WALDEN UNIVERSITY NCLEX-PN TEST-BANK NURS FUNDAMENTALS OF NURSING NCLEX-PN TEST-BANK QUEST, Exams of Nursing

Download WALDEN UNIVERSITY NCLEX-PN TEST-BANK NURS FUNDAMENTALS OF NURSING NCLEX-PN TEST-BANK QUEST and more Exams Nursing in PDF only on Docsity! WALDEN UNIVERSITY NCLEX-PN TEST-BANK NURS FUNDAMENTALS OF NURSING NCLEX-PN TEST-BANK QUESTIONS AND ANSWERS UPDATED 2023/2024 WITH ANSWERS AND EXPLANATION CORRECT VERIFIED AND RATED A+ FOR SUCCESS  The charge nurse is making assignments for the day. After accepting the assignment to a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which action should the charge nurse take? A. Change the nurse’s assignment to another client B. Explain to the nurse that there is no risk to the client C. Ask the nurse if the chickenpox have scabbed D. Ask the nurse if she has ever had the chickenpox Answer D: The nurse who has had the chickenpox has immunity to the illness. Answer A is incorrect because more information is needed to determine whether a change in assignment is necessary. Answer B is incorrect because there could be a risk to the immune- suppressed client. Answer C is incorrect because the client who is immune-suppressed could still be at risk from the nurse’s exposure to the chickenpox, even if scabs are present.  The client with brain cancer refuses to care for herself. Which action by the nurse would be best? A. Alternate nurses caring for the client so that the staff will not get tired of caring for this client B. Talk to the client and explain the need for self-care C. Explore the reason for the lack of motivation seen in the client WALDEN UNIVERSITY NCLEX-PN TEST-BANK NURS FUNDAMENTALS OF NURSING NCLEX-PN TEST-BANK QUESTIONS AND ANSWERS UPDATED 2023/2024 WITH ANSWERS AND EXPLANATION CORRECT VERIFIED AND RATED A+ FOR SUCCESS D. Talk to the doctor about the client’s lack of motivation  Answer C: The nurse should explore the cause for the lack of motivation. The client might be anemic and lack energy, might be in pain, or might be depressed. Alternating staff, as stated in answer A, will prevent a bond from being formed with the nurse. Answer B is not enough, and answer D is not necessary.  The nurse is caring for the client who has been in a coma for 2 months. He has signed a donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle the topic of organ donation with the wife? A. Contact organ retrieval to come talk to the wife B. Tell her that because her husband signed a donor card, the hospital has the right to take the organs upon the death of her husband C. Drop the subject until a later time D. Refrain from talking about the subject until after the death of her husband Answer A: Contacting organ retrieval to talk to the family member is the best choice because a trained specialist has the knowledge to assist the wife with making the decision to donate or not to donate the client’s organs. The hospital will certainly honor the wishes of family members even if the patient has signed a donor card. Answer B is incorrect; answer C might be done, but there might not be time; and answer D is not good nursing etiquette and, therefore, is Answer A: The primary responsibility of the nurse is to take the vital signs before any surgery. The actions in answers B, C, and D are the responsibility of the doctor and, therefore, are incorrect for this question. The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority? j. Starting an IV k. Applying oxygen l. Obtaining blood gases m. Medicating the client for pain Answer B: The client with burns to the neck needs airway assessment and supplemental oxygen, so applying oxygen is the priority. The next action should be to start an IV and medicate for pain, making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor. E. The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client? a. Rest in bed after taking the medication for at least 30 minutes B. Avoid rapid movements after taking the medication C. Take the medication with water only D. Allow at least 1 hour between taking the medicine and taking other medications Answer B: The client with burns to the neck needs airway assessment and supplemental oxygen, so applying oxygen is the priority. The next action should be to start an IV and medicate for pain, making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor. F. The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside? a. A pair of forceps B.A torque wrench C. A pair of wire cutters D. A screwdriver Answer B: A torque wrench is kept at the bedside to tighten and loosen the screws of crutchfield tongs. This wrench controls the amount of pressure that is placed on the screws. A pair of forceps, wire cutters, and a screwdriver, in answers A, C, and D, would not be used and, thus, are incorrect. G. An infant weighs 7 pounds at birth. The expected weight by 1 year should be: a. 10 pounds b. 12 pounds c. 18 pounds D. 21 pounds Answer D: A birth weight of 7 pounds would indicate 21 pounds in 1 year, or triple his birth weight. Answers A, B, and C therefore are process and, thus, are incorrect. K. The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided? a. Bran b. Fresh peaches C. Cucumber salad D. Yeast rolls Answer C: The client with diverticulitis should avoid foods with seeds. The foods in answers A, B, and D are allowed; in fact, bran cereal and fruit will help prevent constipation. L. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? a. Teaching how to irrigate the illeostomy b. Stopping electrolyte loss in the incisional area c. Encouraging a high-fiber diet d. Facilitating perineal wound drainage Answer D: The client with a perineal resection will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illeostomy, as in answer A; he will have some electrolyte loss, but treatment is not focused on preventing the loss, so answer B is incorrect. A high-fiber diet, in answer C, is not ordered at this time. M. The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client’s diet? a. Roasted chicken b. Noodles c. Cooked broccoli d. Custard Answer C: The client with diverticulitis should avoid eating foods that are gas forming and that increase abdominal discomfort, such as cooked broccoli. Foods such as those listed in answers A, B, and D are allowed. N. The nurse is caring for a new mother. The mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is: a. The baby is dehydrated due to polyuria. Q. Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as: a. A cephalohematoma b. Molding c. Subdural hematoma d. Caput succedaneum Answer A: A swelling over the right parietal area is a cephalohematoma, an area of bleeding outside the cranium. This type of hematoma does not cross the suture line because it is outside the cranium but beneath the periosteum. Answer B, molding, is overlapping of the bones of the cranium and, thus, incorrect. In answer C, a subdural hematoma, or intracranial bleeding, is ominous and can be seen only on a CAT scan or x-ray. A caput succedaneum, in answer D, crosses the suture line and is edema. R. The nurse is assisting the RN with discharge instructions for a client with an implantable defibrillator. What discharge instruction is essential? a. “You cannot eat food prepared in a microwave.” b. “You should avoid moving the shoulder on the side of the pacemaker site for 6 weeks.” c. “You should use your cellphone on your right side.” d. “You will not be able to fly on a commercial airliner with the defibrillator in place.” Answer C: The client with an internal defibrillator should learn to use any battery- operated machinery on the opposite side. He should also take his pulse rate and report dizziness or fainting. Answers A, B, and D are incorrect because the client can eat food prepared in the microwave, move his shoulder on the affected side, and fly in an airplane. S. A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure? a. Bradycardia b. Tachycardia c. Premature ventricular beats d. Heart block Answer A: Suctioning can cause a vagal response and bradycardia. Answer B is unlikely and, therefore, not most important, although it can occur. Answers C and D can occur as well, but they are less likely. T. The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period? a. Assessment of the client’s level of anxiety b. Evaluation of the client’s exercise tolerance C. Identification of peripheral pulses D. Assessment of bowel sounds and activity Answer C: The assessment that is most crucial to the client is the identification of peripheral pulses because the aorta is clamped during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of fractured femur. The nurse should anticipate an order for: a. Trendelenburg position b. Ice to the entire extremity C. Buck’s traction D. An abduction pillow Answer C: The client with a fractured femur will be placed in Buck’s traction to realign the leg and to decrease spasms and pain. The Trendelenburg position is the wrong position for this client, so answer A is incorrect. Ice might be ordered after repair, but not for the entire extremity, so answer B is incorrect. An abduction pillow is ordered after a total hip replacement, not for a fractured femur; therefore, answer D is incorrect. X. A client with cancer is to undergo an intravenous pyelogram. The nurse should: a. Force fluids 24 hours before the procedure b. Ask the client to void immediately before the study c. Hold medication that affects the central nervous system for 12 hours pre- and post-test d. Cover the client’s reproductive organs with an x-ray shield Answer B: The client having an intravenous pyelogram will have orders for laxatives or enemas, so asking the client to void before the test is in order. A full bladder or bowel can obscure the visualization of the kidney ureters and urethra. In answers A, C, and D, there is no need to force fluids before the procedure, to withhold medications, or to cover the reproductive organs. Y. The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor: a. That cannot be assessed B. That is in situ C. With increasing lymph node involvement D. With distant metastasis Answer B: Cancer in situ means that the cancer is still localized to the primary site. Cancer is graded in terms of tumor, grade, node involvement, and mestatasis. Answer A is incorrect because it is an untrue statement. Answer C is incorrect because T indicates tumor, not node involvement. Answer D is incorrect because a tumor that is in situ is not metastasized. c. Check in the physician’s progress notes to see if understanding has been documented d. Check with the client’s family to see if they understand the procedure fully Answer A: It is the responsibility of the physician to explain and clarify the procedure to the client. Answers B, C, and D are incorrect because they are not within the nurse’s purview. CC. When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain? a. A history of radiation treatment in the neck region b. A history of recent orthopedic surgery c. A history of minimal physical activity d. A history of the client’s food intake Answer A: Previous radiation to the neck might have damaged the parathyroid glands, which are located on the thyroid gland, and interfered with calcium and phosphorus regulation. Answer B has no significance to this case; answers C and D are more related to calcium only, not to phosphorus regulation. DD. A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170meq/L. What behavior changes would be most common for this client? a. Ange r B. Mania C. Depression D. Psychosis Answer B: The client with serum sodium of 170meq/L has hypernatremia and might exhibit manic behavior. Answers A, C, and D are not associated with hypernatremia and are, therefore, incorrect. EE. The nurse is obtaining a history of an 80-year-old client. Which statement made by the client might indicate a possible fluid and electrolyte imbalance? a. “My skin is always so dry.” b. “I often use a laxative for constipation.” c. “I have always liked to drink a lot of ice tea.” d. “I sometimes have a problem with dribbling urine.” Answer B: Frequent use of laxatives can lead to diarrhea and electrolyte loss. Answers A, C, and D are not of particular significance in this case and, therefore, are incorrect. FF. A client visits the clinic after the death of a parent. Which statement made by the client’s sister signifies abnormal grieving? a. “My sister still has episodes of crying, and it’s been 3 months since Daddy died.” b. “Sally seems to have forgotten the bad things that Daddy did in his lifetime.” c. “She really had a hard time after Daddy’s funeral. She said that she had a sense of longing.” d. “Sally has not been sad at all by Daddy’s death. She acts like nothing has happened.” Answer D: Abnormal grieving is exhibited by a lack of feeling sad; if the client’s sister appears not to grieve, it might be abnormal grieving. This family member might be suppressing feelings of grief. Answers A, minutes B. Insertion of a Levine tube C. Cardiac monitoring D. Dressing changes two times per day Answer B: The client with pancreatitis frequently has nausea and vomiting. Lavage is often used to decompress the stomach and rest the bowel, so the insertion of a Levine tube should be anticipated. Answers A and C are incorrect because blood pressures are not required every 15 minutes, and cardiac monitoring might be needed, but this is individualized to the client. Answer D is incorrect because there are no dressings to change on this client. JJ. The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because: a. The client is at risk for evisceration. b. The client will require frequent dressing changes. c. The straps provide support for drains that are inserted in the incision. d. No sutures or clips are used to secure the incision. Answer B: Montgomery straps are used to secure dressings that require frequent dressing changes because the client with a cholecystectomy usually has a large amount of drainage on the dressing. Montgomery straps are also used for clients who are allergic to several types of tape. This client is not at higher risk of evisceration than other clients, so answer A is incorrect. Montgomery straps are not used to secure the drains, so answer C is incorrect. Sutures or clips are used to secure the wound of the client who has had gallbladder surgery, so answer D is incorrect. KK. The physician has ordered that the client’s medication be administered intrathecally. The nurse is aware that medications will be administered by which method? a. Intravenously b. Rectally c. Intramuscularly d. Into the cerebrospinal fluid Answer D: Intrathecal medications are administered into the cerebrospinal fluid. This method of administering medications is reserved for the client with metastases, the client with chronic pain, or the client with cerebrospinal infections. Answers A, B, and C are incorrect because intravenous, rectal, and intramuscular injections are entirely different procedures. LL. Which client can best be assigned to the newly licensed practical nurse? Answer B: The best action for the nurse to take is to explore the interaction with the nursing assistant. This will allow for clarification of the situation. Changing the assignment in answer A might need to be done, but talking to the nursing assistant is the first step. Answer C is incorrect because discussing the incident with the family is not necessary at this time; it might cause more problems. Answer C is not a first step, even though initiating a group session might be a plan for the future. OO. A home health nurse is planning for her daily visits. Which client should the home health nurse visit first? a. A client with AIDS being treated with Foscarnet b. A client with a fractured femur in a long leg cast C.A client with laryngeal cancer with a laryngetomy D. A client with diabetic ulcers to the left foot Answer C: The client with laryngeal cancer has a potential airway alteration and should be seen first. The clients in answers A, B, and D are not in immediate danger and can be seen later in the day. PP. The nurse is assigned to care for an infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin? a. Increasing the infant’s fluid intake b. Maintaining the infant’s body temperature at 98.6°F c. Minimizing tactile stimulation d. Decreasing caloric intake Answer A: Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temperature is important but will not assist in eliminating bilirubin; therefore, answer B is incorrect. Answers C and D are incorrect because they do not relate to the question. QQ. The graduate licensed practical nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority? a. Maintain the client’s systolic blood pressure at 70mmHg or greater b. Maintain the client’s urinary output greater than 300cc per hour c. Maintain the client’s body temperature of greater than 33°F rectal d. Maintain the client’s hematocrit less than 30% Answer A: When the cadaver client is being prepared to donate an organ, the systolic blood pressure should be maintained at 70mmHg or greater to ensure a blood supply to the donor organ. Answers B, C, and D are incorrect because they are unnecessary actions for organ donation. RR. Which action by the novice nurse indicates a need for further teaching? a. The nurse fails to wear gloves to remove a dressing. b. The nurse applies an oxygen saturation monitor to the ear lobe. c. The nurse elevates the head of the bed to check the blood pressure. d. The nurse places the extremity in a dependent position to acquire a peripheral blood sample. Answer A: The nurse who fails to wear gloves to remove a contaminated dressing needs further instruction. Answers B, C, and D are incorrect because they indicate an understanding of the correct method of completing these tasks. b. A client 1 week post-thyroidectomy c. A client 3 days post- splenectomy D. A client 2 days post-thoracotomy Answer D: The most critical client should be assigned to the registered nurse; in this case, that is the client 2 days post-thoracotomy. The clients in answers A and B are ready for discharge, and the client in answer C who had a splenectomy 3 days ago is stable enough to be assigned to an LPN. VV. The licensed practical nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching? a. The graduate places the client in a supine position to read the manometer. b. The graduate turns the stop-cock to the off position from the IV fluid to the client. C. The graduate instructs the client to perform the Valsalva maneuver during the CVP reading. D. The graduate notes the level at the top of the meniscus. Answer C: The client should breathe normally during a central venous pressure monitor reading. Answer A indicates understanding because the client should be placed supine if he can tolerate being in that position. Answers B and D indicate understanding because the stop-cock should be turned off to the IV fluid, and the reading should be done at the top of the meniscus. WW. Which of the following roommates would be most suitable for the client with myasthenia gravis? a. A client with hypothyroidism b. A client with Crohn’s disease c. A client with pylonephritis d. A client with bronchitis Answer A: The most suitable roommate for the client with myasthenia gravis is the client with hypothyroidism because he is quiet. The client with Crohn’s disease in answer B will be up to the bathroom frequently; the client with pylonephritis in answer C has a kidney infection and will be up to urinate frequently. The client in answer D with bronchitis will be coughing and will disturb any roommate. XX. The nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care? a. A 10-year-old with lacerations of the face AAA. The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client’s ability to care for himself. Which statement made by the client would indicate a need for follow-up after discharge? a. “I live by myself.” b. “I have trouble seeing.” c. “I have a cat in the house with me.” d. “I usually drive myself to the doctor.” Answer B: A client with diabetes who has trouble seeing would require follow-up after discharge. The lack of visual acuity for the client preparing and injecting insulin might require help. Answers A, C, and D will not prevent the client from being able to care for himself and, thus, are incorrect. BBB. The client is receiving total parenteral nutrition (TPN). Which lab test should be evaluated while the client is receiving TPN? a. Hemoglobin b. Creatinine c. Blood glucose d. White blood cell count Answer C: When the client is receiving TPN, the blood glucose level should be drawn. TPN is a solution that contains large amounts of glucose. Answers A, B, and D are not directly related to the question and are incorrect. CCC. The client with a myocardial infarction comes to the nurse’s station stating that he is ready to go home because there is nothing wrong with him. Which defense mechanism is the client using? a. Rationalizati on B. Denial C. Projection D. Conversion reaction Answer B: The client who says he has nothing wrong is in denial about his myocardial infarction. Rationalization is making excuses for what happened, projection is projecting feeling or thoughts onto others, and conversion reaction is converting a psychological trauma into a physical illness; thus, answers A, C, and D are incorrect. DDD.Which laboratory test would be the least effective in making the diagnosis of a myocardial infarction? a. AST b. Troponin c. CK-MB d. Myoglobin Answer A: Answer A, AST, is not specific for myocardial infarction. Troponin, CK- MB, and myoglobin, in answers B, C, and D, are more specific, although myoglobin is also elevated in burns and trauma to muscles. EEE. The licensed practical nurse assigned to the post-partal unit is preparing to administer Rhogam to a postpartum client. Which woman is not a candidate for RhoGam? a. A gravida IV para 3 that is Rh negative with an Rh-positive baby HHH.The client is scheduled for a pericentesis. Which instruction should be given to the client before the exam? a. “You will need to lay flat during the exam.” b. “You need to empty your bladder before the procedure.” c. “You will be asleep during the procedure.” d. “The doctor will inject a medication to treat your illness during the procedure.” Answer B: The client scheduled for a pericentesis should be told to empty the bladder, to prevent the risk of puncturing the bladder when the needle is inserted. A pericentesis is done to remove fluid from the peritoneal cavity. The client will be positioned sitting up or leaning over a table, making answer A incorrect. The client is usually awake during the procedure, and medications are not commonly inserted into the peritoneal cavity during this procedure; thus, answers C and D are incorrect (although this could depend on the circumstances). III. To ensure safety while administering a nitroglycerine patch, the nurse should: a. Wear gloves b. Shave the area where the patch will be applied c. Wash the area thoroughly with soap and rinse with hot water d. Apply the patch to the buttocks Answer A: To protect herself, the nurse should wear gloves when applying a nitroglycerine patch or cream. Answer B is incorrect because shaving the shin might abrade the area. Answer C is incorrect because washing with hot water will vasodilate and increase absorption. The patches should be applied to areas above the waist, making answer D incorrect. JJJ. A 25-year-old male is brought to the emergency room with a piece of metal in his eye. Which action by the nurse is correct? a. Use a magnet to remove the object. b. Rinse the eye thoroughly with saline. C. Cover both eyes with paper cups. D. Patch the affected eye only. c. Compensated respiratory acidosis d. Uncompensated metabolic acidosis Answer C: The client is experiencing compensated respiratory acidosis. The pH is within the normal range but is lower than 7.40, so it is on the acidic side. The CO2 level is elevated, the oxygen level is below normal, and the bicarb level is slightly elevated. In respiratory disorders, the pH will be the inverse of the CO2 and bicarb levels. This means that if the pH is low, the CO2 and bicarb levels will be elevated. Answers A, B, and D are incorrect because they do not fall into the range of symptoms. NNN.The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to: a. Take the blood pressure, pulse, and temperature B.Ask the client to rate his pain on a scale of 0–5 C. Watch the client’s facial expression D. Ask the client if he is in pain Answer B: The best way to evaluate pain levels is to ask the client to rate his pain on a scale. In answer A, the blood pressure, pulse, and temperature can alter for other reasons than pain. Answers C and D are not as effective in determining pain levels. OOO. The nursing is participating in discharge teaching for the post-partal client. The nurse is aware that an effective means of managing discomfort associated with an episiotomy after discharge is: a. Promethazine b. Aspirin c. Sitz baths d. Ice packs Answer C: A sitz bath will help with swelling and improve healing. Ice packs, in answer D, can be used immediately after delivery. Answers A and B are not used in this instance. PPP. Which of the following post-operative diets is most appropriate for the client who has had a hemorroidectomy? a. High-fiber b. Low-residue c. Bland d. Clear-liquid Answer D: After surgery, the client will be placed on a clear-liquid diet and progressed to a regular diet. Stool softeners will be included in the plan of care, to avoid constipation. Later, a high-fiber diet, in answer A, is encouraged, but this is not the first diet after surgery. Answers B and C are not diets for this type of surgery. QQQ. The physician has ordered a culture for the client with suspected gonorrhea. The nurse should obtain which type of culture? a. Blood b. Nasopharyngeal secretions c. Stool d. Genital secretions Answer D: A culture for gonorrhea is taken from the genital d. Providing saliva substitute Answer D: Xerostomia is dry mouth, and offering the client a saliva substitute will help the most. Eating hard candy in answer A can further irritate the mucosa and cut the tongue and lips. Administering an analgesic might not be necessary; thus, answer B is incorrect. Splinting swollen joints, in answer C, is not associated with xerostomia. UUU.A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first? a. A client with brain attack (stroke) with tube feedings b. A client with congestive heart failure complaining of nighttime dyspnea c. A client with a thoracotomy 6 months ago d. A client with Parkinson’s disease Answer B: The client with congestive heart failure who is complaining of nighttime dyspnea should be seen first because airway is number one in nursing care. In answers A, C, and D, the clients are more stable. VVV. A client with glomerulonephritis is placed on a low-sodium diet. Which of the following snacks is suitable for the client with sodium restriction? a. Peanut butter cookies b. Grilled cheese sandwich c. Cottage cheese and fruit D. Fresh peach Answer D: The fresh peach is the lowest in sodium of these choices. Answers A, B, and C have much higher amounts of sodium. WWW. Due to a high census, it has been necessary for a number of clients to be transferred to other units within the hospital. Which client should be transferred to the postpartum unit? a. A 66-year-old female with a gastroenteritis B. A 40-year-old female with a hysterectomy C. A 27-year-old male with severe depression D. A 28-year-old male with ulcerative colitis Answer B: The best client to transport to the postpartum unit is the 40-year- old female with a hysterectomy. The nurses on the postpartum unit will be aware of ZZZ. A new nursing graduate indicates in charting entries that he is a licensed practical nurse, although he has not yet received the results of the licensing exam. The graduate’s action can result in what type of charge: a. Fraud b. Tort c. Malpractice d. Negligence Answer A: Identifying oneself as a nurse without a license defrauds the public and can be prosecuted. A tort is a wrongful act; malpractice is failing to act appropriately as a nurse or acting in a way that harm comes to the client; and negligence is failing to perform care. Therefore, answers B, C, and D are incorrect. AAAA. A client with acute leukemia develops a low white blood cell count. In addition to the institution of isolation, the nurse should: a. Request that foods be served with disposable utensils b. Ask the client to wear a mask when visitors are present c. Prep IV sites with mild soap and water and alcohol D.Provide foods in sealed single-serving packages Answer D: Because the client is immune-suppressed, foods should be served in sealed containers, to avoid food contaminants. Answer B is incorrect because of possible infection from visitors. Answer A is not necessary, but the utensils should be cleaned thoroughly and rinsed in hot water. Answer C might be a good idea, but alcohol can be drying and can cause the skin to break down. BBBB. A 70-year-old male who is recovering from a strike exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect? a. The client is observed shaving only one side of his face. b. The client is unable to distinguish between two tactile stimuli presented simultaneously. c. The client is unable to complete a range of vision without turning his head side to side. d. The client is unable to carry out cognitive and motor activity at the same time. Answer A: The client with unilateral neglect will neglect one side of the body. Answers B, C, and D are not associated with unilateral neglect. CCCC. The nurse is providing discharge teaching for a client taking disulfiram (Antabuse). The nurse should instruct the client to avoid eating: a. Peanuts, dates, raisins b. Figs, chocolate, eggplant c. Pickles, salad with vinaigrette dressing, beef d. Milk, cottage cheese, ice cream Answer C: The client taking antabuse should not eat or drink anything containing alcohol or vinegar. The other foods in answers A, B, and D are allowed. DDDD. A client has been receiving cyanocobalamine (B12) injections for the past 6 weeks. Which laboratory finding indicates that the medication is having the desired effect? rooms because these clients are disruptive or have infections. In the case of answer C, the child is terminal and should be in a private room with his parents. GGGG. The home health nurse is planning for the day’s visits. Which client should be seen first? a. The 78-year-old who had a gastrectomy 3 weeks ago with a PEG tube D. The 30-year-old with an exacerbation of multiple sclerosis being treated b. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension c. The 50-year-old with MRSA being treated with Vancomycin via a PICC line with cortisone via a centrally placed venous catheter Answer D: The priority client is the one with multiple sclerosis who is being treated with cortisone via the central line. This client is at highest risk for complications. MRSA, in answer C, is methicillin- resistant staphylococcus aureas. Vancomycin is the drug of choice and can be administered later, but its use must be scheduled at specific times of the day to maintain a therapeutic level. Answers A and B are incorrect because these clients are more stable. HHHH. The nurse is making assignments for the day. Which client should be assigned to the pregnant nurse? a. The client receiving linear accelerator radiation therapy for lung cancer b. The client with a radium implant for cervical cancer c. The client who has just been administered soluble brachytherapy for thyroid cancer d. The client who returned from placement of iridium seeds for prostate cancer Answer A: The pregnant nurse should not be assigned to any client with radioactivity present. Therefore, the client receiving linear accelerator therapy is correct because this client travels to the radium department for therapy, and the radiation stays in the department; the client is not radioactive. The client in answer B does pose a risk to the pregnant client. The client in answer C is radioactive in very small doses. For approximately 72 hours, the client should dispose of urine and feces in special containers and use plastic spoons and forks. The client in answer D is also radioactive in small amounts, especially upon return from the procedure. Answer B: A persistent cough might be related to an adverse reaction to Captoten. Answers A and D are incorrect because tinnitus and diarrhea are not associated with the medication. Muscle weakness might occur when beginning the treatment but is not an adverse effect; thus, answer C is incorrect. LLLL. The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes: a. Rotating application sites b. Limiting applications to the chest c. Rubbing it into the skin d. Covering it with a gauze dressing Answer A: Sites for the application of nitroglycerin should be rotated, to prevent skin irritation. It can be applied to the back and upper arms, not to the lower extremities, making answer B incorrect. Answer C is contraindicated to the question, and answer D is incorrect because the medication should be covered with a prepared dressing made of a thin paper substance, not gauze. MMMM. Lidocaine is a medication frequently ordered for the client experiencing: a. Atrial tachycardia b. Ventricular tachycardia c. Heart block d. Ventricular brachycardia Answer B: Lidocaine is used to treat ventricular tachycardia. This medication slowly exerts an antiarrhythmic effect by increasing the electric stimulation threshold of the ventricles without depressing the force of ventricular contractions. It is not used for atrial arrhythmias; thus, answer A is incorrect. Answers C and D are incorrect because it slows the heart rate, so it is not used for heart block or brachycardia. NNNN. The client is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. The doctor orders quinidine sulfate. While he is receiving quinidine, the nurse should monitor his ECG for: a. Peaked P wave b. Elevated ST segment c. Inverted T wave d. Prolonged QT interval Answer D: Quinidine can cause widened Q-T intervals and heart block. Other signs of myocardial toxicity are notched P waves and widened QRS complexes. The most common side effects are diarrhea, nausea, and vomiting. The client might experience tinnitus, vertigo, headache, visual disturbances, and confusion. Answers A, B, and C are not related to the use of quinidine. OOOO. The physician has prescribed tranylcypromine sulfate (Parnate) 10mg bid. The nurse should teach the client to refrain from eating foods containing tyramine because it may cause: a. Hypertension b. Hyperthermia c. Melanoma d. Urinary retention Answer A: If the client eats foods high in tyramine, he might experience malignant hypertension. Tyramine is found in cheese, sour cream, Chianti wine, sherry, beer, pickled herring, liver, canned figs, d. She can copy a horizontal or vertical line. Answer B: Children at 18 months of age like push-pull toys. Children at approximately 3 years of age begin to dress themselves and build a tower of eight blocks. At age four, children can copy a horizontal or vertical line. Therefore, answers A, C, and D are incorrect. SSSS.Which information obtained from the mother of a child with cerebral palsy most likely correlates to the diagnosis? a. She was born at 42 weeks gestation. b. She had meningitis when she was 6 months old. c. She had physiologic jaundice after delivery. d. She has frequent sore throats. Answer B: The diagnosis of meningitis at age 6 months correlates to a diagnosis of cerebral palsy. Cerebral palsy, a neurological disorder, is often associated with birth trauma or infections of the brain or spinal column. Answers A, C, and D are not related to the question. TTTT.A 10-year-old is being treated for asthma. Before administering Theodur, the nurse should check the: a. Urinary output b. Blood pressure C. Pulse D. Temperature Answer C: Theodur is a bronchodilator, and a side effect of bronchodilators is tachycardia, so checking the pulse is important. Extreme tachycardia should be reported to the doctor. Answers A, B, and D are not necessary. UUUU. An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with a fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals and cloudiness in the IV medication? a. Discard the solution and order a new bag b. Warm the solution c. Continue the infusion and document the finding d. Discontinue the medication Answer A: Crystals in the solution are not normal and should not be administered to the client. Discard the bad solution immediately. Answer B is incorrect because D. Morning administration mimics the body’s natural secretion of corticosteroid. Answer D: Taking corticosteroids in the morning mimics the body’s natural release of cortisol. Answers A is not necessarily true, and answers B and C are not true. YYYY. A 20-year-old female has a prescription for tetracycline. While teaching the client how to take her medicine, the nurse learns that the client is also taking Ortho-Novum oral contraceptive pills. Which instructions should be included in the teaching plan? a. The oral contraceptives will decrease the effectiveness of the tetracycline. b. Nausea often results from taking oral contraceptives and antibiotics. c. Toxicity can result when taking these two medications together. d. Antibiotics can decrease the effectiveness of oral contraceptives, so the client should use an alternate method of birth control. Answer D: Taking antibiotics and oral contraceptives together decreases the effectiveness of the oral contraceptives. Answers A, B, and C are not necessarily true. ZZZZ.A 60-year-old diabetic is taking glyburide (Diabeta) 1.25mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching? a. “I will keep candy with me just in case my blood sugar drops.” b. “I need to stay out of the sun as much as possible.” C. “I often skip dinner because I don’t feel hungry.” D. “I always wear my medical identification.” Answer C: The client should be taught to eat his meals even if he is not hungry, to prevent a hypoglycemic reaction. Answers A, B, and D are incorrect because they indicate an understanding of the nurse’s teaching. AAAAA. The physician prescribes regular insulin, 5 units subcutaneous. Regular insulin begins to exert an effect: a. In 5–10 minutes b. In 10–20 minutes C. In 30–60 minutes D. In 60–120 minutes Answer C: The time of onset for regular insulin is 30–60 minutes; therefore, answers A, B, and D are incorrect. BBBBB. The client is admitted from the emergency room with multiple injuries sustained from an auto accident. His doctor prescribes a histamine blocker. The reason for this order is: a. To treat general discomfort b. To correct electrolyte imbalances C. To prevent stress ulcers D. To treat nausea Answer C: Histamine blockers are frequently ordered for clients who are hospitalized for prolonged periods and who are in a stressful situation. They are not used to treat discomfort, correct electrolytes, or treat nausea; therefore, answers A, B, and D are incorrect. CCCCC. The client with a recent liver transplant asks the nurse Answer A: Clients having dye procedures should be assessed for allergies to iodine or shellfish. Answers B and D are incorrect because there is no need for the client to be assessed for reactions to blood or eggs. Because an IV cholangiogram is done to detect gallbladder disease, there is no need to ask about answer C. FFFFF. A new diabetic is learning to administer his insulin. He receives 10U of NPH and 12U of regular insulin each morning. Which of the following statements reflects understanding of the nurse’s teaching? a. “When drawing up my insulin, I should draw up the regular insulin first.” b. “When drawing up my insulin, I should draw up the NPH insulin first.” c. “It doesn’t matter which insulin I draw up first.” d. “I cannot mix the insulin, so I will need two shots.” Answer A: Regular insulin should be drawn up before the NPH. They can be given together, so there is no need for two injections, making answer D incorrect. Answer B is obviously incorrect, and answer C is incorrect because it does matter which is drawn first: Contamination of NPH into regular insulin will result in a hypoglycemic reaction at unexpected times. GGGGG. A client with osteomylitis has an order for a trough level to be done because he is taking Gentamycin. When should the nurse call the lab to obtain the trough level? a. Before the first dose b. 30 minutes before the fourth dose c. 30 minutes after the first dose d. 30 minutes after the fourth dose Answer B: Trough levels are the lowest blood levels and should be done 30 minutes before the third IV dose or 30 minutes before the fourth IM dose. Answers A, C, and D are incorrect. HHHHH. A 4-year-old with cystic fibrosis has a prescription for Viokase pancreatic enzymes to prevent malabsorption. The correct time to give pancreatic enzyme is: a. 1 hour before meals b. 2 hours after meals c. With each meal and snack d. On an empty stomach a. Administer a bolus of IV fluid b. Administer pain medication C. Administer an antiemetic D. Allow the patient a chance to eat Answer C: Before chemotherapy, an antiemetic should be given because most chemotherapy agents cause nausea. It is not necessary to give a bolus of IV fluids, medicate for pain, or allow the client to eat; therefore, answers A, B, and D are incorrect. LLLLL. Before administering Methytrexate orally to the client with cancer, the nurse should check the: a. IV site b. Electrolytes c. Blood gases D. Vital signs Answer D: The vital signs should be taken before any chemotherapy agent. If it is an IV infusion of chemotherapy, the nurse should check the IV site as well. Answers B and C are incorrect because it is not necessary to check the electrolytes or blood gases. MMMMM. Vitamin K (aquamephyton) is administered to a newborn shortly after birth for which of the following reasons? a. To prevent dehydration b. To treat infection c. To replace electrolytes D. To facilitate clotting Answer D: Vitamin K is given after delivery because the newborn’s intestinal tract is sterile and lacks vitamin K needed for clotting. Answer A is incorrect because vitamin K is not directly given to prevent dehydration, but will facilitate clotting. Answers B and C are incorrect because vitamin K does not prevent infection or replace electrolytes. NNNNN. The nurse is ready to begin an exam on a 9-month-old infant. The child is sitting in his mother’s lap. What should the nurse do first? a. Check the Babinski reflex b. Listen to the heart and lung sounds c. Palpate the abdomen d. Check tympanic membranes Answer B: The first action that the nurse should take when beginning to examine the infant is to listen to the heart and lungs. If the nurse elicits the Babinski reflex, palpates the abdomen, or looks in the child’s ear first, the child will begin to cry and it will be difficult to obtain an objective finding while listening to the heart and lungs. Therefore, answers A, C, and D are incorrect.