NCLEX NCLEX-RN Exam Dumps

NCLEX NCLEX-RN Sample Question Answers

Question # 1

A female baby was born with talipes equinovarus. Her mother has requested that the nurse assigned to the baby come to her room to discuss the baby’s condition. The nurse knows that the pediatrician has discussed the baby’s condition with her mother and that an orthopedist has been consulted but has not yet seen the baby. What should the nurse do first? 

A. Call the orthopedist and request that he come to see the baby now.
B. Question the mother and find out what the pediatrician has told her about the baby’scondition.
C. Tell the mother that this is not a serious condition.
D. Tell the mother that this condition has been successfully treated with exercises, casts,and/or braces.

Show Answer

Question # 2

A client states to his nurse that “I was told by the doctor not to take one of my drugsbecause it seems to have caused decreasing blood cells.” Based on this information, whichdrug might the nurse expect to be discontinued?

A. Prednisone
B. Timolol maleate (Blocadren)
C. Garamycin (Gentamicin)
D. Phenytoin (Dilantin)

Show Answer

Question # 3

A 3-year-old child is in the burn unit following a home accident. The first sign of sepsis in burned children is:

A. Disorientation  
B. Low-grade fever  
C. Diarrhea  
D. Hypertension  

Show Answer

Question # 4

A 19-month-old child is admitted to the hospital for surgical repair of patent ductusarteriosus. The child is being given digoxin. Prior to administering the medication, the nurseshould:

A. Not give the digoxin if the pulse is_60
B. Not give the digoxin if the pulse is_100
C. Take the apical pulse for a full minute
D. Monitor for visual disturbances, a side effect of digoxin

Show Answer

Question # 5

During the active phase of rheumatic fever, the nurse teaches parents of a child with acute rheumatic fever to assist in minimizing joint pain and promoting healing by:

A. Putting all joints through full range-of-motion twice daily  
B. Massaging the joints briskly with lotion or liniment after bath  
C. Immobilizing the joints in functional position using splints, rolls, and pillows  
D. Applying warm water bottle or heating pads over involved joints  

Show Answer

Question # 6

A 4 year old has an imaginary playmate, which concerns the mother. The nurse’s bestresponse would be:

A. “I understand your concern and will assist you with a referral.”
B. “Try not to worry because you will just upset your child.”
C. “Just ignore the behavior and it should disappear by age 8.”
D. “This is appropriate behavior for a preschooler and should not be a concern.”

Show Answer

Question # 7

One afternoon 3 weeks into his alcohol treatment program, a client says to the nurse, “It’s really not all my fault that I have a drinking problem. Alcoholism runs in my family. Both my grandfather and father were heavy drinkers.” The nurse’s best response would be: 

A. “That might be a problem. Tell me more about them.”  
B. “Risk factors can often be controlled by self-responsibility.”  
C. “It sounds like you’re intellectualizing your drinking problem.”  
D. “Your grandfather and father were both alcoholics?”  

Show Answer

Question # 8

The nurse writes the following nursing diagnosis for a client in acute renal failure—Impairedgas exchange related to:

A. Decreased red blood cell production
B. Increased levels of vitamin D
C. Increased red blood cell production
D. Decreased production of renin

Show Answer

Question # 9

Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis?

A. Urine output 22 mL/hr for 2 hours  
B. Serum potassium level of 3.7  
C. Small T wave of ECG  
D. Serum glucose level of 180  

Show Answer

Question # 10

A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She hasbeen admitted to the pediatric unit after surgical repair of the cleft lip. Which of the followingnursing interventions would be appropriate during the first 24 hours?

A. Position on side or abdomen.
B. Maintain elbow restraints in place unless she is being directly supervised.
C. Clean suture line every shift.
D. Offer pacifier when she cries.

Show Answer

Question # 11

The physician decides to prescribe both a short-acting insulin and an intermediate-actinginsulin for a newly diagnosed 8-year-old diabetic client. An example of a short-acting insulinis:

A. Novolin Regular
B. Humulin NPH
C. Lente Beef
D. Protamine zinc insulin

Show Answer

Question # 12

The nurse is admitting a client with folic acid deficiency anemia. Which of the followingquestions is most important for the nurse to ask the client?

A. “Do you take aspirin on a regular basis?”
B. “Do you drink alcohol on a regular basis?”
C. “Do you eat red meat?”
D. “Have your stools been normal?”

Show Answer

Question # 13

The most important goal in the care plan for a child who was hospitalized with anaccidental overdose would be to:

A. Determine child’s activity pattern
B. Reduce mother’s sense of guilt
C. Instruct parents in use of ipecac
D. Teach parents appropriate safety precautions

Show Answer

Question # 14

A 33-year-old client is diagnosed with bipolar disorder, acute phase. This is her first psychiatric hospitalization, and she is being evaluated for treatment with lithium. Which of the following diagnostic tests are essential prior to the initiation of lithium therapy with this client?

A. Hematocrit, hemoglobin, and white blood cell (WBC) count  
B. Blood urea nitrogen, electrolytes, and creatinine  
C. Glucose, glucose tolerance test, and random blood sugar  
D. X-rays, electroencephalogram, and electrocardiogram (ECG) 

Show Answer

Question # 15

Which of the following physician’s orders would the nurse question on a client with chronicarterial insufficiency?

A. Neurovascular checks every 2 hours
B. Elevate legs on pillows
C. Arteriogram in the morning
D. No smoking

Show Answer

Question # 16

A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will teachher to:

A. Limit activities which require focusing (close vision)
B. Take more frequent naps
C. Use artificial tears
D. Wear a patch over one eye

Show Answer

Question # 17

A 4-year-old boy is brought to the emergency room with bruises on his head, face, arms, and legs. His mother states that he fell down some steps. The nurse suspects that he may have been physically abused. In accordance with the law, the nurse must: 

A. Tell the physician her concerns  
B. Report her suspicions to the authorities  
C. Talk to the child’s father  
D. Confront the child’s mother  

Show Answer

Question # 18

Which of the following nursing orders has the highest priority for a child with epiglottitis? 

A. Vital signs every shift  
B. Tracheostomy set at bedside  
C. Intake and output  
D. Specific gravity every shift  

Show Answer

Question # 19

A client delivered a stillborn male at term. An appropriate action of the nurse would be to: 

A. State, “You have an angel in heaven.”
B. Discourage the parents from seeing the baby.
C. Provide an opportunity for the parents to see and hold the baby for an undeterminedamount of time.
D. Reassure the parents that they can have other children.

Show Answer

Question # 20

In caring at home for a child who just ingested a caustic alkali, the nurse would immediately tell the mother to: 

A. Give vinegar, lemon juice, or orange juice  
B. Phone the doctor  
C. Take the child to the emergency room  
D. Induce vomiting  

Show Answer

Question # 21

A client is receiving IV morphine 2 days after colorectal surgery. Which of the following observations indicate that he may be becoming drug dependent?

A. The client requests pain medicine every 4 hours.
B. He is asleep 30 minutes after receiving the IV morphine.
C. He asks for pain medication although his blood pressure and pulse rate are normal.
D. He is euphoric for about an hour after each injection.

Show Answer

Question # 22

The mother of a child taking phenytoin will need to plan appropriate mouth care and gingival stimulation. When tooth-brushing is contraindicated, the next most effective cleansing and gingival stimulation technique would be:

A. Using a water pik  
B. Rinsing with water  
C. Rinsing with hydrogen peroxide  
D. Rinsing with baking soda  

Show Answer

Question # 23

A measurable outcome criterion in the nursing care of an adolescent with anorexia nervosa would be:

A. Accepting her present body image
B. Verbalizing realistic feelings about her body
C. Having an improved perception of her body image
D. Exhibiting increased self-esteem

Show Answer

Question # 24

Which of the following should the nurse anticipate receiving as an as-needed order for a postoperative carotid endarterectomy client?

A. Nifedipine 10 mg SL for B/P 140/90
B. Furosemide 20 mg/PO for decreased urine output
C. Magnesium salicylate to decrease inflammation
D. Nitroglycerin gr 1/150 for chest pain

Show Answer

Question # 25

The mother of a client is apprehensive about taking home her 2 year old who was diagnosed with asthma after being admitted to the emergency room with difficulty breathing and cyanosis. She asks the nurse what symptoms she should look for so that this problem will not happen again. The nurse instructs her to watch for the following early symptoms: 

A. Fever, runny nose, and hyperactivity  
B. Changes in breathing pattern, moodiness, fatigue, and edema of eyes  
C. Fatigue, dark circles under the eyes, changes in breathing pattern, glassy eyes, and moodiness 
D. Fever, cough, paleness, and wheezing  

Show Answer

Question # 26

A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg pobid. Which of the following should be included in her discharge teaching concerning thewarfarin therapy?

A. “If you forget to take your morning dose, double the night time dose.”
B. “You should take aspirin instead of acetaminophen (Tylenol) for headaches.”
C. “Carry a medications alert card with you at all times.”
D. “You should use a straight-edge razor when shaving your arms and legs.”

Show Answer

Question # 27

Discharge teaching for the client who has a total gastrectomy should include which of thefollowing?

A. Need for the client to increase fluid intake to 3000 mL/day
B. Follow-up visits every 3 weeks for the first 6 months
C. B12 injections needed for the rest of the client’s life
D. Need to eat three full meals with plenty of fiber per day

Show Answer

Question # 28

A female client is started on warfarin (Coumadin) 5 mg po bid. To adequately evaluate theeffectiveness of the warfarin therapy, the nurse must know that this medication:

A. Dissolves any clots already formed in the arteries
B. Prevents the conversion of prothrombin to thrombin
C. Interferes with the synthesis of vitamin K-dependent clotting factors
D. Stimulates the manufacturing of platelets

Show Answer

Question # 29

A 29-year-old client is admitted for a hysterectomy. She has repeatedly told the nurses that she is worried about having this surgery, has not slept well lately, and is afraid that her husband will not find her desirable after the surgery. Shortly into the preoperative teaching, she complains of a tightness in her chest, a feeling of suffocation, lightheadedness, and tingling in her hands. Her respirations are rapid and deep. Assessment reveals that the client is: 

A. Having a heart attack
B. Wanting attention from the nurses
C. Suffering from complete upper airway obstruction
D. Hyperventilating

Show Answer

Question # 30

A 52-year-old female client is admitted to the hospital in acute renal failure. She has beenon hemodialysis for the past 2 years. Stat arterial blood gases are drawn on the clientyielding the following results: pH 7.30, PCO2 51 mm Hg, HCO3, 18 mEq/L, PaO2, 84 mmHg. The nurse would interpret these results as:

A. Compensated metabolic alkalosis
B. Respiratory acidosis
C. Partially compensated metabolic alkalosis
D. Combined respiratory and metabolic acidosis

Show Answer

Question # 31

In discussing the plan of care for a child with chronic nephrosis with the mother, the nurseidentifies that the purpose of weighing the child is to:

A. Measure adequacy of nutritional management
B. Check the accuracy of the fluid intake record
C. Impress the child with the importance of eating well
D. Determine changes in the amount of edema

Show Answer

Question # 32

A child with celiac disease is being discharged from the hospital. The mother demonstratesknowledge of nutritional needs of her child when she is able to state the foods which areincluded in a:

A. Lactose-restricted diet
B. Gluten-restricted diet
C. Phenylalanine-restricted diet
D. Fat-restricted diet

Show Answer

Question # 33

Four days after admission for cirrhosis of the liver, the nurse observes the following whenassessing a male client: increased irritability, asterixis, and changes in his speech pattern.Which of the following foods would be appropriate for his bedtime snack?

A. Fresh fruit
B. A milkshake
C. Saltine crackers and peanut butter
D. A ham and cheese sandwich

Show Answer

Question # 34

Diabetes mellitus is a disorder that affects 3.1 out of every 1000 children younger than 20years old. It is characterized by an absence of, or marked decrease in, circulating insulin.When teaching a newly diagnosed diabetes client, the nurse includes information on thefunctions of insulin:

A. Transport of glucose into body cells and storage of glycogen in the liver
B. Glycogenolysis and facilitation of glucose use for energy
C. Glycogenolysis and catabolism
D. Catabolism and hyperglycemia

Show Answer

Question # 35

The nurse assesses a postoperative mastectomy client and notes that breath sounds arediminished in both posterior bases. The nurse’s action should be to:

A. Encourage coughing and deep breathing each hour
B. Obtain arterial blood gases
C. Increase O2 from 2–3 L/min
D. Remove the postoperative dressing to check for bleeding

Show Answer

Question # 36

The nurse is teaching a client how to perform monthly testicular self-examination (TSE) and states that it is best to perform the procedure right after showering. This statement is made by the nurse based on the knowledge that:

A. The client is more likely to remember to perform the TSE when in the nude  
B. When the scrotum is exposed to cool temperatures, the testicles become large and bulky 
C. The scrotum will be softer and more relaxed after a warm shower, making the testicles easier to palpate 
D. The examination will be less painful at this time  

Show Answer

Question # 37

A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating include:

A. Administering diazepam (Valium) 10–15 mg po q4h and q1h prn for hyperventilating episode 
B. Keeping the temperature in the client’s room at a high level to reduce respiratory stimulation 
C. Having the client hold her breath or breathe into a paper bag when hyperventilation episodes occur
D. Using distraction to help control the client’s hyperventilation episodes  

Show Answer

Question # 38

A 25-year-old client is admitted for a tonsillectomy. She tells the nurse that she has had episodes of muscle cramps, weakness, and unexplained temperature elevation. Many years ago her father died shortly after surgery after developing a high fever. She further tells the nurse that her surgeon is having her take dantrolene sodium (Dantrium) prophylactically prior to her tonsillectomy. Dantrolene sodium is ordered preoperatively to reduce the risk or prevent: 

A. Infection postoperatively  
B. Malignant hyperthermia  
C. Neuroleptic malignant syndrome  
D. Fever postoperatively  

Show Answer

Question # 39

A 27-year-old male client is admitted to the acute care mental health unit for observation.He has recently lost his job, and his wife told him yesterday that she wants a divorce. Theclient is placed on suicide precautions. In assessing suicide potential, the nurse should payclose attention to the client’s:

A. Level of insight
B. Thought processes
C. Mood and affect
D. Abstracting abilities

Show Answer

Question # 40

A 38-year-old female client with a history of chronic schizophrenia, paranoid type, iscurrently an outpatient at the local mental health and mental retardation clinic. The clientcomes in once a week for medication evaluation and/or refills. She self-administershaloperidol 5 mg twice a day and benztropine 1 mg once a day. During a recent clinic visit,she says to the nurse, “I can’t stay still at night. I toss and turn and can’t fall asleep.” Thenurse suspects that she may be experiencing:

A. Akathisia
B. Akinesia
C. Dystonia
D. Opisthotonos

Show Answer

Question # 41

Parents should be taught not to prop the bottle when feeding their infants. In addition to the risk of choking, it puts the infant at risk for:  

A. Otitis media
B. Asthma
C. Conjunctivitis
D. Tonsillitis

Show Answer

Question # 42

Following a gastric resection, a 70-year-old client is admitted to the postanesthesia care unit. He was extubated prior to leaving the suite. On arrival at the postanesthesia care unit, the nurse should: 

A. Check airway, feeling for amount of air exchange noting rate, depth, and quality ofrespirations
B. Obtain pulse and blood pressure readings noting rate and quality of pulse
C. Reassure the client that his surgery is over and that he is in the recovery room
D. Review physician’s orders, administering medications as ordered

Show Answer

Question # 43

A client is started on prednisone 2.5 mg po bid. Which of the following instructions should be included in her discharge teaching specific to this medication?

A. Increase your oral intake of fluids to at least 4000 mL every day.  
B. Avoid contact with people who have contagious illnesses.  
C. Brush your teeth at least 4 times a day with a firm toothbrush.  
D. Immediately stop taking the prednisone if you feel depressed.  

Show Answer

Question # 44

The parents of a 9-year-old child with acute lymphocytic leukemia expressed concernabout his alopecia from cranial irradiation. The nurse explains that:

A. Alopecia is an unavoidable side effect.
B. There are several wig makers for children.
C. Most children select a favorite hat to protect their heads.
D. His hair will grow back in a few months.

Show Answer

Question # 45

Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. The physician is immediately notified and orders 50 mL of dextrose and 10 U of regular insulin IV push. The nurse administering these drugs knows the Rationale for this therapy is to:

A. Remove the potassium from the body by renin exchange  
B. Protect the myocardium from the effects of hypokalemia  
C. Promote rapid protein catabolism  
D. Drive potassium from the serum back into the cells  

Show Answer

Question # 46

The nurse notes multiple bruises on the arms and legs of a newly admitted client withlupus. The client states, “I get them whenever I bump into anything.” The nurse wouldexpect to note a decrease in which of the following laboratory tests?

A. Number of platelets
B. WBC count
C. Hemoglobin level
D. Number of lymphocytes

Show Answer

Question # 47

Three hours postoperatively, a 27-year-old client complains of right leg pain after kneereduction. The first action by the nurse will be to:

A. Assess vital signs
B. Elevate the extremity
C. Perform a lower extremity neurovascular check
D. Remind the client that he has a client-controlled analgesic pump, and reinstruct him onits use

Show Answer

Question # 48

A client is admitted to the hospital with a diagnosis of aplastic anemia and placed on isolation. The nurse notices a family member entering the room without applying the appropriate apparel. The nurse will approach the family member using the following information as a basis for discussion: 

A. The risks of exposure of the visitor to infectious organisms is great.
B. Hospital regulations mandate that everyone in the facility adhere to appropriate codes.
C. The client is at extreme risk of acquiring infections.
D. Adherence to the guidelines are the latest Centers for Disease Control and Preventionrecommendations on use of protective apparel.

Show Answer

Question # 49

A 47-year-old male client is admitted for colon surgery. Intravenous antibiotics are begun 2 hours prior to surgery. He has no known infection. The rationale for giving antibiotics prior to surgery is to: 

A. Provide cathartic action within the colon
B. Reduce the risk of wound infection from anaerobic bacteria
C. Relieve the client’s concern regarding possible infection
D. Reduce the risk of intraoperative fever

Show Answer

Question # 50

A 6-year-old child returned to the surgical floor 20 hours ago after an appendectomy for a gangrenous appendix. His mother tells the nurse that he is becoming more restless and is anxious. Assessment findings indicate that the child has atelectasis. Appropriate nursing actions would include: 

A. Allowing the child to remain in the position of comfort, preferably semi-or high-Fowler position 
B. Administering analgesics as ordered  
C. Having the child turn, cough, and deep breathe every 1–2 hours  
D. Remaining with the child and keeping as calm and quiet as possible  

Show Answer

Question # 51

During discharge planning, parents of a child with rheumatic fever should be able to identifywhich of the following as toxic symptoms of sodium salicylate?

A. Tinnitus and nausea
B. Dermatitis and blurred vision
C. Unconsciousness and acetone odor of the breath
D. Chills and an elevation of temperature

Show Answer

Question # 52

A 3-year-old female client is brought into the pediatric clinic because she limps. She has not been to the clinic since she was 9 months old. The nurse practitioner describes the limp as a “Trendelenburg gait.” This gait is characteristic of: 

A. Scoliosis  
B. Dislocated hip  
C. Fractured femur  
D. Fractured pelvis  

Show Answer

Question # 53

A 14-year-old teenager is hospitalized for anorexia nervosa. She is admitted to the adolescent mental health unit and placed on a behavior modification program. Nursing interventions for the teenager will most likely include: 

A. Establishing routine tasks and activities around mealtimes  
B. Administering medications such as lithium  
C. Requiring the client to eat more during meals  
D. Checking the client’s room frequently  

Show Answer

Question # 54

A client reports to the nurse that the voices are practically nonstop and that he needs toleave the hospital immediately to find his girlfriend and kill her. The best verbal response tothe client by the nurse at this time is:

A. “I understand that the voices are real to you, but I want you to know I don’t hear them.They are a symptom of your illness.”
B. “Just don’t pay attention to the voices. They’ll go away after some medication.”
C. “You can’t leave here. This unit is locked and the doctor has not ordered yourdischarge.”
D. “We will have to put you in seclusion and restraints for a while. You could hurt someonewith thoughts like that.”

Show Answer

Question # 55

When assessing a client, the nurse notes the typical skin rash seen with systemic lupus erythematosus. Which of the following descriptions correctly describes this rash? 

A. Small round or oval reddish brown macules scattered over the entire body
B. Scattered clusters of macules, papules, and vesicles over the body
C. Bright red appearance of the palmar surface of the hands
D. Reddened butterfly shaped rash over the cheeks and nose

Show Answer

Question # 56

A client with a head injury asks why he cannot have something for his headache. Thenurse’s response is based on the understanding that analgesics could:

A. Counteract the effects of antibiotics
B. Elevate the blood pressure
C. Mask symptoms of increasing intracranial pressure
D. Stimulate the central nervous system

Show Answer

Question # 57

The nurse enters the room of a client on which a “do not resuscitate” order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, “please save her!” The nurse’s action would be:

A. Call the physician and inform him that the client has expired.  
B. Remind the husband that the physician wrote an order not to resuscitate.  
C. Discuss with the husband that these orders are written only on clients who are not likely to recover with resuscitative efforts. 
D. Call a code and proceed with cardiopulmonary resuscitation.  

Show Answer

Question # 58

To prevent transmission of bacterial meningitis, the nurse would instruct an infected baby’smother to:

A. Avoid touching the baby while in the room.
B. Stay outside of the baby’s room.
C. Wear a gown and gloves and wash her hands before and after leaving the room.
D. Wear a mask while in the room.

Show Answer

Question # 59

A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements?

A. “When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices.” 
B. “If I have any side effects from my medicines, I will take an extra dose of Cogentin.”  
C. “When I get home, I should be able to taper myself off the Haldol because the voices are gone now.” 
D. “As soon as I leave here, I’m throwing away my medicines. I never thought I needed them anyway.” 

Show Answer

Question # 60

The nurse is collecting a nutritional history on a 28- year-old female client with irondeficiency anemia and learns that the client likes to eat white chalk. When implementing ateaching plan, the nurse should explain that this practice:

A. Will bind calcium and therefore interfere with its metabolism
B. Will cause more premenstrual cramping
C. Interferes with iron absorption because the iron precipitates as an insoluble substance 
D. Causes competition at iron-receptor sites between iron and vitamin B1

Show Answer

Question # 61

The physician orders medication for a client’s unpleasant side effects from the haloperidol.The most appropriate drug at this time is:

A. Lorazepam
B. Triazolam (Halcion)
C. Benztropine
D. Thiothixene

Show Answer

Question # 62

During the assessment, the nurse observes a client scratching his skin. He has beenadmitted to rule out Laennec’s cirrhosis of the liver. The nurse knows the pruritus is directlyrelated to:

A. A loss of phagocytic activity
B. Faulty processing of bilirubin
C. Enhanced detoxification of drugs
D. The formation of collateral circulation

Show Answer

Question # 63

The nurse notes scattered crackles in both lungs and 1+ pitting edema when assessing a cardiac client. The physician is notified and orders furosemide (Lasix) 80 mg IV push stat. Which of the following diagnostic studies is monitored to assess for a major complication of this therapy?

A. Serum electrolytes  
B. Arterial blood gases  
C. Complete blood count  
D. 12-Lead ECG  

Show Answer

Question # 64

A child is admitted with severe headache, fever, vomiting, photophobia, drowsiness, and stiff neck associated with viral meningitis. She will be more comfortable if the nurse:

A. Dims the lights in her room  
B. Encourages her to breathe slowly and deeply  
C. Offers sips of warm liquids  
D. Places a large, soft pillow under her head

Show Answer

Question # 65

A client develops complications following a hysterectomy. Blood cultures revealPseudomonas aeruginosa. The nurse expects that the physician would order anappropriate antibiotic to treat P. aeruginosa such as:

A. Cefoperazone (Cefobid)
B. Clindamycin (Cleocin)
C. Dicloxacillin (Dycill)
D. Erythromycin (Erythrocin)

Show Answer

Question # 66

A couple is experiencing difficulties conceiving a baby. The nurse explains basal body temperature (BBT) by instructing the female client to take her temperature:

A. Orally in the morning and at bedtime  
B. Only one time during the day as long as it is always at the same time of day  
C. Rectally at bedtime  
D. As soon as she awakens, prior to any activity  

Show Answer

Question # 67

A 23-year-old male client is admitted to the chemical dependency unit with a medicaldiagnosis of alcoholism. He reports that the last time he drank was 3 days ago, and thatnow he is starting to “feel kind of shaky.” Based on the information given above, nursingcare goals for this client will initially focus on:

A. Self-concept problems
B. Interpersonal issues
C. Ineffective coping skills
D. Physiological stabilization

Show Answer

Question # 68

A child has a nursing diagnosis of fluid volume excess related to compromised regulatory mechanisms. Which of the following nursing interventions is the most accurate measure to include in his care?

A. Weigh the child twice daily on the same scale.  
B. Monitor intake and output.  
C. Check urine specific gravity of each voiding.  
D. Observe for edema.Answer: A Explanation:  

Show Answer

Question # 69

A 44-year-old client had an emergency cholecystectomy 3 days ago for a rupturedgallbladder. She complains of severe abdominal pain. Assessment reveals abdominalrigidity and distention, increased temperature, and tachycardia. Diagnostic testing revealsan elevated WBC count. The nurse suspects that the client has developed:

A. Gastritis
B. Evisceration
C. Peritonitis
D. Pulmonary embolism

Show Answer

Question # 70

The mother of a preschooler reports to the nurse that he frequently tells lies. The admissionassessment of the child indicates possible child abuse. The nurse knows that his:

A. Behavior is not normal, and a child psychiatrist should be consulted.
B. Mother is lying to protect herself.
C. Lying is normal behavior for a preschool child who is learning to separate fantasy fromreality.
D. Behavior indicates a developmental delay, because preschoolers should be able to tellright from wrong.

Show Answer

Question # 71

A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low, intermittent suction with orders to “Irrigate NG tube with sterile saline q1h and prn.” The rationale for using sterile saline, as opposed to using sterile water to irrigate the NG tube is:

A. Water will deplete electrolytes resulting in metabolic acidosis.  
B. Saline will reduce the risk of severe, colicky abdominal pain during NG irrigation.  
C. Water is not isotonic and will increase restlessness and insomnia in the immediate postoperative period. 
D. Saline will increase peristalsis in the bowel.  

Show Answer

Question # 72

A 2-year-old toddler is hospitalized with epiglottitis. In assessing the toddler, the nurse would expect to find:

A. A productive cough  
B. Expiratory stridor  
C. Drooling  
D. Crackles in the lower lobes  

Show Answer

Question # 73

The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years. Which of the following data is most likely significant in relation to the cause of the low blood pressure?

A. Pedal pulses 11 (weak)  
B. Twenty-four-hour intake 1000 mL/day for past 2 days  
C. Serum potassium 3.3  
D. Pulse rate 150 bpm  

Show Answer

Question # 74

Two hours after the second injection of haloperidol, a client complains to the nurse of a stiffneck and inability to sit still. He is experiencing symptoms consistent with:

A. Parkinsonism and dystonia
B. Dystonia and akathisia
C. Akathisia and parkinsonism
D. Neuroleptic malignant syndrome

Show Answer

Question # 75

A 35-year-old client is receiving psychopharmacological treatment of his major depressionwith tranylcypromine sulfate (Parnate), a monoamine oxidase (MAO) inhibitor. The nurseteaches the client that while he is taking this type of antidepressant, he needs to restrict hisdietary intake of:

A. Potassium-rich foods
B. Tryptophan
C. Tyramine
D. Saturated fats

Show Answer

Question # 76

A 45-year-old client diagnosed with major depression is scheduled for electroconvulsive therapy (ECT) in the morning. Which of the following medications are routinely administered either before or during ECT?

A. Thioridazine (Mellaril), lithium, and benztropine  
B. Atropine, sodium brevitol, and succinylcholine chloride (Anectine)  
C. Sodium, potassium, and magnesium  
D. Carbamazepine (Tegretol), haloperidol, and trihexyphenidyl (Artane)  

Show Answer

Question # 77

Nursing assessment of early evidence of septic shock in children at risk includes: 

A. Fever, tachycardia, and tachypnea
B. Respiratory distress, cold skin, and pale extremities
C. Elevated blood pressure, hyperventilation, and thready pulses
D. Normal pulses, hypotension, and oliguria

Show Answer

Question # 78

The nurse is assessing breath sounds in a bronchovesicular client. She should expect that: 

A. Inspiration is longer than expiration  
B. Breath sounds are high pitched  
C. Breath sounds are slightly muffled  
D. Inspiration and expiration are equal  

Show Answer

Question # 79

When planning care for a 9-year-old client, the nurse uses which of the most effective means of helping siblings cope with their feelings about a brother who is terminally ill?

A. Open discussion and understanding
B. Play-acting out feelings in different roles
C. Storytelling
D. Drawing pictures

Show Answer

Question # 80

A 30-year-old client has been admitted to the psychiatric service with the diagnosis of schizophrenia. He tells the nurse that when the woman he had been dating broke up with him, the CIA had replaced her with an identical twin. The client is experiencing: 

A. Grandiose delusions  
B. Paranoid delusions  
C. Auditory hallucinations  
D. Visual hallucinations  

Show Answer

Question # 81

A family by court order undergoes treatment by a family therapist for child abuse. Thenurse, who is the child’s case manager knows that treatment has been effective when:

A. The child is removed from the home and placed in foster care
B. The child’s parents identify the ways in which he is different from the rest of the family
C. The child’s father is arrested for child abuse
D. The child’s parents can identify appropriate behaviors for children in his age group 

Show Answer

Question # 82

Parents of a child with rheumatic fever express concern that she will always be arthritic. The nurse discusses their concerns and tells them the joint pain usually: 

A. Subsides in<3 weeks  
B. Is relieved by aspirin  
C. Is responsive to ibuprofen (Motrin)  
D. Subsides in 3–6 days  

Show Answer

Question # 83

The initial focus when providing nursing care for a child with rheumatic fever during theacute phase of the illness should be to:

A. Maintain contact with her parents
B. Provide for physical and psychological rest
C. Provide a nutritious diet
D. Maintain her interest in school

Show Answer

Question # 84

A 40-year-old client has been admitted to the hospital with severe substernal chest pain radiating down his left arm. The nurse caring for the client establishes the following priority nursing diagnosis—Alteration in comfort, pain related to: 

A. Increased excretion of lactic acid due to myocardial hypoxia
B. Increased blood flow through the coronary arteries
C. Decreased stimulation of the sympathetic nervous system
D. Decreased secretion of catecholamines secondary to anxiety

Show Answer

Question # 85

The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 1–2 hours if needed. The most likely rationale for this order is: 

A. The client will settle down more quickly if he thinks the staff is medicating him
B. The medication will sedate the client until the physician arrives
C. Haloperidol is a minor tranquilizer and will not oversedate the client
D. Rapid neuroleptization is the most effective approach to care for the violent or potentiallyviolent client

Show Answer

Question # 86

Loss of appetite for a child with leukemia is a major recurrent problem. The plan of careshould be designed to:

A. Reinforce attempts to eat
B. Help the child gain weight
C. Increase his appetite
D. Make mealtimes pleasant

Show Answer