COMPILATION OF NCLEX QUESTIONS
Source of compiled questions: Memory recall of countless generous NCLEX takers and USRNs whom I’ve had the privilege of meeting and knowing. References of rationale: Mosby’s Medical, Nursing, and Allied Health Dictionary Saunders Comprehensive Review NCLEX-RN® Examination 6 th edition published 2013 Disclaimer: I consulted my Saunders 6th edition book along with reputable online sources in answering this compilation but please verify my answers for yourself so that you will have the BEST answer. If I committed errors, kindly edit this compilation accordingly. Salamat po. ^_^ Updated and supplemented last: November 15, 2015
1. You are providing a health teaching for a patient prescribed with medroxyprogesterone acetate (Depo – Provera). What is an appropriate health teaching for the patient? a. It is an injectable contraceptive that is administered every 12 weeks. b. Depo-Provera has a higher failure rate than oral contraceptives. c. Depo-Provera interferes with lactation. d. Like oral contraceptives, Depo-Provera ↑ the risk of venous thrombosis.
Medroxyprogesterone acetate (Depo-Provera) is administered intramuscularly every 85-90 days or 12 weeks. Depot injections provide long acting forms of birth control, from 3 months to 5 years in duration. The most common side effect of Depo-Provera is amenorrhea or irregular bleeding. Amenorrhea usually develops after the 2nd or 3rd injection, while breakthrough bleeding is common during the first 3-6 months. With a failure rate similar to contraceptives, Depo-Provera does not interfere with lactation. Typically, the estrogen component of hormonal contraceptives is associated with thromboembolic disease; Depo-Provera contains only progestin.
2. You have the patient’s chart on hand. Which laboratory value is helpful in identifying heart failure as the cause of dyspnea? a. A-natriuretic peptides (ANP) b. B-natriuretic peptides (BNP) c. C-natriuretic peptides (CNP) d. blood urea nitrogen (BUN)
Natriuretic peptides are neuroendocrine peptides that are used to identify clients with heart failure (HF). There are 3 major peptides: atrial natriuretic peptides (ANP) synthesized in cardiac atrial muscle, brain natriuretic peptides (BNP) synthesized in cardiac ventricular muscle (although originally BNP was identified in extracts of porcine brain), and C-type natriuretic peptides (CNP) synthesized by endothelial cells. BNP is the primary marker for identifying HF as the cause of dyspnea.
3. A client has a tracheostomy in place. Which statement would indicate a need for additional teaching? a. “I can suction no more than 10 seconds each time before removing the catheter.” b. “I can reuse the catheter for oral secretions after the tracheostomy suctioning, if needed.” c. “I will reuse the catheters several times before discarding them, to save money.”
Suction catheters should be inserted only during one suctioning period to minimize the risk of contamination from allowing the catheter to lie out of the sterile packet, which would allow bacteria to grow between suctioning periods.
4. What will be included in health teachings imparted to a patient taking chlorpromazine (Thorazine)? a. watch out for fever. b. check WBCs every month. c. malaise and yellowing of sclera are expected. d. drink alcohol in moderation.
Instruct patient to report signs of agranulocytosis which include sore throat, fever and malaise. Alcohol and other CNS depressants are avoided. Instruct patient to report signs of liver dysfunction including jaundice, malaise, fever and RUQ pain. Agranulocytosis is the most dangerous side effect of antipsychotics and can lead to death if not detected and treated early. In addition to the requirement that weekly analysis of WBCs must be completed before antipsychotics can be reordered, it is important that the client, family, and nursing staff understand that changes in the WBC could occur during the time period between two laboratory tests. Therefore, reporting any observations of suspected infection is an urgent priority.
5. Patient is taking sildenafil (Viagra), further teaching is given to patient when he states? a. I will continue taking nitroglycerin. b. I will continue taking vitamins. c. I have difficulty sleeping at night.
The question is asking for a negative statement. Sildenafil (Viagra) enhances the vasodilating effect of nitric oxide in the corpus cavernosum of the penis, thus sustaining an erection. Because of the effect of the medication, it is contraindicated with concurrent use of organic nitrates and nitroglycerin. Use of vitamins is not contraindicated. Insomnia is an expected side effect.
6. The male parent will take his wife and 6 months old infant home after confinement, which statement indicates that teaching was understood by the father who will drive the car?
a. b. c. d.
The newborn will be placed in the backseat facing forward. The newborn will be placed in the backseat rear facing. The newborn will be placed in a booster seat beside the driver seat. The newborn will be placed in a booster seat in the backseat.
The safest place for all children to ride, regardless of age, is in the back seat of the car. Infants should ride in a semi-reclined, rear-facing position in an infant-only seat or a convertible seat until they weigh at least 20 pounds and are at least 1 year of age. The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat but is generally at a body weight of 9 kg or 20 pounds and 1 year of age. All children whose weight or height is above the forward-facing limit for their car safety seat should use a belt-positioning booster seat until the vehicle seatbelt fits properly, typically when they have reached 4 feet 9 inches in height and are between 8 and 12 years of age.
7. What are appropriate nursing interventions for patients with migraine? Select all that apply: a. “I will apply a warm compress.” b. ↓ stimuli c. “I will stop my exercise program.” d. “I will never be able to drive again, due to my headaches.” e. “I will be keeping a diary of my headaches, so that I can see a pattern.” f. “I will take my medication every 4 hours.”
If the client understands the importance of finding the triggering factors, he/she will be more willing to be involved in decreasing the triggers, including lifestyle changes that might be necessary. The client should continue to exercise for general health and stress management. Driving is permitted. Medication might not be needed every 4 hours.
8. What medication is administered if a patient on ECG monitor exhibits ventricular tachycardia? a. Lidocaine (Xylocaine) b. Atropine c. Diltiazem (Cardizem) d. Metoprolol (Lopressor)
Lidocaine is used to treat ventricular dysrhythmias (premature ventricular contractions, ventricular tachycardia, and ventricular fibrillation), particularly in clients with myocardial infarction. It is a class 1-A antiarrhythmic. Lidocaine suppresses automaticity in the bundle of HIS – Purkinje fiber system by increasing the electrical stimulation threshold of the ventricle during diastole thus decreasing ventricular irritability.
9. You are conducting a health education session on factors for GERD. Which lifestyle modifications will you include? Select all that apply: a. Exercise regularly b. Eat small frequent feedings. c. Avoid peppermint on food.
d. use anticholinergics if prescribed. e. use prokinetic medications if prescribed.
The client is instructed to avoid factors that ↓lower esophageal sphincter pressure or cause esophageal irritation such as peppermint, chocolate, coffee, fried or fatty foods, carbonated beverages, alcoholic beverages, cigarette smoking, nicotine, beta blockers, calcium channel blockers, nitrates, theophylline, ↑ levels of estrogen and progesterone, and anticholinergic drugs. On the other hand, Prokinetic medications are used for they accelerate gastric emptying.
10. What are the manifestations of Cushing’s disease? Select all that apply: a. hypernatremia b. hypokalemia c. weight loss d. petechiae e. purpura f. bruising g. hypercalcemia
Assessment findings for Cushing’s disease include: generalized muscle wasting and weakness; moon face, buffalo hump; truncal obesity with thin extremities, supraclavicular fat pads, weight gain; hirsutism, hyperglycemia, hypernatremia, hypokalemia, hypocalcemia; hypertension; fragile skin that easily bruises, reddish purple striae on the abdomen and upper thighs.
11. You will teach a patient taking bethanechol (Urecholine) to? a. take with meals b. take at bedtime c. use bed pan or urinal to ↑ urine output d. take 2 hours after meals
Bethanechol (Urecholine) is a direct acting cholinergic used to ↑bladder tone and function and to treat non obstructive urinary retention. It is administered on an empty stomach, 1 hour before or 2 hours after meals to lessen nausea and vomiting.
12. What is a positive outcome for an antisocial client? a. Patient manifests ↓ self-destructive behavior. b. Patient socializes with others. c. Consistent limits are maintained d. Development of insight
In caring for clients diagnosed with antisocial personality disorder, it is important to maintain a structured and consistent environment to ↓ their attempts to control the situation through manipulation. It is unlikely that they will develop insight as the causes of the problems in living are externalized. They are frequently quite sociable and take advantage of others for personal profit. Suicidal ideation is not associated with this disorder.
13. A patient is prescribed fluticasone propionate (Flovent HFA). Which is a component of health teachings in the use of this medication? a. wait for one minute in between puffs b. report tinnitus to the physician c. take during episodes of wheezing
Fluticasone propionate (Flovent HFA) is an inhaled glucocorticoid. It is an anti-inflammatory agent and helps ↓ airway edema.
14. What are the adverse effects of fosinopril? Select all that apply: a. dry cough b. orthostatic hypotension c. hypokalemia d. ↑ RBCs e. ↓ platelet count
A patient on ACE inhibitors should be instructed to report development of a cough especially one that is resistant to cough suppressants. Other adverse effects include orthostatic hypotension, hyperkalemia and blood dyscrasias (↓RBCs, ↓WBCs, ↓platelet count)
15. You are the staff nurse on duty. Which patient is a priority? a. A patient with COPD on O2 via nasal cannula with O2 of 92%. b. A patient with pancreatitis complains of shoulder pain. c. A patient with ECG tracing of atrial fibrillation with heart rate of 98 beats per min d. A patient with a femoral cast complains of painful toes and ↓ pulse distal to the area.
Compartment syndrome is a condition in which pressure ↑ in a confined anatomical space, leading to ↓blood flow, ischemia, and dysfunction of these tissues. This complication can occur with casts. Signs of this complication include unrelieved or ↑pain in the limb, pale, dusky or edematous tissue distal to the involved area; pain with passive movement; loss of sensation (paresthesia); and pulselessness (a late sign). The nurse should contact the HCP immediately if signs of neurovascular impairment are noted in a patient with a case because of the risk of tissue ischemia and necrosis.
16. What are the manifestations of toxic shock syndrome? Select all that apply: a. hypertension b. ↑ cardiac rate c. ↑ respiratory rate d. constipation e. ↓ cardiac output f. myalgia
In an otherwise healthy person, the onset of TSS occurs with a sudden fever (temperature is always at least 38.9°C / 102°F, chills, malaise, and muscle pain. Vomiting, diarrhea, hypotension, headache, and signs suggesting early septic shock may develop. A red, macular rash similar to sunburn (diffuse,
macular erythroderma) is a classic sign of TSS. In some patients, this rash appears first on the torso; in others, it is first seen on the hands (palms and fingers) and feet (soles and toes). Inflammation of mucous membranes also may occur. In 7 to 10 days, it desquamates (becomes scaly or peels). Myalgia and dizziness are common. Severe cases can result in acute respiratory distress syndrome (ARDS), and cardiac dysfunction may occur. 17. You are tasked to conduct a nursing conference regarding health risk factors of various races. Native Americans are at risk for? a. Diabetes mellitus b. Sickle cell anemia c. Cancer d. Thalassemia
African Americans are at risk for sickle cell anemia instead of Native Americans. White Americans are at risk for cancer instead of Native Americans. Asian Americans are at risk for thalassemia instead of Native Americans.
18. A patient has disseminated varicella zoster. What will be a component of nursing care? a. keep stethoscope and BP in the room only for the client’s use – contact b. wear gloves before entering the room – contact c. wear surgical mask when feeding the client – droplet d. keep the door closed at all times
Disseminated varicella zoster requires airborne precautions. Airborne precautions include the following: Placing the client in a single room that is maintained under negative pressure; door remains closed except upon entering and exiting. Negative airflow pressure is used in the room, with a minimum of 6 – 12 air exchanges per hour depending on health agency protocol. Ultraviolet germicide irradiation or high efficiency particulate air filter is used in the room. Health care workers wear a mask or personal respiratory protection device. Mask is placed on the client when the client needs to leave the room; client leaves the room only if necessary.
19. ORDERED RESPONSE: Use of crutches in going downstairs with a weak left leg. 1. Assume tripod position 2. Advance crutch with the left leg 3. Shift weight to right leg 4. Move right leg 20. You are taking care of a patient with bipolar disorder. Which statement by the patient will you be most concerned with? a. I gave away all my money because I don’t need it since I live in the White House. b. I’ll have you arrested because I’m from the White House.
Suicidal patients may manifest suicidal ideation by giving away possessions.
21. In which condition is it appropriate for pregnant nurse asks another nurse to administer? a. calcium gluconate b. RotaTeq c. Cefalexin d. Glargine
Rotavirus is teratogenic to pregnant women upon exposure to it. RotaTeq is a form of rotavirus vaccine.
22. Which patient will you see first? a. myasthenia gravis with drooling saliva b. multiple sclerosis with diplopia c. huntington’s disease with wrenching
This presents a potential risk for aspiration and ineffective airway clearance. When the muscles involved in mastication, swallowing, as wells as the diaphragm, and intercostal muscles are weak, the client may aspirate or experience poor gas exchange.
23. A patient’s laboratory findings include WBC = 1,000 mm 3 and platelet count = 50,000 cells/mm3. What are your appropriate nursing interventions? Select all that apply: a. Maintain reverse isolation. b. Instruct patient to avoid crowds. c. Avoid eating fresh fruits and vegetables. d. Teach patient the importance of avoiding bumping or bruising the skin. e. Take aspirin (ASA) regularly. f. Administer IM injections often. g. Avoid rectal temperature-taking. h. Patient should be in a semi- private room.
The patient’s laboratory values indicate leukopenia and thrombocytopenia. Hence, the patient is placed on neutropenic and bleeding precautions. Aspirin intake will lead to further bleeding. Intramuscular and subcutaneous injections are avoided. The patient should stay in a private room instead of a semi-private room.
24. In which situation is a nurse committing negligence? a. A nurse administers atropine sulfate (Isopto Atropine) to a client with glaucoma.
Negligence is the unintentional failure of an individual to perform or not perform an act that a reasonable person would or would not do in the same circumstance. Atropine sulfate is an anticholinergic and mydriatic medication. Anticholinergics are contraindicated in clients with angleclosure glaucoma because they can inhibit flow of aqueous humor and ↑intraocular pressure.
25. A nurse is about to administer alendronate sodium (Fosamax), which indicates correct understanding? Select all that apply: a. It is best taken with water. b. Remain upright after intake. c. It ↑ bone density and mass. d. take with milk
Alendronate sodium (Fosamax) is a bisphosphonate given for patients with osteoporosis and/or Paget’s disease. Milk is taken together with alendronate sodium (Fosamax). This may lead to milk alkali syndrome. It is taken before meals with distilled/plain water. The patient is instructed to avoid taking with mineralized water, orange juice, tea or coffee. The patient is instructed to remain upright after taking the drug.
26. Which patient will you see first? a. Post – operative patient with platelet count of 150,000 cells/mm 3. b. Patient on warfarin therapy with prothrombin time of 40 seconds. c. Postpartum patient with hemoglobin of 12 g/dL. d. Postpartum patient with RBCs 4.5 million/µL
If the PT value is longer than 30 seconds on a client on warfarin therapy, bleeding precautions are instituted.
27. What is an age-appropriate activity for a 5 y/o preschooler? a. bicycle riding b. gymnastics c. ball throwing and catching d. finger paints
At 4 years, the child’s gross movements include catching and throwing balls. School age children are more adept at bicycle riding specifically 6 year olds. School age children are more attuned to gymnastics specifically 8 year olds. Finger paints are appropriate for toddlers.
28. Which diagnostic finding requires follow up for patient taking prolonged Simvastatin (Zocor)? a. ↓ triglycerides b. ↑ HDL c. ↓ LDL d. ↑ AST
Simvastatin (Zocor) is hepatotoxic.↑ Aspartate aminotransferase (AST) indicates hepatotoxicity. Patients on simvastatin therapy should be checked for liver function tests. Simvastatin’s therapeutic effects include ↓LDL, ↓triglycerides and ↑HDL
29. What is an appropriate toy for toddlers?
a. toy telephone b. musical mobile c. set of blocks d. paint-by-number set
Imitative behaviors teach the toddler new skills. Toddlers enjoy such toys as a play telephone. Manipulation of toys develops both gross and fine motor abilities in this period. Paint-by-number sets are recommended for school-aged children. Musical mobiles and a set of blocks are appropriate for infants.
30. A patient develops hyperkalemia, which drug will you give first? a. Intravenous Insulin + 10% glucose b. Polysterene sulfonate (Kayexalate) c. Intravenous sodium bicarbonate (NaHCO3) d. hemodialysis
A patient with hyperkalemia is assessed for ECG changes. If ECG abnormalities are present, calcium gluconate is administered. If ECG abnormalities are absent, insulin + 10% glucose is administered intravenously. Polystyrene sulfonate (Kayexelate) is administered via enema. Hemodialysis is the last resort if the patient has persistent hyperkalemia.
31. What is the drug of choice for premature ventricular contractions (PVCs)? a. Lidocaine (Xylocaine) b. Atropine sulfate c. Isuprel d. Dopamine
Lidocaine is used to treat ventricular dysrhythmias (premature ventricular contractions, ventricular tachycardia, and ventricular fibrillation), particularly in clients with myocardial infarction. It is a class 1-A antiarrhythmic. Lidocaine suppresses automaticity in the bundle of HIS – Purkinje fiber system by increasing the electrical stimulation threshold of the ventricle during diastole thus decreasing ventricular irritability.
32. Which of the following are true regarding Trousseau’s sign? Select all that apply: a. For assessment, inflate the BP cuff in the patient’s arm and observe for carpopedal spasm b. it is the contraction of facial muscles in response to a light tap over the facial nerve in front of the ear. c. It indicates hypocalcemia. d. It indicates hypercalcemia. e. It refers to distal paresthesia elicited by tapping the median nerve on the wrist.
Trosseau’s sign is a carpal spasm induced by inflating a BP cuff. The BP cuff is kept above the systolic pressure for a few minutes.
33. A patient post thyroidectomy suddenly experiences tingling around his/her mouth. The nurse will administer which medication? a. Calcium carbonate (Tums, Os-cal) b. Furosemide (Lasix) c. Ramipril (Altace) d. Digoxin (Lanoxin)
Tingling or numbness around the mouth or circumoral paresthesia is a sign of impending tetany and indicates hypocalcemia. Calcium is administered either orally or intravenously.
34. Administration of filgrastim (Neupogen) is contraindicated to which religion? a. Jehovah’s witnesses b. Roman Catholicism c. Judaism d. Shintoism
Filgrastim (Neupogen) is a leukopoietic growth factor. It helps prevent infections in patients with neutropenia. Members are not allowed to receive blood transfusion.
35. You see a fire in patient's room. What will you do first? a. turn off oxygen first b. remove patient from the room c. activate the fire alarm d. extinguish the fire
Safety is a priority. Oxygen is flammable, so turning off oxygen is an immediate intervention.
36. A client with Meniere’s disease would probably NOT complain of which of the following? a. often tinnitus is present b. vertigo and nausea c. pain when the tragus is touched d. unilateral hearing impairment e. bilateral hearing impairment f. mastoid bone tenderness
Meniere’s disease is associated with vertigo that may last for hours as well as fluctuating hearing loss, nausea, and vomiting. The disorder is unilateral, but because hearing is bilateral, the client often does not realize the extent of the hearing loss.
37. What are you going to observe in a patient with retinal detachment? Select all that apply: a. Floaters b. loss of peripheral vision c. blurred vision
d. loss of central vision e. diplopia f. absence of red reflex
Assessment findings for retinal detachment include: flashes of light; floaters or black spots (signs of bleeding); ↑blurred vision; a sense of curtain being drawn over the eye; loss of a portion of the visual field, painless loss of central or peripheral vision.
38. While assessing airway and breathing, the client presenting with ↑ intracranial pressure, Cushing’s triad presents with? a. BP 190/84 mmHg, HR 150 bpm, and an irregular respiratory pattern b. BP 80/50 mmHg, HR 50 bpm, and Kussmaul’s respirations c. BP 80/50 mmHg, HR 150 bpm, and Cheyne-Stokes respirations d. BP 190/84 mmHg, HR 50 bpm, and an irregular respiratory pattern
The brainstem’s final effort to maintain cerebral perfusion is seen with ↑systolic BP, bradycardia, and an irregular respiratory pattern known as Cushing’s triad.
39. When will the superior fontanel close? a. 2 – 3 months b. 4 – 6 months c. 7 – 10 months c. 12 – 18 months
Superior fontanel also refers to anterior fontanel. It is soft, flat, diamond shaped, 3-4 cm wide x 2-3 cm long. It closes between 12 and 18 months of age. The posterior fontanel is triangular in shape, 0.5-1 cm wide, located between occipital and parietal bones. It closes between 2-3 months of age.
40. When is captopril (Capoten) best taken? a. before meals b. with meals c. after meals d. bedtime
Captopril (Capoten) is taken 20 – 60 minutes before a meal. It is an ACE inhibitor.
41. What are the correct components for preventing VRE spread? Select all that apply: a. dedicated equipment care b. use of clean gloves when entering room c. door is kept closed at all times – airborne d. wear an N95 mask
Vancomycin resistant enterococci infection requires contact precautions. Contact precautions include the following: placing the client in a private room; cohorting with a client whose body cultures
contain the same organism; use of gloves and a gown when in contact with the client. Paraphernalia and equipment are used for the patient’s private use only and is kept at the client’s room. 42. What is an appropriate component of transmission precautions against meningitis? a. face mask b. private room with negative air pressure – airborne c. the door is kept closed at all times – airborne
Meningitis requires droplet precautions. Droplet precautions include the following: placing the client in a private room; cohorting with a client whose body cultures contain the same organism; use of a surgical mask when within 3 feet of the client; placement of a mask on the client when he/she needs to leave the room.
42. Which statement is true about manifestations usually found in patients with small pox? a. vesicles are present b. fever is rare c. there is localized lymph node enlargement d. there is hemorrhage of tissues and organs
Smallpox is transmitted in air droplets and by handling contaminated materials and is higly contagious. Symptoms begin 7 to 17 days after exposure and include fever, back pain, vomiting, malaise, and headache. Papules develop 2 days after symptoms develop and progress to pustular vesicles that are abundant on the face and extremities initially.
43. Doctor’s order: Administer regular insulin 6 units/hr. The RN has an IV bag of 100 ml NS with 20 units of regular insulin. How many ml/hr should be given to the pt.? Step 1: Calculate the amount of medication (units per mL)
Step 2: Calculate for ml/hr
44. You are to administer gentamycin (Garamycin) intravenously, which manifestation will you watch out for?
a. ringing in the ears b. dry cough c. nasal stuffiness d. diplopia
Among the more serious adverse reactions are nephrotoxicity, auditory or vestibular ototoxicity, impairment of neuromuscular transmission, and hypersensitivity reactions. Ototoxicity is manifested by tinnitus or ringing in the ears.
45. Doctor’s order: Administer 0.5 mg of Petrisin. The RN has 0.8 mg Petrisin in 1 ml. How many milliliters should be given to the patient?
46. You are to provide nursing education to discuss atrial fibrillation, which of the following will you include? a. with absence of identifiable P wave b. there is a saw tooth pattern
Atrial fibrillation is characterized by disorganized electrical activity in the atria accompanied by a rapid, irregular ventricular response. The atria quiver instead of pumping in an organized fashion, resulting in compromised ventricular filling and ↓ stroke volume. Stasis of flow ↑the risk of embolic events. Atrial fibrillation is associated with rheumatic heart diseases, mitral stenosis, heart failure, and heart surgery. Treatment includes digitalis, antidysrhythmic drugs, electrical cardioversion, and surgical interruption of impulse transmission.
47. ILLUSTRATION/PICTURE: A cluster of papulovesicular lesions which follow a linear pattern from the side of the abdomen up to the flank. Which components of transmission precautions will you include? a. droplet precautions b. airborne precautions c. contact precautions d. standard precautions
The illustration stated above is seen in Herpes simplex. HSV infection requires contact precautions. Contact precautions include the following: placing the client in a private room; cohorting with a client whose body cultures contain the same organism; use of gloves and a gown when in contact with the client. Paraphernalia and equipment are used for the patient’s private use only and is kept at the client’s room.
48. The patient is diagnosed with beta Thalassemia and asks you about his condition. Which is the correct statement? a. RBCs are small in form. b. patient will need frequent blood transfusion.
Beta-Thalassemia is prevalent in people of Mediterranean descent but also occur in people from the Middle East and Asia. Mild forms present with microcytosis and mild anemia. Severe beta thalassemia (Thalassemia Major or Cooley’s anemia) presents with marked hemolysis and ineffective erythropoiesis. Patients with beta Thalassemia require frequent blood transfusion.
49. Which of the following are at ↑ risk for cervical cancer? a. with a history of human papilloma virus infection b. 28 year-old with multiple sex partners c. late menopause d. cigarette smoking e. use of estrogen replacement therapy f. nulliparity
Risk factors for cervical cancer include: history of HPV infection, cigarette smoking, early intercourse, and multiple sex partners. On the other hand, late menopause, use of estrogen replacement therapy and nulliparity are some of the risk factors for endometrial cancer.
50. ORDERED RESPONSE: Breast Self-Examination 1. Use the pads of your second, third, and fourth fingers to press every part of the breast firmly. 2. Use your right hand to examine your left breast, and use your left hand to examine your right breast. 3. Use circular motions in a spiral or up-and-down motion. 4. Repeat the pattern of palpation under the arm. 5. Check for any lump, hard knot or thickening if the tissue. 51. Which is the appropriate diet for a patient with chronic renal failure? a. ↓ protein, ↓ carbohydrates b. ↓ protein, ↑ carbohydrates c. ↑ protein, ↑ carbohydrates d. ↑ protein, ↓ carbohydrates
Restricting dietary protein early in chronic renal failure may slow the disease progression and also ↓ nausea and vomiting due to anorexia associated with uremia. Protein intake of 0.6 g/kg body weight or approximately 40g/day is usually adequate. Carbohydrates should be ↑ to compensate for energy needs.
52. You are to administer fluphenazine, which adverse effect will you look out for? a. Abnormal involuntary muscular movements
b. dry mouth c. orthostatic hypotension d. constipation
Tardive dyskinesia is an irreversible adverse effect of antipsychotic medication. It is an abnormal condition characterized by involuntary, repetitious movements of the muscles of the face, the limbs, and the trunk. Manifestations include frowning, blinking, grimacing, puckering, blowing, smacking, licking, chewing, tongue protrusion, and spastic facial distortions. This disorder most commonly affects older people who have been treated for extended periods with antipsychotics.
53. You are to administer cholestyramine (Questral). Which is an appropriate nursing intervention? a. do not give ↑ fiber diet.
Cholestyramine is indicated for hyperlipoproteinemia and for pruritus resulting from partial biliary obstruction. Among the more serious adverse reactions are fecal impaction, GI disturbances, and depletion of vitamins A, D, and K. Constipation is common.
54. What are the manifestations of liver disorders? Select all that apply: a. impaired skin integrity b. yellow sclera c. constipation d. flatulence e. easy bruising
The liver synthesizes clotting factors I, II, VII, IX and X as well as prothrombin and fibrinogen. These substances are needed for adequate clotting, so their ↓ leads to ↑risk of bleeding.
55. What are appropriate health teachings to a patient taking ciprofloxacin (Ciprobay)? a. advise patient to have plenty of fluids b. joint and tendon pain is expected c. eruption of rashes are expected
The patient is advised to drink plenty of fluids to ↓ risk of urine crystals. Tendon rupture is an adverse effect from fluoroquinolone therapy. The client is instructed to report joint and tendon pain to the health care providers. Rashes and other hypersensitivity reactions are adverse effects.
56. What is an appropriate diet for clients with iron deficiency anemia? a. Tofu salad b. blueberry cheesecake c. oat meal cookie
Food sources rich in iron include: breads and cereals, dark green vegetables, dried fruits, egg yolk, legumes, liver and meats.
57. Patient is taking trandolapril (Mavik), what are correct health teachings? Select all that apply: a. I should not drive until the effect of the medication is known. b. I should report immediately to the doctor if rashes appear. c. I will have to use a soft bristled toothbrush while taking this drug. d. Sudden weight gain is expected and normal. e. I will contact the physician if I experience a persistent dry cough.
The patient is advised to avoid driving because he/she may experience dizziness and orthostatic hypotension. Soft bristled toothbrushes are used because occurrence of blood dyscrasias is a side effect. The patient is instructed to weigh himself/herself daily and to report rapid weight gain and significant pedal edema. The patient is monitored for development of cough that is resistant to cough suppressants.
58. A patient with anemia is receiving iron dextran, what is the priority nursing assessment? a. hemoglobin = 14 mg/dl b. palmar itching c. joint pain d. nausea
Iron dextran is an injectable hematinic. It is prescribed in the treatment of iron deficiency anemia not responsive to oral iron therapy. It is contraindicated in early pregnancy, anemia other than iron deficiency anemia. Among the more serious adverse effects are severe hypersensitivity reactions, including fatal anaphylaxis. Inflammation or phlebitis at the site of injection, arthralgia, headache, GI distress, fever and lesser hypersensitivity reactions.
59. What would indicate fecal impaction? a. ascites b. diarrhea c. nausea and vomiting d. oliguria
Fecal impaction is an accumulation of hardened or inspissated feces in the rectum or sigmoid colon that the individual is unable to move. Diarrhea may be a sign of fecal impaction since only liquid material is able to pass the obstruction. Occasionally, fecal impaction may cause urinary incontinence because of pressure on the bladder.
60. Which of the following illustrate correct infection control? a. Cohort patient with GBS together with one with rheumatic heart disease. b. Negative pressure room for influenza c. HEPA filter mask for RSV.
Influenza patients require droplet precautions not airborne. RSV requires contact precautions not airborne.
61. A patient is on MRSA precautions. What should the nurse question? a. visitors of MRSA patient are limited to 3 feet distance. b. A gown must be worn in changing wound dressings of a patient with MRSA. c. A disposable meal tray is requested for use. d. A disposable BP cuff must be used and is for the patient’s use only.
The question is looking for a negative answer. MRSA colonization requires contact precautions. Contact precautions include the following: placing the client in a private room; cohorting with a client whose body cultures contain the same organism; use of gloves and a gown when in contact with the client. Paraphernalia and equipment are used for the patient’s private use only and is kept at the client’s room.
62. The nurse is teaching the client the technique of cognitive restructuring in a client who experienced near drowning. What statement by the client indicates to the nurse that the client is making progress? a. “It was my friend’s fault why I wasn’t swiftly rescued from drowning.” b. “I will stop thinking about negative thoughts.” c. “I know how to work this program; I’m too smart to fail.” d. “My family hasn’t yet realized that I’m doing this for them.”
Elements of cognitive restructuring include making a commitment to act therapeutically; not engaging in distorted thinking like blaming others and increasing the sense of perceived control. There should be change in the client’s usual defensive and cognitive pattern.
63. You have the patient’s chart on hand. His serum calcium is 11 mg/dl. What are the expected assessment findings in the patient’s condition? Select all that apply: a. circumoral hyperesthesia b. hypoactive deep tendon reflexes c. hypotension d. tetany e. lethargy f. widened T wave
Assessment findings of hypercalcemia are the following: tachycardia in the early phase and bradycardia that can lead to cardiac arrest in the late phases; hypertension; bounding, full peripheral pulses; ineffective respiratory movement; profound muscle weakness; diminished or absent deep tendon reflexes; disorientation, lethargy, coma; formation of renal calculi, flank pain; ↓GI motility, hypoactive bowel sounds; anorexia, nausea, abdominal distention, constipation; shortened ST segment, widened T wave
64. You have the patient’s chart on hand. His serum sodium is 148 mEq/L. What are the expected assessment findings in the patient’s condition? Select all that apply: a. oliguria b. urine specific gravity of 1.010 c. urine specific gravity of 1.030
d. confusion e. diarrhea f. abdominal cramping
Assessment findings for hypernatremia are the following: spontaneous muscle twitches and irregular muscle contractions in the early phase; skeletal muscle weakness and diminished or absent deep tendon reflexes in the late phase of hypernatremia; altered cerebral function; if with normovolemia or hypovolemia (agitation, confusion, seizures); hypervolemia (lethargy, stupor, coma); extreme thirst; ↓ urine output; dry and flushed skin; dry and sticky tongue and mucous membranes; presence or absence of edema depending on fluid volume changes; ↑urinary specific gravity
65. You are the staff nurse in the oncology ward. Which will you see first? a. patient receiving cisplatin (Platinol) with urine output of 300 ml in 2 hours.
Cisplatin is an alkylating medication. It is a platinum compound that may cause ototoxicity, tinnitus, hypokalemia, hypocalcemia, hypomagnesemia, and nephrotoxicity. The client is assessed for dizziness, tinnitus, hearing loss, incoordination and numbness or tingling of extremities.
66. Which is a correct understanding for a patient taking atorvastatin? a. I will have to go for an annual eye exam. b. I will avoid hot showers.
Patients taking atorvastatin are advised to undergo an annual eye exam.
67. Nurse expects which blood values in a patient with celiac sprue? a. ↑ serum amylase b. ↑ serum IgM c. ↑ WBC count d. ↑ serum gliadin
Gliadin is a protein substance that is obtained from wheat and rye. Its solubility in diluted alcohol distinguishes gliadin from another grain protein, glutenin.
68. You are going to conduct a nursing conference regarding thyroid disorders. What are the signs and symptoms manifested in Grave’s disease? Select all that apply: a. weight loss b. diaphoresis c. hypernatremia d. constipation e. cardiomegaly f. atrial fibrillation
Assessment findings for Grave’s disease otherwise referred to as toxic diffuse goiter include the following: personality changes such as irritability, agitation, and mood swings; nervousness and fine
hand tremors; heat intolerance; weight loss; smooth, soft skin and hair; palpitations, cardiac dysrhythmias (tachycardia or atrial fibrillation); diarrhea; protruding eyeballs (exophthalmos) diaphoresis; hypertension and enlarged thyroid (goiter). This hyperthyroid state is due to the hypersecretion of thyroid hormones with ↑T3 and ↑T4 69. You are going to conduct a nursing conference on neuromuscular disorders. What are the signs and symptoms manifested in myasthenia gravis? Select all that apply: a. weight loss b. ptosis c. blank facial expression d. akinesia e. rigidity with jerky movements f. weakness
Assessment findings for myasthenia gravis include: weakness and fatigue, difficulty chewing and swallowing, dysphagia; ptosis, diplopia; weak, hoarse voice; difficulty breathing, diminished breath sounds, respiratory paralysis and failure.
70. You are taking care of a patient with rheumatic endocarditis. How will you assess for mitral stenosis? a. use bell of stethoscope, left side lying position at the apex of the heart. b. use bell of stethoscope, left side lying position at the 5 th midaxillary line. c. use diaphragm of stethoscope, left side lying position at the 4 th ICS left sternal border. d. use diaphragm of stethoscope, right side lying position at the 4 th ICS right sternal border. 71. ORDERED RESPONSE: Removal of Personal Protective Equipment (PPEs) 1. Gloves 2. Eyewear/Goggles 3. Gown 4. Shoe/Hair Covers 5. Mask/Respirator 6. Hand Hygiene 72. What will you observe in a patient with hepatic encephalopathy? a. change in patient’s handwriting b. change in abdominal girth c. nuchal rigidity d. photophobia
Asterixis is otherwise known as liver flap or flapping tremor. It is a hand flapping tremor seen frequently in hepatic encephalopathy. The tremor is usually induced by extending the arm and dorsiflexing the wrist.
73. You are going to conduct a nursing conference on neuromuscular disorders, what are the signs and symptoms manifested by people with multiple sclerosis? Select all that apply:
a. urinary retention b. nystagmus c. dorsiflexion of the big toe and fanning of the other toes upon stroking the lateral aspect of the sole of the foot d. fasciculations of the face e. focal neurological deficit f. nuchal rigidity
Assessment findings for multiple sclerosis include: fatigue and weakness; ataxia, vertigo, tremors and spasticity of the lower extremities, paresthesia; blurred vision, diplopia, transient blindness; nystagmus; dysphasia; ↓perception to pain, touch, and T°; bladder and bowel disturbances ( urgency, frequency, retention and incontinence); abnormal reflexes (hyperreflexia, absent reflexes, and positive Babinski reflex); emotional changes (apathy, euphoria, irritability, and depression); memory changes and confusion
74. You are providing dietary instructions to a patient with renal failure. He is instructed to avoid which of the following? a. lettuce b. soy sauce c. potato d. veal
Patients with renal failure observe a prescribed diet which is usually a ↓ to moderate protein and ↓ carbohydrate diet. Potassium and sodium intake is restricted based on serum electrolyte levels. Soy sauce is ↑ in sodium. Foods that are ↓ in sodium include fruits and vegetables (lettuce and potato) because they do not contain physiologic saline.
75. Your patient’s chart is on hand. His serum K + level is 3 mEq/L. What are the assessment findings will you expect? Select all that apply: a. tall peaked T waves b. flat P waves c. ST depression d. leg cramps e. oliguria f. paresthesia g. constipation
Assessment findings of hypokalemia include the following: thread, weak, irregular pulse; weak peripheral pulses; orthostatic hypotension; shallow, ineffective respirations that result from profound weakness of the skeletal muscles of respiration; diminished breath sounds; anxiety, lethargy, confusion, coma; skeletal muscle weakness, eventual flaccid paralysis; loss of tactile discrimination; paresthesia; deep tendon hyporeflexia; ↓GI motility, hypoactive or absent bowel sounds; nausea, vomiting, constipation, abdominal distention; paralytic ileus; ST depression; shallow, flat, or inverted T wave, prominent U wave.
76. A patient has an IVF infusing at 125 ml/hr. The nurse auscultates the patient’s lungs and observes crackles. What is the next action that the nurse will take? a. place patient in Fowler’s position b. obtain O2 saturation c. slow the infusion d. Assess patient’s pulse and blood pressure
The presence of crackles signifies fluid overload. The infusion rate should be slowed to as low as possible to prevent worsening of the problem. The patient is then positioned appropriately. Then vital signs are assessed.
77. You are taking care of a patient diagnosed with Diabetes Mellitus type 1. He becomes diaphoretic and irritable. What will you do first? a. administer 1 cup of grape juice. b. obtain blood glucose level. c. inform physician. d. administer glucagon intramuscularly.
Always abide by the nursing process. Assessment entails obtaining the patient’s blood glucose level.
78. Post-TABHSO FOR 24 hours complains that the wound “feels opened”. Which will be your nursing intervention? a. position at an angle of 30° b. transfer to OR c. check the operative site d. instruct the client not to cough
Wound dehiscence is separation of the wound edges at the suture line; it usually occurs 6 – 8 days after surgery. The nurse first assesses the site, calls for help, stays with the client, and asks another nurse to contact the surgeon and obtain the needed supplies to care for the client. The nurse places the client in a low-Fowler’s position, and the client is kept quiet, and instructed not to cough.
79. A patient has unrelieved chest pain, which will be your priority nursing intervention? a. administer oxygen b. administer ACE inhibitors c. administer diuretics d. administer morphine
Pain relief ↑ oxygen supply to the myocardium. Morphine is administered as a priority in managing pain the client having unrelieved chest pain.
80. You are conducting a health teaching for a patient regarding proper foot care. What are the components of diabetic foot care? Select all that apply:
a. keep feet always dry b. check shoes before wearing c. soak in hot water d. avoid smoking e. treat corns and ingrown toenails on your own f. apply moisturizing lotion in between toes
Diabetic foot care include: meticulous skin care and proper foot care; daily inspection of feet and monitoring for redness, swelling, or break in skin integrity; prevention of thermal injuries from hot water, heating pads, and baths; washing of feet with warm (not hot) water and drying thoroughly; referring corns, blisters, or ingrown toenails to podiatrist; not crossing legs or wearing tight garments that may constrict blood flow; application of moisturizing lotion to the feet but not between the toes; wearing loose socks and well-fitting (not tight) shoes; wearing clean cotton socks to keep the feet warm; avoiding wearing the same pair of shoes 2 days in a row; avoiding wearing open-toed shoes; checking shoes for cracks or tears; breaking in shoes gradually; cutting toenails straight across and smoothing of nails with an emery board; avoiding smoking.
81. A client receiving chemotherapy is experiencing neutropenia. The client can be cohorted with whom? a. patient with pneumonia with hematemesis b. patient with osteomyelitis c. patient with HIV infection d. patient with varicella zoster
The client with neutropenia is at ↑ risk for infection. The patient with HIV, unless currently infected with another infection, does not pose a risk.
82. You are going to conduct a nursing conference on toxoplasmosis. What can lead to toxoplasmosis? a. ingestion of contaminated meat b. spore inhalation from bird droppings c. exposure to asbestos
Toxoplasmosis is caused by an infection with the intracellular protozoan parasite Toxoplasma gondii which produces a rash and symptoms of acute, flulike infection. Transmission is through ingestion of raw meat or handing of cat litter of infected cats. Histoplasmosis is caused by the inhalation of spores from contaminated soil and bird droppings. Diffuse interstitial fibrosis is due to sustained exposure to asbestos, talc or beryllium.
83. ILLUSTRATION: How will you position a patient after liver biopsy? a. right side lying b. left side lying c. supine d. semi-fowler’s
A priority for a client post-liver biopsy is bleeding, because the liver is a highly vascular organ. Positioning the client right side lying helps ↓ bleeding, because the pressure is exerted both by the weight of the chest above and the mattress below.
84. A student nurse inquires about the different signs and symptoms of hypermagnesemia. Which of the following are included? Select all that apply: a. cardiac dysrhythmias b. absent deep tendon reflexes c. tachycardia d. hypertension e. positive Trosseau’s sign f. prolonged PR interval
Assessment findings of hypermagnesemia include the following: bradycardia, dysrhythmias, hypotension; respiratory insufficiency; diminished or absent deep tendon reflexes, skeletal muscle weakness; drowsiness and lethargy that progresses to coma; prolonged PR interval, widened QRS complexes
85. The nurse suspects that hepatotoxicity is developing in an African American client who is on an antibiotic. In what area of the body should the nurse assess for jaundice? a. palms of the hands or soles of the feet b. sclera c. hard palate of the oral cavity d. conjunctivae
Jaundice in the dark-skinned client can best be observed by assessing the hard palate. Normally, fat may be deposited in the layer beneath the conjunctivae that can reflect as a yellowish hue of the conjunctivae and the adjacent sclera in contrast to the dark periorbital skin. In these clients, palms and soles may appear jaundiced, but calluses on the surface of their skin can also make the skin appear yellow.
86. A patient has latex allergy. Which items is the patient instructed to avoid? Select all that apply: a. kiwi b. papaya c. spinach d. hazelnut e. lettuce f. avocado
Individuals allergic to latex are instructed to avoid kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts and chestnuts. This is because there is a possible cross-reaction between these and the latex allergen.
87. Which statement illustrates a correct understanding of positive and negative symptoms of Schizophrenia?
a. Anhedonia is a positive symptom of schizophrenia. b. Avolition is a negative symptom of schizophrenia. c. Thought blocking is a positive symptom of schizophrenia. d. Hallucinations are negative symptoms of schizophrenia.
Positive symptoms of schizophrenia include: hallucinations, delusions, disorganized speech and bizarre behavior. Negative symptoms of schizophrenia include: blunted affect, poverty of thought (alogia), loss of motivation (avolition), and inability to experience pleasure or joy (anhedonia)
88. You are the staff nurse, which manifestation of a patient’s condition is your highest priority? a. T4 injury 10 days ago, presents with excessive diaphoresis b. Water chamber with continuous bubbling c. Patient with DM foot ulcer is scheduled for foot care
Spinal cord injury at or above the level of T6 can experience an exaggerated sympathetic response, seen only after recovery from spinal shock. If untreated, autonomic dysreflexia is potentially fatal as bradycardia and severe hypertension progresses. Autonomic dysreflexia is a neurological emergency and must be treated promptly to prevent a hypertensive stroke.
89. Which of the following laboratory findings is helpful in diagnosing that a patient has Grave’s disease? a. ↑ T4 b. ↑ TSH c. ↓T4 d. ↓T3
Assessment findings for Grave’s disease otherwise referred to as toxic diffuse goiter include the following: personality changes such as irritability, agitation, and mood swings; nervousness and fine hand tremors; heat intolerance; weight loss; smooth, soft skin and hair; palpitations, cardiac dysrhythmias (tachycardia or atrial fibrillation); diarrhea; protruding eyeballs (exophthalmos) diaphoresis; hypertension and enlarged thyroid (goiter). This hyperthyroid state is due to the hypersecretion of thyroid hormones with ↑T3 and ↑T4
90. A patient is prescribed escitalopram (Lexapro), which of the following described correct understanding? a. improvement will be evident on his/her 3rd day. b. he/she may experience sexual dysfunction. c. continue taking MAOIs. d. continue taking OTC cold medications.
Escitalopram (Lexapro) is a selective serotonin reuptake inhibitor (SSRI). ↓ libido is an expected side effect of SSRIs. Antidepressants may take several weeks to produce the desired effect. Client response may not occur until 2 – 4 weeks after the 1 st dose. SSRIs are not taken concomitantly with MAOIs because of the potential for serotonin syndrome. OTC cold medications also ↑ the risk for selective
serotonin syndrome. Serotonin syndrome is characterized by ↑ T°, ↑ creatinine phosphokinase and muscle rigidity. 91. Which of the following statements illustrate/s correct understanding about Hepatitis A? Select all that apply: a. “It is transmitted through the fecal – oral route.” b. “I can get infected with Hepatitis D because of this.” c. “I can have this disease throughout my entire life.” d. “I should always wash my hands.” e. “I should prepare and cook foods appropriately.”
Hepatitis A is transmitted through the fecal – oral route via contaminated food/ water or infected food handlers. Strict and frequent handwashing is essential in preventing the spread of all types of hepatitis. Hepatitis D occurs with Hepatitis B and causes infection only in the presence of active HBV infection and not Hepatitis A.
92. ORDERED RESPONSE: Opthalmic drug administration 1. Assist patient to supine position. 2. Instruct patient to look up. 3. Hold the medication 2 inches away from the conjunctival sac. 4. Place the heel of your hand on his/her cheekbone. 5. Drop the medication on the conjunctival sac. 93. A patient has cellulitis, which will be prescribed? a. antiviral b. antibiotic c. antiprotozoal d. antifungal
Cellulitis is an infection of the dermis and underlying hypodermis; the causative organism is usually group A Streptococcus or Staphylococcus aureus. Cellulitis is treated with antibiotics, antibacterial dressings, ointments, or gels as prescribed. A culture of the area is obtained prior to initiating antibiotics.
94. Which of the following statements illustrate correct understanding about restraints? a. check restraints by inserting 2 fingerbreadths b. keep patient in supine position
It is important that circulation is checked regularly. The application of restraints requires a doctor’s order but there is no need to wait for the physician to release the restraints. Physical restraints impede a client’s freedom, and thus their use needs to be ordered every 24 hours. Because restraints may also impede circulation, they should be removed according to agency policy, which is generally every 1-2 hours to evaluate skin condition and circulation.
95. A patient is on restraints, which situation needs follow up? a. make sure to check orders if HCP signed within the past 24 hrs. b. wait for the physician to release the restraints. c. remove the restraints every 1-2 hours.
It is important that circulation is checked regularly. The application of restraints requires a doctor’s order but there is no need to wait for the physician to release the restraints. Physical restraints impede a client’s freedom, and thus their use needs to be ordered every 24 hours. Because restraints may also impede circulation, they should be removed according to agency policy, which is generally every 1-2 hours to evaluate skin condition and circulation.
96. Methadone (Dolophine) is used in treating withdrawal symptoms from which addiction? a. methamphetamine b. cocaine c. heroin d. alcohol
Methadone (Dolophine) treats withdrawal symptoms of heroin and opioid addiction. Clients undergoing withdrawal from heroin exhibit craving, lacrimation, yawning, and diaphoresis.
97. Which is the psychosocial developmental task for a 9 year old child? a. Autonomy vs. shame and doubt b. Industry vs. inferiority c. Initiative vs. guilt d. Identity vs. role confusion
Based on Erik Erikson’s developmental theory, a 9 year old child must accomplish the developmental task of inculcating industry in himself/herself.
Infancy Toddler Preschooler School age Adolescents Young adult Adult Older adults
Age 0 – 18 months 18 months – 3 years 3 – 5 years 6 – 12 years 12 – 20 years 20 – 25 years 25 – 65 years 65+
Developmental task Trust vs. Mistrust Autonomy vs. Shame & Doubt Initiative vs. Guilt Industry vs. Inferiority Role identity vs. Role confusion Intimacy vs. Isolation Generativity vs Stagnation Ego integrity vs. Despair
98. What is the appropriate health teaching for a client who underwent cataract surgery? a. sleep on the affected side for 1 week. b. practice coughing and deep breathing. c. avoid bending over to pick up objects from the floor.
d. keep the protective eye shield in place at all times
Proper positioning is important after eye surgery to avoid complications. The client should avoid bending, straining, and strenuous activity in order to ↓ intraocular pressure in the affected eye.
99. You are going to conduct a nursing conference regarding oncological disorders. What are the risk factors for cervical cancer? Select all that apply: a. exposure to HPV b. multiple sex partners c. early sexual intercourse d. nulliparity e. postmenopausal bleeding f. history of polycystic ovary disease
Patients are at risk for cervical cancer if they have the following: Human papilloma virus (HPV) infection; cigarette smoking; engaging in early sexual intercourse and with multiple sex partners.
100. ILLUSTRATION of an ECG strip: Atrial fibrillation: Which action by the co-staff RN will need your intervention? a. prepare for defibrillation b. give atropine sulfate c. administer oxygen d. place patient in upright position
This question is looking for a negative answer. Instead of defibrillation, the client is prepared for cardioversion as prescribed. The patient is administered oxygen. Anticoagulants are administered as prescribed because of the risk of emboli. Cardiac medications are administered to control the ventricular rhythm and assist in the maintenance of cardiac output.
101. A client with a total hip replacement is concerned about dislocation of the prosthesis. What can the nurse say to reassure the client? a. “Use incentive spirometer 4 times daily.” b. “Avoid activities that cause adduction of the hip to prevent dislocation.” c. “Perform bending exercises as often to prevent dislocation.” d. “Remove the foam abduction pillow as soon as possible as postoperatively.”
Extremes of internal rotation, adduction, and 90° flexion of the hip should be avoided 4-6 weeks after surgery to prevent dislocation. Although use of elevated seats prevents excess flexion of the hip, it alone does not suffice in preventing dislocation. Bending activities (such as putting on shoes) place the client at risk for dislocation. Abduction pillows are used to prevent external rotation and must be used postoperatively.
102. You are taking care of a postoperative patient with a fractured femur. Which are signs and symptoms of fat embolism? Select all that apply:
a. acute chest pain b. acute lumbar pain c. petechiae on his/her chest and neck d. sudden difficulty of breathing e. diminished breath sounds f. hypertension
Fat embolism is the sudden dislodgement of a fat globule that is freed into the circulation, where it can lodge in a blood vessel and obstruct blood flow to tissue distal to the obstruction. Assessment findings include restlessness, hypoxemia, mental status changes, dyspnea, tachypnea, tachycardia, and hypotension. In addition, a petechial rash may present over the upper chest and neck
103. What are signs and symptoms of mild Alzheimer’s disease? Select all that apply: a. short term memory loss b. unable to recognize wife c. constipation d. seeks assistance in eating
Clients with Alzheimer’s disease experience patterns of forgetfulness and progressive confusion, and cannot perform daily activities.
104. Which statement illustrates a correct understanding about RSV? a. HCPs should wear surgical masks – droplet b. The patient is placed in a negative pressure airflow room – airborne c. RN wears gloves and gown during nursing care
Infection of respiratory syncytial virus requires contact precautions. Contact precautions include the following: placing the client in a private room; cohorting with a client whose body cultures contain the same organism; use of gloves and a gown when in contact with the client. Paraphernalia and equipment are used for the patient’s private use only and is kept at the client’s room.
105. You are caring for a patient with a staphylococcal infection. Which is the appropriate transmission precaution? a. wear particulate mask – airborne b. do not leave the stethoscope at the client’s room c. wear gloves, gown, goggles for possible splashes d. keep door closed at all times – airborne
Staphylococcal infections require contact precautions. Contact precautions include the following: placing the client in a private room; cohorting with a client whose body cultures contain the same organism; use of gloves and a gown when in contact with the client. Paraphernalia and equipment are used for the patient’s private use only and is kept at the client’s room.
106. You are to administer a MMR vaccine. What does the nurse anticipate in the vaccine administration?
a. allergy to shellfish b. allergy to eggs c. allergy to cephalosporins d. aluminum hydroxide
Measles, mumps, rubella (MMR) vaccine is administered by the subcutaneous route. Contraindications include severe allergic reaction to a previous dose or vaccine component (gelatin, neomycin, and eggs), pregnancy and known immunodeficiency.
107. A patient is on Buck’s traction. Which observation needs follow up? a. weights hang freely over the edge of the bed. b. placing the bed in Trendelenburg position c. the foot of the bed is elevated d. the head of the bed is elevated
Buck’s (extension) skin traction is used to alleviate muscle spasms and immobilize a lower limb by maintaining a straight pull on the limb with the use of weights. A boot appliance is applied to attach to the traction. The weights are attached to a pulley; the weights are allowed to hang freely over the edge of the bed; not more than 8 – 10 lb of weight is applied as prescribed. The foot of the bed is elevated to provide the traction. Counter traction will prevent the client from sliding to the foot of the bed. This can be achieved with Trendelenburg position of the bed or raising the foot of the bed slightly if the client’s body weight is not sufficient.
108. A patient with left sided paresis uses a quadripod cane. Which of the following illustrates appropriate use of quadripod canes? a. assist the patient on the right side when ambulating. b. ask the rehabilitative department to change the cane into single cane for proper balance. c. consult the physician for possible change of assistive devices. d. position the quad cane 6 inches from the unaffected side, with the hand grip level with greater trochanter.
Hemicanes or quadripod canes are used for clients who have the use of only one upper extremity. They provide more security than a single-tipped cane. The cane is positioned at the client’s unaffected side, with the straight, non-angled side adjacent to the body. The cane is positioned 6 inches from the unaffected side, with the hand grip level with the greater trochanter.
109. Which illustrates negligence in taking care of a patient with angle-closure glaucoma? a. administration of atropine sulfate (Isopto Atropine). b. The staff nurse relays updates to the health care team but does not disclose information to those not involved in the patient’s care.
Negligence is the unintentional failure of an individual to perform or not perform an act that a reasonable person would or would not do in the same circumstance. Atropine sulfate is an
anticholinergic and mydriatic medication. Anticholinergics are contraindicated in clients with angleclosure glaucoma because they can inhibit flow of aqueous humor and ↑intraocular pressure. 110. ILLUSTRATION: Patient’s chart. Chief complaint: night sweats, weight loss Assessment: (+) fever Diagnostics: (+) AFB smear What will you anticipate with the patient’s care? Select all that apply: a. b. c. d. e.
place in negative airflow pressure room put on particulate mask put on a surgical mask – droplet wear gloves during patient care – contact put patient in a room with another client – contact
Tuberculosis requires airborne precautions. Airborne precautions include the following: Placing the client in a single room that is maintained under negative pressure; door remains closed except upon entering and exiting. Negative airflow pressure is used in the room, with a minimum of 6 – 12 air exchanges per hour depending on health agency protocol. Ultraviolet germicide irradiation or high efficiency particulate air filter is used in the room. Health care workers wear a mask or personal respiratory protection device. Mask is placed on the client when the client needs to leave the room; client leaves the room only if necessary.
111. Which of the following statement illustrates proper use of a metered dose inhaler? a. hold the metered dose inhaler about 4 fingerbreadths in front of the mouth. b. slowly inhale for 3-5 seconds after puff c. clean the mouthpiece with sodium chloride every after use d. wait from 30 minutes before giving steroids
The metered dose inhaler may be held about 2 fingerbreadths (1 ½ inches) in front of the mouth. Alternatively, an inhaler with a spacer device can be used. Clients should breathe deeply once before activating the inhaler and then continue breathing in for about 5 seconds. Clients then should hold their breath for 10 – 15 seconds before breathing out slowly. If a second dose is needed, clients should wait 1 – 2 minutes before taking another dose.
112. Which statement illustrates incorrect understanding about Montelukast (Singulair)? a. “I will continue to take this medication even if I’m feeling okay.” b. “I will take this with meals.”
Montelukast (Singulair) is a leukotriene modifier. The client is instructed to take the medication 1 hour before or 2 hours after meals. The client is instructed to continue to take leukotriene modifiers as prescribed, even during symptom free periods.
113. A patient has celiac disease, which of the following connotes a correct understanding of this disease? a. You have to ↓ your fluid intake to 3 liters/day b. you must ↑ your carbohydrate intake c. avoid adding barley in your diet
Clients with celiac disease must maintain a gluten-free diet, substituting corn, rice, and millet as grain sources. The client is instructed about lifelong elimination of gluten sources such as wheat, rye, oats, and barley. His/her diet is supplemented with vitamins and minerals. Celiac crisis is precipitated by fasting, infection, or ingestion of gluten sources. Oral fluid intake is ↑ to avoid celiac crisis.
114. You are to provide health teachings on promoting a safe home environment for toddlers and prevention of poisoning. What will be the components of this health teaching? Select all that apply: a. keep small objects and toys out of reach b. teach him/her not to eat non-food items c. medications should be kept in childproof containers. d. solutions should be transferred from its original container to a childproof container. e. give medications to children and refer to the medicine as candy. f. keep medications on cabinets to keep them out of reach.
Toddlers are at risk for poisoning due to their developmentally inquisitive behavior. Toddlers explore things with their hands and mouths. Small objects should be kept out of reach. It is developmentally inappropriate to attempt to teach a toddler to stop normal hand-to-mouth activity. They must be supervised at all times. Toxic substances and medications should be stored in a locked cabinet. Medications should be kept in childproof containers.
115. You are taking care of a patient post hip replacement surgery. Which statement by the patient requires your intervention? a. “We changed the house lighting.” b. “We removed throw rugs from the floor.” c. “We removed the throw rug from the floor and yet I often slip.”
The client with hip surgery should avoid all activities that will cause hip adduction, internal rotation, and flexion beyond 90°. Nursing interventions are instituted to prevent falls such as: keeping the bed in the lowest position with bed rails up; elimination of obstacles and clutter; providing adequate lighting; keeping the call light within reach; and reduction of other safety hazards.
116. A patient is on monoclonal antibodies, you will assess for which signs and symptoms? Select all that apply: a. nausea b. diarrhea c. headache d. fever
e. hyperglycemia f. rash
Side/adverse effects include: infection site reactions, viral infections, upper respiratory infections, sinusitis, headache, pharyngitis, anaphylaxis and malignancies. The patient is assessed for respiratory rate, rhythm, depth and lung sounds. The patient is also assessed for allergic reactions such as urticaria and rash.
117. A patient undergoing blood transfusion suddenly exhibits fever, chills and lower back pain. The nurse has stopped the infusion. What will be his/her next action? Select all that apply: a. Infuse PNSS with the same IV tubing and regulate at KVO. b. Notify the physician. c. Return the blood bag and tubing to the blood bank. d. Obtain an ABG sample from the patient for testing. e. Obtain a urine specimen from the patient for testing.
If the client exhibits signs of a transfusion reaction, the nurse immediately stops the transfusion and changes the IV tubing down to the IV site to prevent the entrance of additional blood solution into the client. Normal saline solution is hung and infused to keep the IV line open in the event that emergency medications need to be administered. The HCP is notified and the nurse also notifies the blood bank of the occurrence. The nurse stays with the client and monitors the client closely while other personnel obtain needed supplies to treat the client. As prescribed by the HCP, the nurse administers emergency medications such as antihistamines, vasopressors, fluids, and corticosteroids. The nurse then obtains a urine specimen for laboratory studies and any other laboratory studies as prescribed to check for free hemoglobin indicating that red blood cells were hemolyzed. The blood bag tubing, attached labels, and transfusion record are returned to the blood bank can check the items to determine the reason that the reaction occurred. Finally, the nurse documents the occurrence, actions taken, and the client’s response.
118. You are to administer varicella vaccine for a child. You will be alert for which finding? a. His/her mother is pregnant. b. He/she has a cold.
The varicella vaccine is prepared with a live virus; therefore, it is not appropriate to administer to a person who will be in contact with a pregnant woman.
119. Who is at a ↑ risk for contracting hepatitis B? a. patient on codeine. b. patient undergoing hemodialysis c. patient eating contaminated food.
Individuals at risk for Hepatitis B include: IV drug users, clients undergoing long term hemodialysis and health care personnel.
120. A patient is prescribed hormonal therapy, which entry into the patient’s medical history will warrant questioning the doctor’s order?
a. History of deep vein thrombosis b. History of pancreatitis c. History of tuberculosis d. History of tonsillitis
Use of hormonal therapy places the client at risk for thrombus and embolus formation. The client is instructed to report thromboembolic complications while on hormonal therapy.
121. When triaging in the clinic, which client should be seen first? The client with: a. Genital herpes infection diagnosed yesterday, with a severe headache. b. Recurrent herpes infection for 3 years, with burning during urination. c. Chlamydia diagnosed yesterday, now with worsening pelvic pain. d. Secondary syphilis diagnosed last month, due for penicillin injection.
The primary genital herpes infection involves systemic viremia, and encephalitisis a possible complication. Headache and stiff neck may indicate encephalitis, and require further investigation.
122. The nurse notices the fire in the patient’s room. He/she rescues the patient. What will be his/her next action? a. activate the fire alarm b. confine the fire c. extinguish the fire
In the event of a fire, one should first rescue clients in immediate danger. Secondly, the fire alarm is activated. Thirdly, the fire is confined by closing all doors. Lastly, the fire is extinguished.
123. You are taking care of pediatric patients, who is your priority? a. 7 y/o child who starts a fire in trash cans and disposes of dismembered spiders b. 8 y/o child who interrupts other children during play time c. 12 y/o who steals valuables of other children d. 13 y/o child who argues with her parents
Options A & C exemplify antisocial behavior. Stealing, cruelty, and arson are included in the antisocial behaviors seen in children with CD. Between the two, option A exhibits arson and animal cruelty which is more dangerous than stealing. On the other hand, Options B & D exemplify oppositional behavior. Children with oppositional defiance disorder (ODD) are primarily disruptive, argumentative, hostile, and irritable.
124. You have the patient’s chart on hand, what laboratory finding will support the diagnosis of atherosclerosis? a. creatinine kinase = 170 units/L b. LDL = 120 mg/dL c. HDL = 60 mg/dL
d. homocysteine levels = 20 mmol/dL
The normal homocysteine level is less than 14 mmol/dL. ↑ homocysteine levels correlate with ↑risk for the development of atherosclerotic heart disease. Homocysteine is an amino acid that is produced by the breakdown of the amino acid methionine.
125. A client has an order for an iron preparation to be given by the parenteral route. The nurse plans to give the medication by which of the following routes? a. intermittent infusion b. deep gluteal intramuscular (IM) injection, using the Z-track method c. intramuscular in the deltoid to promote medication dissipation through muscle contraction d. subcutaneous injection with weekly site rotation
IM administration is recommended over intravenous infusion because of the potential for anaphylaxis. The gluteal muscle is the best route of administration since the muscle is large and highly vascular. The Z-track method is preferable to prevent tattooing of the skin and tissue necrosis caused by infiltration into the subcutaneous infusion.
126. A confined depressed client says, “I feel I will have to stay here forever.” What will be your therapeutic response? a. You are concerned that you will not recover?
The communication technique of restating occurs by repeating back to clients the main points or content of the conversation.
127. Which is true about total parenteral nutrition (TPN) administration? a. change bag every 24 hours. b. change dressing every 96 hours. c. change IV tubing every 72 hours.
The TPN solution is changed every 12 – 24 hours as prescribed or according to agency protocol. The IV tubing is changed every 24 hours. The dressing is changed every 48 hours.
128. What is the appropriate positioning for a patient who underwent radical neck dissection? a. Bed elevation of just 15° b. supine position c. prone position d. high fowler’s position
For patients who underwent laryngectomy (radical neck dissection), the patient is placed in a semi – Fowler’s position or Fowler’s position to maintain a patent airway and minimize edema.
129. Using the rule of nines, the nurse would expect burns in which area if it was computed at 41.5%?
a. anterior and posterior torso, anterior head and neck b. anterior and posterior torso with perineum c. anterior and posterior torso c. anterior and posterior lower extremities 130. ILLUSTRATION: Erythema Migrans. How will you correctly document the figure? a. red rash with a clear ring on the center b. a rash with irregular borders c. raised and circumscribed 131. You witness a patient who is standing, clenches his neck and cannot cough. What will you do first? a. call for help. b. stand behind the client. c. administer 5 chest compressions. d. open airway and do finger sweep.
In providing abdominal thrust maneuvers, the rescuer should first stand behind the victim. The rescuer places his/her arms around the victim’s waist. The rescuer makes a fist. The rescuer places the thumb side of his/her fist above the victim’s umbilicus/belly button and well below the xiphoid process. 5 quick abdominal thrusts are performed in and up (between the umbilicus and the xiphoid process)
132. ILLUSTRATION: What is the correct positioning for enema administration? a. Supine b. Low Fowler’s position c. Right Sims’ positon d. Left Sims’ position
For patients undergoing enema administration, the patient is placed in the left Sims’ position to allow the solution to flow by gravity in the natural direction of the colon.
133. You are caring for psychiatric patients, which patient will you see first? a. patient taking thorazine has muscle rigidity. b. patient taking escitalopram has insomnia. c. patient taking lithium complains of abdominal upset and diarrhea.
Signs & symptoms of mild lithium toxicity include: apathy, lethargy, diminished concentration, mild ataxia, coarse hand tremors and slight muscle weakness. Signs & symptoms of moderate lithium toxicity include: nausea, vomiting, severe diarrhea, mild to moderate ataxia and incoordination, slurred speech, tinnitus, blurred vision, muscle twitching, irregular tremor. Signs & symptoms include: nystagmus, muscle fasciculations, deep tendon hyperreflexia, visual or tactile hallucinations, oliguria or anuria, impaired level of consciousness, tonic – clonic seizures or coma, leading to death.
134. The nurse would be most concerned with which post-operative patient?
a. T-tube drainage of 200 ml/hr post cholecystectomy b. Coffee ground drainage 2 days post subtotal gastrectomy c. During a 16 – hour period on the 2nd day of a postop hip replacement surgery, 500 ml of sanguineous fluid was noted. d. Chest tube drainage of 100 ml/hr on the collection chamber
By the 2nd day, the drainage fluid should have slowed down considerably. A volume of 500 ml is almost 2 units of blood, and if the drainage is still sanguineous on the 2 nd day, the nurse should suspect that a problem is present. Frank bleeding should have stopped soon after surgery, and secretions gradually should become more serosanguineous in nature within a few hours post op. The normal drainage in the collection chamber connected to a chest tube is 70-100 ml/hr. The HCP is notified if drainage exceeds 70-100 ml/hr.
135. Which task can you attempt to a nursing assistant? a. bathing a patient with a WBC = 4000 cells/mm 3 1 hour prior to chemotherapy. b. ambulating a patient with platelet count = 15,000 cells/mm 3 2 hours prior to paracentesis. c. feeding a patient 2 days post CVA who is shifting to a soft diet.
Nursing assistants/unlicensed assistive personnel are assigned noninvasive interventions such as skin care, range of motion exercises, ambulation, grooming and hygiene practices.
136. Proper positioning for a patient who will undergo central venous catheter insertion. a. b. c. d.
Semi-fowler’s position High fowler’s position Sitting position Trendelenburg position
For central line insertion, tubing change, and line removal, place the client in the Trendelenburg’s position if not contraindicated or in supine position, and instruct the client to perform the Valsalva maneuver to ↑ pressure in the central veins when the IV system is open.
137. What is the appropriate needle gauge for a peripheral vascular device? a. b. c. d.
14 – gauge 18 – gauge 20 – gauge 24 – gauge
For rapid emergency fluid administration, blood products, or anesthetics, large-diameter lumen needles or cannulas are used such as 14-, 16-, 18-, or 19- gauge. For peripheral fat emulsion/ lipid infusions, a 20- or 21- gauge lumen or cannula is used. For standard IV fluid and clear liquid IV medications, a 22- or 24- gauge lumen or cannula is used. If the client has very small veins, a 24- to 25- gauge lumen or cannula is used.
138. What are you going to monitor during continuous ambulatory peritonea dialysis (CAPD)?
a. b. c. d.
Assess for bruit Palpate for thrill Maintain dwell time Monitor functionality of the peritoneal cycling machine
In continuous ambulatory peritoneal dialysis (CAPD), renal function is closely resembled because it is a continuous process. A machine is not required for the procedure. It promotes client independence. The client performs self-dialysis 24 hours a day, 7 days a week. 4 dialysis cycles are usually administered in a 24 hour period, including an overnight 8-hour dwell time. 1 ½ - 2 liters of dialysate is instilled into the abdomen 4 times daily and allow to dwell as prescribed. After dwell, the bag is placed lower than the insertion site so that fluid drains by gravity flow. After fluid is drained, the bag is changed, new dialysate is instilled into the abdomen, and the process continues. Between exchanges, the catheter is clamped.
139. Which is a component of peritoneal dialysis infusion? a. advance the catheter when the drainage flow stops. b. count the retained dialysate as intake. c. allow dwell time to extend beyond the doctor’s prescription. d. cloudy outflow is considered normal.
1 infusion (fill), dwell, and drain is considered 1 exchange. Fill: 1-2 liters of dialysate as prescribed is infused by gravity into the peritoneal space, which usually takes 10-20 minutes. Dwell time: the amount of time that the dialysate solution remains in the peritoneal cavity is prescribed by the HCP and can last 20-30 minutes to 8 or more hours, depending on the type of dialysis used. Drain (outflow): fluid drains out of the body by gravity into the drainage bag. Nursing interventions include: monitoring of vital signs, monitoring for respiratory distress, pain or discomfort, signs of pulmonary edema, malaise, nausea and vomiting, hypotension and hypertension. The catheter site is assessed for wetness or bleeding. Dwell time is not allowed to extend beyond the HCP’s prescription as this ↑risk for hyperglycemia. Outflow is initiated by turning the client side to side if the outflow is slow to start. Outflow should be a continuous stream after the clamp is considered. Outflow is monitored for color and clarity. Intake and output is monitored accurately; if outflow is less than inflow, the difference is equal to the amount absorbed or retained by the client during dialysis and should be counted as intake. An outflow greater than inflow should be reported to the HCP as well as the appearance of frank blood or cloudiness in the outflow.
140. Which of the following is a correct health teaching for a patient with Meniere’s disease? a. take aspirin for pain b. stop taking antihistamines c. ↓ salt intake to control symptoms d. ↑ oral fluid intake
Nonsurgical interventions for Meniere’s disease include: preventing injury during vertigo attacks; providing bed rest in a quiet environment; providing assistance with walking; instructing the client to move the head slowly to prevent worsening of the vertigo; sodium and fluid restriction; smoking cessation; avoiding watching television because the flickering of lights may exacerbate symptoms;
administration of nicotinic acid (niacin), antihistamines, antiemetics, tranquilizers, sedatives, mild diuretics; and vestibular rehabilitation. 141. Which is the appropriate diet for prevention of diverticular disease? a. restrict drinking juices like oranges b. ↑ intake of cereals and dietary bran c. restrict intake of fibers, citrus fruits and juices
The client is advised to consume a ↑ fiber and ↑ fluid intake to prevent diverticulitis. Nursing interventions for diverticular disease include: constipation is prevented with dietary bran and bulk laxatives as ordered; the client is kept on NPO and gastric decompression during acute episode; the client is monitored for signs of peritonitis; administration of fluid and electrolyte replacement; and administration of antibiotic therapy.
142. You are going to conduct a nursing conference on neurological disorders. What are the pathophysiological factors regarding ↑intracranial pressure (ICP). Select all that apply: a. space occupying lesions and hemorrhage can cause ↑ ICP. b. cerebral perfusion pressure ↑ as ICP ↑. c. ↑ ICP happens when compensatory mechanisms are exhausted. d. proliferation and growth of tissues can ↑ ICP. e. hypoxia does not ↑ ICP. f. Venous return has no effect with ICP.
↑ intracranial pressure is caused by: cerebral edema (contusion, tumor, water intoxication/hypoosmolality, alteration in the blood brain barrier where protein leaks into cerebral tissue); hypoxia (a ↓ in the PaO2 causes cerebral vasodilation); hypercapnia (causes vasodilation); impaired venous return (↑cerebral blood volume); ↑ in intrathoracic/ intraabdominal pressure (↑in these pressures cause a ↓ in venous return).
143. What is the appropriate nursing intervention when the high pressure alarm of the ventilator is activated? a. Disconnect and manually ventilate b. Give prn anxiolytics
If a cause for an alarm cannot be determined, the client is ventilated manually with a bag valve mask until the problem is addressed. For mechanical ventilators, high pressure alarms are due to: obstruction of the ventilator tubing, secretions, kinks; patient coughing and gagging; patient trying to fight the ventilator; endotracheal tube displacement; or bronchospasm. Low pressure alarms are due to: air leaks, disconnection, or spontaneous breathing.
144. Which is an appropriate health teaching for patient taking methylphenidate (Ritalin)? a. administer at bedtime. b. change in appetite is expected. c. insomnia is expected.
Methylphenidate hydrochloride (Ritalin) is a CNS stimulant. It is prescribed in the treatment of hyperkinesis in children and in the treatment of narcolepsy in adults. It is contraindicated to patients with glaucoma, severe anxiety, tension, mental depression, and is not given to children under 6 years of age. Side/adverse effects include: tachycardia, anorexia and weight loss, ↑BP, dizziness and agitation. Children and parents are instructed to avoid OTC medications. The last dose is taken at least 6 hours before bedtime (14 hours for extended-release forms) to prevent insomnia. The child’s weight and height are monitored. The client and parents are instructed that a drug free period may be prescribed to allow growth of the child if the medication caused growth retardation.
145. Which doctor’s order will you question? a. apripazole (Abilify) for schizophrenia b. lorazepam (Ativan) for anxiety c. lithium (Eskalith) for mania d. paclitaxel (Taxol) for panic disorder
Paclitaxel (Taxol) is an antineoplastic drug used for ovarian or metastatic breast cancer. Aripiprazole (Abilify) is an atypical antipsychotic. Lorazepam (Ativan) is an anxiolytic. Lithium (Eskalith) is a mood stabilizer for mania.
146. You are going to conduct a nursing conference about Lyme disease. Which of the following is a component of nursing care for Lyme disease? a. doxycycline is used for treatment b. amphotericin B is used for treatment
Health teachings for prevention of Lyme disease include: avoiding direct contact with ticks usually found in wooded and busy areas; application of repellants. Upon exposure to tick bites, the tick is promptly removed with tweezers. The person takes a bath immediately. Then drugs are administered such as doxycycline, amoxicillin, and cefuroxime.
147. What can you delegate to a nursing assistant when caring for a patient with 2 nd degree pressure ulcer? a. change sterile dressings b. position patient on the unaffected side. c. administer IV antibiotics
Nursing assistants/unlicensed assistive personnel are assigned noninvasive interventions such as skin care, range of motion exercises, ambulation, grooming, and hygiene practices. Licensed practical nurses (LPN) can be delegated routine tasks such as dressing changes. RNs have the responsibility to administer intravenous medications.
148. A patient is on teletherapy, what will you apply on the site? a. lotion b. zinc oxide
c. warm water d. topical cream
Teletherapy or external beam radiation is a form of radiation therapy. Nursing care include: leaving radiology marks intact on skin, avoiding use of creams, lotions, deodorants, perfumes; use of lukewarm water to cleanse the area or mild soap; assessment of skin for redness and cracking; administration of antiemetics for nausea and analgesics for pain; avoiding exposure of area to cold or sunlight; use of cotton, unrestrictive clothing
149. ILLUSTRATION of Erythema migrans, which doctor’s order will you question? a. giving acyclovir (Zovirax) b. giving doxycycline
Erythema migrans is the hallmark sign of Lyme disease. Health teachings for prevention of Lyme disease include: avoiding direct contact with ticks usually found in wooded and busy areas; application of repellants. Upon exposure to tick bites, the tick is promptly removed with tweezers. The person takes a bath immediately. Then drugs are administered such as doxycycline, amoxicillin, and cefuroxime.
150. A patient post lumbar puncture, what is the essence of placing the patient flat on bed? a. prevent headache b. prevent hypotension c. prevent dehydration
The patient is placed flat on bed to prevent spinal headache and to relax lumbar and abdominal muscles.
151. A patient with UTI utters the following statements, which of these needs follow up? a. “I will use loose fitting cotton underwear.” b. “I will urinate after sexual intercourse.” c. “I will take warm bubble baths instead of showers.”
Health teachings for prevention of UTIs include: good perineal care wiping from front to back; avoiding bubble baths, tub baths, and use of vaginal deodorants or sprays; voiding regularly; wearing of loose cotton pants; avoiding use of tight clothing; avoiding sitting with a wet bathing suit for a prolonged span of time; use of water-soluble lubricants for intercourse; application of vaginal creams to restore vaginal pH; and voiding after sexual intercourse.
152. ORDERED RESPONSE: Application of a dry sterile dressing. 1. Put on gloves. 2. Inspect wound for appearance, drains, exudate, and integrity. Measure wound size (length, width, and depth. Avoid contact with contaminated material. 3. Cleanse wound. 4. Use separate swab for each cleansing stroke, or spray wound surface.
5. 6. 7. 8. 9. 10.
Clean wound from least contaminated area to most contaminated. Apply loose woven gauze as contact layer. Cut 4 x 4 gauze flat to fit around drain if present or use precut split drain flat. Apply 2nd layer of gauze. Apply thicker woven pad (surgi-pad). Secure dressing with tape, Montgomery ties or straps (which are applied perpendicular to the wound), or binder. Sometimes strips of a hydrocolloid dressing are placed on the skin under the Montgomery ties to further protect the skin.
Dry dressings are most commonly used for abrasions and non – draining postoperative (primary intention healing) incisions. The dry dressing does not debride the wound and should not be selected for wounds requiring debridement. It is not appropriate for an open wound that is healing by secondary intention. If a dry dressing adheres to a wound, the nurse should moisten the dressing with sterile normal saline or water before removing the woven gauze. Moistening the dressing in this manner ↓ the adherence of the dressing to the wound and ↓ the risk of further trauma to the wound.
153. ORDERED RESPONSE: Irrigation of colostomy or ileostomy. 1. If ambulatory, position the client sitting on the toilet. If on bed rest, position the client on his/her side. 2. Hang the irrigation bag so that the bottom of the bag is at the level of the client’s shoulder or slightly higher. 3. Insert the irrigation tube carefully without force. 4. Begin the flow of irrigation. 5. Clamp the tubing if cramping occurs; release the tubing as cramping subsides. 6. Perform irrigation at about the same time each day. Perform irrigation preferably 1 hour after meal.
The purpose of colostomy irrigation is to cleanse the bowel of feces before tests or surgical procedures, to relieve constipation or to establish a pattern of regular bowel elimination after ostomy surgery. Irrigations for achieving regular bowel evacuation can be achieved only with descending and sigmoid end colostomies.
154. What is the proper assessment of the facial nerve (CN VII)? a. Tell patient to clench teeth and palpate temples. b. Tell patient to close eyes and touch a part of the patient’s face and let the patient identify location c. Tell patient to stick out tongue to midline and move it from side to side. d. Tell patient to shrug shoulders and turn head against passive resistance.
Option A assesses the trigeminal nerve (CN V). Option C assesses the hypoglossal nerve (CN XII). Option D assesses the spinal accessory nerve (CN XI).
155. Which of the following is the proper assessment for trigeminal nerve (CN V)?
a. b. c. d.
Tell client to clench teeth and palpate temples. Tell client to identify different nonirritating aromas such as coffee and vanilla. Tell the patient to identify salty or sweet taste on front of tongue. Tell the patient to identify sour or sweet taste on the back of the tongue.
Option B assesses the olfactory nerve (CN I). Option C assesses the facial nerve (CN VII). Option D assesses the glossopharyngeal nerve (CN IX).
156. ORDERED RESPONSE: Administering blood transfusion 1. 2. 3. 4. 5. 6.
Prepare blood component for administration. Attach the primed tubing to the IV catheter. Open lower clamp. Remain with the client during the first 5-15 minutes of a transfusion. Monitor client vital signs 5 minutes after the blood product has begun infusing. Regulate the rate of transfusion according to physician’s orders. After blood has transfused, clear IV tubing with 0.9 % normal saline.
Transfusion therapy is the intravenous administration of whole blood or blood components. It may be used to restore intravascular volume with whole blood or albumin, to restore the oxygen-carrying capacity of blood by replacing red blood cells, to replace clotting factors and/or platelets to reverse coagulopathy, or to replace white blood cells in neutropenic clients.
157. You are on duty with a nursing attendant. A patient dies, in which situation will you intervene? a. NA removes dentures b. NA removes jewelry c. NA removes indwelling catheter
If a person wore dentures, they are inserted. If mouth fails to close, a rolled up towel is placed under the chin. It is difficult to insert dentures after rigor mortis occurs. Dentures maintain natural facial expression.
158. Patient with pelvic and femoral fracture experiences sudden dyspnea and chest pain. After repositioning, what will you do next? a. auscultate breath sounds b. give PRN analgesics c. ↑ IVF infusion rate
The patient is possibly experiencing fat embolism, after repositioning, further assessment is warranted.
159. ORDERED RESPONSE: Dressing change for central vascular access device 1. Carefully remove old dressing in the direction the catheter was inserted, noting drainage and appearance of catheter or needle insertion site. 2. Apply sterile gloves.
3. Clean placement or exit site with alcohol swabs by starting from inside moving out in a circular fashion creating concentric circles. Clean about a 3 cm area. Allow alcohol to remain on the skin for at least 60 seconds. 4. Clean placement or exit site with povidone iodine swabs. 5. Redress site using sterile gauze and tape or transparent dressing as indicated. 6. Dispose of soiled supplies; remove gloves and wash hands. 160. What indicates correct understanding of use of distraction in pain management of patient with chronic low back pain? a. I will start to deeply breathe and exhale to a slow rhythmical pattern when pain begins. b. I will lie down and think of a positive thought when I have low back pains. c. I will watch a comedy movie when my back starts to hurt.
Distraction is a technique that diverts an individual’s attention away from the pain sensation. By introducing meaningful stimuli, the nurse helps the client refocus attention. The client’s pain tolerance ↑ as distraction ↓ awareness of pain. Typically, distraction is most effective for mild to moderate pain, but with intense concentration even acute pain can be relieved. In most cases the pain relief lasts only as long as the distraction; when the distraction is removed, the client may have a heightened awareness of pain. Examples of distraction include music, visitors, television, breathing exercises, or active listening.
161. Which doctor’s order will you question for a patient with COPD? a. Oxygen face mask at 6 LPM
Clients with COPD are administered a ↓ concentration of oxygen at 1-2 lpm as prescribed; their stimulus to breathe is a ↓ arterial PO2 instead of an ↑ PCO2
162. ORDERED RESPONSE: Staple removal in postoperative period 1. Place lower tips of staple extractor under 1 st staple. As you close handles, upper tip of extractor depresses center of staple, causing both ends of staple to be bent upward and simultaneously exit their insertion sites in the dermal layer. 2. Carefully control staple extractor. 3. As soon as both ends of staple are visible, move it away from skin surface and continue on until staple is over refuse bag. 4. Release handles of staple extractor, allowing staple to drop into refuse bag.
Staples are made of stainless steel wire. Their use is restricted by the location of the incision, because there must be adequate distance between the skin and structures that lie below the skin, including bone and vascular structures. The cosmetic result may not be as desirable as that obtained with finer suture material. Staples do provide ample strength. Removal requires a sterile staple extractor and maintenance of aseptic technique.
163. You are taking care of a patient with COPD. Which is the correct instruction for pursed lip breathing? a. make sure that exhalation is longer than inhalation
b. inhale and exhale through your mouth c. inhale using mouth and exhale through your nose
Pursed lip breathing facilitates maximal expiration and promotes carbon dioxide elimination. This type of breathing allows better expiration by ↑ airway pressure that keeps air passages open during exhalation.
164. Which diagnostic value is a priority for pancreatitis? a. ↑ serum lipase b. ↓ calcium
Hypocalcemia in pancreatitis manifests deterioration in the client’s condition. Calcium is deposited in the fatty necrotic tissue of the pancreas. Options A & C are expected findings.
165. Which of the following is an appropriate health teaching for a patient with stomatitis? a. gargle with lemon glycerin solution b. use soft bristled toothbrush c. use OTC mouthwash
For a client with stomatitis, he/she is advised to rinse his/her mouth before and after meals and at bedtime using normal saline or solution of ½ to 1 teaspoon of salt or baking soda to one pint of tepid water. Soft-bristled toothbrush is used. To loosen and remove thick mucus, use 1 part of hydrogen peroxide to 4 parts of normal saline followed by warm water or saline rinse.
166. A patient who underwent abdominal surgery suddenly complains of chest pain and difficulty of breathing. This is possibly caused by: a. activated partial thromboplastin time ↑ 2x the control value b. history of deep vein thrombosis
Pulmonary embolism is a complication of deep vein thrombosis. Sudden chest pain and dyspnea are characteristic of pulmonary embolism. Option A indicates a normal value. During heparin therapy, the therapeutic level of activated partial thromboplastin time equals 1.5-2 times the control value.
167. Which complication is a priority for a patient who underwent paracentesis 2 days ago? a. I feel my abdomen is full. b. I have fever and chills last night.
The physician is promptly notified if a patient contracts a fever and chills which are indicative of infection and possible perforation. Other complications of paracentesis include hypovolemic shock and peritonitis.
168. On his 2nd day after undergoing radical neck dissection, the patient expresses helplessness. What will be your therapeutic response?
a. “I will sit here for a while. Let us talk when you’re ready to talk.” b. “Do you want to go for a walk?”
Silence is a therapeutic communication technique. It allows client time to think and gain insights, slows the pace of the interaction, and encourages client to initiate conversation, while conveying nurse’s support, understanding, and acceptance.
169. You approach a schizophrenic patient pacing. How will you communicate with him/her therapeutically? a. “You seem upset.” b. “Stop pacing and sit down!”
Reflection is a therapeutic communication technique that validates nurse’s understanding of what client is saying and signifies empathy, interest, and respect for client.
170. You are assigned to the psychiatric ward, what describes working phase in a therapeutic relationship with a depressed client? a. It's good that you are sharing your past problems. b. Let us set your goals that are appropriate for you. c. Let us talk about your discharge.
The therapeutic nurse-client relationship consists of four phases: pre-interaction, introduction or orientation, working, and termination. The orientation phase involves assessing the client, formulating a contract, exploring feelings, and establishing expectations about the relationship. Roles are clarified, information is collected, goals are established, misunderstandings are clarified, and rapport is established between the nurse and client. When the strategies of the orientation phase are successful and the client is ready, the work toward effective goal attainment can begin with the working phase of the nurse-client relationship. During the working phase, the nurse and client evaluate and refine the goals established during the orientation phase. In addition, major therapeutic work takes place and insight is integrated into a plan of action. During the termination phase, the nurse prepares the client for separation and explores feelings about the end of the relationship. The termination phase consists of evaluation and summary of progress toward prescribed goals.
171. Which pediatric patient with fever will be your priority? a. Infant b. Toddler c. Preschooler d. School aged child
Infants are very sensitive to slight changes in environmental temperatures. Underdeveloped temperature control mechanisms in infants and children can cause temperature to rise and fall rapidly.
172. Which assessment findings support a ruptured suspected ectopic pregnancy? Select all that apply:
a. b. c. d. e. f.
cold, clammy skin severe vaginal bleeding low abdominal pain that radiates to her shoulder headache blurred vision pressure in perineal area
Assessment findings for ruptured ectopic pregnancy include: acute pain, referred shoulder pain and signs of shock such as pallor, tachycardia, and hypotension.
173. What is the significance for daily resistive isometric exercise? a. to ↓ CAD risk b. help promote bone maintenance and growth
Resistive isometric exercises help to promote muscular strength and provide the necessary stress for bone maintenance and growth. Without sufficient stress against bone, osteoclastic activity ↑ over osteoblastic activity. The result is demineralization of the bone and eventual osteoporosis. Examples of resistive isometric exercises are performing push-ups, pushing against a footboard to move up in bed, and hip lifting. Isotonic exercises ↑circulation and respiratory rate and have beneficial effects on the entire body. Some individuals, however, are unable to tolerate such exercises in activity.
174. A patient has celiac disease and is visibly irritable. Her laboratory results include: WBC = 11,000 cells/mm3; Hgb = 8.8 mg/dl a. prepare for culture & sensitivity b. instruct to eliminate gluten – rich foods
Clients with celiac disease must maintain a gluten-free diet, substituting corn, rice, and millet as grain sources. The client is instructed about lifelong elimination of gluten sources such as wheat, rye, oats, and barley. His/her diet is supplemented with vitamins and minerals. Celiac crisis is precipitated by fasting, infection, or ingestion of gluten sources. Oral fluid intake is ↑ to avoid celiac crisis.
175. Which is evident in a patient with cocaine intoxication? a. hypertension b. hypotension c. bradypnea d. bradycardia
Cocaine is a CNS stimulant. Assessment findings of intoxication include: mydriasis, euphoria, hypertension, impairment of judgment and social or occupational functioning, insomnia, nausea and vomiting, paranoia, delusions, hallucinations, potential for violence, tachycardia.
176. You are taking care of a depressed client who is severely withdrawn. He does not speak and avoids eating his meals. His weight has gone down to 52 kg. You expect the physician to order which intervention?
a. b. c. d.
Administration of SSRIs Electroconvulsive therapy Administration of thorazine Prescription for St. John’s wort
Use of electroconvulsive therapy (ECT) is indicated when antidepressant medications have no effect; when there is a need for rapid definitive response, such as when a client is suicidal or homicidal; when the client is in extreme agitation or stupor; when the risks of other treatments outweigh the risk of ECT; when the client has a history of poor medication response, a history of good ECT response, or both; when the client prefers ECT as treatment.
177. What are the assessment findings for digoxin toxicity? Select all that apply: a. b. c. d. e. f.
Loss of appetite Nausea Constipation Headaches Xanthopsia Rashes
Early signs of digoxin toxicity present as gastrointestinal manifestations (anorexia, nausea, vomiting, diarrhea); then, visual disturbances (diplopia, blurred vision, yellow-green halos, photophobia) and heart rate abnormalities occur
178. What is the therapeutic diet for a patient taking fosinopril? a. ↑ protein, ↑ sodium diet b. ↓sodium, ↓fat diet
Lifestyle modifications for hypertension include: weight control and reduction to attain a normal BMI; adherence to dietary approaches to stop hypertension (DASH) eating plan such as ↑ intake of fruits, vegetables, and ↓ fat dairy products that are rich in calcium and potassium; sodium restriction (less than 2.4 g daily); aerobic exercise at least 30 minutes on most days; alcohol moderation; smoking cessation and stress management.
179. What is the priority finding for a patient with systemic lupus erythematosus (SLE)? a. b. c. d.
Low-grade fever ↑ erythrocyte sedimentation rate (ESR) Pericarditis Proteinuria
Signs of organ involvement include: pleuritic, nephritis, pericarditis, coronary artery disease, hypertension, neuritis, anemia, and peritonitis.
180. Which of the following are manifestations of Addison’s disease? Select all that apply:
a. b. c. d. e. f. g.
Lethargy Truncal obesity Hirsutism Hypokalemia Hyperkalemia Hyponatremia Hypernatremia
Assessment findings for Addison’s disease include: lethargy, fatigue, muscle weakness; gastrointestinal disturbances, weight loss; menstrual changes in women, impotence in men; hypoglycemia, hyponatremia, hyperkalemia, hypercalcemia; hypertension, and bronze hyperpigmentation of skin.
181. What are the side effects of nitroglycerin? Select all that apply: a. b. c. d. e. f.
Constipation Dizziness Flushing Agranulocytosis Dry mouth Hyperglycemia
Side effects of nitroglycerin include: headache, orthostatic hypotension, dizziness, weakness, faintness, nausea, vomiting, flushing or pallor, confusion, rashes, dry mouth, and reflex tachycardia
182. What is a priority nursing action for a patient with ascites who was ordered for IFC insertion? a. b. c. d.
Check for albumin levels Check for electrolytes Check for urine specific gravity Check for urine pH
Hypoalbuminemia and ↓ membrane permeability predisposes the patient for bladder perforation during urinary catheterization.
183. You are assigned to the medical-surgical unit. Which is your priority? a. patient with esophageal varices complains of incessant dry cough b. patient with ulcerative colitis complains of blood-streaked stool
Bleeding can manifest as a resistant nonproductive cough. The goal of treatment is to control bleeding, prevent complications, and prevent the recurrence of bleeding. Rupture and resultant hemorrhage of esophageal varices is the primary concern because it is a life-threatening situation.
184. You are taking care of a child diagnosed with ADHD, he displays inappropriate behavior. What will be an appropriate nursing action? a. Encourage the child to explore the inappropriateness of his behavior.
b. Allow inappropriate behavior as child is unable to perceive norms.
Elements of cognitive restructuring include making a commitment to act therapeutically; not engaging in distorted thinking like blaming others and increasing the sense of perceived control. There should be change in the client’s usual defensive and cognitive pattern.
185. ORDERED RESPONSE: 24 hour urine collection 1. 2. 3. 4. 5. 6.
Instruct client to void and discard initial specimen. Encourage client to void and collect urine specimen. Place all voided urine in labeled specimen bottle with appropriate additive. Keep specimen bottle in specimen refrigerator or in container of ice in bathroom. Send labeled specimen to laboratory with appropriate requisition. Document findings.
Timed urine collection begins after a client urinates. The first specimen is discarded and then every successive specimen is collected until the time period has ended. The specimen is transferred immediately to a large collection bottle kept in the client’s bathroom. Any missed specimens make test results inaccurate. The client should always provide the last specimen as close as possible to the end of the collection period.
186. ORDERED RESPONSE: Inserting a straight catheter to a female client 1. Assist patient to dorsal recumbent position (supine with knees flexed). Ask client to relax thighs so the hip joints can be externally rotated. 2. Lubricate 2.5 – 5 cm (1 – 2 inches) for women 3. With nondominant hand, carefully retract labia to fully expose urethral meatus. 4. Using forceps in sterile dominant hand pick up cotton ball saturated with antiseptic solution and clean perineal area, wiping front to back from clitoris toward anus. Using a new cotton ball for each area, wipe along the far labial fold, and directly over center of urethral meatus. 5. Advance catheter a total of 5 – 7.5 cm (2 – 3 inches) in adult or until urine flows out catheter’s end. When urine appears, advance catheter another 2.5 – 5 cm (1 – 2 inches). Do not force against resistance. Place end of catheter in urine tray receptacle. 6. Remove straight, single-use catheter. Withdraw catheter slowly but smoothly until removed.
Catheterization of the bladder involves introducing a rubber or plastic tube through the urethra and into the bladder. The catheter provides for a continuous flow of urine in clients unable to control micturition or in those with obstruction to urine outflow.
187. What are manifestations of peripheral arterial disease? Select all that apply: a. b. c. d. e. f.
Patient cramps when sitting. Patient felt pain while playing tennis. Loss of hair in the lower extremities. Thickened toenails. Strong peripheral pulses BP measurement at the thigh, calf, and ankle ↑ than the brachial pressure.
Assessment findings for peripheral arterial disease include: intermittent claudication (pain in the muscle resulting from an inadequate blood supply); rest pain (numbness, burning, or aching in the distal portion of the lower extremities, which awakens the client at night and is relieved by placing the extremity in a dependent position); lumbosacral discomfort; loss of hair and dry scaly skin on the lower extremities; thickened toenails; cold and gray-blue skin color in the lower extremities; elevational pallor and dependent rubor in the lower extremities; ↓ or absent peripheral pulses; signs of arterial ulcer formation occurring on or between the toes or on the upper aspect of the foot and are characterized as painful; BP measurements at the thigh, calf, and ankle are ↓ than the brachial pressure (normally, BP readings in the thigh and calf are ↑ than those in the upper extremities).
188. What is NOT an appropriate component of intermittent catheterization of an 87 year old client? a. Sterile technique is used. b. Intermittent catheterization should not be routinely done. c. Catheter is cleaned by soap and tap water every after use.
Straight catheters are used only once and disposed of properly. Sterile asepsis is used to ↓ the risk of bladder infections. A client with a catheter is especially vulnerable to UTI. The frail order adult client who is physically compromised runs the additional risk of developing septicemia. Therefore, the client who is incontinent should not be routinely catheterized.
189. A nurse is to perform IFC insertion to a female patient. What should the nurse do to minimize Foleyrelated infection? a. clean perineum and urethral meatus with tap water before insertion. b. with the nondominant hand, carefully retract labia to fully expose urethral meatus. c. use petroleum jelly to lubricate catheter. d. ask client to bear down gently as if to void and slowly insert catheter through urethral meatus.
Option B provides full visualization of urethral meatus is provided. Full retraction prevents contamination of urethral meatus during cleansing. Instead of tap water, sterile antiseptic solution is used in cleaning the perineum and urethral meatus. Option D provides for relaxation of external sphincter aids in insertion of the catheter.
190. A client on continuous bladder irrigation complains of unrelieved bladder spasms. What is an appropriate nursing intervention? a. monitor for signs of hemorrhage b. flush the line with 0.9% sterile normal saline solution. c. use sterile irrigating solution below room temperature
An ↑ in bladder spasms may indicate occlusion of catheter with blood clots. The physician is notified if bladder spasms ↑ or are unrelieved. Sterile irrigating solution is kept in room temperature because cold solution could cause bladder spasms.
191. Which of the following statements by a client with liver cirrhosis indicates correct understanding about his diet?
a. “I should take multivitamin supplements.” b. “I need to ↓ my protein intake.” c. “I need to ↑ my sodium intake.”
Dietary modification for clients with liver cirrhosis include: intake of supplemental multivitamins (vitamins A, B complex C, K, folic acid and thiamine) as prescribed; sodium and fluid restriction as prescribed.
192. You are the staff nurse on duty, which patient will you see first? a. patient with SIADH, has serum Na = 132 mg/dl b. patient with pancreatitis has serum Ca = 7 mg/dl c. patient with ESRD has BUN = 25 mg/dl
Hypocalcemia in pancreatitis manifests deterioration in the client’s condition. Calcium is deposited in the fatty necrotic tissue of the pancreas. Options A & C are expected findings.
193. You are to provide nursing education about the Good Samaritan law, which of the following will you include? a. A nurse pulls the victim of a vehicular accident out of the care and provides prompt care. b. Neighbor asking you for referral to another health care provider because she is not satisfied with the present health care provider. c. The nurse accepts a reward from the victim’s family for the aid provided.
In the U.S., state legislatures pass Good Samaritan laws, which vary from state to state. These laws encourage health care professionals to assist in emergency situations and limit liability and offer legal immunity for persons helping in an emergency, provided that they give reasonable care. Immunity from suit applies only when all conditions of the state law are met, such as the health care provider receives no compensation for the care provided and the care given is not intentionally negligent.
194. What is an inappropriate way to obtain consent? a. A 17 year old does not consult her parents in providing consent to undergo HIV testing. b. A 17 year old asks her mother to give consent prior to undergoing caesarian section.
Parental or guardian consent should be obtained before treatment is initiated for a minor except in the following cases: in an emergency; in situations in which the consent of the minor is sufficient, including treatment related to substance abuse; treatment of STDs, HIV, and AIDS; birth control services, pregnancy; or psychiatric services; the minor is an emancipated minor; or a court order or other legal authorization has been obtained. An emancipated minor has established independence from his/her parents through marriage, pregnancy, service in the armed forces, or by a court order. An emancipated minor is considered legally capable of signing an informed consent.
195. All are components of informed consent? EXCEPT: a. Risks, benefits, treatments, complications and prognosis
b. The client has the right to withdraw consent at any time. c. The client cannot waive informed consent for urgent medical and surgical intervention.
An informed consent is a legal document, and the client must be informed by the health care provider, in understandable terms, of the risks and benefits of surgery, treatments, procedures, and plan of care. The client needs to be a participant in decisions regarding health care. A client may withdraw consent at any time. An informed consent can be waived for urgent medical or surgical intervention as long as institutional policy so indicates.
196. A patient is diagnosed with lactose intolerance and inquires about alternate calcium sources. Which will you include in your teaching? a. Yogurt b. Skimmed milk
Clients with lactose intolerance need to incorporate sources of calcium other than dairy products into their dietary patterns regularly. Milk may be tolerated in cooked form, such as in custards or fermented dairy products. Cheese and yogurt sometimes are tolerated. Lactase, an enzyme, may be prescribed and is taken before ingesting milk or milk products. Lactase – treated milk or lactose – free products are also available commercially.
197. Which is the appropriate nursing intervention for constipation? a. instruct to drink 2 glasses of warm milk every morning. b. instruct to eat raw carrots and celery in between meals.
Nursing interventions for constipation include: teaching parents to provide foods with fiber; teach parents to ↑ amount of fluid; bowel retraining; appropriate use of enema and laxatives.
198. ORDERED RESPONSE: Removal of antiembolism stockings 1. 2. 3. 4.
Grasp top of stocking with your thumb and fingers. Smoothly pull stocking off inside out to heel. Support foot and ease stocking over it. Assess the extremities for peripheral pulses, edema, and changes in sensation, and movement.
Antiembolism stockings promote venous return by maintaining pressure on superficial veins to prevent venous pooling; thereby ↓ risk of clot formation in the lower extremities. They prevent passive dilation of superficial veins, thereby ↓ the risk of endothelial tears.
199. What is an appropriate nursing intervention for a child who underwent cleft lip repair? a. keep patient on NPO for 24 hours b. place patient on prone position for 48 hours c. apply elbow restraints
Postoperative nursing care for cleft lip repair include: provision of lip protection; a meta appliance or adhesive strips may be taped securely to the cheeks to prevent trauma to the suture line; avoiding positioning the infant on the side or in the prone position because these positions can cause rubbing of the surgical site on the mattress (position on the back upright and position to prevent airway obstruction by secretions, blood, or the tongue); keeping the surgical site clean and dry; after feeding, the suture line is cleansed of formula or serosanguineous drainage with a solution such as normal saline or as designated by agency procedure; application of antibiotic ointment to the site as prescribed; use of elbow restraints to prevent the infant from injuring or traumatizing the surgical site; and monitoring the patient for infection.
200. What are the appropriate nursing interventions for a patient who underwent bone marrow aspiration? a. Watch out for tenderness, erythema, hypotension, and tachycardia.
Bone marrow aspiration is the removal of a small amount of the liquid organic material in the medullary canals of selected bones, in particular the sternum and the posterior superior iliac crests. In children, the proximal tibia may be used. Tenderness, erythema, hypotension and tachycardia may indicate infection at the site or shock
201. You are assigned to the psychiatric ward. Which psychiatric client is your priority? a. manic patient taking lithium b. depressed client with sudden euphoria.
Safety is the priority for all clients. Suicidal clients who are depressed are at highest risk for suicide when they begin to demonstrate improvement and have sufficient energy to carry out a suicidal act.
196. A patient has xerostoma, what are your nursing interventions for mouth care? a. hydrogen peroxide b. commercial mouthwash c. commercial saliva replacement 197. What are your nursing interventions for patient with aphasia? Select all that apply: a. b. c. d. e.
Provide repetitive directions. Break tasks down one step at a time. Repeat names of objects frequently used. Allow time for the client to communicate. Use a picture board, communication board, or computer technology.
198. You are going to conduct a nursing conference regarding gastric surgeries. What is true regarding a continent ileostomy? a.
Continent ileostomy otherwise referred to as Kock ileostomy is an intraabdominal pouch that stores the feces and is constructed from the terminal ileum. The pouch is connected to the stoma with a nipple-like valve constructed from a portion of the ileum; the stoma is flush with the skin. A catheter is used to empty the pouch, and a small dressing or adhesive bandage is between emptying.
199. What are appropriate nursing interventions for a patient diagnosed with left CVA? Select all that apply: a. instruct patient to eat pureed foods and liquid. b. instruct patient to flex the chin. c. instruct to extend the chin. 200. Who is your priority in the hospital after a disaster? a. Penetrating wound b. Fixed, dilated pupil with apnea c. Pain upon inspiration with fracture 201. You are the admitting nurses, who can be with the HIV patient in the same room? a. Streptococcal infection b. Patient who underwent appendectomy 202. A patient with Schizophrenia exhibits the following manifestations, which needs immediate action? a. Rocking chair with blank face 203. Nurses should get individual insurance protection plan because? a. I need it to protect nurse since the institution is concerned on the act of the suit. b. I don’t need it because I am protected by the Good Samaritan law. c. I need it to protect me if I was named in the suit involving negligence and malpractice. 204. Which patient will you see first? a. a patient with cholelithiasis yelling and asking for pain medication b. a post cholangiogram complaining of abdominal pain 205. Nurse is concerned if a patient is taking which combination of medications? a. Diazide with Diabetes mellitus b. Chlorehydrate with hypoparathyroidism 206. You are taking care of an AIDS patient. How can you promote effective infection control? a. clean dishes and utensils in the dishwasher b. clean kitchen and sink with soap and water
c. limit one hour exposure to household pet d. prevent visitors from entering the patient’s room 207. Which comorbidity does a patient have that predisposes him/her for cholecystitis? a. Hepatitis C b. Diabetes mellitus 208. Which is an appropriate diet for a patient with end stage renal disease? a. ↓ CHON intake b. ↓ fluid intake only if no urine output 209. A patient is on amlodipine besylate (Norvasc), you as the nurse on duty will be most concerned if? a. “My heartbeat is 60 bpm since I started taking the drug.” b. “My BP is 100/80 mmHg.” c. “I rise slowly because I have dizziness with the drug.” 210. What is negative wound therapy? a. healing takes place by debriding some of devitalized tissue to promote healing b. c/t DNA synthesis in the wound promote wound healing c. wound will heal with pressure dressing 211. The nurse manager says, “Congratulations! Because of your suggestions, there is improved work efficiency for the past 3 months.” This statement reflects which of the following? a. trust between management and staff nurses b. allow staff efficient self-direction 212. A patient is taking sildenafil (Viagra). Which of these following statements indicate that he requires further teaching? a. I will take sildenafil (Viagra) 1 hour before sex. b. It keeps me erect for 15 minutes without sexual stimulation. c. I will continue taking Zoltax while on Viagra. d. I’ll report facial flushing to the physician. 213. Which is appropriate teaching about the drug Botox? a. Paralyzes the muscle of the face. b. Side effect include headache. c. Apply hot pack when painful. d. Patient can have botulism. 214. You are the home health nurse, which patient are you to visit first?
a. visit first the least infective patient. 215. A nursing student is about to provide health teaching on substance abuse, you determine that he/she needs further teaching when he/she states? a. Cocaine gives you confidence b. Cannabis intoxication is like alcohol intoxication. 216. ILLUSTRATION: Which position will facilitate proper assessment of diastolic BP? a. Supine b. Side lying c. Semi – fowler’s d. Trendelenburg 217. A patient with CHF has abnormal potassium and ↑ cholesterol, which medications are contraindicated? a. Potassium durule b. Digoxin (Lanoxin) c. Furosemide (Lasix) d. Atorvastatin (Lipitor) e. Nesiritide (Natrecor) f. Colace 218. Which of the following exemplifies the appropriate diet for cystic fibrosis? a. ↑ calcium ↑ sodium b. ↓ calcium ↓ sodium
A child with cystic fibrosis requires a ↑calorie, ↑protein, and well-balanced diet to meet energy and growth needs; multivitamins and vitamins A, D, E, and K are also administered; for those with severe lung disease, energy requirements may be as high as 20% to 50% or more of the recommended daily allowance.
219. You are assigned to a visually impaired client, which exemplifies therapeutic communication? a. speak loudly and slowly b. give therapeutic touch to get attention c. say when you're leaving patient's room 220. Which patient is your priority in triage? a. 4 inch laceration above the head with headache b. 2nd degree burn with dry cough 221. A patient with Parkinson’s disease is taking Levodopa. Which statement will you follow up?
a. This drug is not working for me. I want to stop taking. 222. You are the school nurse, which is an appropriate response by the parent? a. I will allow my child to go to school until/when vesicles are crusted. 223. Which is the drug of choice for MRSA? a. Vancomycin (Vancocin) b. Zyvox c. Synercid 224. 80 year old complaints about his difficulty sleeping and asks you for advice. Which of the following will you include? Select all that apply: a. exercise vigorously 30 minutes before sleeping b. drink warm/hot chocolate c. eat a midnight snack 226. You are the admitting nurse, which cohorting is appropriate? a. Patient with Hepatitis B + Patient with Hepatitis D b. Patient with Crohn's disease + Patient with ulcerative colitis 227. A patient has CVA with dysphagia, the nurse observes his co-staff nurse. You will intervene if you see him/her? a. put patient in semi – fowler’s/high fowler’s when eating. b. give coffee with the patient’s breakfast. 228. How will you accurately take a patient’s intra-aortic blood pressure? a. locate patient’s phlebotomy axis. b. maintain pressure to 200 mmHg. 229. What are the appropriate nursing interventions for a patient who was administered with radioisotopes? a. ↑ hydration 230. A patient is taking captopril (Capoten) for primary hypertension. What assessment needs follow up? a. I can use salt substitutes instead of table salt to ↓ my BP. b. I should discontinue my oral potassium supplements. c. I can take this with thiazide diuretic to treat my hypertension. 231. Kayexelate enema administration. What is incorrect?
a. It is mixed with sorbitol before administration. b. patient should be instructed to hold enema for 15 minutes. c. A balloon tipped catheter is used for administration. 232. Which are correct regarding surgical positioning? Select all that apply: a. restraints are placed at the wrist. b. position is chosen based on location of organ and exposure. c. pads and supports are placed to where it is needed. d. patient should be gently rolled after anesthesia administration. e. position should avoid thoracic compression. 233. Elderly patient. What are expected findings? Select all that apply: a. “I am using OTC laxatives every 3 days because I get constipated a lot.” b. “I do not drive at night because I easily get glared by lights.” c. “I have dry skin even though I applied moisturizer after baths.” d. “I have a mole on my back and it seems to be growing.” 234. You are conducting an assessment of an elderly patient. Which needs follow up? a. ↑ shallow respirations b. rales at the base of the lungs c. oral intake of at least 1500 ml per day 235. A patient is to ambulate after prolonged bed rest. Which is a priority? a. patient expectorates clear mucus b. fatigue after performing ADLs c. RR of 24 turns to 11 236. Which would the nurse call back first? a. patient with heart failure loses 2 lbs. in 24 hours. b. patient with ulcerative colitis reports he just experienced 3 loose stools with streaks of blood during the past hour. 237. A patient is rushed to the ER for submersion injury. What sign would need priority intervention? a. dyspnea b. restlessness c. frequent coughing d. pulse oximetry = 90% 238. A maternity nurse is floated to the ER. She is assigned to whom? a. a patient with laceration who needs dry sterile dressing change. b. a patient who will undergo paracentesis.
c. a patient who is to have CTT placement. 239. Which among the patients who came from the PACU will the nurse attend to first? a. Post TURP patient complaining of intermittent bladder spasms. b. A patient with central venous access device inserted 2 hours ago complaining of dry mouth. c. Patient who underwent CTT insertion with fluctuation in the drainage bottle. 240. Patient disagrees to take medications and asks nurse to focus care on other patients. What is an appropriate response? a. “Is there something bothering you?” b. “What have I done for you to act this way?” c. “You seem upset.” 241. A nurse observes a schizophrenic client shouting at other patients. Other patients and personnel had many attempts trying to make the patient go back to his room. Which is the best intervention? a. call other staff to work as a team. b. set limits for the patient’s behavior and assist back to his room. c. administer PRN antipsychotics. d. Tell the patient to have a 30 minute “time out”. 242. Priority referral to nutritionist. a. patient with ESRD having a ↑ fat and ↑ carbohydrate diet. b. patient with COPD eating 3 large full meals in a day. c. patient with DM with 50% of total calories coming from carbohydrates. 244. Precaution for basilar skull fracture. a. instruct visitors to avoid bringing fresh flowers. b. nurse wears mask when obtaining patient’s BP. c. keep patient’s room cleaned all the time. 245. Which is a priority? a. patient with new colostomy complaining of abdominal cramps b. DM 1 patient with blood glucose = 189 c. patient with ulcerative colitis with blood streaked stool 246. ORDERED RESPONSE: Changing from permanent infusion line into intermittent infusion line. 248. Which patient will you attend to first? a. post cholecystectomy with shoulder pain b. pneumonia with productive cough c. diverticulitis with LLQ pain
d. COPD patient using accessory muscles for breathing 249. Which finding in a patient 36 hours postpartum requires follow up? a. mid epigastric pain and vomiting 250. Postpartum discharge teaching. Select all that apply: a. fishy odor of lochia is a sign of infection. b. report if lochia is increasing. c. can begin with vaginal douching. d. report if temperature is above 38° C e. avoid sexual intercourse for 8 weeks. 251. What is an appropriate preoperative nursing intervention 24 hours prior to an appendectomy of a patient? a. administer IV antibiotics 252. Patient’s chart: Temperature = 38°C, BP = 98/50 mmHg, HR = 120 bpm, O2 sat = 91% a. place patient in high Fowler’s position. b. request doctor for ↑ in IVF rate.
Nursing interventions for patients in shock include: elevation of the legs; notifying the HCP; oxygen administration; monitoring of the patient’s LOC, vital signs, intake and output; assessment of the color, temperature, turgor and moisture of the skin and mucous membranes; and administration of IV fluids, blood and colloid solutions as prescribed.
253. A woman uses efavirenz (Evista) a. advise to change contraceptive method from hormonal pills to a different birth control method.
Evista is a selective estrogen receptor modulator.
254. A patient with Alzheimer’s disease has bruises. Which will be an appropriate nursing intervention? a. report incidence of abuse. b. ask family members. c. ask patient if you can talk in private.
256. ILLUSTRATION: Proper site to administer DTaP for 2 month old child.
a. vastus lateralis b. deltoid c. ventrogluteal d. dorsogluteal 257. ILLUSTRATION: Expected dermatological changes for elderly. a. cob web veins b. cigarette scars c. ↓ skin turgor 258. Correct immunization schedule a. MMR at 2 months. b. Hepatitis B 2 doses. c. TDaP 5 doses at different intervals. 259. Which is not a side effect of antipsychotic medications? a. akathisia b. pseudoparkinsonism c. dysphagia d. urinary retention 260. According to hospital policy, only 2 visitors enter a client’s room at a time. A terminally ill client’s family wishes to enter and be beside him. What will the nurse do? a. coordinate with the supervisor. b. allow the family to enter 2 members at a time. c. allow them all to enter. 261. What is an incorrect understanding about suctioning of a tracheostomy? a. wear clean gloves when suctioning 262. Sites of edema in right sided heart failure. Select all that apply: a. shoulder b. girdle c. thorax 264. A patient is prescribed with indomethacin (Indocin); which are the side effects of this drug? Select all that apply: a. headache b. blurred vision c. metallic taste d. muscle ache
Indomethacin (Indocin) is a prostaglandin inhibitor.
265. A child is scheduled for surgery, her parents were divorced but they have joint custody of the child. The mother has signed the consent. What will you do? a. proceed to comply with preoperative checklist b. notify the physician c. call the father and seek consent
A minor is a client under legal age as defined by state statute (usually younger than 18 years). A minor may not give legal consent must be obtained from a parent or the legal guardian; assent by the minor is important because it allows for communication of the minor’s thoughts and feelings.
266. What is NOT an example of therapeutic communication? a. the nurse instructs the patient who is aggressive to move away from the group b. the nurse talks to the patient in a calm, nonjudgmental manner c. the nurse tells the patient that what she will share with her will be kept confidential and will not be shared with the health care team. 267. Which of the following statements illustrate a correct understanding about renal transplantation? Select all that apply: a. I have to avoid contact sports for a couple of weeks. b. I need to take immunosuppresants for the remainder of my life. c. I am now at risk for cardiovascular disease. 268. Which is the appropriate diet for patients with pressure ulcers? a. ↑ CHON, ↑ vitamin C b. ↑ K+, ↑ Nac. ↓ CHON, ↓ vitamin C 269. Which is the appropriate diet for patients with renal calculi? a. Give vitamin D and vitamin A daily b. ↑ fluid intake c. tell patient to exercise regularly 270. You are assigned to the medical-surgical unit. Which patient is your priority? a. a diabetic client breathes rapidly and deeply.
Diabetic ketoacidosis is an emergency.
271. Which is the appropriate diet for a CVA patient with dysphagia?
a. vegetable soup and cranberry juice b. tuna sandwich with mayonnaise c. broiled pork chop with applesauce 272. Which laboratory result supports a diagnosis of CVA? a. ↑ partial thromboplastin time b. CSF with (+) RBCs 273. A patient with CVA has right sided hemiparesis, which nursing intervention needs follow up? a. put the patient in upright position b. put the food tray on the affected field c. approach the patient on his unaffected part 274. Which indicates correct understanding for a patient taking raloxifene (Evista)? a. I will have to walk at least 3 days a week. b. I will not experience hot flashes anymore.
Raloxifene (Evista) is a selective estrogen receptor modulator.
275. Which patient needs to be seen first in the out-patient department? a. patient with papulovesicular rash with chills and fever. b. patient with white patches in his buccal mucosa. c. patient with non-productive cough. 276. ILLUSTRATION: cluster of rashes along his flank area a. administer an oral antibiotic b. administer antiviral within 72 hours of appearance c. application of topical cream d. cauterization 277. A patient states: “I don’t know if I really want this pregnancy.” a. do you want to know about the available choices you have? b. You should decide if you really want it or not. c. I will discuss to you the possible changes during pregnancy. d. let your husband decide about this. 278. A 36 week pregnant client is HIV positive. a. Isolate the patient from other laboring clients. b. externally monitor for FHT rather than internally. c. infuse proper antiviral medication.
279. What is the cause of an infant’s hip dislocation? a. oligohydramnios b. breech presentation c. folic acid deficiency 280. Which illustrates Nonmaleficence? a. explains procedures to a patient and answers questions regarding the procedure. b. closes curtains when patient undergoes a procedure c. relays truthful statements d. administers vaccines 281. What is an appropriate health teaching about cholecystectomy? a. “You can resume your normal diet.” b. “↓ your sodium intake.” c. “Enzyme replacement for lifetime use.” 282. What is an appropriate health teaching for a patient with pancreatitis? a. “↓ fat in your diet.” b. “Consider alcohol intake as the etiology of the disease.” 283. What is a component of pre-ECT procedure? a. ask if the patient has metal implants b. ask about seizure history c. ask if he had myocardial infarction before 284. Which assessment finding indicates effective management of depression? a. patient is alert and productive b. patient has ↑ energy level c. patient has ↑ serum dopamine level 285. A patient is on warfarin therapy, you will question the doctor’s order if the patient has a history of? a. Deep vein thrombosis b. Peptic ulcer disease c. CVA d. Hyperlipidemia 286. A 45 year old female patient states, “I have prolonged menstruation, how would I know if this would lead to malignancy?” What will be your response? a. count the number of pads used.
b. take note of the volume of bleeding c. describe your usual menstruation pattern 287. A patient with osteomyelitis has a pressure ulcer; the nurse emphasizes which component of nursing care? a. adhere to proper wound care b. adhere to completion of antibiotic regimen c. encourage ambulation 288. An elderly patient states his dietary preferences. Which items will you suggest to complement this? a. egg and poultry b. rice and pasta c. fruits and vegetables 289. Which statement/s made by an elderly patient illustrates elderly abuse? Select all that apply: a. My grandchildren cook my food but it tastes terrible. b. My grandchildren hold my credit card and withdraw money when needed. c. My grandchildren use my car to drive me to my doctor’s appointment. d. My grandchildren don’t want me to go out of my room. 290. The nurse overheard the elderly patient’s son: “I sold your care because I don’t have money.” After the son leaves the room, the nurse will impart which instructions to the elderly patient? Select all that apply: a. We should talk in private. b. Do you have episodes of forgetfulness? c. I will let you know about contact numbers of authorities that you can call when you are abused. 291. An infant is on phototherapy to eliminate excess bilirubin. The mother states, “My baby is having frequent bowel movements.” The nurse will? a. provide small frequent feedings b. check fontanels for depression 292. How will you administer liquid medications to a 3 year old patient with URTI? a. use syringe to aspirate the medication and put on the middle portion of his/her tongue. b. use dropper and put on anterior part of his/her tongue. c. use spoon and put on posterior part of his/her tongue. 293. The nurse asks which of the following questions that may delay administration of chemotherapy? a. when was your last meal? b. have you been nauseated before?
c. do you have mouth sores? 294. You are taking care of patients with STDs, who is your priority? a. Patient with foul smelling fishy discharge. b. Patient with white vaginal discharge. c. Patient with frothy yellow discharge. d. Patient with painless vaginal ulcers.
The primary genital herpes infection involves systemic viremia, and encephalitis is a possible complication. Headache and stiff neck may indicate encephalitis, and require further investigation.
295. Which of the following statements by the patient indicate correct understanding of fluphenazine decanoate regimen? a. I will need to undergo blood tests during treatment. b. I can go out under the sun.
Besides this compilation, the following are helpful references for passing the NCLEX-RN Exam: A. Textbook 1. Saunders Comprehensive Review NCLEX-RN Examination 6th Edition published 2013 – In my opinion, the Best textbook for the international nursing licensure exams – Saunders publishes a brand new edition every 3 years so the 7 th edition will be published in 2016 I suppose. It would be best to acquire the latest edition of Saunders because of the updated content which may be part of the NCSBN test pool. B. Computer programs 1. Evolve Reach Test by HESI – the most difficult NCLEX computer program I have ever answered. I along with my friends who passed the actual NCLEX-RN Exam had failing scores while answering this computer program so it really is a commendable computer program 2. Comprehensive Review for NCLEX-RN by Prentice Hall/Pearson Vue/Mary Ann Hogan 3. Silvestri: Saunders Strategies for Alternate Item Formats on the NCLEX-RN® Exam – Alternate item formats include: Ordered responses, Select all that apply questions, Audiovisual format
If this compilation helps you in passing the NCLEX-RN exam, kindly pay it forward by sharing it so that other nurses can fulfill their dreams of being NCLEX-RNs as well. Please update, proofread, and edit this compilation every time other NCLEX-RNs are kind and generous enough to supplement it.
Let us all strive to be a blessing to those around us. God bless you all! Aja!!! ^_^ “For I know the plans I have for you,” declares the Lord, “plans to prosper you and not to harm you, plans to give you hope and a future.” — Jeremiah 29:11
