NCLEX RN Practice Test 8

Dark red to purple stoma indicates inadequate blood supply.

Veil-like loss of vision is a symptom of a detached retina not glaucoma. Answers B C and D are symptoms associated with glaucoma; therefore they are incorrect.

Tuberculosis should be considered for any clients with a persistent cough, weight loss, anorexia, night sweats, hemoptysis, shortness of breath, fever, or chills. The client’s previous exposure to tuberculosis should also be assessed and correlated with the clinical manifestations.

Right Answer is:
After a spinal cord injury, women usually remain fertile; therefore, you may consider contraception if you don’t want to become pregnant.

Liver and kidney function studies are done before initiation of chemotherapy to evaluate the child’s ability to metabolize the chemotherapeutic agents. A CBC is performed to assess for anemia and white blood cell count. A peripheral blood smear is done to assess the maturity and morphology of red blood cells. A lumbar puncture is performed to assess for central nervous system infiltration.

Foods high in purine include dried beans peas spinach oatmeal poultry fish liver lobster and oysters. Answers B C and D are incorrect because they are low in purine. Other sources low in purine include most vegetables milk and gelatin.

The client with sickle cell crisis and sequestration can be expected to have signs of hypovolemia including decreased blood pressure. Answer B is incorrect because the client would have dry mucus membranes. Answer C is incorrect because the client would have increased respirations because of pain associated with sickle cell crisis. Answer D is incorrect because the clients blood pressure would be decreased.

Prepare for a prosthesis

Anthrax can have an incubation period of hours to seven (7) days with an average of 48 (hours). Since the question stated exposure, we can assume that the mailman is in the incubation phase.

During pregnancy the thyroid gland triples in size. This makes it more difficult to regulate thyroid medication. Answer A is incorrect because there could be a need for thyroid medication during pregnancy. Answer C is incorrect because the thyroid function does not slow. Fetal growth is not arrested if thyroid medication is continued so answer D is incorrect.

Ineffective individual coping

Cold dialysate increases discomfort. The solution should be warmed to body temperature in warmer or heating pad; don’t use microwave oven.

The client should avoid over-the-counter allergy medications because many of them contain Benadryl (diphenhydramine). Benadryl is used to counteract the effects of antipsychotic medications that are prescribed for schizophrenia. Answer B refers to the client taking an MAO inhibitor and answer C refers to the client taking lithium; therefore they are incorrect. Over-the-counter pain relievers are safe for the client taking antipsychotic medication so answer D is incorrect.

Carbon monoxide levels between 11% and 20% result in flushing, headache, decreased visual activity, decreased cerebral functioning, and slight breathlessness; levels of 21% to 40% result in nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, and tachycardia; levels of 41% to 60% result in seizure and coma; and levels higher than 60% result in death.

Mode of transmission is the weakest link in the chain of infection. It is easily manipulated by the nurses using the tiers of prevention, either by instituting transmission based precautions, universal precaution or isolation techniques.

An INR of 8 indicates that the blood is too thin. The normal INR is 2.03.0 so answer B is incorrect because the doctor will not increase the dosage of coumadin. Answer C is incorrect because now is not the time to instruct the client about the therapy. Answer D is not correct because there is no need to increase the neurological assessment.

The client with serum sodium of 170meq/L has hypernatremia and might exhibit manic behavior. Answers A C and D are not associated with hypernatremia and are therefore incorrect.

Right Answer is:
Relax bronchial smooth muscle

Right Answer is:
Avoid applying creams and powder to the area.

Rationale: The NGT’s primary purpose is for bowel decompression especially for clients suffering from obstruction.

Buck’s (extension) traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps to immobilize the fracture. Traction does not allow for bony healing to begin or provide rigid immobilization. Traction does not lengthen the leg for the purpose of preventing blood vessel severance. This type of traction involves pulleys and wheels, not pins and screws.

Right Answer is:
Lack of privacy

The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. The test results in option C are abnormally elevated, reflecting CRF and the kidneys’ decreased ability to remove nonprotein nitrogen waste from the blood. CRF causes decreased pH and increased hydrogen ions — not vice versa. CRF also increases serum levels of potassium, magnesium, and phosphorous, and decreases serum levels of calcium. A uric acid analysis of 3.5 mg/dl falls within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls with the normal range of 60% to 75%.

Right Answer is:
3 months

Aplastic anemia decreases the bone marrow production of RBC’s, white blood cells, and platelets. The client is at risk for bruising and bleeding tendencies.

Integrate the solutions to his day-to-day activities is expected to happen during the third stage of change when the change agent incorporate the selected solutions to his system and begins to create a change.

The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.

To help clients cope with their problems by learning behaviors that we are more functional and be better equipped to face reality and make decisions.

Social isolation

Using the ABCD approach to the client with multiple trauma the nurse in the ER would: establish an airway determine whether the client is breathing check circulation (control hemorrhage) and check for deficits (head injuries). Answers A B and D are incorrect because they are not in the appropriate sequence for maintaining life.

My child should not use a pacifier after age 6 months

The blood must be stopped at once, and then normal saline should be infused to keep the line patent and maintain blood volume.

The central venous pressure of 15mm H20 indicates fluid overload. Answers A B and C are incorrect because they are not a cause for concern; therefore they do not need to be reported to the physician.

Gantrisin and other sulfa drugs should be given 30 minutes before meals to enhance absorption. Answer A is incorrect because the medication should be given before eating. Answer C is incorrect because the medication should be given on an empty stomach. Answer D is incorrect because the medication is to be given in divided doses throughout the day.

Right Answer is:
Arguments between nurses and residents regarding treatment

Dietary changes

Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters. Option 1 describes eczema, option 2 describes herpes zoster, and option 4 describes psoriasis.

Effective communication

Right Answer is:
Positions of flexion

She does it regularly as an important responsibility

Right Answer is:
CSF leakage due to the puncture created by the spinal needle in the membrane that surrounds the spinal cord.

2 fingers below umbilicus

A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.

The Diagnostic and Statistic Manual of Mental Disorders, 4th edition, defines schizophrenia as a disturbance in multiple psychological processes that affects thought content and form, perception, affect, sense of self, volition, relationship to the external world, and psychomotor behavior. Loss of identity sometimes occurs but is only one characteristic of the disorder. Multiple personalities typify multiple personality disorder, a dissociative personality disorder. Mood disorders are commonly accompanied by increased or decreased self-esteem. Schizophrenia doesn’t cause a disturbance in sensorium, although the client may exhibit confusion, disorientation, and memory impairment during the acute phase.

Apply an occlusive dressing to the insertion site.

Continue the plan of care as written

The XII hypoglossal cranial nerve deals with the function of the tongue and its movement. Clients can exhibit weakness and deviation with impairment of this cranial nerve. Answers A B and C are not tested by this procedure. Cranial nerve I is involved with smelling cranial nerve II is involved with visual function and cranial nerve X deals with the gag reflex.

Stimuli are provided via all the senses; since the infant’s behavioral development is enhanced through parent-infant interactions, these interactions should be encouraged.

When performing a nutritional assessment, one of the first things the nurse should do is to assess what the client typically eats. The client shouldn’t be permitted to eat as desired. Weighing the client daily, placing her on I & O status, and drawing blood to determine electrolyte level aren’t part of a nutritional assessment.

At the time of diagnosis, a painless cervical lesion is often present. The back, chest, and groin areas aren’t involved.

Urine output of 20 mL/hour.

Both benzodiazepines, such as alprazolam, and barbiturates, such as phenobarbital, are addictive, controlled substances. All the other drugs listed aren’t addictive substances.

Whole grains

An infiltrated intravenous (IV) line is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, edema, pain, numbness, and blanched skin are the results of IVfluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IVsolution will stop, and if an electronic pump is being used, it will alarm. Erythema can be associated with infection, phlebitis, or thrombosis. Formation of a red streak and purulent drainage is associated with phlebitis and infection.

By writing down her suspicions the nurse leaves herself open for a suit of libel a defamatory tort that discloses a privileged communication and leads to a lowering of opinion of the client. Defamatory torts include libel and slander. Libel is a written statement whereas slander is an oral statement. Thus answer B is incorrect because it involves oral statements. Malpractice is an unreasonable lack of skill in performing professional duties that result in injury or death; therefore answer C is incorrect. Negligence is an act of omission or commission that results in injury to a person or property making answer D incorrect.

Hodgkin’s disease (a type of lymphoma) is a malignancy of the lymph nodes. Specific clinical manifestations associated with Hodgkin’s disease include painless, firm, and movable adenopathy in the cervical and supraclavicular areas and abdominal pain as a result of enlarged retroperitoneal nodes. Hepatosplenomegaly also is noted. Although fever, malaise, anorexia, and weight loss are associated with Hodgkin’s disease, these manifestations are seen in many disorders.

Ineffective gas exchange related to broncho spasm

A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis refers to a crisis of disaster, is not a part of everyday life, and is unplanned and accidental. Adventitious crises may result from a natural disaster (e.g., floods, fires, tornadoes, earthquakes), a national disaster (e.g., war, riots, airplane crashes), or a crime of violence (e.g., rape, assault, murder in the workplace or school, bombings, or spousal or child abuse).

Ineffective gas exchange related to bronchospam

Acquired immunodeficiency syndrome (AIDS) is a disorder caused by HIV and characterized by generalized dysfunction of the immune system. The most common opportunistic infection of children infected with HIV is Pneumocystis jiroveci pneumonia, which occurs most frequently between the ages of 3 and 6 months, when HIV status may be indeterminate. Cough is a common sign of this opportunistic infection. Cytomegalovirus infection is also characteristic of HIV infection; however, it is not the most common opportunistic infection. Liver failure is a common sign of this complication. Although gastrointestinal disturbances and neurological abnormalities may occur in a child with HIVinfection, options 3 and 4 are not specific opportunistic infections noted in the HIV-infected child. Watery stool is noted with gastroenteritis and nuchal rigidity is seen in meningitis.

Polycystic kidney disease is a genetic familial disease in which the kidneys enlarge with cysts that rupture and scar the kidney, eventually resulting in end-stage renal disease. Treatment options include hemodialysis or kidney transplant. Clients usually undergo bilateral nephrectomy to remove the large, painful, cyst-filled kidneys. Peritoneal dialysis is not a treatment option due to the infected cysts. The condition does not respond to immunosuppression.

Chronic hyperglycemia, resulting from poor glycemic control, contributes to the microvascular and macrovascular complications of diabetes mellitus. Classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Diaphoresis may occur in hypoglycemia. Hypoglycemia is an acute complication of diabetes mellitus; however, it does not predispose a client to the chronic complications of diabetes mellitus. Therefore, option 2 can be eliminated because this finding is characteristic of hypoglycemia. Options 3 and 4 are not associated with diabetes mellitus.

Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. All three incorrect options identify normal laboratory values. The correct option identifies the presence of hypokalemia.

Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. No currently accepted intervention changes this response, and it is not the highest priority of care at this time.

The nurse should plan to care for the client who has an elevated white blood cell count and a fever first because this client’s needs are the priority. The client who is ambulatory with steady gait and the client scheduled for physical therapy for a crutch-walking session do not have priority needs. Waiting for pain medication to take effect before providing care to the postoperative client is best.

Remember that intact skin and mucous membrane is our first line of defense against infection.

The concept that behavior is motivated and has meaning comes from the psychodynamic framework. According to this perspective, behavior arises from internal wishes or needs. Much of what motivates behavior comes from the unconscious. The remaining responses do not address the internal forces thought to motivate behavior.

Confabulation or the filling in of memory gaps with imaginary facts is a defense mechanism used by people experiencing memory deficits.

Diarrhea causes a bicarbonate deficit. With loss of the relative alkalinity of the lower GI tract, the relative acidity of the upper GI tract predominates leading to metabolic acidosis. Diarrhea doesn’t lead to respiratory acid-base imbalances, such as respiratory acidosis and respiratory alkalosis. Loss of acid, which occurs with severe vomiting, may lead to metabolic alkalosis.

At 32 weeks gestation the fetus can be expected to be active. Answers A B and C are not typical findings during the Leopold maneuver of a client who is 32 weeks gestation; therefore they are incorrect.

Right Answer is:
Head cap, scrub suit, mask, OR shoes

Opioid analgesics may be prescribed to relieve moderate to severe pain associated with labor. Opioid toxicity can occur and cause respiratory depression. Naloxone is an opioid antagonist, which reverses the effects of opioids and is given for respiratory depression. Morphine sulfate and hydromorphone hydrochloride are opioid analgesics. Betamethasone is a corticosteroid administered to enhance fetal lung maturity.

The school-age child (eight or nine years old) engages in cooperative play. These children enjoy competitive games in which there are rules and guidelines for winning. Answers B and D describe peer-group relationships of the preschool child and answer C describes peer-group relationships of the preteen.

Nodding or smiling by a Japanese American client may reflect only the cultural value of interpersonal harmony. This nonverbal behavior may not be an indication of acceptance of the treatment, agreement with the speaker, or understanding of the procedure.

The main sources of vitamin A are yellow and green vegetables (such as carrots, sweet potatoes, squash, spinach, collard greens, broccoli, and cabbage) and yellow fruits (such as apricots, and cantaloupe). Animal sources include liver, kidneys, cream, butter, and egg yolks.

Cohesiveness

A therapeutic nurse-patient relationship is defined as a helping relationship that’s based on mutual trust and respect, the nurturing of faith and hope, being sensitive to self and others, and assisting with the gratification of your patient’s physical, emotional, and spiritual needs through your knowledge and skill.

The nurse should prepare a client for ECT in a manner similar to that for general anesthesia.

An ophthalmologist

Right Answer is:
postoperative respiratory dysfunction

An MRI uses a powerful magnetic force; therefore any metal or jewelry should be removed before this test. Answers A B and D are not appropriate for this test.

An anorexic client who requires hospitalization is in poor physical condition from starvation and may die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalances. Therefore, monitoring the client’s vital signs, serum electrolyte level, and acid base balance is crucial. Option A may worsen anxiety. Option B is incorrect because a weight obtained after breakfast is more accurate than one obtained after the evening meal. Option D would reward the client with attention for not eating and reinforce the control issues that are central to the underlying psychological problem; also, the client may record food and fluid intake inaccurately.

A turning schedule with a signing sheet will help ensure that the client gets turned and thus, help prevent pressure ulcers. Turning should occur every 1-2 hours—not every 8 hours—for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist but should avoid vigorous massage, which could damage capillaries. When moving the client, the nurse should lift rather than slide the client to void shearing.

Right Answer is:
Hyperglycemia and Hypokalemia

Right Answer is:
Fever and Weight Gain

The client is continued on medication therapy for up to 12 months, depending on the situation. The client generally is considered noncontagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to work when the results of 3 sputum cultures are negative.

After administering naloxone (Narcan) the nurse should monitor the client’s respiratory status carefully, because the drug is short acting & respiratory depression may recur after its effects wear off.

The nurse has no authority order the radiology department for a chest x ray evaluation nor order for a sputum exam. The client need not be isolated because Mantoux test do not determine the activeness of the disease.

Bounding pulse

The anterior fontanel is diamond-shaped and located on the top of the head. The fontanel should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. The nurse would document the finding because it is normal. There is no useful reason to increase oral fluids, notify the HCP, or elevate the head of the bed to 90 degrees.

Chinese believes that male newborns are demon magnets. To fool those demons, they put female clothes to their male newborn.

end of each Visit

Glaucoma

acute ear infection

Counting then number of heart beats during exercise for 10 seconds, then multiply by 6

Loose associations are thoughts that are presented without the logical connections usually necessary for the listening to interpret the message.

With the babinski reflex, the newborn’s toes hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward form the heel and across the ball of the foot. With the startle reflex, the newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement of loud noise. With the rooting and sucking reflex, the newborn turns his head in the direction of stimulus, opens the mouth, and begins to suck when the cheeks, lip, or corner of mouth is touched. With the crawl reflex, the newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface.

Clients taking trimethoprim-sulfamethoxazole should be informed about early signs and symptoms of blood disorders that can occur from this medication. These include sore throat, fever, and pallor, and the client should be instructed to notify the health care provider (HCP) if these occur. The other options do not require HCP notification.

The nurse should reinforce the need for a diet balanced in all nutrients and fiber. Foods that often cause diarrhea and bloating associated with irritable bowel syndrome include fried foods caffeinated beverages alcohol and spicy foods. Therefore answers B C and D are incorrect.

The 5 main categories of CAM include whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine. Magnetic therapy and massage therapy are therapies within specific categories of CAM.