contact C) Proceed from head to toe D) Explain the exam in detail Review Information: The correct answer is:B) Use minimal physical contact. NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale The nurse should approach the toddler slowly and use minimal physical contact initially so as to gain the toddler''s cooperation. Be flexible in the sequence of the exam, and give only brief simple explanations just prior to the action. Question 50 A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of the following symptoms noted on the initial nursing assessment is expected? A) Recent weight gain B) Physical growth delay C) Protruding eyeballs D) Sudden onset of irritability Review Information: The correct answer is:C) Protruding eyeballs. Exophthalmos or protruding eyeballs is a distinctive characteristic of Graves'' Disease. Question 51 When assessing a client admitted to the hospital for diabetic acidosis, which of the following clinical manifestations would the nurse expect? A) A blood pH level above 7.5 B) Arterial blood PCO2 above 40 C) Blood pH level below 7.3 D) Arterial blood PCO2 below 10 Review Information: The correct answer is:C) Blood pH level below 7.3. In the absence of insulin, which facilitates the transport of glucose into the cell, the body breaks down fats and proteins to supply energy ketones, a by-product of fat metabolism. These accumulate causing metabolic acidosis (pH < 7.3). Question 52 The nurse is explaining the proper use of syrup of ipecac to a group of parents. For which of the following accidental poisonings is the treatment appropriate? A) Oven cleaner B) Drain cleaner C) Kerosene D) Chewable vitamins NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Review Information: The correct answer is:D) Chewable vitamins. Of the above choices, poisoning with vitamins is the only case in which it is safe to induce vomiting with syrup of ipecac. Question 53 A two year-old child is brought to the pediatrician's office with a chief complaint of mild diarrhea for two days. Nutritional counseling by the nurse should include which one of the following statements? A) Place the child on clear liquids and gelatin for 24 hours B) Continue with the regular diet and include oral rehydration fluids C) Give bananas, apples, rice and toast as tolerated D) Place NPO for 24 hours, then rehydrate with milk and water Review Information: The correct answer is:B) Continue with the regular diet and include oral rehydration fluids. Current recommendations for mild to moderate diarrhea are to maintain a normal diet with rehydration fluids. Question 54 The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. The nurse's BEST recommendation for the client is A) Nebulized treatments for home care B) Adding a spacer device to the MDI canister C) Asking a family member to assist the client with the MDI D) Request a visiting nurse to follow the client at home Review Information: The correct answer is:B) Adding a spacer device to the MDI canister. The majority of pulmonary medications for COPD are delivered by inhalation.This is often preferred over oral administration because a lower drug dose is needed and systemic side effects are reduced. In addition, the onset of action of bronchodilator medication given via inhalation is faster. Question 55 Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students? A) Scratching the head more than usual NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Infuse the specified amount of blood within 4 hours. If the infusion will exceed this time, the blood should be divided into appropriately sized quantities. Question 61 A client with a documented pulmonary embolism has the following arterial blood gases: PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 7.45, SaO2 - 87%, HCO3 - 22. Based on thisdata, what is the FIRST nursing action? A) Review other lab data B) Notify the physician C) Administer oxygen D) Calm the client Review Information: The correct answer is:C) Administer oxygen. The client has a low PCO2 due to increased respiratory rate from the hypoxemia and signs of respiratory alkalosis. Immediate intervention is indicated. Question 62 A client diagnosed with hepatitis C discusses his health history with the admitting nurse. The nurse should recognize which of the following as the MOST important data? A) Recent travel to Central America B) Ingestion of raw shellfish last week C) Multiple sex partners D) Blood transfusion 15 years ago Review Information: The correct answer is:D) Blood transfusion 15 years ago. The client who was transfused prior to blood screening for hepatitis C may show symptoms many years later. Question 63 A client is recovering from a thyroidectomy. While monitoring the client's initial post operative condition, which of the following should the nurse report immediately? A) Tetany and paresthesia B) Mild stridor and hoarseness NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale C) Irritability and insomnia D) Headache and nausea Review Information: The correct answer is: A) Tetany and paresthesia. Because the parathyroid gland may be damaged in this surgery, secondary hypocalcemia may occur. Symptoms of hypoparathyroidism include tetany, paresthesia, muscle cramps and seizures. Question 64 A client is admitted with a right upper lobe infiltrate, and also to rule out tuberculosis. The isolation precautions the nurse would institute include A) Positive pressure ventilation B) Gown and gloves C) Particulate respirator mask D) Barrier precautions Review Information: The correct answer is:C) Particulate respirator mask. Tight fitting, high-efficiency masks are required when caring for clients who have suspected communicable disease of the airborne variety. Question 65 A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report? A) The client lost 2 pounds B) The client's potassium level is 4 mEq/liter. C) The client's urine output was 1500 cc in five hours D) The client is to receive another dose of Lasix at 10 PM Review Information: The correct answer is:C) The client's urine output was 1500 cc in five hours. Although all of these may be correct information to include in report, the essential piece would be the urine output. Question 66 NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale The nurse is caring for a client with a colostomy. During a teaching session, the nurse recommends that the pouch be emptied A) When it is one third to one half full B) Prior to meals C) After each fecal elimination D) At the same time each day Review Information: The correct answer is:A) When it is one third to one half full. If the pouch becomes more than half full it may separate from the flange. Question 67 A couple asks the nurse about risks of several birth control methods. The MOST appropriate response by the nurse would be A) Norplant is safe and may be removed easily B) Oral contraceptives should not be used by smokers C) Depo-Provera is convenient with few side effects D) The IUD gives protection from pregnancy and infection Review Information: The correct answer is:B) Oral contraceptives should not be used by smokers. The use of oral contraceptives in a pregnant woman who smokes increases her risk of cardiovascular problems. Question 68 Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment? A) An increase in appetite B) A decrease in fluid retention C) A decrease in lethargy D) A reduction in jaundice Review Information: The correct answer is:C) A decrease in lethargy. Lactulose produces and acid environment in the bowel and trapsammonia in the gut; the laxative effect then aids in removing the ammonia from the body. This decreases the effects of hepatic encephalopathy, including lethargy and confusion. NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale A) Shellfish B) Molds C) Balloons D) Perfumed soap Review Information: The correct answer is:C) Balloons. Allergy to balloons indicates a latex allergy. All personnel in contact with the child will need to be aware of this condition and use non-latex gloves. Question 75 The nurse is caring for a client who is post-op following a thoracotomy. The client has two chest tubes in place,connected to one chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the MOST appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Continue to monitor the client to see if the bubbling increases D) Instruct the client to try to avoid coughing Review Information: The correct answer is:C) Continue to monitor the client to see if the bubbling increases. Bubbling associated with coughing after lung surgery is to be expected as small amounts of air escape the pleural space when pressures inside the chest increase with coughing. Monitoring is the only nursing action required. Question 76 The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. The nurse should instruct the client to A) Complete the entire course of the medication for an effective cure B) Begin treatment with acyclovir at the onset of symptoms of recurrence C) Stop treatment if she thinks she may be pregnant to prevent birth defects D) Continue to take prophylactic doses for at least five years after the diagnosis Review Information: The correct answer is:B) Begin treatment with acyclovir at the onset of symptoms of recurrence. NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale When the client is aware of early symptoms, such as pain, itching or tingling, treatment is very effective. Question 77 An eight year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which one of the following is the BEST choice? A) Bologna sandwich, pudding, milk B) Frankfurter, baked potato, milk C) Chicken strips, corn on the cob, milk D) Grilled cheese sandwich, apple, milk Review Information: The correct answer is:C) Chicken strips, corn on the cob, milk. This menu is lowest in sodium. Ideally, low fat milk would be available. Question 78 The nurse is teaching parents about accidental poisoning in children. Which of the following should be emphasized? A) Start treatment before calling the Poison Control Center B) Empty the child's mouth in any case of possible poisoning C) Do not move the child if a toxic substance was inhaled D) Induce vomiting if the poison is a hydrocarbon Review Information: The correct answer is:B) Empty the child''s mouth in any case of possible poisoning. Emptying the mouth of poison interferes with further ingestion and should be done first to limit contact with the substance. Question 79 Which of the following symptoms contraindicate the use of haloperidol (Haldol) and warrant withholding the dose? A) Drowsiness, lethargy, and inactivity B) Dry mouth, nasal congestion, and blurred vision C) Rash, blood dyscrasias, severe depression D) Hyperglycemia, weight gain, and edema NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Review Information: The correct answer is:C) Rash, blood dyscrasias, severe depression. Rash and blood dyscrasias are side effects of anti-psychotic drugs. A history of severe depression is a contraindication to the use of neuroleptics. Question 80 The nurse is planning care for a 14 year-old client returning from scoliosis corrective surgery. Which of the following actions should receive PRIORITY in the plan? A) Antibiotic therapy for 10 days B) Teach client isometric exercises for legs C) Assess movement and sensation of extremities D) Assist to stand up at bedside within the first 24 hours Review Information: The correct answer is:C) Assess movement and sensation of extremities. Following corrective surgery for scoliosis, neurological status requires special attention and assessment, especially that of the extremities. Question 81 A three year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack? A) Cheese crackers B) Peanut butter sandwich C) Potato chips D) Vanilla cookies Review Information: The correct answer is:C) Potato chips. Children with celiac disease should eat a gluten free diet. Gluten is found mainly in grains of wheat and rye and in smaller quantities in barley and oats. Corn, rice, soybeans and potatoes are digestible in persons with celiac disease. Question 82 The nurse is caring for a 14 month-old just diagnosed with Cystic Fibrosis. The parents state this is the first child in either family with this disease, and ask about the risk to future children. The BEST response by the nurse is based on the knowledge that there is a A) 1 in 4 chance for each child to carry that trait B) 1 in 4 risk for each child to have the disease C) 1 in 2 chance of avoiding the trait and disease NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the following lab reports should the nurse review FIRST? A) Protime (PT) and partial thromboplastin time (PTT) B) Red blood cell and white blood cell counts C) Blood urea nitrogen and creatinine clearance D) Liver enzymes (AST and ALT) Review Information: The correct answer is:D) Liver enzymes (AST and ALT). Because acetaminophen is toxic to the liver and causes hepatic cellular necrosis, liver enzymes are released into the blood stream and serum levels of those enzymes rise. Other lab values are reviewed as well. Question 86 The nurse is teaching parents about diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include A) Formula or breast milk B) Broth and tea C) Rice cereal and apple juice D) Gelatin and ginger ale Review Information: The correct answer is:A) Formula or breast milk. The usual diet for a young infant should be followed. Question 87 The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk because this medication A) Retards pepsin production B) Stimulates hydrochloric acid production C) Slows stomach emptying time D） Decreases production of hydrochloric acid Review Information: The correct answer is:B) Stimulates hydrochloric acid production. Decadron increases the production of hydrochloric acid, which may cause gastrointestinal ulcers. NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Question 88 The nurse is planning care for a 3 month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to A) Assess for abdominal distention B) Maintain infant in an upright position C) Begin formula feedings when infant is alert D) Pump the shunt to assess for proper function Review Information: The correct answer is:A) Assess for abdominal distention. The child is observed for abdominal distention because cerebrospinal fluid may cause peritonitis or a postoperative ileus as a complication of distal catheter placement. Question 89 The mother of a two year-old hospitalized child asksthe nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. The BEST response of the nurse would be to A) Request the mother to remain with the child at all times B) Explain that this behavior will stop with in a few days C) Help the mother understand this is a normal response to hospitalization D) Suggest that the mother "sneak out" of the child's room when he sleep Review Information: The correct answer is:C) Help the mother understand this is a normal response to hospitalization. The protest phase of separation anxiety is a normal response for a child this age. Question 90 When caring for a client receiving warfarin sodium (Coumadin), the nurse would monitor the results of the client's A) Bleeding time B) Coagulation time C) Prothrombin time D) Partial thromboplastin time Review Information: The correct answer is:C) Prothrombin time. NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Coumadin is ordered daily, based on the client''s prothrombin time (PT). This test evaluates the adequacy of the extrinsicsystem and common pathway in the clotting cascade; Coumadin affects the Vitamin K dependent clotting factors. Question 91 The nurse is caring for a four year-old two hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported IMMEDIATELY? A) Vomiting of dark emesis B) Complaints of throat pain C) Apical heart rate of 110 D) Increased restlessness Review Information: The correct answer is:D) Increased restlessness. Restlessness and increased respiratory and heart rates are often early signs of hemorrhage. care of infants and children. Question 92 The nurse admits a 7 year-old to the emergency room following a leg injury. X-rays show that there is a femur fracture near the epiphysis. The nurse should be aware that at this age, the injury MOST likely will A) Heal quickly because of thin periosteum B) Result in retarded bone growth C) Stimulate bone growth in the affected leg D) Show more rapid union than that of a younger child Review Information: The correct answer is: B) Result in retarded bone growth. An epiphyseal (growth) plate fracture in a 7 year-old often results in retarded bone growth. Limbs will be different in length. Question 93 A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse assesses this as A) Dystonia NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Dropping the canister into a bowl of water assesses the amount of medications remaining in a metered- dose inhaler. The client should obtain a refill when the inhaler rises to the surface and begins to tip over. Question 99 While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is MOST important for the nurse to teach them to A) Maintain good oral hygiene and dental care B) Omit medication if the child is seizure free C) Administer acetaminophen to promote sleep D) Serve a diet that is high in iron Review Information: The correct answer is:A) Maintain good oral hygiene and dental care. Swollen and tender gums occur often with use of phenytoin. Oral hygiene and regular visits to the dentist should be emphasized. Question 100 A two year-old child has just been diagnosed with Cystic Fibrosis. The child's father asks the nurse "What are the chances that another child of ours will have Cystic Fibrosis?" Which of the following is the BEST response? A) "The probability of recurrence is unknown." B) "Cystic Fibrosis is more common in Asians." C) "Each of your children have a 25% chance of having Cystic Fibrosis." D) "The incidence of Cystic Fibrosis is approximately 1: 14,000 live births." Review Information: The correct answer is:C) "Each of your children have a 25% chance of having Cystic Fibrosis.". Cystic Fibrosis is an autosomal recessive disease. There is a 25% chance of each pregnancy of these parents resulting in a child with Cystic Fibrosis. Question 101 A 7 month pregnant woman is admitted with complaints of painless vaginal bleeding over several hours. The nurse should prepare the client for an immediate A) Non stress test NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale B) Abdominal ultrasound C) Pelvic exam D) X-ray of abdomen Review Information: The correct answer is:B) Abdominal ultrasound. The standard for diagnosis of placenta previa, which is suggested in the client''s history, is abdominal ultrasound. Question 102 The nurse is assessing a 17 year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate? A) Increased serum glucose B) Decreased albumin C) Decreased potassium D) Increased sodium retention Review Information: The correct answer is:C) Decreased potassium. In bulimia, loss of electrolytes can occur in addition to signs and symptoms of starvation and dehydration. Question 103 An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which of the following laboratory results should the nurse analyze FIRST? A) Potassium levels B) Blood pH C) Magnesium levels D) Blood urea nitrogen Review Information: The correct answer is:A) Potassium levels. The most common cause of digitalis toxicity is a low potassium level. Clients must be taught that it is important to have adequate potassium intake while taking diuretics. Question 104 NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale A mother telephones the clinic and tells the nurse she is concerned because her breastfed 1 month-old has soft, yellow stoolsafter each feeding. The nurse's BEST response would be based on the knowledge that A) This type of stool is normal for breast fed infants B) The stool should have turned to light brown by now C) Formula supplements will add bulk to the stools D) Water should be offered several times each day Review Information: The correct answer is:A) This type of stool is normal for breast fed infants. In breast-fed infants, stools are frequent and yellow to golden and vary from soft to thick liquid in consistency. No change in feedings is indicated. Question 105 The nurse caring for a 9 year-old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which of the following nursing diagnoses is a PRIORITY at this time? A) Risk for fluid volume deficit related to morphine overdose B) Decreased gastrointestinal mobility related to mucosal irritation C) Ineffective breathing patterns related to central nervous system depression D) Altered nutrition related to inability to control nausea and vomiting Review Information: The correct answer is:C) Ineffective breathing patterns related to central nervous system depression. Respiratory depression is a life-threatening risk in this overdose. Question 106 A pregnant client asks the nurse about the scheduled blood test for alpha-fetoprotein (AFP). The nurse's BEST explanation i A) "It tells us how far along your pregnancy is." B) "The results help determine if the baby is growing normally." C) "Placental exchange of oxygen is measured." D) "Possible neurological defects may be identified." Review Information: The correct answer is:D) "Possible neurological defects may be identified.". NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale A) "They will be back right after supper." B) "In about 2 hours, you will see them." C) "After you play awhile, they will be here." D) "When the clock hands are on 6 and 12." Review Information: The correct answer is:A) "They will be back right after supper." Time is not completely understood by a 4 year-old. The child interprets time with his own frame of reference. Thus it is best to explain time in relationship to an event. Question 113 The nurse is providing instructions for a client with asthma. Which of the following should the client monitor on a daily basis? A) Respiratory rate B) Peak air flow volumes C) Pulse oximetry D) Skin color Review Information: The correct answer is:B) Peak air flow volumes. The peak airflow volume decreases about 24 hours before clinical manifestations. Question 114 Therapeutic nurse-client interaction occurs when the nurse A) Assists the client to clarify the meaning of what the client is communicating B) Interprets the client's covert communication C) Praises the client for appropriate behavior D) Advises the client on ways to resolve problems Review Information: The correct answer is:A) Assists the client to clarify the meaning of what the client is communicating. Clarification is a facilitating/therapeutic communication strategy. Approval, changing the focus/subject, and advising are non-therapeutic/barriers to communication. Question 115 A 14 month-old child ingested half a bottle of aspirin tablets. Which of the following would the nurse expect to see in the child? NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale A) Hypothermia B) Edema C) Dyspnea D) Epistaxis Review Information: The correct answer is:D) Epistaxis. A large dose of aspirin inhibits prothrombin formation and lowers platelet levels. With an overdose, clotting time is prolonged. Question 116 The nurse is caring for a client with a distal tibia fracture. The client has had a closed reduction and application of a toe to groin cast. Thirty-six hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 degrees F. The FIRST assessment the nurse should perform is A) Orientation to time, place and person B) Pulse oximetry C) Circulation to casted extremity D) Blood pressure Review Information: The correct answer is:B) Pulse oximetry. Restlessness, confusion, irritability and disorientation may be the first signs of fat embolism syndrome followed by a very high temperature. The nurse needs to confirm hypoxia first. Question 117 Which nursing intervention will be MOST effective in helping a withdrawn client to develop relationship skills? A) Offer the client frequent opportunities to interact with you B) Remind the client frequently to interact with other clients C) Assist the client to analyze the meaning of her behavior D) Identify for her other clients who have similar problems Review Information: The correct answer is:A) Offer the client frequent opportunities to interact with you. The withdrawn client is uncomfortable in social interaction. The nurse client relationship is a corrective relationship in which the client learns both tolerance and skills for relationships. Question 118 NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale The nurse is assessing a client with a stage 2 skin ulcer. Which of the following treatments is most effective to promote healing? A) Covering the wound with a dry dressing B) Using hydrogen peroxide soaks C) Leaving the area open to dry D) Applying a transparent film cover Review Information: The correct answer is:D) Applying a transparent film cover. For this type of ulcer, the most effective treatment is a transparent cover. Question 119 A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If this turns out to be cancer and I have to have my breast removed, my husband will never come near me." The nurse's BEST response would be A) "You are underestimating your husband's ability to love you." B) "Are you concerned that your husband will reject you?" C) "Are you wondering about the effect on your sexual relations?" D) "Are you worried that the surgery will change you?" Review Information: The correct answer is:D) "Are you worried that the surgery will change you?" This is a response that encourages further discussion without focusing on an area that the nurse, but possibly not the client, feels is a problem. Question 120 When teaching suicide prevention to the parents of a 15 year-old who recently attempted suicide, the nurse describes the following behavioral cue A) Angry outbursts at significant others B) Fears of being left alone C) Giving away valued personal items D) Experiencing the loss of a boyfriend Review Information: The correct answer is:C) Giving away valued personal items. 80% of all potential suicide victims give some type of clue. These clues might lead one to suspect that a client is holding suicidal thoughts or is developing a plan. NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale D) Talk with the father and help him accept the wife's decision Review Information: The correct answer is:B) Help the mother to express her feelings and concerns. Non-judgmental support for expressed feelings may lead to resolution of competitive feelings in a new family. Cultural influences may also be revealed. Question 127 Which of the following statements made by a female client indicate to the nurse that she may have a thought disorder? A) "I'm so angry about this. Wait until my husband hears about this." B) "I'm a little confused. What time is it?" C) "I can't find my 'mesmer' shoes. Have you seen them?" D) "I'm fine. It's my daughter who has the problem." Review Information: The correct answer is:C) "I can''t find my ''mesmer'' shoes. Have you seen them?". A Neologism is a new word self invented by a person and not readily understood by another that is often associated with a thought disorder. Question 128 The nurse is aware that which of the following psychosocial needs are BEST described in the adolescent when hospitalized? A) Independence, confidence, narcissism B) Group sports, competition, being right C) Privacy, autonomy, peer interactions D) School performance, reading, journal writing Review Information: The correct answer is:C) Privacy, autonomy, peer interactions. Adolescents display the need for privacy, autonomy and peer interaction concurrent with an evolving sense of identity. Question 129 The nurse is observing a client with an obsessive-compulsive disorder in an in-patient setting. Which of the following behaviors is consistent with this diagnosis? A) Repeatedly checking that the door is locked NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale B) Verbalized suspicions about thefts C) Preference for consistent care givers D) Repetitive, involuntary movements Review Information: The correct answer is:A) Repeatedly checking that the door is locked. Behaviors that are repeated are symptomatic of obsessive-compulsive disorders. These behaviors often interfere with normal function and employment. Question 130 A young adult seeks treatment in an out-patient mental health center. The client tells the nurse he is a government official being followed by spies. On further questioning, he reveals that his warnings must be heeded to prevent nuclear war. What is the MOST therapeutic approach by the nurse? A) Listen quietly without comment B) Ask for further information on the spies C) Confront the client on a delusion D) Contact the government agency Review Information: The correct answer is:A) Listen quietly without comment. The client''s comments demonstrate grandiose ideas. The most therapeutic response is to listen but avoid incorporation into the delusion. Question 131 The client's self-esteem is MOST damaged by the nurse's A) Anger B) Indifference C) Disapproval D) Fear Review Information: The correct answer is:B) Indifference. Positive connectedness/caring objectivity characterizes therapeutic relationships and is incongruent with indifference. Question 132 NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale An 8 year-old client is admitted to the child mental health unit for evaluation. Following his mother's departure, the client cries and refuses his dinner. The BEST approach by the nurse is to A) Offer to play with him B) Remind him that he is expected to eat his meals C) Tell him that he will be denied privileges for uncooperative behavior D) Tell him that his mother will be upset with him if he does not cooperate Review Information: The correct answer is:A) Offer to play with him. Play is both distracting and an avenue for a child's communication. Play facilitates mastery of feelings. Question 133 A client is admitted to a psychiatric unit with delusions. The nurse can expect which of the following signs and symptoms? A) Flight of ideas and hyperactivity B) Suspiciousness and resistance to therapy C) Anorexia and hopelessness D) Panic and multiple physical complaints Review Information: The correct answer is:B) Suspiciousness and resistance to therapy. Clinical features of delusional disorder include extreme suspiciousness, jealousy, distrust, belief that others intend to harm. Question 134 A client states, "People think I'm no good, you know what I mean?" Which of the following nursing responses would be MOST therapeutic for this client? A) "Well people often take their own feelings of inadequacy out on others." B) "I think you're good. So you see, there's one person who likes you." C) "I'm not sure what you mean. Tell me a bit more about that." D) "Have you done something to create this impression on people?" Review Information: The correct answer is:C) "I'm not sure what you mean. Tell me a bit more about that." Therapeutic communication technique that elicits more information is delivered in an open non-judgmental fashion. NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Question 140 A spouse is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that A) Such fantasies can gratify unconscious wishes or prepare for anticipated future events B) Detaching or dissociating in this way postpones painful feelings C) This conversion or transferring of a mental conflict to a physical symptom can lead to marital conflict D) Isolating her feelings in this way reduces conflict Review Information: The correct answer is: A) Such fantasies can gratify unconscious wishes or prepare for anticipated future events. Fantasy is imagined events (daydreaming) to express unconscious conflicts or gratifying unconscious wishes. Question 141 An important goal in the development of a therapeutic in-patient milieu is A) Providing a businesslike atmosphere where clients can work on individual goals B) Providing a group forum in which clients decide on unit rules, regulations, and policies C) Providing a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions D) Discouraging expressions of anger because they can be disruptive to other clients Review Information: The correct answer is: C) Providing a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions. A therapeutic milieu is purposeful and planned to provide safety and a testing ground for new patterns of behavior. Question 142 The nurse's PRIMARY intervention for a client who is experiencing a panic attack is to NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale A) Develop a trusting relationship B) Assist the client to describe his experience in detail C) Maintain safety for the client D) Teach the client to control his or her own behavior Review Information: The correct answer is: C) Maintain safety for the client. Clients who display signs of severe anxiety need to be supervised closely until the anxiety is decreased because they may harm themselves or others. Question 143 A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove her dentures prior to leaving the unit for the operating room. The MOST appropriate intervention by the nurse is A) Explain to the client that the dentures must come out as they may get lost or broken in the operating room B) Ask the client if she is having second thoughts about the procedure C) Notify the surgeon of the client's refusal D) Ask the client if she would prefer removing the dentures in the operating room receiving area Review Information: The correct answer is: D) Ask the client if she would prefer removing the dentures in the operating room receiving area. Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client''s sense of self-esteem and self-concept. Question 144 Which of the following interventions BEST demonstrates the nurse's sensitivity to a 16 year- old's appropriate need for autonomy? A) Alertness for feelings regarding body image B) Allows young siblings to visit C) Provides opportunity to discuss concerns without presence of parents NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale D) Explores his feelings of resentment to identify causes Review Information: The correct answer is: C) Provides opportunity to discuss concerns without presence of parents. This intervention provides the teen with the opportunity to have control and encourages decision making. Question 145 A client with anorexia is hospitalized on a medical unit due to electrolyte imbalance and cardiac dysrhythmias. Additional assessment findings that the nurse would expect to observe are A) Brittle hair, lanugo, amenorrhea B) Diarrhea, nausea, vomiting, dental erosion C) Hyperthermia, tachycardia, increased metabolic rate D) Excessive anxiety about symptoms Review Information: The correct answer is: A) Brittle hair, lanugo, amenorrhea. Physical findings associated with anorexia are brittle hair, lanugo, and dehydration, lowered metabolic rate and vital signs. Question 146 A depressed client in an assisted living facility tells the nurse that "life isn't worth living anymore." What is the BEST response to this statement? A) "Come on, it is not that bad." B) "Have you thought about hurting yourself?" C) "Did you tell that to your family?" D) "Think of the many positive things in life." Review Information: The correct answer is: NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale C) Justice D) Autonomy Review Information: The correct answer is: D) Autonomy. Individuals must be free to make independent decisions about participation in research without coercion from others. Question 2 The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should the nurse do FIRST? A) Explain that the procedure will help him to get well B) Show a cartoon character with a blood pressure cuff C) Explain that the blood pressure checks the heart pump D) Permit handling the equipment before putting the cuff in place Review Information: The correct answer is: D) Permit handling the equipment before putting the cuff in place. The best way to gain the toddler's cooperation is to encourage handling the equipment. Detailed explanations are not helpful. Question 3 The nurse must know that the MOST accurate oxygen delivery system available is A) The venturi mask B) Nasal cannula C) Partial non-rebreather mask D) Simple face mask Review Information: The correct answer is: A) The venturi mask. The most accurate way to deliver oxygen to the client is through a venturi system such as the Venti Mask. The Venti Mask is a high flow device that NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale entrains room air into a reservoir device on the mask and mixes the room air with 100% oxygen. The size of the opening to the reservoir determines the concentration of oxygen. The client's respiratory rate and respiratory NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale pattern do not affect the concentration of oxygen delivered. The maximum amount of oxygen that can be delivered by this system is 55%. Question 4 The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an IMMEDIATE response from the nurse? A) Decreased breath sounds in right lower lobe B) Aspiration of a residual of 100cc of formula C) Decrease in bowel sounds D) Urine output of 250 cc in past eight hours Review Information: The correct answer is: A) Decreased breath sounds in right lower lobe. The most common problem associated with enteral feedings is atelectasis. Maintain client at 30 degrees during feedings and monitor for signs of aspiration. Check for tube placement prior to each feeding or every four to eight hours if continuous feeding. Question 5 A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). The nurse would anticipate the physician ordering A) Oral Coumadin therapy B) Heparin 5000 units subcutaneously b.i.d. C) Heparin infusion to maintain the PTT at 1.5-2.5 times the control value NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale more objective in the decision making. NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Question 8 The nurse is caring for a client who has altered cerebral tissue perfusion related to a subarachnoid hemorrhage. To reduce the risk of rebleeding, the nurse should plan to A) Restrict visitors to immediate family B) Arouse the client frequently C) Keep client's hips flexed at 120 degrees D) Apply warming blankets Review Information: The correct answer is: A) Restrict visitors to immediate family. Maintaining a quiet environment will assist in decreasing cerebral swelling and rebleeding. Question 9 The nurse is caring for a client with renal calculi. Which physician order would be a PRIORITY? A) Morphine sulfate as client controlled analgesia B) Push oral fluids and keep vein open C) Continuous warm compresses to the flank area D) Intravenous antibiotics Review Information: The correct answer is: A) Morphine sulfate as client controlled analgesia. Administering narcotic analgesics provide prompt relief of the severe pain caused by kidney stones. Question 10 The nurse is teaching parents of a 7 month-old about adding table foods. Which of the following is an APPROPRIATE finger food? NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale A) Hot dog pieces B) Sliced bananas NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Review Information: The correct answer is: D) The loss is within normal limits. A newborn is expected to lose 5-10% of the birth weight in the first few days because of changes in elimination and feeding. Question 13 A five year-old has been rushed to the emergency room several hours after acetaminophen poisoning. Which of the following laboratory results should receive PRIORITY attention by the nurse? A) Sedimentation rate B) Profile 2 C) Bilirubin D) Neutrophils Review Information: The correct answer is: C) Bilirubin. Bilirubin, along with liver enzymes ALT and AST, may rise in the second stage (1-3 days) after a significant overdose, indicating cellular necrosis and liver dysfunction. A prolonged prothrombin may also occur. Question 14 An 18 month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When the nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. The PRIORITY nursing action is based on the understanding that A) Live vaccines are withheld in children with renal chronic illness B) The MMR vaccine should be given now, prior to the transplant C) An inactivated form of the vaccine can be given at any time NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale D) The risk of vaccine side effects precludes giving the vaccine NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Review Information: The correct answer is: B) The MMR vaccine should be given now, prior to the transplant. MMR is a live virus vaccine, and should be given at this time. Post- transplant, immunosuppressive drugs will be given and the administration of the live vaccine at that time would be contraindicated because of the compromised immune system. Question 15 The nurse working with clients from many different cultures recognizes that it is a PRIORITY to A) Speak another language B) Learn about all the cultures C) Refer to experts from those countries D) Recognize personal attitudes and biases Review Information: The correct answer is: D) Recognize personal attitudes and biases. The nurse must discover personal attitudes, prejudices and biases. Sensitivity to these will affect interactions with clients and families across cultures. Question 16 When teaching a client about the use of sublingual nitroglycerin, the nurse should emphasize that the MOST common side effect is A) Headache B) Dry mouth C) Depression D) Anorexia Review Information: The correct answer is: A) Headache. The most common side effect is headache, related to the generalized vasodilatation. NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Question 19 You are caring for a client with Parkinson's disease who has developed hallucinations. Which of the following medications that the client is receiving may have been a contributing factor? A) L-Dopa NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale B) Cogentin C) Baclofen D) Benadryl Review Information: The correct answer is: A) L-Dopa. While it is unclear whether some 1/3 of clients with Parkinson's disease have a dementia, the nurse should ask about hallucinations because the Parkinson's disease medications will cause hallucinations when they are at too high a dose. This should be asked at each client visit in home care or clinic visits. Question 20 A nurse admits a client transferred from the emergency room. The client, diagnosed with a myocardial infarction, is complaining of substernal chest pain, diaphoresis and nausea. The FIRST action by the nurse should be A) Order an EKG B) Administer pain medication as ordered C) Start an IV D) Measure vital signs Review Information: The correct answer is: B) Administer pain medication as ordered. Decreasing the clients pain is the most important priority at this time. As long as pain is present there is danger in extending the infarcted area. Question 21 Decentralized scheduling is used on a nursing unit. A CHIEF advantage of this management strategy is that it A) Considers client and staff needs B) Conserves time for planning C) Frees the nurse manager from this task D) Allows for requests for special privileges NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Review Information: The correct answer is: A) Considers client and staff needs. Decentralized staffing takes into consideration specific client needs and staff interests and abilities. Question 22 A client with angina has been instructed about the use of sublingual nitroglycerin. Which of the following statements made to the nurse indicates a need for FURTHER teaching? A) "I will rest briefly right after taking one tablet." B) "I can take 2-3 tablets at once if I have severe pain." C) "I'll call the doctor if pain continues after 3 tablets 5 minutes apart." D) "I understand that the medication should be kept in the dark bottle." Review Information: The correct answer is: B) "I can take 2-3 tablets at once if I have severe pain." Clients must understand that just one sublingual tablet should be taken at a time. After rest and a five minute interval, a second and then a third tablet may be necessary. Question 23 The nurse is talking with the family of an 18 month-old newly diagnosed with retinoblastoma. A PRIORITY in communicating with the parents is A) Discussing the need for genetic counseling B) Informing them that combined therapy is seldom effective C) Preparing for the child's permanent disfigurement D) Suggesting that total blindness may follow surgery Review Information: The correct answer is: NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale C) Repeat the test in 2 hours NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale D) Check other laboratory findings Review Information: The correct answer is: C) Repeat the test in 2 hours. This blood sugar is within the normal range for a full term newborn. Because of the birth weight, repeated blood sugars will be drawn. Question 27 A client with atrial fibrillation is receiving digoxin (Lanoxin). It is MOST important for the nurse to A) Monitor blood pressure every 4 hours B) Measure apical pulse prior to administration C) Maintain accurate intake and output records D) Record an EKG strip after administration Review Information: The correct answer is: B) Measure apical pulse prior to administration. Digitoxin decreases conduction velocity through the AV node and prolongs the refractory period. If the apical heart rate is less than 60 beats/minute, withhold the drug. The apical pulse should be taken with a stethoscope so that there will be no mistake about what the heart rate actually is. Question 28 A client is brought to the emergency room following a motor vehicle accident. When assessing the client one-half hour after admission, the nurse notes several physical changes. Which of the following changes would require the nurse's IMMEDIATE attention? A) Increased restlessness B) Tachycardia C) Tracheal deviation D) Tachypnea NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Review Information: The correct answer is: C) Tracheal deviation. The deviated trachea is a sign that a mediastinal shift has occurred. This is a medical emergency. NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Pulmonary Nursing Care. St. Louis: Mosby. Lewis, S., Collier, I., & Heitkemper, M.M. (1996). Medical-Surgical Nursing. (4th ed.). St. Louis: Mosby. Question 31 A nurse assessing the newborn of a diabetic mother understands that hypoglycemia is related to A) Disruption of fetal glucose supply B) Pancreatic insufficiency C) Maternal insulin dependency D) Reduced glycogen reserves Review Information: The correct answer is: A) Disruption of fetal glucose supply. After delivery, the high glucose levels which crossed the placenta to the fetus are suddenly stopped. The newborn continues to secrete insulin in anticipation of glucose. When oral feedings begin, the newborn will adjust insulin production within a day or two. Lowdermilk, D., Perry, S., Bobak, I. (1997). Maternal and Women's Health NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Care. (6th ed.). St. Louis, Mosby. Wong, D. (1999). NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Whaley and Wong's Nursing Care of Infants and Children. (5th ed.). St. Louis: Mosby. Question 32 The nurse is administering an intravenous piggyback infusion of penicillin. Which of the following client statements would require the nurse's IMMEDIATE attention? A) "I have a burning sensation when I urinate." B) "I have soreness and aching in my muscles." C) "I am itching all over." D) "I have cramping in my stomach." Review Information: The correct answer is: C) "I am itching all over." Complaints of itching, feeling hot all over and/or the appearance of raised, red welts on the skin are symptoms of an allergic reaction to the penicillin infusion. Therefore, the drug administration should be stopped immediately. Carroll, P. (1994). Speed: The Essential Response to Anaphylaxis. RN 57(6), 26-31. Ignatavicius, D.D., Workman, M.L., Mishler, M.A. (1995). Medical-Surgical Nursing. Philadelphia: WB Saunders. NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale C) Neurological signs every two hours D) Oxygen saturation every eight hours Review Information: The correct answer is: B) Blood glucose levels every twelve hours. The drug Decadron increases glycogenesis. This may lead to hyperglycemia. Therefore the blood sugar level and acetone production must be monitored. Nettina, Sandra (2000). The Lippincott Manual of Nursing Practice. Philadelphia-New York: Lippincott. Skidmore-Roth, Linda. (2001). Mosby's Nursing Drug Reference 2002. St. Louis: Mosby-Year Book, Inc. Question 35 When managing a client's pain, which of the following statements BEST describes the ethical considerations of the nurse? A) The client's self-report is the most important consideration B) Cultural sensitivity is fundamental to pain management C) Clients have the right to have their pain relieved D) Nurses should not prejudge a client's pain using their own values NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Review Information: The correct answer is: A) The client's self-report is the most important consideration. Pain is a complex phenomenon that is perceived differently by each individual. Pain is whatever the client says it is. Luckmann, Joan. (1997). Saunders Manual of Nursing Care. Philadelphia: W.B. Saunders Company. Springhouse. (1997). Diseases. (2nd ed.). Springhouse, PA: Springhouse Corporation. Question 36 The nurse is performing an assessment of the motor function in a client with a head injury. The BEST technique is A) A firm touch to the trapezius muscle or arm B) Pinching any body part C) Sternal rub D) Gentle pressure on eye orbit Review Information: The correct answer is: D) Gentle pressure on eye orbit. NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale This is an acceptable stimuli. Urden, L., Davie, J. & Thelan, L. (1997). NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale Question 38 The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects? A) Neurotoxicity B) Hepatomegaly C) Nephrotoxicity D) Ototoxicity Review Information: The correct answer is: C) Nephrotoxicity. Nephrotoxicity is a common side effect of calcium disodium edetate, in addition to lead poisoning in general. McHenry & Salerno. (2000). Mosby Pharmacology in Nursing. St. Louis: Mosby-Yearbook. Wong, D. (1999). Whaley & Wong's Nursing Care of Infants and Children.. St. Louis: Mosby. Question 39 NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale The nurse admits a two year-old child who has had a seizure. Which of the following statement by the child's parent would be important in determining the etiology of the seizure? A) "He has been taking long naps for a week." NCSBN TEST BANK - for the NCLEX-RN & NCLEX- PN, Updated 2021, Complete Questions & Answers with rationale B) "He has had an ear infection for the past two days." C) "He has been eating more red meat lately." D) "He seems to be going to the bathroom more frequently." Review Information: The correct answer is: B) "He has had an ear infection for the past two days.". Contributing factors to seizures in children include those such as age (more common in first 2 years), infections (late infancy and early childhood), fatigue, not eating properly and excessive fluid intake or fluid retention. Wong, D. (1999). Whaley & Wong's Nursing Care of Infants and Children.. St. Louis: Mosby. Ashwill, J. W. & Droske, S. C. (1997). Nursing Care of Children: Principles and Practice. Philadelphia: W. B. Saunders. Question 40 The nurse is caring for a client with Hodgkin's disease who will be receiving radiation therapy. The nurse recognizes that, as a result of the radiation therapy, the client is MOST likely to experience A) High fever B) Nausea C) Face and neck edema D) Night sweats