NCLEX RN Practice Test 9 0% 0 NCLEX NCLEX RN Practice Test 9 This NCLEX RN Practice Test 9 contains more than 100 questions. Attempt them all and check your learnings 1 / 100 A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus and the urinary output for the past hour is 100mL. The nurse should: Slow the infusion rate and turn the client on her left side. Stop the infusion of magnesium sulfate and contact the physician. Administer calcium gluconate IV push and continue to monitor the blood pressure. Continue the infusion of magnesium sulfate while monitoring the clients blood pressure. The clients blood pressure and urinary output are within normal limits. The only alteration from normal is the decreased deep tendon reflexes. The nurse should continue to monitor the blood pressure and check the magnesium level. The therapeutic level is 4.08.0mg/dL. Answers B C and D are incorrect because there is no need to stop the infusion at this time or slow the rate. Calcium gluconate is the antidote for magnesium sulfate but there is no data to indicate toxicity. 2 / 100 Aclient calls the nurse in the emergency department and states that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction because the client’s neighbor experienced such a reaction just 1 week ago. Which action should the nurse take? Ask the client if he ever sustained a bee sting in the past. Tell the client not to worry about the sting unless difficulty with breathing occurs. Tell the client to call an ambulance for transport to the emergency department. Advise the client to soak the site in hydrogen peroxide. In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. The appropriate action, therefore, would be to ask the client if he ever experienced a bee sting in the past. Option 1 is not appropriate advice. Option 3 is unnecessary. The client should not be told “not to worry.†3 / 100 What is the best position in palpating the breast? Lithotomy Side lying Trendelenburg Supine Supine 4 / 100 Therapeutic communication begins with? Encoding Showing empathy Knowing your client Knowing yourself It is important for the nurse to know herself to identify kinds of behavior of ideas that make her anxious and to seed help for her problems. Otherwise, she is likely to add new problems to those with which the patient is already struggling. 5 / 100 BCG in community health nursing is what type of prevention? Primary Tertiary Secondary None of the above Primary 6 / 100 A patient required long-term antibiotic has a central line catheter inserted into the right subclavian vein by the physician .Which of the following must be verified prior to the first use of the catheter? Catheter potency Length of catheter X-ray Blood return X-ray 7 / 100 Which of the following foods would the nurse encourage the client in sickle cell crisis to eat? Steak Popsicle Cottage cheese Lima beans Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles gelatin juice and pudding have high fluid content. The foods in answers A B and D do not aid in hydration and are therefore incorrect. 8 / 100 When do coronary arteries primarily receive blood flow? During expiration During inspiration During systole During diastole Although the coronary arteries may receive a minute portion of blood during systole, most of the blood flow to coronary arteries is supplied during diastole. Breathing patterns are irrelevant to blood flow 9 / 100 The neonate of a mother with diabetes mellitus is prone to developing hypoglycemia because: The baby is reacting to the insulin given to the mother There is rapid diminution of glucose level in the baby’s circulating blood and his pancreas is normally secreting insulin His kidneys are immature leading to a high tolerance for glucose The pancreas is immature and unable to secrete the needed insulin Answer: (B) There is rapid diminution of glucose level in the baby’s circulating blood and his pancreas is normally secreting insulin If the mother is diabetic, the fetus while in utero has a high supply of glucose. When the baby is born and is now separate from the mother, it no longer receives a high dose of glucose from the mother. In the first few hours after delivery, the neonate usually does not feed yet thus this can lead to hypoglycemia. 10 / 100 When a nurse is teaching a woman about her menstrual cycle she mentions that which of the following is the most important change that happens during the follic- ular phase of the menstrual cycle? Maturation of the graafian follicle. Multiplication of the fimbriae. Proliferation of the endometrium. Secretion of human chorionic gonadotropin. 1. FSH is elevated during the follicular phase and the graafian follicle matures. 2. The fimbriae are located at the ends of the fallopian tubes. They do not multiply in number. 3. The hormone hCG is not produced during the menstrual cycle. It is produced by the fertilized egg in early pregnancy. 4. Endometrial proliferation occurs during the secretory phase of the menstrual cycle. 11 / 100 Wilfredo with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse Patricia position the client for this test initially? Prone with the torso elevated Bent over with hands touching the floor Lying on the left side with knees bent Lying on the right side with legs straight For a colonoscopy, the nurse initially should position the client on the left side with knees bent. Placing the client on the right side with legs straight, prone with the torso elevated, or bent over with hands touching the floor wouldn’t allow proper visualization of the large intestine. 12 / 100 A 50-year-old patient is being admitted to the hospital in a vegetative state of unknown etiology what is the PRIORITY nursing diagnosis? Altered cerebral tissue perfusion Risk for impaired skin integrity Altered thought processes Impaired swallowing Risk for impaired skin integrity 13 / 100 The difference between rectal and auxiliary temp is: 0.8 c 0.5 c 2 c 1 c. 1 c. 14 / 100 A patient admitted with a cerebrovascular accident (CVA), is unable to chew or swallowed. The patient is a risk for aspiration. The nurse would anticipate receiving which of the following orders for this patient? Refer the patient to physical therapy for muscle strengthening Refer the patient to a psychiatrist for depression related to the CVA Give no food by mouth and start intravenous hydration Start a pureed diet with thickened liquids Give no food by mouth and start intravenous hydration 15 / 100 Which of the following clinical manifestations would alert the nurse to lithium toxicity? Increasingly agitated behaviour. Anorexia with nausea and vomiting. Sudden increase in blood pressure. Markedly increased food intake. Anorexia with nausea and vomiting. 16 / 100 A child with β-thalassemia is receiving long-term blood transfusion therapy for the treatment of the disorder. Chelation therapy is prescribed as a result of too much iron from the transfusions. Which medication should the nurse anticipate to be prescribed? Deferoxamine Meropenem Metoprolol Fragmin β-Thalassemia is an autosomal recessive disorder characterized by the reduced production of 1 of the globin chains in the synthesis of hemoglobin (both parents must be carriers to produce a child with β-thalassemia major). The major complication of long-term transfusion therapy is hemosiderosis. To prevent organ damage from too much iron, chelation therapy with either Exjade or deferoxamine may be prescribed. Deferoxamine is classified as an antidote for acute iron toxicity. Fragmin is an anticoagulant used as prophylaxis for postoperative deep vein thrombosis. Meropenem is an antibiotic. Metoprolol is a beta blocker used to treat hypertension. 17 / 100 The nurse is aware that the most common indication in using ECT is: Schizophrenia Bipolar Depression Anorexia Nervosa Depression 18 / 100 What is the first intervention for a client experiencing MI? Administer morphine Administer sublingual nitroglycerin Administer oxygen (wasn’t from the list) Obtain an ECG Administer morphine 19 / 100 A couple asks the nurse about risks of several birth control methods. What is the most appropriate response by the nurse? Oral contraceptives should not be used by smokers The IUD gives protection from pregnancy and infection Depo-Provera is convenient with few side effects Norplant is safe and may be removed easily Oral contraceptives should not be used by smokers The use of oral contraceptives in a pregnant woman who smokes increases her risk of cardiovascular problems, such as thromboembolic disorders. 20 / 100 a 45-yr-old auto mechanic comes to the physician’s office because an exacerbation of his psoriasis is making it difficult to work. He tells the nurse that his finger joints are stiff and sore in the morning. The nurse should respond by: Asking him if he has been diagnosed or treated for carpal tunnel syndrome Inquiring further about this problem because psoriatic arthritis can accompany psoriasis vulgaris Validating his complaint but assuming it’s an adverse effect of his vocation Suggesting he take aspirin for relief because it’s probably early rheumatoid arthritis Anyone with psoriasis vulgaris who reports joint pain should be evaluated for psoriatic arthritis. Approximately 15% to 20% of individuals with psoriasis will also develop psoriatic arthritis, which can be painful and cause deformity. It would be incorrect to assume that his pain is caused by early rheumatoid arthritis or his vocation without asking more questions or performing diagnostic studies. Carpal tunnel syndrome causes sensory and motor changes in the fingers rather than localized pain in the joints. 21 / 100 The nurse is in public area of the health care facility when an adult falls to the floor. Which of the following actions should the nurse take NEXT? Activate the emergency call system Determine unresponsiveness Open the airway Obtain the automatic electronic defibrillator(AED) Determine unresponsiveness 22 / 100 An adult client was burned in an explosion. The burn initially affected the client’s entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client’s clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? 0.18 0.36 0.24 0.48 According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower half of both arms equals 9%. The subsequent burn included the posterior half of the head, equaling 4.5%, and the upper half of posterior torso, equaling 9%. This totals 36%. 23 / 100 A client receiving Parnate (tranylcypromine) is admitted in a hypertensive crisis. Which food is most likely to produce a hypertensive crisis when taken with the medication? Cream cheese Cottage cheese Cheddar cheese Processed cheese The client taking MAOI including Parnate should avoid eating aged cheeses such as cheddar cheese because a hypertensive crisis can result. Answer A is incorrect because processed cheese is less likely to produce a hypertensive crisis. Answers B and C do not cause a hypertensive crisis in the client taking an MAOI; therefore they are incorrect. 24 / 100 Which of the following may happen if the uterus becomes overstimulated by oxytocin during the induction of labor? Increased pain with bright red vaginal bleeding Weak contraction prolonged to more than 70 seconds Tetanic contractions prolonged to more than 90 seconds Increased restlessness and anxiety Hyperstimulation of the uterus such as with oxytocin during the induction of labor may result in tetanic contractions prolonged to more than 90seconds, which could lead to such complications as fetal distress, abruptio placentae, amniotic fluid embolism, laceration of the cervix, and uterine rupture. Weak contractions would not occur. Pain, bright red vaginal bleeding, and increased restlessness and anxiety are not associated with hyperstimulation. 25 / 100 The nurse implements a teaching plan for a preg- nant client who is newly diagnosed with gesta- tional diabetes mellitus. Which statement made by the client indicates a need for further teaching? “I should stay on the diabetic diet.†“I should be aware of any infections and report signs of infection immediately to my health care provider (HCP).†“I should perform glucose monitoring at home.†“I should avoid exercise because of the negative effects on insulin production.†Exercise is safe for a client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet. Many clients are taught to perform blood glucose monitoring. If the client is not performing the blood glucose monitoring at home, it is performed at the clinic or HCP’s office. Signs of infection need to be reported to the HCP. 26 / 100 What type of relaxation technique does Lyza uses if a machine is showing her pulse rate, temperature and muscle tension which she can visualize and assess? Massage Autogenic training Biofeedback Visualization and Imagery Biofeedback is a technique you can use to learn to control your body’s functions, such as your heart rate. With biofeedback, you’re connected to electrical sensors that help you receive information (feedback) about your body (bio). This feedback helps you focus on making subtle changes in your body, such as relaxing certain muscles, to achieve the results you want, such as reducing pain. In essence, biofeedback gives you the power to use your thoughts to control your body, often to help with a health condition or physical performance. Biofeedback is often used as a relaxation technique. 27 / 100 A client with major depression has not verbalized problem areas to staff or peers since admission to a psychiatric unit. Which activity should the nurse recommend to help this client express himself? Watching movie with the peer group Art therapy in a small group Basketball game with peers on the unit Reading a self-help book on depression Art therapy provides a nonthreatening vehicle for the expression of feelings, and use of a small group will help the client become comfortable with peers in a group setting. Basketball is a competitive game that requires energy; the client with major depression is not likely to participate in this activity. Recommending that the client read a self-help book may increase, not decrease his isolation. Watching movie with a peer group does not guarantee that interaction will occur; therefore, the client may remain isolated. 28 / 100 A client tells the nurse that she is allergic to eggs dogs rabbits and chicken feathers. Which order should the nurse question? TB skin test ELISA test Rubella vaccine Chest x-ray The client who is allergic to dogs eggs rabbits and chicken feathers is most likely allergic to the rubella vaccine. The client who is allergic to neomycin is also at risk. There is no danger to the client if he has an order for a TB skin test ELISA test or chest x-ray; thus answers A C and D are incorrect. 29 / 100 Situation:– The nurse-patient relationship is a modality through which the nurse meets the client’s needs. Q. All of the following response are non therapeutic. Which is the MOST direct violation of the concept, congruence of behavior? Rejecting the client as a unique human being Tolerating all behavior in the client Responding in a punitive manner to the client Communicating ambivalent messages to the client Rejecting the client as a unique human being 30 / 100 Marianne is now at the Defervescence stage of the fever, which of the following is expected? Cyanotic nail beds Delirium Goose flesh Sweating Sweating 31 / 100 Situation: The question with regards to the OPERATING ROOM. Q. During surgery, movement of personnel should be: restricted monitored eliminated when possible kept to a minimum Right Answer is: kept to a minimum 32 / 100 Situation :– In the OR, there are safety protocols that should be followed. The OR nurse should be well versed with all these to safeguard the safety and quality to patient delivery outcome. Q. OR nurses should be aware that maintaining the client’s safety is the overall goal of nursing care during the intraoperative phase. As the circulating nurse, you make certain that throughout the procedure… strap made of strong non-abrasive material are fastened securely around the joints of the knees and ankles and around the 2 hands around an arm board the surgeon and anesthesiologist are in tandem client is monitored throughout the surgery by the assistant anesthesiologist the surgeon greets his client before induction of anesthesia Right Answer is: strap made of strong non-abrasive material are fastened securely around the joints of the knees and ankles and around the 2 hands around an arm board 33 / 100 The nurse is completing an obstetric history of a woman in labor. Which event in the obstetric history will help the nurse suspects dysfunctional labor in the current pregnancy? First labor lasting 24 hours. Uterine fibroid noted at time of cesarean delivery. Total time of ruptured membranes was 24 hours with the second birth. Second birth by cesarean for face presentation. An abnormality in the uterine muscle could reduce the effectiveness of uterine contractions and lengthen the duration of subsequent labors. 34 / 100 A patient has exacerbation of congestive heart failure, with one of the nursing diagnosis being excess fluid (lasix). The nurse closely monitors fluid intake and output and administers furesemide (lasix). Which of the following indicates theefficacy of the nursing intervention? The patient has leg edema The patient has decreased in weight The patient has shortness of breath The patient has jugular vein distention The patient has decreased in weight 35 / 100 She notes that there is an increasing unrest of the staff due to fatigue brought about by shortage of staff. Which action is a priority? Develop a plan and implement it Initiate a group interaction Identify external and internal forces. Evaluate the overall result of the unrest Initiate a group interaction will be an opportunity to discuss the problem in the open. 36 / 100 A client has a regular 30-day menstrual cycles. When teaching about the rhythm method, Which the client and her husband have chosen to use for family planning, nurse Dianne should emphasize that the client’s most fertile days are: Days 9 to 11 Days 15 to 17 Days 18 to 20 Days 12 to 14 Ovulation occurs approximately 14 days before the next menses, about the 16th day in 30 day cycle; the 15th to 17th days would be the best time to avoid sexual intercourse. 37 / 100 A client with schizophrenia is receiving antipsychotic medication. Which nursing diagnosis may be appropriate for this client? Risk for injury related to a severely decreased level of consciousness Urinary frequency related to adverse effects of antipsychotic medication Ineffective protection related to blood dyscrasias Risk for injury related to electrolyte disturbances Antipsychotic medications may cause neutropenia and granulocytopenia, life-threatening blood dyscrasias, that warrant a nursing diagnosis of Ineffective protection related to blood dyscrasias. These medications also have anticholinergic effects, such as urine retention, dry mouth, and constipation. Urinary frequency isn’t an approved nursing diagnosis. Although antipsychotic medications may cause sedation, they don’t severely decrease the level of consciousness, eliminating option C. These drugs don’t cause electrolyte disturbances, eliminating option D. 38 / 100 A 28 year old male is recovering from a moderate concussion following a motor vehicle accident 2 weeks ago, when he suddenly develops an increased thirst, craving coldwater. The patient urinates very large amount of dilute, water like urine with aspecific gravity of 1.001 to 1.005 the patient is MOST likely develop[ing Hypothyroidism THyroid storm Diabetic mellitus Diabetic insipidus Diabetic insipidus 39 / 100 Nurse Karen is caring for clients in the OR. The nurse is aware that the last physiologic function that the client loss during the induction of anesthesia is: Corneal reflex Consciousness Respiratory movement Gag reflex There is no respiratory movement in stage 4 of anesthesia, prior to this stage, respiration is depressed but present. 40 / 100 Situation: A nurse should be aware that some problems in the emergency setting are not always physiologic. Sometimes, Crisis can affect the patient in an emergency setting. Q. Which of the following statements best describes acquaintance rape? Sexual intercourse when one person engaging in the activity is unsure about wanting to do so Sexual intercourse committed with force or the threat of force without a person’s consent When two people don’t love each other and engage in sexual activities When someone on a date tricks the other person into having sexual intercourse When someone on a date tricks the other person into having sexual intercourse 41 / 100 Serious adverse effects of oral contraceptives include: Increase in skin oil followed by acne. Thromboembolic complications. Early or mid-cycle bleeding. Headache and dizziness. Oral contraceptives have been associated with an increased risk of stroke, myocardial infarction, and deep vein thrombosis. These risks are increased in women who smoke. Increased skin oil and acne are effects of progestin excess. Headache and dizziness are effects of estrogen excess. Early or mid-cycle bleeding are effects of estrogen deficiency. 42 / 100 Situation :– As a member of the health and nursing team you have a crucial role to play in ensuring that all the members participate actively is the various tasks agreed upon, Q. You have been designated as a member of the task force to plan activities for the Cancer Consciousness Week. Your committee has 4 months to plan and implement the plan. You are assigned to contact the various cancer support groups in your hospital. What will be your priority activity? Find out if there is a budget for this activity Clarify objectives of the activity with the task force before contacting the support groups Find out how many support groups there are in the hospital and get the contact number of their president Determine the VIPs and Celebrities who will be invited Right Answer is: Clarify objectives of the activity with the task force before contacting the support groups 43 / 100 The nurse is aware that cocaine is classified as: Psycho stimulant Narcotic Anxiolytic Hallucinogen Psycho stimulant 44 / 100 Situation: A nurse should be aware that some problems in the emergency setting are not always physiologic. Sometimes, Crisis can affect the patient in an emergency setting. Q. One of four factors describing the experience of sexually abused children and the effect it has on their growth and development is stigmatization. Stigma will occur when: The child’s agony is shared by other members of the family or friends when the sexual abuse becomes public knowledge The child has been blamed by the abuser for his or her sexual behaviors, saying that the child asked to be touched or did not make the abuser to stop A child blames him or herself for the sexual abuse and begins to withdraw and Isolate Newspapers and the media don’t keep sexual abuse private and accidentally or on purpose reveal the name of the victim The child’s agony is shared by other members of the family or friends when the sexual abuse becomes public knowledge 45 / 100 Mr. Snyder is admitted to your unit with a brain tumor. The type of tumor he has is currently unknown. You begin to think about the way brain tumors are classified. Q. Potential post intracranial surgery problems include all but which of the following? leakage of cerebrospinal fluid seizures extracranial hemorrhage increased ICP extracranial hemorrhage Hemorrhage is predominantly intracranial, although there may be some bloody drainage on external dressings. Increased ICP may result from hemorrhage or edema. CSF leakage may result in meningitis. Seizures are another postoperative concern. 46 / 100 A patient who is receiving chemotherapy has a platelet count of 49,000/mm3 (normal value 150,000 to 400,000/ mm3 ). Which of the following nursing action is necessary? Monitor the temperature every 4 hours Crush oral medications Minimize invasive procedure Limit intake of vitamin K rich foods Minimize invasive procedure 47 / 100 A patient has a central line catheter and is receiving a three-in-one total parenteral nutrition that contains glucose, proteins and lipids. The pump is set to deliver the infusion over a 12-hour period. After how many hours should the intravenous administration set be changed? 48 12 72 24 24 48 / 100 Which of the following is an adverse reaction to glipizide (Glucotrol)? hypotension headache photosensitivity constipation Glipizide may cause adverse skin reactions, such as pruritus, and photosensitivity. It doesn’t cause headache, constipation, or hypotension. 49 / 100 Situation: Miss Matias, found out that Mr. Carding, newly admitted patient, has terminal cancer and that his nurse has not yet informed him of the diagnosis. Q. Which of the following will be the most helpful therapy for the Grieving family? Group meeting with other grieving families Watching the video of the dying client over and over to encourage moving on A course on death and dying Psychotherapy Right Answer is: Group meeting with other grieving families 50 / 100 To further assess a client’s suicidal potential. Nurse Katrina should be especially alert to the client expression of: Anxiety & loneliness Anger & resentment Frustration & fear of death Helplessness & hopelessness The expression of these feeling may indicate that this client is unable to continue the struggle of life. 51 / 100 Tony is aware the Chairman of the Municipal Health Board is: Mayor Municipal Health Officer Public Health Nurse Any qualified physician The local executive serves as the chairman of the Municipal Health Board. 52 / 100 RN assumes 24 hour responsibility for the client to maintain continuity of care across shifts, days or visits. Total patient care Functional nursing Primary nursing Team nursing Your keyword in Primary Nursing is the 24 hours. This does not necessarily mean the nurse is awake for 24 hours. The nurse can have secondary nurses that can take care of the the patient during shifts where the primary nurse is not around. 53 / 100 The client with an ileostomy is being discharged. Which teaching should be included in the plan of care? Using Neosporin ointment to protect the skin. Using Karaya powder to seal the bag. Irrigating the ileostomy daily. Using stomahesive as the best skin protector. The best protector for the client with an ileostomy to use is stomahesive. Answer A is not correct because the bag will not seal if the client uses Karaya powder. Answer B is incorrect because there is no need to irrigate an ileostomy. Neosporin answer D is not used to protect the skin because it is an antibiotic. 54 / 100 Jose Miguel is a little bit nauseous. Among the following beverages, Which could help relieve JM’s nausea? Orange Juice or Lemon Juice Mirinda Coke Sprite One of the ingredients in coke is sodium bicarbonate, or baking soda. This is an alkaline substance, and therefore can help balance the pH level in the stomach. So, if the cause of the nausea has to do with too much acid in the stomach, or acid rising from the stomach into the esophagus, coke can have a relieving effect on the condition. Doctors recommend letting the soda go flat before drinking, or adding a pinch of salt over the top. 55 / 100 The following are important considerations to teach the woman who is on low dose (mini-pill) oral contraceptive EXCEPT: If the woman fails to take a pill in one day, she needs to take another temporary method until she has consumed the whole pack If the woman fails to take a pill in one day, she must take 2 pills for added protection If she is breast feeding, she should discontinue using mini-pill and use the progestin-only type The pill must be taken everyday at the same time Answer: (B) If the woman fails to take a pill in one day, she must take 2 pills for added protection If the woman fails to take her usual pill for the day, taking a double dose does not give additional protection. What she needs to do is to continue taking the pills until the pack is consumed and use at the time another temporary method to ensure that no pregnancy will occur. When a new pack is started, she can already discontinue using the second temporary method she employed. 56 / 100 The client is admitted to the unit. A vaginal exam reveals that she is 3cm dilated. Which of the following statements would the nurse expect her to make? I cant decide what to name the baby. Dont touch me. Im trying to concentrate. When can I get my epidural? It feels good to push with each contraction. The client is usually given epidural anesthesia at approximately three centimeters dilation. Answer A is vague answer B would indicate the end of the first stage of labor and answer C indicates the transition phase not the latent phase of labor. 57 / 100 A couple seeks medical advice in the community health care unit. A couple has been unable to conceive; the man is being evaluated for possible problems. The physician ordered semen analysis. Which of the following instructions is correct regarding collection of a sperm specimen? Collect a specimen at the clinic, place in iced container, and give to laboratory personnel immediately. Collect specimen after 48-72 hours of abstinence and bring to clinic within 2 hours. Collect specimen in the morning after 24 hours of abstinence and bring to clinic immediately. Collect specimen at night, refrigerate, and bring to clinic the next morning. Is correct because semen analysis requires that a freshly masturbated specimen be obtained after a rest (abstinence) period of 48-72 hours. 58 / 100 Situation : A computer analyst, Mr. Ricardo J. Santos, 25 was brought to the hospital for diagnostic workup after he had experienced seizure in his office. Q. Mr. Santos is scheduled for CT SCAN for the next day, noon time. Which of the following is the correct preparation as instructed by the nurse? No special preparation is needed. Instruct the patient to keep his head still and stead. Shampoo hair thoroughly to remove oil and dirt Shave scalp and securely attach electrodes to it Give a cleansing enema and give until 8 AM Right Answer is: No special preparation is needed. Instruct the patient to keep his head still and stead. 59 / 100 The nurse is ready to begin an exam on a nine-month-old infant. The child is sitting in his mothers lap. Which should the nurse do first? Palpate the abdomen Check tympanic membranes Listen to the heart and lung sounds Check the Babinski reflex The first action that the nurse should take when beginning to examine the infant is to listen to the heart and lungs. If the nurse elicits the Babinski reflex palpates the abdomen or looks in the childs ear first the child will begin to cry and it will be difficult to obtain an objective finding while listening to the heart and lungs. Therefore answers A C and D are incorrect. 60 / 100 Which of the following complications is of greatest concern when caring for a preoperative abdominal aneurysm client? HPN Cardiac arrhythmias Diminished pedal pulses Aneurysm rupture Rupture of the aneurysm is a life-threatening emergency and is of the greatest concern for the nurse caring for this type of client. Hypertension should be avoided and controlled because it can cause the weakened vessel to rupture. Diminished pedal pulses, a sign of poor circulation to the lower extremities, are associated with an aneurysm but isn’t life threatening. Cardiac arrhythmias aren’t directly linked to an aneurysm. 61 / 100 Which of the following solutions would be best for the nurse to use when cleaning the inner cannula of a tracheostomy tube? Providone-iodine Sodium hydrochloride Hydrogen peroxide IsopropyI alcohol Right Answer is: Hydrogen peroxide 62 / 100 A type of heat loss that occurs when the heat is dissipated by air current Convection Radiation Conduction Evaporation Convection 63 / 100 The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? Increased urinary output Elevated hematocrit levels Decreased heart rate Increased blood pressure The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% (0.50 to 0.55) are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys and renal perfusion and glomerular filtration are decreased, resulting in low urine output. The burn client is prone to hypovolemia and the body attempts to compensate by increased pulse rate and lowered blood pressure. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts. 64 / 100 During surgery, the nurse is assigned the following duties: setting up the sterile field, preparing sutures and ligatures assisting the surgeon during the procedure by anticipating the instruments and supplies that will be required and labeling tissue specimen obtained during surgery. The nurse MOST likely performing in what role? RN first assistance Nurse anesthetist Scrub Nurse Circulating nurse Circulating nurse 65 / 100 Situation:– it is the first day of clinical experience of nursing students at the Psychiatry Ward- During the orientation, the nurse emphasizes that the team members including nursing students are legally responsible to safeguard patient’s records from loss or destruction or from people not authorized to bead it. Q. The following are SOAP (Subjective – Objective – Analysis – Plan) statements on a problem: Anxiety about diagnosis. What is the objective data? “I’m so worried about what else they’ll find wrong with me†Has periods of crying, frequently verbalizes fear of what diagnostic tests will reveal Relate patient’s feelings to physician initiate and encourage her to verbalize her fears give emotional support by spending more time with patient, continue to make necessary explanations regarding diagnostic test. Anxiety due to the unknown Has periods of crying, frequently verbalizes fear of what diagnostic tests will reveal 66 / 100 A patient suffered a head trauma which resulted in a nasal fracture requiringsurgical intervention. Which of the following nursing diagnoses would MOST likely be a problem this patient? Risk for perioperative-positioning injury Ineffective breathing pattern Impaired gas exchange system Delayed surgical recovery Ineffective breathing pattern 67 / 100 Situation :– Because severe burn can affect the person’s totality it is important that you apply interventions focusing on the various dimensions of man. You also have to understand the rationale of the treatment. Q. Oral analgesics are most frequently used to control burn injury pain: upon patient request during the cute phase during the emergent phase after hospital discharge Right Answer is: after hospital discharge 68 / 100 The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication: 30 minutes before a meal With each meal 30 minutes after meals In a single dose at bedtime Proton pump inhibitors should be taken prior to the meal. Answers B C and D are incorrect times for giving proton pump inhibitors like Nexium. 69 / 100 What is Nurse John likely to note in a male client being admitted for alcohol withdrawal? Recent alcohol intake. Impending coma. Perceptual disorders. Depression with mutism. Frightening visual hallucinations are especially common in clients experiencing alcohol withdrawal. 70 / 100 The nurse is monitoring a client receiving levothyroxinesodium for hypothyroidism.Which findings indicate the presence of a side effect associated with this medication? Select all that apply. 1. Insomnia 2. Weight loss 3. Bradycardia 4. Constipation 5. Mild heat intolerance 2, 3, 4, 5 1, 2, 5 1, 2, 3, 4 2, 3, 5 Insomnia, weight loss, and mild heat intolerance are side effects of levothyroxine sodium. Bradycardia and constipation are not side effects associated with this medication, and rather are associated with hypothyroidism, which is the disorder that this medication is prescribed to treat. 71 / 100 A client with benign prostatic hypertrophy has been started on Proscar (finasteride). The nurses discharge teaching should include: Instructing the client to take the medication at bedtime to prevent nocturia Explaining that the medication should be taken with meals Telling the client that symptoms will improve in 1-2 weeks Telling the clients wife not to touch the tablets Finasteride is an androgen inhibitor; therefore women who are pregnant or who might become pregnant should be told to avoid touching the tablets. Answer B is incorrect because there are no benefits to giving the medication with food. Answer C is incorrect because the medication can take six months to a year to be effective. Answer D is not an accurate statement; therefore it is incorrect. 72 / 100 The autopsy results in SIDS-related death will show the following consistent findings: Intraventricular hemorrhage and cerebral edema Pulmonary edema and intrathoracic hemorrhages Abnormal central nervous system development Abnormal cardiovascular development Although the cause remains unknown autopsy results consistently reveal the presence of pulmonary edema and intrathoracic hemorrhages in infants dying with SIDS. Answers A B and C have not been linked to SIDS deaths; therefore they are incorrect. 73 / 100 A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of “suppression� “I don’t remember anything about what happened to me.†“My mother is heartbroken about this.†“It’s the other entire guy’s fault! He was going too fast.†“I’d rather not talk about it right now.†Suppression is willfully putting an unacceptable thought or feeling out of one’s mind. A deliberate exclusion “voluntary forgetting†is generally used to protect one’s own self esteem. 74 / 100 A patient who is scheduled for a tonsillectomy is in the preoperative unit. The nurse notes an order for preanesthetic medication to be given "on call to operating room." The nurse should give this medication. When the operating room staff arrives to transport the patient Only if clearly needed after Immediately upon being notified to prepare the patient for transport None of the above Immediately upon being notified to prepare the patient for transport 75 / 100 Autism is diagnosed at: 5 years old School age Infancy 3 years old 3 years old 76 / 100 Situation : In the OR, there are safety protocols that should be followed. The OR nurse should be well versed with all these to safeguard the safety and quality of patient delivery outcome. Q. Surgeries like I and D (incision and drainage) and debridement are relatively short procedures but considered ‘dirty cases’. When are these procedures best scheduled? According to availability of anaesthesiologist Last case In between cases According to the surgeon’s preference Right Answer is: Last case 77 / 100 Situation : Overpopulation is one problem in the Philippines that case economic drain. Most Filipinos are against in legalizing abortion. As a nurse, Mastery of contraception is needed to contribute to the society and economic growth. Dana has asked about GIFT procedure. What makes her a good candidate for GIFT? Her husband is taking sildenafil (Viagra), so all sperms will be motile. She has normal uterus, so the sperm can be injected through the cervix into it. She has patent fallopian tubes, so fertilized ova can be implanted on them. She is RH negative, a necessary stipulation to rule out RH incompatibility. She has patent fallopian tubes, so fertilized ova can be implanted on them. 78 / 100 A nurse is administering IM injection to an infant, the nurse should use any area: Rectus femoris None of the above Left glottal Right glottal Rectus femoris 79 / 100 The nurse recognizes that which of the following would be most appropriate to wear when providing direct care to a client with a cough? Shoe covers Gown Mask Gloves If the nurse is exposed to the client with a cough the best item to wear is a mask. If the answer had included a mask gloves and a gown all would be appropriate but in this case only one item is listed; therefore answers B and C are incorrect. Shoe covers are not necessary so answer D is incorrect. 80 / 100 A Roman Catholic couple is infertile. Their health care practitioner advises them that their best chance of getting pregnant is via in vitro fertilization with a mixture of the man’s sperm and donor sperm. Which of the following issues, related to this procedure, should the nurse realize may be in conflict with the couple’s religious beliefs? Select all that apply. 1. The man will ejaculate by masturbation into a specially designed condom. 2. The woman may become pregnant with donor sperm. 3. Fertilization is occurring in the artificial environment of the laboratory. 4. More embryos will be created than will be used to inseminate the woman. 5. The woman will receive medications to facilitate the ripening of her ova. 1, 2, 3, 4 and 5 1, 3, 5 1, 2, 4 1, 2, 3 and 4 1, 2, 3, and 4 are the correct choices. 1. Masturbation, as well as the use of a condom, even for the express purpose of creating life, are considered sins in the Catholic tradition. 2. Procreation with the man’s sperm alone is unlikely. The addition of the donor sperm makes this unacceptable in the eyes of the Catholic Church since a woman should only become pregnant by her husband. 3. According to the precepts of the Catholic church, fertilization may only take place within the body of the woman. 4. It is immoral, in the Catholic tradition, to create more embryos than are needed to conceive. 5. The medications, alone, would not be contraindicated per the Catholic Church—but only if the ova were being ripened in order for them to become fertilized within her own body. Only then does the church condone the use of the medications. 81 / 100 Situation : Josh is a 2-year old child who was bom with a unilateral cleft lip and palate. He is being readmitted for a palate repair. Q. Which of the following would be the most important factor in preparing Josh for his hospitalization? Gratification of Josh wishes Never leaving Josh with strangers Josh’s previous hospitalization Assurance of affection and security Right Answer is: Assurance of affection and security 82 / 100 The nurse is reviewing a health care provider’s prescriptions for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child’s record should the nurse question? Select all that apply. 1. Restrict fluid intake. 2. Position for comfort. 3. Avoid strain on painful joints. 4. Apply nasal oxygen at 2 L/minute. 5. Provide a high-calorie, high-protein diet. 6. Give meperidine, 25 mg intravenously, every 4 hours for pain. 4, 6 2, 3, 4, 5, 6 1, 6 1, 3, 5 Sickle cell anemia is one of a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell; insufficient oxygen causes the cells to assume a sickle shape, and the cells become rigid and clumped together, obstructing capillary blood flow. Oral and intravenous fluids are an important part of treatment. Meperidine is not recommended for a child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. The nurse would question the prescription for restricted fluids and meperidine for pain control. Positioning for comfort, avoiding strain on painful joints, oxygen, and a high-calorie and high-protein diet are also important parts of the treatment plan. 83 / 100 A vaginal exam reveals that the cervix is 4cm dilated with intact membranes and a fetal heart tone rate of 160 to 170bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is: The fetal heart tones are within normal limits. The cervix is closed. The contractions are intense enough for insertion of an internal monitor. The membranes are still intact. The nurse decides to apply an external monitor because the membranes are intact. Answers A C and D are incorrect. The cervix is dilated enough to use an internal monitor if necessary. An internal monitor can be applied if the client is at 0-station. Contraction intensity has no bearing on the application of the fetal monitor. 84 / 100 Which of the following can be used to determine if a prescribed pain management therapy is effective for a non-verbal patient? Braden’s scale Papanicolaoutest Apgar assessment tool Faces rating scale Faces rating scale 85 / 100 In planning a lecture for a community group effect of acquired immunodeficiency syndrome gerontological community, the nurse would be correct in including which of the following stat regarding the incidence of the illness in people be 55 and 64 years of age? Treatment is more effective in this age group The illness is almost unheard of in this age group prior to 2003 There are not many people living with the disease as it quickly fatal The illness has more than doubled between 1998 and 2003 The illness has more than doubled between 1998 and 2003 86 / 100 A home care nurse visits a patient who is wheelchair bound due to recent motor vehicle accident. The patient has been sitting in the wheel chair for extended periods of time which resulted in the development of a stage pressure sore on the right buttocks. What is the BEST nursing intervention? Encourage the patient to consume an increased amount of calcium Instruct caretaker to change the patient’s position every 2 hours Apply hydrogel to the stage I pressure sore every 8 hours Refer the patient to wound care specialist for debridement Instruct caretaker to change the patient’s position every 2 hours 87 / 100 Period of nursing where religious Christian orders emerged to take care of the sick Contemporary period Dark period Educative period Apprentice period Apprentice period is marked by the emergence of religious orders the are devoted to religious life and the practice of nursing. 88 / 100 Pelvic rocking is an appropriate exercise in pregnancy to relieve which discomfort? Backache Urinary frequency Leg cramps Orthostatic hypotension Backache is caused by the stretching of the muscles of the lower back because of the pregnancy. Pelvic rocking is good to relieve backache. 89 / 100 The nurse is preparing to administer eye drops. Which interventions should the nurse take to administer the drops? Select all that apply. 1. Wash hands. 2. Put gloves on. 3. Place the drop in the conjunctival sac. 4. Pull the lower lid down against the cheekbone. 5. Instruct the client to squeeze the eyes shut after instilling the eye drop. 6. Instruct the client to tilt the head forward, open the eyes, and look down. 2, 3, 4 1, 2, 5 1, 2, 3, 4 1, 2, 3, 4, 5 To administer eye medications, the nurse should wash hands and put gloves on. The client is instructed to tilt the head backward, open the eyes, and look up. The nurse pulls the lower lid down against the cheekbone and holds the bottle like a pencil with the tip downward. Holding the bottle, the nurse gently rests the wrist of the hand on the client’s cheek and squeezes the bottle gently to allow the drop to fall into the conjunctival sac. The client is instructed to close the eyes gently and not to squeeze the eyes shut to prevent the loss of medication. 90 / 100 The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? Increased respiratory rate Inspiratory crackles Intercostal retractions Bilateral wheezing The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles. 91 / 100 A client with paranoid type schizophrenia becomes angry and tells the nurse to leave him alone. The nurse should tell him that she’ll leave for now but will return soon. ask him why he wants to be left alone. tell him that she won’t let anything happen to him ask him if it’s okay if she sits quietly with him. If the client tells the nurse to leave, the nurse should leave but let the client know that she’ll return so that he doesn’t feel abandoned. Not heeding the client’s request can agitate him further. Also, challenging the client isn’t therapeutic and may increase his anger. False reassurance isn’t warranted in this situation 92 / 100 Which of the following are qualities of a good recording? 1. Brevity 2. Completeness and chronology 3. Appropriateness 4. Accuracy 1,2,3 1,2,3,4 3,4 1,2 Documentation in nursing is also an integral part of providing quality and safe care to patients. Qualities of a good recording include Brevity, Completeness and chronology, Appropriateness and Accuracy. 93 / 100 Sally Baker, a 40-year-old woman, is admitted to the hospital with an established diagnosis of mitral stenosis. She is scheduled for surgery to repair her mitral valve. Q. On physical exam of Ms. Baker, several abnormal findings can be observed. Which of the following is not one of the usual objective findings associated with mitral stenosis? low-pitched rumbling diastolic murmur, precordial thrill, and parasternal lift small crepitant rales at the bases of the lungs chest x-ray shows left ventricular hypertrophy weak, irregular pulse, and peripheral and facial cyanosis in severe disease Answer D: chest x-ray shows left ventricular hypertrophy Evidence of left atrial enlargement may be seen on chest x-ray and ECG. The other objective findings may be seen in chronic mitral stenosis with episodes of atrial fibrillation and right heart failure. 94 / 100 Situation : Nurse Gloria is the staff nurse assigned at the Emergency Department. During her shift, a patient was rushed – in the ED complaining of severe heartburn, vomiting and pain that radiates to the flank. The doctor suspects gastric ulcer. Q. She is for occult blood test, what specimen will you collect? Stool Urine Blood Gastric Juice Rationale: Occult blood test or stool guaiac test is a test that detects the presence of hidden (occult) blood in the stool (bowel movement). The stool guaiac is the most common form of fecal occult blood test (FOBT) in use today. So stool specimen will be collected. 95 / 100 Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action? Give two sharp thumps to the precordium, and check the pulse. Administer two quick blows. Clear the airway Call for help and note the time. Having established, by stimulating the client, that the client is unconscious rather than sleep, the nurse should immediately call for help. This may be done by dialing the operator from the client’s phone and giving the hospital code for cardiac arrest and the client’s room number to the operator, of if the phone is not available, by pulling the emergency call button. Noting the time is important baseline information for cardiac arrest procedure. 96 / 100 Prolonged occlusion of the right coronary artery produces an infarction in which of he following areas of the heart? Apical Anterior Lateral Inferior The right coronary artery supplies the right ventricle, or the inferior portion of the heart. Therefore, prolonged occlusion could produce an infarction in that area. The right coronary artery doesn’t supply the anterior portion ( left ventricle ), lateral portion ( some of the left ventricle and the left atrium ), or the apical portion ( left ventricle ) of the heart. 97 / 100 A client has a bone marrow aspiration performed, immediately after the procedure, the nurse should: Cleanse the site with an antiseptic solution Position the client on the affected side Briefly apply pressure over the aspiration site Begin frequent monitoring of vital signs Right Answer is: Briefly apply pressure over the aspiration site 98 / 100 During the second day of hospitalization of the client after a Myocardial Infarction. Which of the following is an expected outcome? Severe chest pain Can recognize the risk factors of Myocardial Infarction Able to perform self-care activities without pain Can Participate in cardiac rehabilitation walking program By the 2nd day of hospitalization after suffering a Myocardial Infarction, Clients are able to perform care without chest pain 99 / 100 Situation : Mr. Sean is admitted to the hospital with a bowel obstruction. He complained of colicky pain and inability to pass stool. Q. Client education should be given in order to prevent constipation. Nurse Leonard’s health teaching should include which of the following? use of natural laxatives use of OTC laxatives complete bed rest fluid intake of 6 glasses per day Rationale: The use of natural laxatives such as foods and fruits high in fiber is still the best way of preventing constipation Increasing fluid intake, taking laxatives judiciously and exercise also can prevent this. 100 / 100 Situation:– it is the first day of clinical experience of nursing students at the Psychiatry Ward- During the orientation, the nurse emphasizes that the team members including nursing students are legally responsible to safeguard patient’s records from loss or destruction or from people not authorized to bead it. Q. In an extreme situation and when no other resident or intern is available, should a nurse receive, telephone orders, the order has to be correctly written and signed by the physician within. 36 hours 12 hours 24 hours 48 hours 24 hours Your score is The average score is 0% LinkedIn Facebook Twitter VKontakte 0% Restart quiz