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NCLEX Practice Questions RN 1/7

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Question 1 of 451
1. Question
1. Question Tag: hypertension
  Question Category: Physiological Integrity, Reduction of Risk Potential
Which individual is at greatest risk for developing hypertension?
- • A. 45-year-old African-American attorney
- • B. 60-year-old Asian-American shop owner
- • C. 40-year-old Caucasian nurse
- • D. 55-year-old Hispanic teacher
Correct
Incorrect
Question 2 of 451
2. Question
1. Question Tag: acetaminophen
  Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
A 15-year-old female who ingested 15 tablets of maximum strength acetaminophen 45 minutes ago is rushed to the emergency department. Which of these orders should the nurse do first?
- • A. Gastric lavage
- • B. Administer acetylcysteine (Mucomyst) orally
- • C. Start an IV Dextrose 5% with 0.33% normal saline to keep the vein open
- • D. Have the patient drink activated charcoal mixed with water
Correct
Incorrect
Question 3 of 451
3. Question
1. Question Tag: cardiac catheterization
  Question Category: Safe and Effective Care Environment, Management of Care
Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?
- • A. Angina at rest
- • B. Thrombus formation
- • C. Dizziness
- • D. Falling blood pressure
Correct
Incorrect
Question 4 of 451
4. Question
1. Question Tag: renal calculi, flank pain
  Question Category: Physiological Integrity, Basic Care and Comfort
A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is:
- • A. Maintain fluid and electrolyte balance
- • B. Control nausea
- • C. Manage pain
- • D. Prevent urinary tract infection
Correct
Incorrect
Question 5 of 451
5. Question
1. Question Tag: growth, school age
  Question Category: Health Promotion and Maintenance
What would the nurse expect to see while assessing the growth of children during their school age years?
- • A. Decreasing amounts of body fat and muscle mass
- • B. Little change in body appearance from year to year
- • C. Progressive height increase of 4 inches each year
- • D. Yearly weight gain of about 5.5 pounds per year
Correct
Incorrect
Question 6 of 451
6. Question
1. Question Tag: blood pressure
  Question Category: Health Promotion and Maintenance
At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states “My blood pressure is usually much lower.” The nurse should tell the client to:
- • A. Go get a blood pressure check within the next 15 minutes
- • B. Check blood pressure again in two (2) months
- • C. See the healthcare provider immediately
- • D. Visit the health care provider within one (1) week for a BP check
Correct
Incorrect
Question 7 of 451
7. Question
1. Question Tag: prioritization
  Question Category: Safe and Effective Care Environment, Safety and Infection Control
The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission?
- • A. A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago.
- • B. A young adult with diabetes mellitus Type 2 for over ten (10) years and admitted with antibiotic-induced diarrhea 24 hours ago.
- • C. An elderly client with a history of hypertension, hypercholesterolemia, and lupus, and was admitted with Stevens-Johnson syndrome that morning.
- • D. An adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago.
Correct
Incorrect
Question 8 of 451
8. Question
1. Question Tag:hypothyroidism, levothyroxine
  Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
A 25-year-old male client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:
- • A. Should be taken in the morning
- • B. May decrease the client’s energy level
- • C. Must be stored in a dark container
- • D. Will decrease the client’s heart rate
Correct
Incorrect
Question 9 of 451
9. Question
1. Question Tag: epiglottis
  Question Category: Physiological Integrity, Physiological Adaptation
A 3-year-old child was brought to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first?
- • A. Prepare the child for X-ray of upper airways
- • B. Examine the child’s throat
- • C. Collect a sputum specimen
- • D. Notify the healthcare provider of the child’s status
Correct
Incorrect
Question 10 of 451
10. Question
1. Question Tag: diabetes, school-age
  Question Category: Physiological Integrity, Physiological Adaptation
In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school-age child for evaluation?
- • A. Polyphagia
- • B. Dehydration
- • C. Bedwetting
- • D. Weight loss
Correct
Incorrect
Question 11 of 451
11. Question
1. Question Tag: pelvic inflammatory disease
  Question Category: Physiological Integrity, Physiological Adaptation
A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection?
- • A. Trichomoniasis
- • B. Chlamydia
- • C. Staphylococcus
- • D. Streptococcus
Correct
Incorrect
Question 12 of 451
12. Question
1. Question Tag: prioritization
  Question Category: Safe and Effective Care Environment, Management of Care
A registered nurse who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?
- • A. A middle-aged client who says “I took too many diet pills” and “my heart feels like it is racing out of my chest.”
- • B. A young adult who says “I hear songs from heaven. I need money for beer. I quit drinking two (2) days ago for my family. Why are my arms and legs jerking?”
- • C. An adolescent who has been on pain medications terminal cancer with an initial assessment reactive pupils and a relaxed respiratory rate of 11,
- • D. An elderly client who reports having taken a “large crack hit” and a fall 10 minutes prior to walking into the emergency room.
Correct
Incorrect
Question 13 of 451
13. Question
1. Question Tag: coronary artery disease, nutrition
  Question Category: Health Promotion and Maintenance
When teaching a client with coronary artery disease about nutrition, the nurse should emphasize:
- • A. Eating three (3) balanced meals a day
- • B. Adding complex carbohydrates
- • C. Avoiding very heavy meals
- • D. Limiting sodium to 7 gms per day
Correct
Incorrect
Question 14 of 451
14. Question
1. Question Tag: morphine, pain management
  Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain breakthrough for morphine drip is not working?
- • A. The client complains of discomfort at the IV insertion site
- • B. The client states “I just can’t get relief from my pain.”
- • C. The level of drug is 100 ml at 8 AM and is 80 ml at noon
- • D. The level of the drug is 100 ml at 8 AM and is 50 ml at noon
Correct
Incorrect
Question 15 of 451
15. Question
1. Question Tag: health promotion, chiropractic treatment
  Question Category: Health Promotion and Maintenance
The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response?
- • A. Electrical energy fields
- • B. Spinal column manipulation
- • C. Mind-body balance
- • D. Exercise of joints
Correct
Incorrect
Question 16 of 451
16. Question
1. Question Tag: neurological assessment, CVA
  Question Category: Physiological Integrity, Physiological Adaptation
The nurse is performing a neurological assessment on a client post right cerebrovascular accident. Which finding, if observed by the nurse, would warrant immediate attention?
- • A. Decrease in level of consciousness
- • B. Loss of bladder control
- • C. Altered sensation to stimuli
- • D. Emotional lability
Correct
Incorrect
Question 17 of 451
17. Question
1. Question Tag: cystic fibrosis
  Question Category: Physiological Integrity, Physiological Adaptation
A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time?
- • A. Positive sweat test
- • B. Bulky greasy stools
- • C. Moist, productive cough
- • D. Meconium ileus
Correct
Incorrect
Question 18 of 451
18. Question
1. Question Tag: wound care
  Question Category: Physiological Integrity, Physical Adaptation
The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two (2) hours ago. The nurse should
- • A. Place a call to the client’s health care provider for instructions
- • B. Send him to the emergency room for evaluation
- • C. Reassure the client’s wife that the symptoms are transient
- • D. Instruct the client’s wife to call the doctor if his symptoms become worse
Correct
Incorrect
Question 19 of 451
19. Question
1. Question Tag: KUB radiograph
  Question Category:Physiological Integrity, Reduction of Risk potential
Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiography test?
- • A. Client must be NPO before the examination
- • B. Enema to be administered prior to the examination
- • C. Medicate client with furosemide 20 mg IV 30 minutes prior to the examination
- • D. No special orders are necessary for this examination
Correct
Incorrect
Question 20 of 451
20. Question
1. Question Tag: myocardial infarction
  Question Category: Health Promotion and Maintenance
The nurse is giving discharge teaching to a client seven (7) days post myocardial infarction. He asks the nurse why he must wait six (6) weeks before having sexual intercourse. What is the best response by the nurse to this question?
- • A. “You need to regain your strength before attempting such exertion.”
- • B. “When you can climb 2 flights of stairs without problems, it is generally safe.”
- • C. “Have a glass of wine to relax you, then you can try to have sex.”
- • D. “If you can maintain an active walking program, you will have less risk.”
Correct
Incorrect
Question 21 of 451
21. Question
1. Question Tag: triaging
  Question Category: Safe and Effective Care Environment, Management of Care
A triage nurse has these four (4) clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?
- • A. A 2-month-old infant with a history of rolling off the bed and has bulging fontanelle with crying
- • B. A teenager who got a singed beard while camping
- • C. An elderly client with complaints of frequent liquid brown colored stools
- • D. A middle-aged client with intermittent pain behind the right scapula
Correct
Incorrect
Question 22 of 451
22. Question
1. Question Tag: toddler, developmental changes
  Question Category: Health Promotion and Maintenance
While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child’s developmental needs?
- • A. “I want to protect my child from any falls.”
- • B. “I will set limits on exploring the house.”
- • C. “I understand the need to use those new skills.”
- • D. “I intend to keep control over our child.”
Correct
Incorrect
Question 23 of 451
23. Question
1. Question Tag: enteral feeding, nasogastric feeding
  Question Category: Physiological Integrity, Basic Care and Comfort
The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is:
- • A. Verify correct placement of the tube
- • B. Check that the feeding solution matches the dietary order
- • C. Aspirate abdominal contents to determine the amount of last feeding remaining in stomach
- • D. Ensure that feeding solution is at room temperature
Correct
Incorrect
Question 24 of 451
24. Question
1. Question Tag: potassium, hyperkalemia
  Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq potassium chloride in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued?
- • A. Narrowed QRS complex
- • B. Shortened “PR” interval
- • C. Tall peaked “T” waves
- • D. Prominent “U” waves
Correct
Incorrect
Question 25 of 451
25. Question
1. Question Tag: rhabdomyosarcoma
  Question Category: Physiological Integrity, Physiological Adaptation
A nurse prepares to care for a 4-year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?
- • A. All striated muscles
- • B. The cerebellum
- • C. The kidneys
- • D. The leg bones
Correct
Incorrect
Question 26 of 451
26. Question
1. Question Tag: Chinese medicine
  Question Category: Health Promotion and Maintenance
The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to:
- • A. Achieve harmony
- • B. Maintain a balance of energy
- • C. Respect life
- • D. Restore yin and yang
Correct
Incorrect
Question 27 of 451
27. Question
1. Question Tag: cardiomyopathy
  Question Category: Physiological Integrity, Physiological Adaptation
During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to:
- • A. Increase fluids that are high in protein
- • B. Restrict fluids
- • C. Force fluids and reassess blood pressure
- • D. Limit fluids to non-caffeine beverages
Correct
Incorrect
Question 28 of 451
28. Question
1. Question Tag: pulmonary artery catheter, Swan-Ganz catheter
  Question Category: Physiological Integrity, Reduction of Risk Potential
The nurse prepares the client for insertion of a pulmonary artery catheter (Swan-Ganz catheter). The nurse teaches the client that the catheter will be inserted to provide information about:
- • A. Stroke volume
- • B. Cardiac output
- • C. Venous pressure
- • D. Left ventricular functioning
Correct
Incorrect
Question 29 of 451
29. Question
1. Question Tag: chest compressions
  Question Category: Physiological Integrity, Physiological Adaptation
A nurse enters a client’s room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is:
- • A. Start a peripheral IV
- • B. Initiate high-quality chest compressions
- • C. Establish an airway
- • D. Obtain the crash cart
Correct
Incorrect
Question 30 of 451
30. Question
1. Question Tag: digoxin, metoprolol
  Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy
A client is receiving digoxin (Lanoxin) 0.25 mg daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?
- • A. Blood pressure 94/60 mm Hg
- • B. Heart rate 76 bpm
- • C. Urine output 50 ml/hour
- • D. Respiratory rate 16 bpm
Correct
Incorrect
Question 31 of 451
31. Question
1. Question Tag: infant, assessment
  Question Category: Health Promotion and Maintenance
While assessing a one-month-old infant, which of the findings warrants further investigation by the nurse? Select all that apply.
- • A. Abdominal respirations
- • B. Irregular breathing rate
- • C. Inspiratory grunt
- • D. Increased heart rate with crying
- • E. Nasal flaring
- • F. Cyanosis
- • G. Asymmetric chest movement
Correct
Incorrect
Question 32 of 451
32. Question
1. Question Tag: postmature fetus, maternal nursing
  Question Category: Health Promotion and Maintenance
The nurse practicing in a maternity setting recognizes that the postmature fetus is at risk due to:
- • A. Excessive fetal weight
- • B. Low blood sugar levels
- • C. Depletion of subcutaneous fat
- • D. Progressive placental insufficiency
Correct
Incorrect
Question 33 of 451
33. Question
1. Question Tag: total hip replacement
  Question Category: Physiological Integrity, Reduction of Risk Potential
The nurse is caring for a client who had a total hip replacement seven (7) days ago. Which statement by the client requires the nurse’s immediate attention?
- • A. I have bad muscle spasms in my lower leg of the affected extremity.
- • B. “I just can’t ‘catch my breath’ over the past few minutes and I think I am in grave danger.”
- • C. “I have to use the bedpan to pass my water at least every 1 to 2 hours.”
- • D. “It seems that the pain medication is not working as well today.”
Correct
Incorrect
Question 34 of 451
34. Question
1. Question Tag: furosemide, side effect
  Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
A 33-year-old male client with heart failure has been taking furosemide for the past week. Which of the following assessment cues below may indicate the client is experiencing a negative side effect from the medication?
- • A. Weight gain of 5 pounds
- • B. Edema of the ankles
- • C. Gastric irritability
- • D. Decreased appetite
Correct
Incorrect
Question 35 of 451
35. Question
35.Question Tag: obstetrics, miscarriage
Question Category: Health Promotion and Maintenance
A 32-year-old pregnant woman comes to the clinic for her prenatal visit. The nurse gathers data about her obstetric history, which includes 3-year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information? Fill in the blanks.
- Gravida para
Correct
Incorrect
Question 36 of 451
36. Question
1. Question Tag: venous stasis ulcer
  Question Category: Physiological Integrity, Basic care and Comfort
The nurse is caring for a 27-year-old female client with venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?
- • A. Apply dressing using sterile technique
- • B. Improve the client’s nutrition status
- • C. Initiate limb compression therapy
- • D. Begin proteolytic debridement
Correct
Incorrect
Question 37 of 451
37. Question
1. Question Tag: meperidine hydrochloride, atropine sulfate, promethazine hydrochloride
  Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy
A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a preoperative client. List the order in which the nurse must carry out the following actions prior to the administration of preoperative medications.
- • Place the call bell within reach
- • Have the client empty bladder
- • Instruct the client to remain in bed
- • Raise the side rails on the bed
View Answers:
Correct
Incorrect
Question 38 of 451
38. Question
1. Question Tag: nursing management and leadership, reward-feedback system
  Question Category: Health Promotion and Maintenance
Which of these statements best describes the characteristics of an effective reward-feedback system?
- • A. Specific feedback is given as close to the event as possible
- • B. Staff is given feedback in equal amounts over time
- • C. Positive statements are to precede a negative statement
- • D. Performance goals should be higher than what is attainable
Correct
Incorrect
Question 39 of 451
39. Question
1. Question Tag: multiple sclerosis
  Question Category: Health Promotion and Maintenance
The nurse is providing information to a client with multiple sclerosis on performing exercises and physical activities. The nurse determines the client needs additional teaching if the client makes which statements? Select all that apply.
- • A. “I can lift weights and do resistance training.”
- • B. “I should exercise to the point of exhaustion.”
- • C. “I can include aerobic exercises in my routine.”
- • D. “Proper stretching should be done before starting my routine.”
- • E. “I should exercise continuously without rest.”
Correct
Incorrect
Question 40 of 451
40. Question
1. Question Tag: home care, Alzheimer’s disease
  Question Category: Safe and Effective Care Environment, Safety and Infection Control
During the evaluation of the quality of home care for a client with Alzheimer’s disease, the priority for the nurse is to reinforce which statement by a family member?
- • A. “At least two (2) full meals a day are eaten.”
- • B. “We go to a group discussion every week at our community center.”
- • C. “We have safety bars installed in the bathroom and have 24-hour alarms on the doors.”
- • D. “The medication is not a problem to have it taken three (3) times a day.”
Correct
Incorrect
Question 41 of 451
41. Question
1. Question Tag: medications, pregnancy
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy
A nurse is reviewing a patient’s medication during shift change. Which of the following medications would be contraindicated if the patient were pregnant? Select all that apply.
- • A. Warfarin (Coumadin)
- • B. Finasteride (Propecia, Proscar)
- • C. Celecoxib (Celebrex)
- • D. Clonidine (Catapres)
- • E. Transdermal nicotine (Habitrol)
- • F. Clofazimine(Lamprene)
Correct
Incorrect
Question 42 of 451
42. Question
1. Question Tag: history, photosensitivity
  Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy
A nurse is reviewing a patient’s past medical history (PMH). The history indicates the patient has photosensitive reactions to medications. Which of the following drugs is associated with photosensitive reactions? Select all that apply.
- • A. Ciprofloxacin (Cipro)
- • B. Sulfonamide
- • C. Norfloxacin (Noroxin)
- • D. Sulfamethoxazole and Trimethoprim (Bactrim)
- • E. Isotretinoin (Accutane)
- • F. Nitro-Dur patch
Correct
Incorrect
Question 43 of 451
43. Question
1. Question Tag: discolored urine
  Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy
A patient tells you that her urine is starting to look discolored. If you believe this change is due to medication, which of the following of the patient’s medication does not cause urine discoloration?
- • A. Sulfasalazine
- • B. Levodopa
- • C. Phenolphthalein
- • D. Aspirin
Correct
Incorrect
Question 44 of 451
44. Question
1. Question Tag: refrigerated drugs
  Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy
You are responsible for reviewing the nursing unit’s refrigerator. Which of the following drugs, if found inside the fridge, should be removed?
- • A. Nadolol (Corgard)
- • B. Opened (in-use) Humulin N injection
- • C. Urokinase (Kinlytic)
- • D. Epoetin alfa IV (Epogen)
Correct
Incorrect
Question 45 of 451
45. Question
1. Question Tag: pregnancy, autoimmune disease, immunoglobulin
  Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy
A 34-year-old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb?
- • A. IgA
- • B. IgD
- • C. IgE
- • D. IgG
Correct
Incorrect
Question 46 of 451
46. Question
1. Question Tag: needlestick, AIDS
  Question Category: Safe and Effective Care Environment, Safety and Infection Control
A second-year nursing student has just suffered a needlestick while working with a patient that is positive for AIDS. Which of the following is the most significant action that the nursing student should take?
- • A. Immediately see a social worker
- • B. Start prophylactic AZT treatment
- • C. Start prophylactic Pentamidine treatment
- • D. Seek counseling
Correct
Incorrect
Question 47 of 451
47. Question
1. Question Tag: insulin-dependent, diabetes
  Question Category: Physiological Integrity, Physiological Adaptation
A thirty-five-year-old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect?
- • A. Atherosclerosis
- • B. Diabetic nephropathy
- • C. Autonomic neuropathy
- • D. Somatic neuropathy
Correct
Incorrect
Question 48 of 451
48. Question
1. Question Tag: BMI, induced vomiting, constipation
  Question Category: Physiological Integrity, Physiological Adaptation
You are taking the history of a 14-year-old girl who has a (BMI) of 18. The girl reports inability to eat, induced vomiting and severe constipation. Which of the following would you most likely suspect?
- • A. Multiple sclerosis
- • B. Anorexia nervosa
- • C. Bulimia nervosa
- • D. Systemic sclerosis
Correct
Incorrect
Question 49 of 451
49. Question
1. Question Tag: myeloma, confusion
  Question Category: Physiological Integrity, Physiological Adaptation
A 24-year-old female is admitted to the ER for confusion. This patient has a history of a myeloma diagnosis, constipation, intense abdominal pain, and polyuria. Based on the presenting signs and symptoms, which of the following would you most likely suspect?
- • A. Diverticulosis
- • B. Hypercalcemia
- • C. Hypocalcemia
- • D. Irritable bowel syndrome
Correct
Incorrect
Question 50 of 451
50. Question
1. Question Tag: Rhogam
  Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy
Rhogam is most often used to treat____ mothers that have a ____ infant.
- • A. RH positive, RH positive
- • B. RH positive, RH negative
- • C. RH negative, RH positive
- • D. RH negative, RH negative
Correct
Incorrect
Question 51 of 451
51. Question
1. Question Tag: phenylketonuria
  Question Category: Health Promotion and Maintenance
A new mother has some questions about phenylketonuria (PKU). Which of the following statements made by a nurse is not correct regarding PKU?
- • A. A Guthrie test can check the necessary lab values.
- • B. The urine has a high concentration of phenylpyruvic acid
- • C. Mental deficits are often present with PKU
- • D. The effects of PKU are reversible
Correct
Incorrect
Question 52 of 451
52. Question
1. Question Tag: overdose, aspirin
  Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy
A patient has taken an overdose of aspirin. Which of the following should a nurse must closely monitor during acute management of this patient?
- • A. Onset of pulmonary edema
- • B. Metabolic alkalosis
- • C. Respiratory alkalosis
- • D. Parkinson’s disease type symptoms
Correct
Incorrect
Question 53 of 451
53. Question
1. Question Tag: blind, deaf
  Question Category: Safe and Effective Care Environment, Safety and Infection Control
A 50-year-old blind and deaf patient has been admitted to your floor. As the charge nurse, your primary responsibility for this patient is?
- • A. Let others know about the patient’s deficits.
- • B. Communicate with your supervisor your patient safety concerns.
- • C. Continuously update the patient on the social environment.
- • D. Provide a secure environment for the patient.
Correct
Incorrect
Question 54 of 451
54. Question
1. Question Tag: COPD, PVD
  Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy
A patient is getting discharged from a skilled nursing facility (SNF). The patient has a history of severe COPD and PVD. The patient is primarily concerned about his ability to breathe easily. Which of the following would be the best instruction for this patient?
- • A. Deep breathing techniques to increase oxygen levels.
- • B. Cough regularly and deeply to clear airway passages.
- • C. Cough following bronchodilator utilization.
- • D. Decrease CO2 levels by increased oxygen take output during meals.
Correct
Incorrect
Question 55 of 451
55. Question
1. Question Tag: congenital heart defect
  Question Category: Physiological Integrity, Physiological Adaptation
A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present?
- • A. Slow pulse rate
- • B. Weight gain
- • C. Decreased systolic pressure
- • D. Irregular WBC lab values
Correct
Incorrect
Question 56 of 451
56. Question
1. Question Tag: Down’s syndrome
  Question Category: Physiological Integrity, Physiological Adaptation
A mother has recently been informed that her child has Down’s syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Down’s syndrome?
- • A. Simian crease
- • B. Brachycephaly
- • C. Oily skin
- • D. Hypotonicity
Correct
Incorrect
Question 57 of 451
57. Question
1. Question Tag: myocardial infarction, tissue plasminogen activator, alteplase
  Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy
A client with myocardial infarction is receiving tissue plasminogen activator, alteplase (Activase, tPA). While on the therapy, the nurse plans to prioritize which of the following?
- • A. Observe for neurological changes
- • B. Monitor for any signs of renal failure
- • C. Check the food diary
- • D. Observe for signs of bleeding
Correct
Incorrect
Question 58 of 451
58. Question
1. Question Tag: folic acid
  Question Category: Physiologic Integrity, Basic Care and Comfort
A patient asks a nurse, “My doctor recommended I increase my intake of folic acid. What type of foods contain the highest concentration of folic acids?”
- • A. Green vegetables and liver
- • B. Yellow vegetables and red meat
- • C. Carrots
- • D. Milk
Correct
Incorrect
Question 59 of 451
59. Question
1. Question Tag: meningitis
  Question Category: Physiological Integrity, Physiological Adaptation
A nurse is putting together a presentation on meningitis. Which of the following microorganisms has not been linked to meningitis in humans?
- • A. S. pneumoniae
- • B. H. influenzae
- • C. N. meningitidis
- • D. Cl. difficile
Correct
Incorrect
Question 60 of 451
60. Question
1. Question Tag: hemoglobin, RBC
  Question Category: Physiologic Integrity, Physiological Adaptation
A nurse is administering blood to a patient who has a low hemoglobin count. The patient asks how long do red blood cells live in my body? The correct response is:
- • A. The life span of RBC is 45 days
- • B. The life span of RBC is 60 days
- • C. The life span of RBC is 90 days
- • D. The life span of RBC is 120 days
Correct
Incorrect
Question 61 of 451
61. Question
1. Question Tag: spinal stenosis, discharge
  Question Category: Health Promotion and Maintenance
A 65-year-old man has been admitted to the hospital for spinal stenosis surgery. When should the discharge training and planning begin for this patient?
- • A. Following surgery
- • B. Upon admission
- • C. Within 48 hours of discharge
- • D. Preoperative discussion
Correct
Incorrect
Question 62 of 451
62. Question
1. Question Tag: psychosocial development, Erik Erikson, school-age
  Question Category:Psychosocial Integrity
A 5-year-old child and has been recently admitted to the hospital. According to Erik Erikson’s psychosocial development stages, the child is in which stage?
- • A. Trust vs. mistrust
- • B. Initiative vs. guilt
- • C. Autonomy vs. shame and doubt
- • D. Intimacy vs. isolation
Correct
Incorrect
Question 63 of 451
63. Question
1. Question Tag: psychosocial development, Erik Erikson, toddler
  Question Category: Psychosocial Integrity
A toddler is 26 months old and has been recently admitted to the hospital. According to Erikson, which of the following stages is the toddler in?
- • A. Trust vs. mistrust
- • B. Initiative vs. guilt
- • C. Autonomy vs. shame and doubt
- • D. Intimacy vs. isolation
Correct
Incorrect
Question 64 of 451
64. Question
1. Question Tag: psychosocial development, Erik Erikson, young adult
  Question Category: Psychosocial Integrity
A young adult is 20 years old and has been recently admitted to the hospital. According to Erikson, which of the following stages is the adult in?
- • A. Trust vs. mistrust
- • B. Initiative vs. guilt
- • C. Autonomy vs. shame
- • D. Intimacy vs. isolation
Correct
Incorrect
Question 65 of 451
65. Question
1. Question Tag:vital signs
  Question Category: Physiological Integrity, Reduction of Risk Potential
A nurse is making rounds taking vital signs. Which of the following vital signs is abnormal?
- • A. 11-year-old male: 90 BPM, 22 RPM, 100/70 mmHg
- • B. 13-year-old female: 105 BPM, 22 RPM, 105/50 mmHg
- • C. 5-year-old male: 102 BPM, 24 RPM, 90/65 mmHg
- • D. 6-year-old female: 100 BPM, 26 RPM, 90/70 mmHg
Correct
Incorrect
Question 66 of 451
66. Question
1. Question Tag: depression, anxiety disorder, history
  Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy
When you are taking a patient’s history, she tells you she has been depressed and is dealing with an anxiety disorder. Which of the following medications would the patient most likely be taking?
- • A. Amitriptyline (Elavil)
- • B. Calcitonin
- • C. Pergolide mesylate (Permax)
- • D. Verapamil (Calan)
Correct
Incorrect
Question 67 of 451
67. Question
1. Question Tag: erythromycin
  Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy
Which of the following conditions would a nurse not administer erythromycin?
- • A. Campylobacteriosis infection
- • B. Legionnaires disease
- • C. Pneumonia
- • D. Multiple Sclerosis
Correct
Incorrect
Question 68 of 451
68. Question
1. Question Tag: hyperkalemia
  Question Category:Physiological Integrity, Physiological Adaptation
A patient’s chart indicates a history of hyperkalemia. Which of the following would you not expect to see with this patient if this condition were acute?
- • A. Decreased HR
- • B. Paresthesias
- • C. Muscle weakness of the extremities
- • D. Migraines
Correct
Incorrect
Question 69 of 451
69. Question
1. Question Tag: ketoacidosis
  Question Category: Physiological Integrity, Physiological Adaptation
A patient’s chart indicates a history of ketoacidosis. Which of the following would you not expect to see with this patient if this condition were acute?
- • A. Vomiting
- • B. Extreme Thirst
- • C. Weight gain
- • D. Acetone breath smell
Correct
Incorrect
Question 70 of 451
70. Question
1. Question Tag: meningitis
  Question Category: Physiological Integrity, Physiological Adaptation
A patient’s chart indicates a history of meningitis. Which of the following would you NOT expect to see with this patient if this condition were acute?
- • A. Increased appetite
- • B. Vomiting
- • C. Fever
- • D. Poor tolerance of light
Correct
Incorrect
Question 71 of 451
71. Question
1. Question Tag: conjunctivitis
  Question Category: Physiological Integrity, Physiological Adaptation
A nurse is reviewing a patient’s chart and notices that the patient suffers from conjunctivitis. Which of the following microorganisms is related to this condition?
- • A. Yersinia pestis
- • B. Helicobacter pylori
- • C. Vibrio cholerae
- • D. Haemophilus aegyptius
Correct
Incorrect
Question 72 of 451
72. Question
1. Question Tag: Lyme disease
  Question Category: Physiological Adaptation
A nurse is reviewing a patient’s chart and notices that the patient suffers from Lyme disease. Which of the following microorganisms is related to this condition?
- • A. Borrelia burgdorferi
- • B. Streptococcus pyogenes
- • C. Bacillus anthracis
- • D. Enterococcus faecalis
Correct
Incorrect
Question 73 of 451
73. Question
1. Question Tag: confusion, falls, hemiparesis
  Question Category: Physiological Integrity, Reduction of Risk Potential
A fragile 87-year-old female has recently been admitted to the hospital with increased confusion and falls over the last two (2) weeks. She is also noted to have a mild left hemiparesis. Which of the following tests is most likely to be performed?
- • A. CBC (Complete blood count)
- • B. ECG (electrocardiogram)
- • C. Thyroid function tests
- • D. CT scan
Correct
Incorrect
Question 74 of 451
74. Question
1. Question Tag: mobility, weight gain
  Question Category: Physiological Integrity, Reduction of Risk Potential
An 85-year-old male has been losing mobility and gaining weight over the last two (2) months. The patient also has the heater running in his house 24 hours a day, even on warm days. Which of the following tests is most likely to be performed?
- • A. CBC (complete blood count)
- • B. ECG (electrocardiogram)
- • C. Thyroid function tests
- • D. CT scan
Correct
Incorrect
Question 75 of 451
75. Question
1. Question Tag: fever, rash
  Question Category: Physiological Integrity, Reduction of Risk Potential
A 20-year-old female attending college is found unconscious in her dorm room. She has a fever and a noticeable rash. She has just been admitted to the hospital. Which of the following tests is most likely to be performed first?
- • A. Blood sugar check
- • B. CT scan
- • C. Blood cultures
- • D. Arterial blood gases
Correct
Incorrect
Question 76 of 451
76. Question
1. Question Tag: confusion
  Question Category: Physiological Integrity, Reduction of Risk Potential
A 28-year-old male has been found wandering around in a confusing pattern. The male is sweaty and pale. Which of the following tests is most likely to be performed first?
- • A. Blood sugar check
- • B. CT scan
- • C. Blood cultures
- • D. Arterial blood gases
Correct
Incorrect
Question 77 of 451
77. Question
1. Question Tag: toilet training
  Question Category: Health Promotion and Maintenance
A mother is inquiring about her child’s ability to potty train. Which of the following factors is the most important aspect of toilet training?
- • A. The age of the child
- • B. The child’s ability to understand instruction.
- • C. The overall mental and physical abilities of the child.
- • D. Frequent attempts with positive reinforcement.
Correct
Incorrect
Question 78 of 451
78. Question
1. Question Tag: poisoning
  Question Category: Safety and infection Control
A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child drank for 20 minutes. Which of the following is the most important instruction the nurse can give the parent?
- • A. This too shall pass.
- • B. Take the child immediately to the ER
- • C. Contact the Poison Control Center quickly
- • D. Give the child syrup of ipecac
Correct
Incorrect
Question 79 of 451
79. Question
1. Question Tag: vitamin K
  Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy
A nurse is administering a shot of Vitamin K to a 30 day-old infant. Which of the following target areas is the most appropriate?
- • A. Gluteus maximus
- • B. Gluteus minimus
- • C. Vastus lateralis
- • D. Vastus medialis
Correct
Incorrect
Question 80 of 451
80. Question
1. Question Tag: toddler, language
  Question Category:Safe and Effective Care Environment, Safety and Infection Control
A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4-year-old boy who is non-verbal. This child does not have any identification on. What should the nurse do?
- • A. Contact the provider
- • B. Ask the child to write their name on paper
- • C. Ask a coworker about the identification of the child
- • D. Ask the father who is in the room the child’s name
Correct
Incorrect
Question 81 of 451
81. Question
1. Question Tag: Parkinson’s disease
Question Category: Safe and Effective Care Environment, Management of Care
A patient with Parkinson’s disease has a nursing diagnosis of Impaired Physical Mobility related to neuromuscular impairment. You observe a nursing assistant performing all of these actions. For which action must you intervene?
- • A. The NA assists the patient to ambulate to the bathroom and back to bed.
- • B. The NA reminds the patient not to look at his feet when he is walking.
- • C. The NA performs the patient’s complete bath and oral care.
- • D. The NA sets up the patient’s tray and encourages the patient to feed himself.
Correct
Incorrect
Question 82 of 451
82. Question
1. Question Tag: low back pain
Question Category: Health Promotion and Maintenance
The nurse is preparing to discharge a patient with chronic low back pain. Which statement by the patient indicates that additional teaching is necessary?
- • A. “I will avoid exercise because the pain gets worse.”
- • B. “I will use heat or ice to help control the pain.”
- • C. “I will not wear high-heeled shoes at home or work.”
- • D. “I will purchase a firm mattress to replace my old one.”
Correct
Incorrect
Question 83 of 451
83. Question
1. Question Tag: Spinal cord injury
Question Category: Physiological Integrity, Physiological Adaptation
A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute), diaphoresis, and flushing of the face and neck. What action should you take first?
- • A. Administer the ordered acetaminophen (Tylenol).
- • B. Check the Foley tubing for kinks or obstruction.
- • C. Adjust the temperature in the patient’s room.
- • D. Notify the physician about the change in status.
Correct
Incorrect
Question 84 of 451
84. Question
1. Question Tag: Neurologic unit
Question Category: Safe and Effective Care Environment, Management of Care
Which patient should you, as charge nurse, assign to a new graduate RN who is orienting to the neurologic unit?
- • A. A 28-year-old newly admitted patient with spinal cord injury.
- • B. A 67-year-old patient with a stroke 3 days ago and left-sided weakness.
- • C. An 85-year-old dementia patient to be transferred to long-term care today.
- • D. A 54-year-old patient with Parkinson’s who needs assistance with bathing.
Correct
Incorrect
Question 85 of 451
85. Question
1. Question Tag: Spinal cord injury
Question Category: Physiological Integrity, Physiological Adaptation
A patient with a spinal cord injury at level C3-4 is being cared for in the ED. What is the priority assessment?
- • A. Determine the level at which the patient has intact sensation.
- • B. Assess the level at which the patient has retained mobility.
- • C. Check blood pressure and pulse for signs of spinal shock.
- • D. Monitor respiratory effort and oxygen saturation level.
Correct
Incorrect
Question 86 of 451
86. Question
1. Question Tag: delegation
Question Category: Safe and Effective Care Environment, Management of Care
You are pulled from the ED to the neurologic floor. Which action should you delegate to the nursing assistant when providing nursing care for a patient with SCI?
- • A. Assess the patient’s respiratory status every 4 hours.
- • B. Take a patient’s vital signs and record them every 4 hours.
- • C. Monitor nutritional status including calorie counts.
- • D. Have the patient turn, cough, and deep breathe every 3 hours.
Correct
Incorrect
Question 87 of 451
87. Question
1. Question Tag: spinal cord injury
Question Category: Basic Care and Comfort
You are helping the patient with an SCI to establish a bladder-retraining program. What strategies may stimulate the patient to void? Select all that apply.
- • A. Stroke the patient’s inner thigh.
- • B. Pull on the patient’s pubic hair.
- • C. Initiate intermittent straight catheterization.
- • D. Pour warm water over the perineum.
- • E. Tap the bladder to stimulate detrusor muscle.
Correct
Incorrect
Question 88 of 451
88. Question
1. Question Tag: cervical SCI
Question Category: Safe and Effective Care Environment, Management of Care
The patient with a cervical SCI has been placed in fixed skeletal traction with a halo fixation device. When caring for this patient the nurse may delegate which action (s) to the LPN/LVN? Select all that apply.
- • A. Check the patient’s skin for pressure from the device.
- • B. Assess the patient’s neurologic status for changes.
- • C. Observe the halo insertion sites for signs of infection.
- • D. Clean the halo insertion sites with hydrogen peroxide.
Correct
Incorrect
Question 89 of 451
89. Question
1. Question Tag: SCI
Question Category: Physiological Integrity, Physiological Adaptation
You are preparing a nursing care plan for the patient with SCI including the nursing diagnosis Impaired Physical Mobility and Self-Care Deficit. The patient tells you, “I don’t know why we’re doing all this. My life’s over.” What additional nursing diagnosis takes priority based on this statement?
- • A. Risk for Injury related to altered mobility
- • B. Imbalanced Nutrition, Less Than Body Requirements
- • C. Impaired Adjustment to Spinal Cord Injury
- • D. Poor Body Image related to immobilization
Correct
Incorrect
Question 90 of 451
90. Question
1. Question Tag: neurologic care
Question Category: Safe and Effective Care Environment, Management of Care
Which patient should be assigned to the traveling nurse, new to neurologic nursing care, who has been in the neurologic unit for 1 week?
- • A. A 34-year-old patient newly diagnosed with multiple sclerosis (MS).
- • B. A 68-year-old patient with chronic amyotrophic lateral sclerosis (ALS).
- • C. A 56-year-old patient with Guillain-Barre syndrome (GBS) in respiratory distress.
- • D. A 25-year-old patient admitted with CA level spinal cord injury (SCI).
Correct
Incorrect
Question 91 of 451
91. Question
1. Question Tag: hyperparathyroidism
  Question Category: Physiological Integrity, Reduction of Risk Potential
A patient is admitted to the hospital with a diagnosis of primary hyperparathyroidism. A nurse checking the patient’s lab results would expect which of the following changes in laboratory findings?
- • A. Elevated serum calcium
- • B. Low serum parathyroid hormone (PTH)
- • C. Elevated serum vitamin D
- • D. Low urine calcium
Correct
Incorrect
Question 92 of 451
92. Question
1. Question Tag: Addison’s disease
  Question Category: Health Promotion and Maintenance
A patient with Addison’s disease asks a nurse for nutrition and diet advice. Which of the following diet modifications is not recommended?
- • A. A diet high in grains
- • B. A diet with adequate caloric intake
- • C. A high protein diet
- • D. A restricted sodium diet
Correct
Incorrect
Question 93 of 451
93. Question
1. Question Tag: diabetes mellitus, cholecystectomy
  Question Category: Physiological Integrity, Physiological Adaptation
A patient with a history of diabetes mellitus is on the second postoperative day following cholecystectomy. She has complained of nausea and isn’t able to eat solid foods. The nurse enters the room to find the patient confused and shaky. Which of the following is the most likely explanation for the patient’s symptoms?
- • A. Anesthesia reaction
- • B. Hyperglycemia
- • C. Hypoglycemia
- • D. Diabetic ketoacidosis
Correct
Incorrect
Question 94 of 451
94. Question
1. Question Tag: fiberoptic colonoscopy
  Question Category: Physiological Integrity, Reduction of Risk Potential
A nurse assigned to the emergency department evaluates a patient who underwent fiberoptic colonoscopy 18 hours previously. The patient reports increasing abdominal pain, fever, and chills. Which of the following conditions poses the most immediate concern?
- • A. Bowel perforation
- • B. Viral Gastroenteritis
- • C. Colon cancer
- • D. Diverticulitis
Correct
Incorrect
Question 95 of 451
95. Question
1. Question Tag: liver biopsy, coagulation
  Question Category: Physiological Integrity, Reduction of Risk Potential
A patient is admitted to the same-day surgery unit for a liver biopsy. Which of the following laboratory tests assesses coagulation? Select all that apply.
- • A. Partial thromboplastin time
- • B. Prothrombin time
- • C. Platelet count
- • D. Hemoglobin
Correct
Incorrect
Question 96 of 451
96. Question
1. Question Tag: hepatitis A
  Question Category: Safe and Effective Care Environment, Safety and Infection Control
A nurse is assessing a clinic patient with a diagnosis of hepatitis A. Which of the following is the most likely route of transmission?
- • A. Sexual contact with an infected partner
- • B. Contaminated food
- • C. Blood transfusion
- • D. Illegal drug use
Correct
Incorrect
Question 97 of 451
97. Question
1. Question Tag: leukemia, blood transfusion
  Question Category:Safe and Effective Care Environment, Safety and Infection Control
A leukemia patient has a relative who wants to donate blood for transfusion. Which of the following donor medical conditions would prevent this?
- • A. A history of hepatitis C five years previously
- • B. Cholecystitis requiring cholecystectomy one year previously
- • C. Asymptomatic diverticulosis
- • D. Crohn’s disease in remission
Correct
Incorrect
Question 98 of 451
98. Question
1. Question Tag: acute gastritis
  Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy
A physician has diagnosed acute gastritis in a clinic patient. Which of the following medications would be contraindicated for this patient?
- • A. Naproxen sodium (Naprosyn)
- • B. Calcium carbonate
- • C. Clarithromycin (Biaxin)
- • D. Furosemide (Lasix)
Correct
Incorrect
Question 99 of 451
99. Question
1. Question Tag: cholecystitis
  Question Category: Health Promotion and Maintenance
The nurse is conducting nutrition counseling for a patient with cholecystitis. Which of the following information is important to communicate?
- • A. The patient must maintain a low-calorie diet
- • B. The patient must maintain a high protein/low carbohydrate diet.
- • C. The patient should limit sweets and sugary drinks.
- ‎• D. The patient should limit fatty foods.
Correct
Incorrect
Question 100 of 451
100. Question
1. Question Tag: myocardial infarction, pulmonary edema
  Question Category: Physiological Integrity, Physiological Adaptation
A patient admitted to the hospital with myocardial infarction develops severe pulmonary edema. Which of the following symptoms should the nurse expect the patient to exhibit?
- • A. Slow, deep respirations
- • B. Stridor
- • C. Bradycardia
- • D. Air hunger
Correct
Incorrect
Question 101 of 451
101. Question
1. Question Tag: cardioverter-defibrillator
  Question Category: Physiological Integrity, Reduction of Risk Potential
A nurse caring for several patients in the cardiac unit is told that one is scheduled for implantation of an automatic internal cardioverter-defibrillator. Which of the following patients is most likely to have this procedure?
- • A. A patient admitted for myocardial infarction without cardiac muscle damage. ‎
- • B. A postoperative coronary bypass patient, recovering on schedule.
- • C. A patient with a of ventricular tachycardia and syncopal episodes.
- • D. A patient with a history of atrial tachycardia and fatigue.
Correct
Incorrect
Question 102 of 451
102. Question
1. Question Tag: MRI, lung cancer
  Question Category: Physiological Integrity, Reduction of Risk Potential
A patient is scheduled for a magnetic resonance imaging (MRI) scan for suspected lung cancer. Which of the following is a contraindication to the study for this patient?
- • A. The patient is allergic to shellfish.
- • B. The patient has a pacemaker.
- • C. The patient suffers from claustrophobia.
- • D. The patient takes antipsychotic medication.
Correct
Incorrect
Question 103 of 451
103. Question
103.Question Tag: pulmonary embolism
Question Category: Physiological Integrity, Physiological Adaptation
A nurse calls a physician with the concern that a patient has developed a pulmonary embolism. Which of the following symptoms has the nurse most likely observed?
- • A. The patient is somnolent with decreased response to the family.
- • B. The patient suddenly complains of chest pain and shortness of breath.
- • C. The patient has developed a wet cough and the nurse hears crackles on auscultation of the lungs.
- • D. The patient has a fever, chills, and loss of appetite.
Correct
Incorrect
Question 104 of 451
104. Question
1. Question Tag: abdominal aortic aneurysm
  Question Category: Physiological Integrity, Reduction of Risk Potential
A patient comes to the emergency department with abdominal pain. Work-up reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Which of the following actions should the nurse expect?
- • A. The patient will be admitted to the medicine unit for observation and medication.
- • B. The patient will be admitted to the day surgery unit for sclerotherapy.
- • C. The patient will be admitted to the surgical unit and resection will be scheduled.
- • D. The patient will be discharged home to follow-up with his cardiologist in 24 hours.
Correct
Incorrect
Question 105 of 451
105. Question
1. Question Tag: leukemia, chemotherapy, platelet count
  Question Category: Physiological Integrity, Reduction of Risk Potential
A patient with leukemia is receiving chemotherapy that is known to depress bone marrow. A CBC (complete blood count) reveals a platelet count of 25,000/microliter. Which of the following actions related specifically to the platelet count should be included in the nursing care plan?
- • A. Monitor for fever every 4 hours.
- • B. Require visitors to wear respiratory masks and protective clothing.
- • C. Consider transfusion of packed red blood cells.
- • D. Check for signs of bleeding, including examination of urine and stool for blood.
Correct
Incorrect
Question 106 of 451
106. Question
1. Question Tag: increased intracranial pressure
  Question Category: Physiological Integrity, Physiological Adaptation
A nurse in the emergency department is observing a 4-year-old child for signs of increased intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms would be cause for concern?
- • A. Bulging anterior fontanel
- • B. Repeated vomiting
- • C. Signs of sleepiness at 10 PM
- • D. Inability to read short words from a distance of 18 inches
Correct
Incorrect
Question 107 of 451
107. Question
1. Question Tag: rubeola
  Question Category: Health Promotion and Maintenance
A nonimmunized child appears at the clinic with a visible rash. Which of the following observations indicates the child may have rubeola (measles)?
- • A. Small blue-white spots are visible on the oral mucosa.
- • B. The rash begins on the trunk and spreads outward.
- • C. There is low-grade fever.
- • D. The lesions have a “teardrop-on-a-rose-petal” appearance.
Correct
Incorrect
Question 108 of 451
108. Question
1. Question Tag: scarlet fever
  Question Category: Physiological Adaptation
A child is seen in the emergency department for scarlet fever. Which of the following descriptions of scarlet fever is not correct?
- • A. Scarlet fever is caused by infection with group A Streptococcus bacteria.
- • B. “Strawberry tongue” is a characteristic sign.
- • C. Petechiae occur on the soft palate.
- • D. The pharynx is red and swollen.
Correct
Incorrect
Question 109 of 451
109. Question
109.Question Tag: allergic reaction, diphenhydramine
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy
A child weighing 30 kg arrives at the clinic with diffuse itching as the result of an allergic reaction to an insect bite. Diphenhydramine (Benadryl) 25 mg 3 times a day is prescribed. The correct pediatric dose is 5 mg/kg/day. Which of the following best describes the prescribed drug dose?
- • A. It is the correct dose
- • B. The dose is too low
- • C. The dose is too high
- • D. The dose should be increased or decreased, depending on the symptoms
Correct
Incorrect
Question 110 of 451
110. Question
1. Question Tag: undescended testis
  Question Category: Health Promotion and Maintenance
The mother of a 2-month-old infant brings the child to the clinic for a well-baby check. She is concerned because she feels only one testis in the scrotal sac. Which of the following statements about the undescended testis is the most accurate?
- • A. Normally, the testes are descended by birth.
- • B. The infant will likely require surgical intervention.
- • C. The infant probably has only one testis.
- • D. Normally, the testes descend by one year of age.
Correct
Incorrect
Question 111 of 451
111. Question
1. Question Tag: Wilms tumor
  Question Category: Physiological Integrity, Physiological Adaptation
A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which of the following statements most accurately describes this stage?
- • A. The tumor is less than 3 cm. in size and requires no chemotherapy.
- • B. The tumor did not extend beyond the kidney and was completely resected.
- • C. The tumor extended beyond the kidney but was completely resected.
- • D. The tumor has spread into the abdominal cavity and cannot be resected.
Correct
Incorrect
Question 112 of 451
112. Question
112.Question Tag: acute glomerulonephritis
Question Category: Physiological Integrity, Reduction of Risk Potential
A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Select all that apply.
- • A. Urine specific gravity of 1.040.
- • B. Urine output of 350 ml in 24 hours.
- • C. Brown (“tea-colored”) urine.
- • D. Generalized edema.
Correct
Incorrect
Question 113 of 451
113. Question
113.Question Tag: acute glomerulonephritis
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following conditions most commonly causes acute glomerulonephritis?
- • A. A congenital condition leading to renal dysfunction.
- • B. Prior infection with group A Streptococcus within the past 10-14 days.
- • C. Viral infection of the glomeruli.
- • D. Nephrotic syndrome.
Correct
Incorrect
Question 114 of 451
114. Question
1. Question Tag: hydrocele
  Question Category: Physiological Integrity, Physiological Adaptation
An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but fluid is still visible on illumination. Which of the following actions is the physician likely to recommend?
- • A. Massaging the groin area twice a day until the fluid is gone.
- • B. Referral to a surgeon for repair.
- • C. No treatment is necessary; the fluid is reabsorbing normally.
- • D. Keeping the infant in a flat, supine position until the fluid is gone.
Correct
Incorrect
Question 115 of 451
115. Question
1. Question Tag: peripheral vascular disease
  Question Category: Physiological Integrity, Physiological Adaptation
A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms?
- • A. Inadequate tissue perfusion leading to nerve damage.
- • B. Fluid overload leading to compression of nerve tissue.
- • C. Sensation distortion due to psychiatric disturbance.
- • D. Inflammation of the skin on the hands and feet.
Correct
Incorrect
Question 116 of 451
116. Question
1. Question Tag: atherosclerosis
  Question Category: Health Promotion
A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis?
- • A. Family history of heart disease
- • B. Overweight
- • C. Smoking.
- • D. Age.
Correct
Incorrect
Question 117 of 451
117. Question
1. Question Tag: peripheral vascular disease, claudication
  Question Category: Physiological Integrity, Physiological Adaptation
Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? Select all that apply:
- • A. It results when oxygen demand is greater than oxygen supply.
- • B. It is characterized by pain that often occurs during rest.
- • C. It is a result of tissue hypoxia.
- • D. It is characterized by cramping and weakness.
- • E. It always affects the upper extremities.
Correct
Incorrect
Question 118 of 451
118. Question
1. Question Tag: peripheral vascular disease
  Question Category: Health Promotion and Maintenance
A nurse is providing discharge information to a patient with peripheral vascular disease. Which of the following information should be included in instructions?
- • A. Walk barefoot whenever possible.
- • B. Use a heating pad to keep feet warm.
- • C. Avoid crossing the legs.
- • D. Use antibacterial ointment to treat skin lesions at risk of infection.
Correct
Incorrect
Question 119 of 451
119. Question
1. Question Tag: vasospastic disorder, Raynaud’s disease
  Question Category: Health Promotion and Maintenance
A patient who has been diagnosed with vasospastic disorder (Raynaud’s disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient?
- • A. An adolescent male
- • B. An elderly woman
- • C. A young woman
- • D. An elderly man
Correct
Incorrect
Question 120 of 451
120. Question
1. Question Tag: pregnancy, chest pain
  Question Category: Health Promotion and Maintenance
A 23-year-old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?
- • A. Myocardial infarction due to a history of atherosclerosis.
- • B. Pulmonary embolism due to deep vein thrombosis (DVT)
- • C. Anxiety attacks due to worries about her baby’s health.
- • D. Congestive heart failure due to fluid overload.
Correct
Incorrect
Question 121 of 451
121. Question
1. Question Tag: thrombolytic therapy, stroke
  Question Category: Health Promotion and Maintenance
Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy?
- • A. Air embolus
- • B. Cerebral hemorrhage.
- • C. Expansion of the clot.
- • D. Resolution of the clot.
Correct
Incorrect
Question 122 of 451
122. Question
1. Question Tag: infant, head position
  Question Category: Health Promotion and Maintenance
An infant is brought to the clinic by his mother, who has noticed that he holds his head in an unusual position and always faces to one side. Which of the following is the most likely explanation?
- • A. Torticollis, with shortening of the sternocleidomastoid muscle.
- • B. Craniosynostosis, with premature closure of the cranial sutures.
- • C. Plagiocephaly, with flattening of one side of the head.
- • D. Hydrocephalus, with increased head size.
Correct
Incorrect
Question 123 of 451
123. Question
1. Question Tag: Addison’s disease
  Question Category: Health Promotion and Maintenance
An adolescent brings a physician’s note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?
- • A. The condition was caused by the student’s competitive swimming schedule.
- • B. The student will most likely require surgical intervention.
- • C. The student experiences pain in the inferior aspect of the knee.
- • D. The student is trying to avoid participation in physical education.
Correct
Incorrect
Question 124 of 451
124. Question
1. Question Tag: assessment
  Question Category: Health Promotion and Maintenance
The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?
- • A. Spinal flexibility
- • B. Leg length disparity
- • C. Hypostatic blood pressure
- • D. Scoliosis
Correct
Incorrect
Question 125 of 451
125. Question
1. Question Tag:child abuse
  Question Category: Psychosocial Integrity
A clinic nurse interviews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse least likely to find in an abusing parent?
- • A. Low self-esteem
- • B. Unemployment
- • C. Self-blame for the injury to the child
- • D. Single status
Correct
Incorrect
Question 126 of 451
126. Question
1. Question Tag: juvenile idiopathic arthritis
  Question Category: Physiological Integrity,
A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate?
- • A. The child has a poor chance of recovery without joint deformity.
- • B. Most children progress to adult rheumatoid arthritis.
- • C. Nonsteroidal anti-inflammatory drugs are the first choice in treatment.
- • D. Physical activity should be minimized.
Correct
Incorrect
Question 127 of 451
127. Question
1. Question Tag: osteomyelitis
  Question Category: Safe and Effective Care Environment, Safety and Infection Control
A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started?
- • A. The admission orders are written.
- • B. A blood culture is drawn.
- • C. A complete blood count with differential is drawn.
- • D. The parents arrive.
Correct
Incorrect
Question 128 of 451
128. Question
1. Question Tag: swelling, leg injury
  Question Category: Physiological Integrity, Physiological Adaptation
A two-year-old child has sustained an injury to the leg and refuses to walk. The nurse in the emergency department documents swelling of the lower affected leg. Which of the following does the nurse suspect is the cause of the child’s symptoms?
- • A. Possible fracture of the tibia.
- • B. Bruising of the gastrocnemius muscle.
- • C. Possible fracture of the radius.
- • D. No anatomic injury, the child wants his mother to carry him.
Correct
Incorrect
Question 129 of 451
129. Question
1. Question Tag: cerebral palsy
  Question Category: Health Promotion and Maintenance
A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Select all that apply.
- • A. Regular developmental screening is important to avoid secondary developmental delays.
- • B. Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties.
- • C. Developmental milestones may be slightly delayed but usually will require no additional intervention.
- • D. Parent support groups are helpful for sharing strategies and managing health care issues.
- • E. Therapies and surgical interventions can cure cerebral palsy.
Correct
Incorrect
Question 130 of 451
130. Question
1. Question Tag: Duchenne’s muscular dystrophy
  Question Category: Health Promotion and Maintenance
A child has recently been diagnosed with Duchenne muscular dystrophy (DMD). The parents are receiving genetic counseling prior to planning another pregnancy. Which of the following statements includes the most accurate information?
- • A. Duchenne’s is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease.
- • B. Duchenne’s is an X-linked recessive disorder, so both daughters and sons have a 50% chance of developing the disease.
- • C. Each child has a 1 in 4 (25%) chance of developing the disorder.
- • D. Sons only have a 1 in 4 (25%) chance of developing the disorder.
Correct
Incorrect
Question 131 of 451
131. Question
1. Question Tag:percutaneous transluminal coronary angioplasty
Question Category: Physiological Integrity, Reduction of Risk Potential
A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the
- • A. Surgical repair of a diseased coronary artery.
- • B. Placement of an automatic internal cardiac defibrillator.
- • C. Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow.
- • D. Non-invasive radiographic examination of the heart.
Correct
Incorrect
Question 132 of 451
132. Question
1. Question Tag:hypothyroidism
Question Category: Physiological Integrity, Physiological Adaptation
A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize:
- • A. They can expect the child will be mentally retarded.
- • B. Administration of thyroid hormone will prevent problems.
- • C. This rare problem is always hereditary.
- • D. Physical growth/development will be delayed.
Correct
Incorrect
Question 133 of 451
133. Question
1. Question Tag:mental illness
Question Category: Psychosocial Integrity
A priority goal of involuntary hospitalization of the severely mentally ill client is
- • A. Re-orientation to reality
- • B. Elimination of symptoms
- • C. Protection from harm to self or others
- • D. Return to independent functioning
Correct
Incorrect
Question 134 of 451
134. Question
1. Question Tag:suppression
Question Category: Psychosocial Integrity
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”?
- • A. “I don’t remember anything about what happened to me.”
- • B. “I’d rather not talk about it right now.”
- • C. “It’s the other entire guy’s fault! He was going too fast.”
- • D. “My mother is heartbroken about this.”
Correct
Incorrect
Question 135 of 451
135. Question
1. Question Tag:premature rupture of membranes
Question Category: Health Promotion and Maintenance
The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?
- • A. Altered tissue perfusion
- • B. Risk for fluid volume deficit
- • C. High risk for hemorrhage
- • D. Risk for infection
Correct
Incorrect
Question 136 of 451
136. Question
1. Question Tag:hip spica cast
Question Category: Physiological Integrity, Physiological Adaptation
A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should:
- • A. Expose the cast to air and turn the child frequently.
- • B. Use a heat lamp to reduce the drying time.
- • C. Handle the cast with the abductor bar.
- • D. Turn the child as little as possible.
Correct
Incorrect
Question 137 of 451
137. Question
1. Question Tag:intravenous pyelogram
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy
A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:
- • A. Instruct the client to maintain a regular diet the day prior to the examination.
- • B. Restrict the client’s fluid intake 4 hours prior to the examination.
- • C. Administer a laxative to the client the evening before the examination.
- • D. Inform the client that only 1 x-ray of his abdomen is necessary.
Correct
Incorrect
Question 138 of 451
138. Question
1. Question Tag: acute glomerulonephritis
Question Category: Physiological Integrity, Physiological Adaptation
Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child, the parent’s remark: “We just don’t know how he caught the disease!” The nurse’s response is based on an understanding that:
- • A. AGN is a streptococcal infection that involves the kidney tubules.
- • B. The disease is easily transmissible in schools and camps.
- • C. The illness is usually associated with chronic respiratory infections.
- • D. It is not “caught” but is a response to a previous B-hemolytic strep infection.
Correct
Incorrect
Question 139 of 451
139. Question
1. Question Tag:diarrhea, vomiting
Question Category: Physiological Integrity, Physiological Adaptation
The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3-day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the healthcare provider immediately?
- • A. 3 episodes of vomiting in 1 hour.
- • B. Periodic crying and irritability.
- • C. Vigorous sucking on a pacifier.
- • D. No measurable voiding in 4 hours.
Correct
Incorrect
Question 140 of 451
140. Question
1. Question Tag: vaginal delivery
Question Category: Physiological Integrity, Physiological Adaptation
While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse’s first action?
- • A. Check vital signs.
- • B. Massage the fundus.
- • C. Offer a bedpan.
- • D. Check for perineal lacerations.
Correct
Incorrect
Question 141 of 451
141. Question
1. Question Tag: developmental dysplasia
Question Category: Physiological Integrity, Physiological Adaptation
The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?
- • A. Unequal leg length
- • B. Limited adduction
- • C. Diminished femoral pulses
- • D. Symmetrical gluteal folds
Correct
Incorrect
Question 142 of 451
142. Question
1. Question Tag:Valsalva maneuver, acute myocardial infarction
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy
To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would:
- • A. Assist the client to use the bedside commode.
- • B. Administer stool softeners every day as ordered.
- • C. Administer antidysrhythmics prn as ordered.
- • D. Maintain the client on strict bed rest.
Correct
Incorrect
Question 143 of 451
143. Question
1. Question Tag: psychiatric unit
Question Category: Safe and Effective Care Environment, Management of Care
On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to:
- • A. Give the client orientation materials and review the unit rules and regulations.
- • B. Introduce him/her and accompany the client to the client’s room.
- • C. Take the client to the day room and introduce her to the other clients.
- • D. Ask the nursing assistant to get the client’s vital signs and complete the admission search.
Correct
Incorrect
Question 144 of 451
144. Question
1. Question Tag:glaucoma
Question Category: Physiological Integrity, Physiological Adaptation
During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem?
- • A. “I have constant blurred vision.”
- • B. “I can’t see on my left side.”
- • C. “I have to turn my head to see my room.”
- • D. “I have specks floating in my eyes.”
Correct
Incorrect
Question 145 of 451
145. Question
1. 145. Question Tag:asthma
Question Category: Physiological Integrity, Physiological Adaptation
A client with asthma has low pitched wheezes present in the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client:
- • A. Has increased airway obstruction.
- • B. Has improved airway obstruction.
- • C. Needs to be suctioned.
- • D. Exhibits hyperventilation.
Correct
Incorrect
Question 146 of 451
146. Question
1. Question Tag: domestic abuse
Question Category: Psychosocial Integrity
Which behavioral characteristic describes the domestic abuser?
- • A. Alcoholic
- • B. Overconfident
- • C. High tolerance for frustrations
- • D. Low self-esteem
Correct
Incorrect
Question 147 of 451
147. Question
1. Question Tag:long leg cast
Question Category: Health Promotion and Maintenance
The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend:
- • A. Isometric
- • B. Range of motion
- • C. Aerobic
- • D. Isotonic
Correct
Incorrect
Question 148 of 451
148. Question
1. Question Tag: pregnancy
Question Category: Physiological Integrity, Reduction of Risk Potential
A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby’s father. Which of the following nursing interventions is a priority?
- • A. Counsel the woman to consent to HIV screening.
- • B. Perform tests for sexually transmitted diseases.
- • C. Discuss her high risk for cervical cancer.
- • D. Refer the client to a family planning clinic.
Correct
Incorrect
Question 149 of 451
149. Question
Question Category: Psychosocial Integrity
A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her, and begins to cry. What would be the initial action by the nurse?
- • A. Arrange to change client care assignments.
- • B. Explain that this behavior is expected.
- • C. Discuss the appropriate use of “time-out”.
- • D. Explain that the child needs extra attention.
Correct
Incorrect
Question 150 of 451
150. Question
1. Question Tag:toddler, separation anxiety
Question Category: Psychosocial Integrity
While planning care for a 2-year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?
- • A. Strange bed and surroundings.
- • B. Separation from parents.
- • C. Presence of other toddlers.
- • D. Unfamiliar toys and games.
Correct
Incorrect
Question 151 of 451
151. Question
1. Question Tag:cognitive development
Question Category: Psychosocial Integrity
While explaining an illness to a 10-year-old, what should the nurse keep in mind about cognitive development at this age?
- • A. They are able to make simple associations of ideas.
- • B. They are able to think logically in organizing facts.
- • C. Interpretation of events originates from their own perspective.
- • D. Conclusions are based on previous experiences.
Correct
Incorrect
Question 152 of 451
152. Question
152.Question Tag: depression
Question Category: Psychosocial Integrity
The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?
- • A. Nutrition
- • B. Elimination
- • C. Activity
- • D. Safety
Correct
Incorrect
Question 153 of 451
153. Question
1. Question Tag:school-age
Question Category: Safe and Effective Care Environment, Safety and Infection Control
Which playroom activities should the nurse organize for a small group of 7-year-old hospitalized children?
- • A. Sports and games with rules.
- • B. Finger paints and water play.
- • C. “Dress-up” clothes and props.
- • D. Chess and television programs
Correct
Incorrect
Question 154 of 451
154. Question
1. Question Tag:congestive heart failure
Question Category: Health Promotion and Maintenance
A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?
- • A. High Fowler’s
- • B. Supine
- • C. Left lateral
- • D. Low Fowler’s
Correct
Incorrect
Question 155 of 451
155. Question
1. Question Tag:burns
Question Category: Physiological Integrity, Physiological Adaptation
The nurse is caring for a 10-year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is:
- • A. Urinary output of 30 ml per hour
- • B. No complaints of thirst
- • C. Increased hematocrit
- • D. Good skin turgor around burn
Correct
Incorrect
Question 156 of 451
156. Question
156.Question Tag: migraine
Question Category: Physiological Integrity, Physiological Adaptation
What is the priority nursing diagnosis for a patient experiencing a migraine headache?
- • A. Acute pain related to biologic and chemical factors
- • B. Anxiety related to change in or threat to health status
- • C. Hopelessness related to deteriorating physiological condition
- • D. Risk for Side effects related to medical therapy
Correct
Incorrect
Question 157 of 451
157. Question
1. Question Tag: migraine
Question Category: Health Promotion and Maintenance
You are creating a teaching plan for a patient with newly diagnosed migraine headaches. Which key items should be included in the teaching plan? Select all that apply.
- • A. Avoid foods that contain tyramine, such as alcohol and aged cheese.
- • B. Avoid drugs such as Tagamet, nitroglycerin and Nifedipine.
- • C. Abortive therapy is aimed at eliminating the pain during the aura.
- • D. A potential side effect of medications is rebound headache.
- • E. Complementary therapies such as relaxation may be helpful.
- • F. Continue taking estrogen as prescribed by your physician.
Correct
Incorrect
Question 158 of 451
158. Question
1. Question Tag: seizure
Question Category: Safe and Effective Care Environment, Management of Care
The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant?
- • A. Document the seizure
- • B. Perform neurologic checks
- • C. Take the patient’s vital signs
- • D. Restrain the patient for protection
Correct
Incorrect
Question 159 of 451
159. Question
1. Question Tag: seizure disorder
Question Category: Safe and Effective Care Environment, Management of Care
You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to LPN/LVN?
- • A. Complete admission assessment.
- • B. Set up oxygen and suction equipment.
- • C. Place a padded tongue blade at the bedside.
- • D. Pad the side rails before the patient arrives.
Correct
Incorrect
Question 160 of 451
160. Question
1. Question Tag:epilepsy
Question Category: Health Promotion and Maintenance
A nursing student is teaching a patient and family about epilepsy prior to the patient’s discharge. For which statement should you intervene?
- • A. “You should avoid consumption of all forms of alcohol.”
- • B. “Wear your medical alert bracelet at all times.”
- • C. “Protect your loved one’s airway during a seizure.”
- • D. “It’s OK to take over-the-counter medications.”
Correct
Incorrect
Question 161 of 451
161. Question
1. Question Tag: toddler, language
  Question Category:Safe and Effective Care Environment, Safety and Infection Control
A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4-year-old boy who is non-verbal. This child does not have any identification on. What should the nurse do?
- • A. Contact the provider
- • B. Ask the child to write their name on paper
- • C. Ask a coworker about the identification of the child
- • D. Ask the father who is in the room the child’s name
Correct
Incorrect
Question 162 of 451
162. Question
1. Question Tag: multiple sclerosis
Question Category: Physiological Integrity, Basic Care and Comfort
The patient with multiple sclerosis tells the nursing assistant that after physical therapy she is too tired to take a bath. What is your priority nursing diagnosis at this time?
- • A. Fatigue related to disease state
- • B. Activity Intolerance due to generalized weakness
- • C. Impaired Physical Mobility related to neuromuscular impairment
- • D. Self-care Deficit related to fatigue and neuromuscular weakness
Correct
Incorrect
Question 163 of 451
163. Question
1. Question Tag: GBS
Question Category: Physiological Integrity, Reduction of Risk Potential
The LPN/LVN, under your supervision, is providing nursing care for a patient with GBS. What observation would you instruct the LPN/LVN to report immediately?
- • A. Complaints of numbness and tingling.
- • B. Facial weakness and difficulty speaking.
- • C. Rapid heart rate of 102 beats per minute.
- • D. Shallow respirations and decreased breath sounds.
Correct
Incorrect
Question 164 of 451
164. Question
1. Question Tag: myasthenia gravis
Question Category: Physiological Adaptation
The nursing assistant reports to you, the RN, that the patient with myasthenia gravis (MG) has an elevated temperature (102.20 F), heart rate of 120/minute, rise in blood pressure (158/94), and was incontinent of urine and stool. What is your best first action at this time?
- • A. Administer an acetaminophen suppository
- • B. Notify the physician immediately
- • C. Recheck vital signs in 1 hour
- • D. Reschedule patient’s physical therapy session
Correct
Incorrect
Question 165 of 451
165. Question
1. Question Tag: acute hemorrhagic stroke
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
You are providing care for a patient with an acute hemorrhage stroke. The patient’s husband has been reading a lot about strokes and asks why his wife did not receive alteplase. What is your best response?
- • A. “Your wife was not admitted within the time frame that alteplase is usually given.”
- • B. “This drug is used primarily for patients who experience an acute heart attack.”
- • C. “Alteplase dissolves clots and may cause more bleeding into your wife’s brain.”
- • D. “Your wife had gallbladder surgery just 6 months ago and this prevents the use of alteplase.”
Correct
Incorrect
Question 166 of 451
166. Question
1. Question Tag: right hemisphere stroke
Question Category: Safe and Effective Care Environment, Management of Care
You are supervising a senior nursing student who is caring for a patient with a right hemisphere stroke. Which action by the student nurse requires that you intervene?
- • A. The student instructs the patient to sit up straight, resulting in the patient’s puzzled expression.
- • B. The student moves the patient’s tray to the right side of her over-bed tray.
- • C. The student assists the patient with passive range-of-motion (ROM) exercises.
- • D. The student combs the left side of the patient’s hair when the patient combs only the right side.
Correct
Incorrect
Question 167 of 451
167. Question
1. Question Tag: arteries
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following arteries primarily feeds the anterior wall of the heart?
- • A. Circumflex artery
- • B. Internal mammary artery
- • C. Left anterior descending artery
- • D. Right coronary artery
Correct
Incorrect
Question 168 of 451
168. Question
1. Question Tag: coronary arteries
Question Category: Physiological Integrity, Physiological Adaptation
When do coronary arteries primarily receive blood flow?
- • A. During inspiration
- • B. During diastole
- • C. During expiration
- • D. During systole
Correct
Incorrect
Question 169 of 451
169. Question
1. Question Tag: cause of death
Question Category: Health Promotion and Maintenance
Which of the following illnesses is the leading cause of death in the US?
- • A. Cancer
- • B. Coronary artery disease
- • C. Liver failure
- • D. Renal failure
Correct
Incorrect
Question 170 of 451
170. Question
1. Question Tag: coronary artery disease
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following conditions most commonly results in CAD?
- • A. Atherosclerosis
- • B. DM
- • C. MI
- • D. Renal failure
Correct
Incorrect
Question 171 of 451
171. Question
1. Question Tag: atherosclerosis
Question Category: Physiological Integrity, Physiological Adaptation
Atherosclerosis impedes coronary blood flow by which of the following mechanisms?
- • A. Plaques obstruct the vein
- • B. Plaques obstruct the artery
- • C. Blood clots form outside the vessel wall
- • D. Hardened vessels dilate to allow the blood to flow through
Correct
Incorrect
Question 172 of 451
172. Question
1. Question Tag: coronary artery disease
Question Category: Health Promotion and Maintenance
Which of the following risk factors for coronary artery disease cannot be corrected?
- • A. Cigarette smoking
- • B. DM
- • C. Heredity
- • D. HPN
Correct
Incorrect
Question 173 of 451
173. Question
1. Question Tag: cholesterol, coronary artery disease
Question Category: Physiological Integrity, Reduction of Risk Potential
Exceeding which of the following serum cholesterol levels significantly increases the risk of coronary artery disease?
- • A. 100 mg/dl
- • B. 150 mg/dl
- • C. 175 mg/dl
- • D. 200 mg/dl
Correct
Incorrect
Question 174 of 451
174. Question
1. Question Tag: coronary artery disease
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following actions is the first priority care for a client exhibiting signs and symptoms of coronary artery disease?
- • A. Decrease anxiety
- • B. Enhance myocardial oxygenation
- • C. Administer sublingual nitroglycerin
- • D. Educate the client about his symptoms
Correct
Incorrect
Question 175 of 451
175. Question
1. Question Tag: coronary artery disease
Question Category: Physiological Integrity, Physiological Adaptation
Medical treatment of coronary artery disease includes which of the following procedures?
- • A. Cardiac catheterization
- • B. Coronary artery bypass surgery
- • C. Oral medication administration
- • D. Percutaneous transluminal coronary angioplasty
Correct
Incorrect
Question 176 of 451
176. Question
1. Question Tag: infarction
Question Category: Physiological Integrity, Physiological Adaptation
Prolonged occlusion of the right coronary artery produces an infarction in which of the following areas of the heart?
- • A. Anterior
- • B. Apical
- • C. Inferior
- • D. Lateral
Correct
Incorrect
Question 177 of 451
177. Question
1. Question Tag: myocardial infarction
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following is the most common symptom of myocardial infarction?
- • A. Chest pain
- • B. Dyspnea
- • C. Edema
- • D. Palpitations
Correct
Incorrect
Question 178 of 451
178. Question
1. Question Tag: apical pulse
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following landmarks is the correct one for obtaining an apical pulse?
- • A. Left intercostal space, midaxillary line
- • B. Left fifth intercostal space, midclavicular line
- • C. Left second intercostal space, midclavicular line
- • D. Left seventh intercostal space, midclavicular line
Correct
Incorrect
Question 179 of 451
179. Question
1. Question Tag: pain
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following systems is the most likely origin of pain the client describes as knifelike chest pain that increases in intensity with inspiration?
- • A. Cardiac
- • B. Gastrointestinal
- • C. Musculoskeletal
- • D. Pulmonary•
Correct
Incorrect
Question 180 of 451
180. Question
1. Question Tag: heart murmurs
Question Category: Physiological Integrity, Physiological Adaptation
A murmur is heard at the second left intercostal space along the left sternal border. Which valve area is this?
- • A. Aortic
- • B. Mitral
- • C. Pulmonic
- • D. Tricuspid
Correct
Incorrect
Question 181 of 451
181. Question
1. Question Tag: cardiac damage
Question Category: Physiological Integrity, Reduction of Risk Potential
Which of the following blood tests is most indicative of cardiac damage?
- • A. Lactate dehydrogenase
- • B. Complete blood count
- • C. Troponin I
- • D. Creatine kinase
Correct
Incorrect
Question 182 of 451
182. Question
1. Question Tag: morphine, myocardial infarction
Question Category: Physiological Integrity, Pharmacological and Parenteral therapies
What is the primary reason for administering morphine to a client with myocardial infarction?
- • A. To sedate the client
- • B. To decrease the client’s pain
- • C. To decrease the client’s anxiety
- • D. To decrease oxygen demand on the client’s heart
Correct
Incorrect
Question 183 of 451
183. Question
1. Question Tag: myocardial infarction
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following conditions is most commonly responsible for myocardial infarction?
- • A. Aneurysm
- • B. Heart failure
- • C. Coronary artery thrombosis
- • D. Renal failure
Correct
Incorrect
Question 184 of 451
184. Question
1. Question Tag: furosemide
Question Category: Physiological Integrity, Pharmacological and Parenteral therapies
What supplemental medication is most frequently ordered in conjunction with furosemide (Lasix)?
- • A. Chloride
- • B. Digoxin
- • C. Potassium
- • D. Sodium
Correct
Incorrect
Question 185 of 451
185. Question
1. Question Tag: glucose, fatty acids
Question Category: Physiological Integrity, Physiological Adaptation
After myocardial infarction, serum glucose levels and free fatty acids are both increased. What type of physiologic changes are these?
- • A. Electrophysiologic
- • B. Hematologic
- • C. Mechanical
- • D. Metabolic
Correct
Incorrect
Question 186 of 451
186. Question
1. Question Tag: heart sounds
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following complications is indicated by a third heart sound (S3)?
- • A. Ventricular dilation
- • B. Systemic hypertension
- • C. Aortic valve malfunction
- • D. Increased atrial contractions
Correct
Incorrect
Question 187 of 451
187. Question
187.Question Tag: crackles
Question Category: Physiological Integrity, Physiological Adaptation
After an anterior wall myocardial infarction, which of the following problems is indicated by auscultation of crackles in the lungs?
- • A. Left-sided heart failure
- • B. Pulmonic valve malfunction
- • C. Right-sided heart failure
Correct
Incorrect
Question 188 of 451
188. Question
1. Question Tag: myocardial damage
Question Category: Physiological Integrity, Reduction of Risk Potential
Which of the following diagnostic tools is most commonly used to determine the location of myocardial damage?
- • A. Cardiac catheterization
- • B. Cardiac enzymes
- • C. Echocardiogram
- • D. Electrocardiogram
Correct
Incorrect
Question 189 of 451
189. Question
1. Question Tag: myocardial infarction
Question Category: Physiological Integrity, Physiological Adaptation
What is the first intervention for a client experiencing myocardial infarction?
- • A. Administer morphine
- • B. Administer oxygen
- • C. Administer sublingual nitroglycerin
- • D. Obtain an electrocardiogram
Correct
Incorrect
Question 190 of 451
190. Question
1. Question Tag: myocardial infarction
Question Category: Psychosocial Integrity
What is the most appropriate nursing response to a myocardial infarction client who is fearful of dying?
- • A. “Tell me about your feelings right now.”
- • B. “When the doctor arrives, everything will be fine.”
- • C. “This is a bad situation, but you’ll feel better soon.”
- • D. “Please be assured we’re doing everything we can to make you feel better.”
Correct
Incorrect
Question 191 of 451
191. Question
1. Question Tag: ischemic myocardium
Question Category: Physiological Integrity, Pharmacological and Parenteral therapies
Which of the following classes of medications protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation?
- • A. Beta-adrenergic blockers
- • B. Calcium channel blockers
- • C. Narcotics
- • D. Nitrates
Correct
Incorrect
Question 192 of 451
192. Question
1. Question Tag: myocardial infarction
Question Category: Physiological Integrity, Physiological Adaptation
What is the most common complication of a myocardial infarction?
- • A. Cardiogenic shock
- • B. Heart failure
- • C. Arrhythmias
- • D. Pericarditis
Correct
Incorrect
Question 193 of 451
193. Question
1. Question Tag: jugular vein distention
Question Category: Physiological Integrity, Physiological Adaptation
With which of the following disorders is jugular vein distention most prominent?
- • A. Abdominal aortic aneurysm
- • B. Heart failure
- • C. Myocardial infarction
- • D. Pneumothorax
Correct
Incorrect
Question 194 of 451
194. Question
1. Question Tag: jugular vein distention
Question Category: Physiological Integrity, Physiological Adaptation
What position should the nurse place the head of the bed in to obtain the most accurate reading of jugular vein distention?
- • A. High-Fowler’s
- • B. Raised 10 degrees
- • C. Raised 30 degrees
- • D. Supine position
Correct
Incorrect
Question 195 of 451
195. Question
1. Question Tag: digoxin
Question Category: Physiological Integrity, Pharmacological and Parenteral therapies
Which of the following parameters should be checked before administering digoxin?
- • A. Apical pulse
- • B. Blood pressure
- • C. Radial pulse
- • D. Respiratory rate
Correct
Incorrect
Question 196 of 451
196. Question
1. Question Tag: toxicity
Question Category: Physiological Integrity, Pharmacological and Parenteral therapies
Toxicity from which of the following medications may cause a client to see a green halo around lights?
- • A. Digoxin
- • B. Furosemide
- • C. Metoprolol
- • D. Enalapril
Correct
Incorrect
Question 197 of 451
197. Question
1. Question Tag: heart failure
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following symptoms is most commonly associated with left-sided heart failure?
- • A. Crackles
- • B. Arrhythmias
- • C. Hepatic engorgement
- • D. Hypotension
Correct
Incorrect
Question 198 of 451
198. Question
1. Question Tag: sacral edema
Question Category: Physiological Integrity, Physiological Adaptation
In which of the following disorders would the nurse expect to assess sacral edema in bedridden client?
- • A. DM
- • B. Pulmonary emboli
- • C. Renal failure
- • D. Right-sided heart failure
Correct
Incorrect
Question 199 of 451
199. Question
1. Question Tag: right-sided heart failure
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following symptoms might a client with right-sided heart failure exhibit?
- • A. Adequate urine output
- • B. Polyuria
- • C. Oliguria
- • D. Polydipsia
Correct
Incorrect
Question 200 of 451
200. Question
1. Question Tag: ventricular contractility
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
Which of the following classes of medications maximizes cardiac performance in clients with heart failure by increasing ventricular contractility?
- • A. Beta-adrenergic blockers
- • B. Calcium channel blockers
- • C. Diuretics
- • D. Inotropic agents
Correct
Incorrect
Question 201 of 451
201. Question
1. Question Tag: sympathetic nervous system
Question Category: Physiological Integrity, Physiological Adaptation
Stimulation of the sympathetic nervous system produces which of the following responses?
- • A. Bradycardia
- • B. Tachycardia
- • C. Hypotension
- • D. Decreased myocardial contractility
Correct
Incorrect
Question 202 of 451
202. Question
1. Question Tag: heart failure
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following conditions is most closely associated with weight gain, nausea, and a decrease in urine output?
- • A. Angina pectoris
- • B. Cardiomyopathy
- • C. Left-sided heart failure
- • D. Right-sided heart failure
Correct
Incorrect
Question 203 of 451
203. Question
1. Question Tag: abdominal aortic aneurysm
Question Category: Physiological Integrity, Physiological Adaptation
What is the most common cause of abdominal aortic aneurysm?
- • A. Atherosclerosis
- • B. DM
- • C. HPN
- • D. Syphilis
Correct
Incorrect
Question 204 of 451
204. Question
204.Question Tag: abdominal aortic aneurysm
Question Category: Physiological Integrity, Physiological Adaptation
In which of the following areas is an abdominal aortic aneurysm most commonly located?
- • A. Distal to the iliac arteries
- • B. Distal to the renal arteries
- • C. Adjacent to the aortic branch
- • D. Proximal to the renal arteries
Correct
Incorrect
Question 205 of 451
205. Question
205.0Question Tag: abdominal mass
Question Category: Physiological Integrity, Physiological Adaptation
A pulsating abdominal mass usually indicates which of the following conditions?
- • A. Abdominal aortic aneurysm
- • B. Enlarged spleen
- • C. Gastric distention
- • D. Gastritis
Correct
Incorrect
Question 206 of 451
206. Question
206.Question Tag: abdominal aortic aneurysm
Question Category: Physiological Integrity, Physiological Adaptation
What is the most common symptom in a client with abdominal aortic aneurysm?
- • A. Abdominal pain
- • B. Diaphoresis
- • C. Headache
- • D. Upper back pain
Correct
Incorrect
Question 207 of 451
207. Question
1. Question Tag: abdominal aortic aneurysm
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm?
- • A. Abdominal pain
- • B. Absent pedal pulses
- • C. Angina
- • D. Lower back pain
Correct
Incorrect
Question 208 of 451
208. Question
1. Question Tag: abdominal aortic aneurysm
Question Category: Physiological Integrity, Reduction of Risk Potential
What is the definitive test used to diagnose an abdominal aortic aneurysm?
- • A. Abdominal X-ray
- • B. Arteriogram
- • C. CT scan
- • D. Ultrasound
Correct
Incorrect
Question 209 of 451
209. Question
1. Question Tag: abdominal aneurysm
Question Category: Physiological Integrity, Reduction of Risk Potential
Which of the following complications is of greatest concern when caring for a preoperative abdominal aneurysm client?
- • A. HPN
- • B. Aneurysm rupture
- • C. Cardiac arrhythmias
- • D. Diminished pedal pulses
Correct
Incorrect
Question 210 of 451
210. Question
1. Question Tag: aneurysm
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following blood vessel layers may be damaged in a client with an aneurysm?
- • A. Externa
- • B. Interna
- • C. Media
- • D. Interna and Media
Correct
Incorrect
Question 211 of 451
211. Question
1. Question Tag: abdominal aortic aneurysm
Question Category: Health Promotion and Maintenance
When assessing a client for an abdominal aortic aneurysm, which area of the abdomen is most commonly palpated?
- • A. Right upper quadrant
- • B. Directly over the umbilicus
- • C. Middle lower abdomen to the left of the midline
- • D. Midline lower abdomen to the right of the midline
Correct
Incorrect
Question 212 of 451
212. Question
1. Question Tag: aneurysm
Question Category: Health Promotion and Maintenance
Which of the following conditions is linked to more than 50% of clients with abdominal aortic aneurysms?
- • A. DM
- • B. HPN
- • C. PVD
- • D. Syphilis
Correct
Incorrect
Question 213 of 451
213. Question
1. Question Tag: auscultation
Question Category: Health Promotion and Maintenance
Which of the following sounds is distinctly heard on auscultation over the abdominal region of an abdominal aortic aneurysm client?
- • A. Bruit
- • B. Crackles
- • C. Dullness
- • D. Friction rubs
Correct
Incorrect
Question 214 of 451
214. Question
1. Question Tag: ruptured abdominal aneurysm
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following groups of symptoms indicated a ruptured abdominal aneurysm?
- • A. Lower back pain, increased BP, decreased RBC, increased WBC
- • B. Severe lower back pain, decreased BP, decreased RBC, increased WBC
- • C. Severe lower back pain, decreased BP, decreased RBC, decreased WBC
- • D. Intermittent lower back pain, decreased BP, decreased RBC, increased WBC
Correct
Incorrect
Question 215 of 451
215. Question
1. Question Tag: hematoma
Question Category: Physiological Integrity, Reduction of Risk Potential
Which of the following complications of an abdominal aortic repair is indicated by detection of a hematoma in the perineal area?
- • A. Hernia
- • B. Stage 1 pressure ulcer
- • C. Retroperitoneal rupture at the repair site
- • D. Rapid expansion of the aneurysm
Correct
Incorrect
Question 216 of 451
216. Question
1. Question Tag: aneurysm
Question Category: Physiological Integrity, Physiological Adaptation
Which hereditary disease is most closely linked to aneurysm?
- • A. Cystic fibrosis
- • B. Lupus erythematosus
- • C. Marfan’s syndrome
- • D. Myocardial infarction
Correct
Incorrect
Question 217 of 451
217. Question
1. Question Tag: ruptured aneurysm
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following treatments is the definitive one for a ruptured aneurysm?
- • A. Antihypertensive medication administration
- • B. Aortogram
- • C. Beta-adrenergic blocker administration
- • D. Surgical intervention
Correct
Incorrect
Question 218 of 451
218. Question
1. Question Tag: cardiovascular diseases
Question Category: Physiological Integrity, Reduction of Risk Potential
Which of the following heart muscle diseases is unrelated to other cardiovascular diseases?
- • A. Cardiomyopathy
- • B. Coronary artery disease
- • C. Myocardial infarction
- • D. Pericardial Effusion
Correct
Incorrect
Question 219 of 451
219. Question
1. Question Tag: cardiomyopathy
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following types of cardiomyopathy can be associated with childbirth?
- • A. Dilated
- • B. Hypertrophic
- • C. Myocarditis
- • D. Restrictive
Correct
Incorrect
Question 220 of 451
220. Question
1. Question Tag: cardiomyopathy
Question Category: Physiological Integrity, Physiological Adaptation
Septal involvement occurs in which type of cardiomyopathy?
- • A. Congestive
- • B. Dilated
- • C. Hypertrophic
- • D. Restrictive
Correct
Incorrect
Question 221 of 451
221. Question
1. Question Tag: cardiomyopathy
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following recurring conditions most commonly occurs in clients with cardiomyopathy?
- • A. Heart failure
- • B. DM
- • C. MI
- • D. Pericardial effusion
Correct
Incorrect
Question 222 of 451
222. Question
1. Question Tag: heart muscle
Question Category: Physiological Integrity, Physiological Adaptation
What is the term used to describe an enlargement of the heart muscle?
- • A. Cardiomegaly
- • B. Cardiomyopathy
- • C. Myocarditis
- • D. Pericarditis
Correct
Incorrect
Question 223 of 451
223. Question
1. Question Tag: heart failure
Question Category: Physiological Integrity, Physiological Adaptation
Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the following conditions?
- • A. Pericarditis
- • B. Hypertension
- • C. Obliterative
- • D. Restrictive
Correct
Incorrect
Question 224 of 451
224. Question
224.Question Tag: cardiomyopathy
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following types of cardiomyopathy does not affect cardiac output?
- • A. Dilated
- • B. Hypertrophic
- • C. Restrictive
- • D. Obliterative
Correct
Incorrect
Question 225 of 451
225. Question
1. Question Tag: heart sounds
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following cardiac conditions does a fourth heart sound (S4) indicate?
- • A. Dilated aorta
- • B. Normally functioning heart
- • C. Decreased myocardial contractility
- • D. Failure of the ventricle to eject all the blood during systole
Correct
Incorrect
Question 226 of 451
226. Question
1. 226. Question Tag: cardiomyopathy
Question Category: Pharmacological and Parenteral Therapies
Which of the following classes of drugs is most widely used in the treatment of cardiomyopathy?
- • A. Antihypertensive
- • B. Beta-adrenergic blockers
- • C. Calcium channel blockers
- • D. Nitrates
Correct
Incorrect
Question 227 of 451
227. Question
1. Question Tag: delegation
Question Category: Safe and Effective Care Environment, Management of Care
Which action (s) should you delegate to the experienced nursing assistant when caring for a patient with a thrombotic stroke with residual left-sided weakness? Select all that apply.
- • A. Assist the patient to reposition every 2 hours.
- • B. Reapply pneumatic compression boots.
- • C. Remind the patient to perform active ROM.
- • D. Check extremities for redness and edema.
Correct
Incorrect
Question 228 of 451
228. Question
1. Question Tag: stroke
Question Category: Safe and Effective Care Environment, Management of Care
The patient who had a stroke needs to be fed. What instruction should you give to the nursing assistant who will feed the patient?
- • A. Position the patient sitting up in bed before you feed her.
- • B. Check the patient’s gag and swallowing reflexes.
- • C. Feed the patient quickly because there are three more waiting.
- • D. Suction the patient’s secretions between bites of food.
Correct
Incorrect
Question 229 of 451
229. Question
1. Question Tag: bacterial meningitis
Question Category: Physiological Integrity, Physiological Adaptation
You have just admitted a patient with bacterial meningitis to the medical-surgical unit. The patient complains of a severe headache with photophobia and has a temperature of 102.60 F orally. Which collaborative intervention must be accomplished first?
- • A. Administer codeine 15 mg orally for the patient’s headache.
- • B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection.
- • C. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever.
- • D. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure.
Correct
Incorrect
Question 230 of 451
230. Question
1. Question Tag: meningococcal meningitis
Question Category: Physiological Integrity, Management of Care
You are mentoring a student nurse in the intensive care unit (ICU) while caring for a patient with meningococcal meningitis. Which action by the student requires that you intervene immediately?
- • A. The student enters the room without putting on a mask and gown.
- • B. The student instructs the family that visits are restricted to 10 minutes.
- • C. The student gives the patient a warm blanket when he says he feels cold.
- • D. The student checks the patient’s pupil response to light every 30 minutes.
Correct
Incorrect
Question 231 of 451
231. Question
1. Question Tag: delegation
Question Category: Safe and Effective Care Environment, Management of Care
A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient’s care will be best to delegate to an LPN/LVN whom you are supervising? Select all that apply.
- • A. Document the onset time, nature of seizure activity, and postictal behaviors for all seizures.
- • B. Administer phenytoin (Dilantin) 200 mg PO daily
- • C. Teach the patient about the need for good oral hygiene.
- • D. Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation.
- • E. Gather information about the seizure activity
Correct
Incorrect
Question 232 of 451
232. Question
1. Question Tag: seizure disorder
Question Category: Physiological Integrity, Physiological Adaptation
While working in the ICU, you are assigned to care for a patient with a seizure disorder. Which of these nursing actions will you implement first if the patient has a seizure?
- • A. Place the patient on a non-rebreather mask will the oxygen at 15 L/minute.
- • B. Administer lorazepam (Ativan) 1 mg IV.
- • C. Turn the patient to the side and protect the airway.
- • D. Assess level of consciousness during and immediately after the seizure.
Correct
Incorrect
Question 233 of 451
233. Question
NCLEXRN-04-007
Question Tag: phenytoin
Question Category: Physiological Integrity, Pharmacological and Parenteral therapies
A patient recently started on phenytoin (Dilantin) to control simple complex seizures is seen in the outpatient clinic. Which information obtained during his chart review and assessment will be of greatest concern?
- • A. The gums appear enlarged and inflamed.
- • B. The white blood cell count is 2300/mm3.
- • C. Patient occasionally forgets to take the phenytoin until after lunch.
- • D. Patient wants to renew his driver’s license next month.
Correct
Incorrect
Question 234 of 451
234. Question
1. Question Tag: prioritization
Question Category: Safe and Effective Care Environment,Management of Care
After receiving a change-of-shift report at 7:00 AM, which of these patients will you assess first?
- • A. A 23-year-old with a migraine headache who is complaining of severe nausea associated with retching.
- • B. A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching.
- • C. A 59-year-old with Parkinson’s disease who will need a swallowing assessment before breakfast.
- • D. A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank pain.
Correct
Incorrect
Question 235 of 451
235. Question
1. Question Tag: delegation
Question Category: Safe and Effective Care Environment, Management of Care
All of these nursing activities are included in the care plan for a 78-year-old man with Parkinson’s disease who has been referred to your home health agency. Which ones will you delegate to a nursing assistant (NA)? Select all that apply.
- • A. Check for orthostatic changes in pulse and blood pressure.
- • B. Monitor for improvement in tremor after levodopa (L-dopa) is given.
- • C. Remind the patient to allow adequate time for meals.
- • D. Monitor for abnormal involuntary jerky movements of extremities.
- • E. Assist the patient with prescribed strengthening exercises.
- • F. Adapt the patient’s preferred activities to his level of function.• F. Adapt the patient’s preferred activities to his level of function.
Correct
Incorrect
Question 236 of 451
236. Question
1. Question Tag: delegation
Question Category: Safe and Effective Care Environment, Management of Care
As the manager in a long-term-care (LTC) facility, you are in charge of developing a standard plan of care for residents with Alzheimer’s disease. Which of these nursing tasks is best to delegate to the LPN team leaders working in the facility?
- • A. Check for improvement in resident memory after medication therapy is initiated.
- • B. Use the Mini-Mental State Examination to assess residents every 6 months.
- • C. Assist residents to the toilet every 2 hours to decrease the risk for urinary intolerance.
- • D. Develop individualized activity plans after consulting with residents and family.
Correct
Incorrect
Question 237 of 451
237. Question
1. Question Tag: Alzheimer’s disease
Question Category: Physiological Integrity, Basic Care and Comfort
A patient who has been admitted to the medical unit with new-onset angina also has a diagnosis of Alzheimer’s disease. Her husband tells you that he rarely gets a good night’s sleep because he needs to be sure she does not wander during the night. He insists on checking each of the medications you give her to be sure they are the same as the ones she takes at home. Based on this information, which nursing diagnosis is most appropriate for this patient?
- • A. Decreased Cardiac Output related to poor myocardial contractility
- • B. Caregiver Role Strain related to continuous need for providing care
- • C. Ineffective Therapeutic Regimen Management related to poor patient memory
- • D. Risk for Falls related to patient wandering behavior during the night
Correct
Incorrect
Question 238 of 451
238. Question
1. Question Tag: glioblastoma
Question Category: Physiological Integrity, Pharmacological and Parenteral therapies
You are caring for a patient with a recurrent glioblastoma who is receiving dexamethasone (Decadron) 4 mg IV every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns you the most?
- • A. The patient does not recognize family members.
- • B. The blood glucose level is 234 mg/dL.
- • C. The patient complains of a continued headache.
- • D. The daily weight has increased by 1 kg.
Correct
Incorrect
Question 239 of 451
239. Question
1. Question Tag: lethargy
Question Category: Safe and Effective Care Environment, Management of Care
A 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence is admitted to the hospital ED. His wife tells you that he fell down the stairs about a month ago, but “he didn’t have a scratch afterward.” She feels that he has become gradually less active and sleepier over the last 10 days or so. Which of the following collaborative interventions will you implement first?
- • A. Place on the hospital alcohol withdrawal protocol.
- • B. Transfer to radiology for a CT scan.
- • C. Insert a retention catheter to straight drainage.
- • D. Give phenytoin (Dilantin) 100 mg PO.
Correct
Incorrect
Question 240 of 451
240. Question
1. Question Tag: delegation
Question Category: Safe and Effective Care Environment, Management of Care
Which of these patients in the neurologic ICU will be best to assign to an RN who has floated from the medical unit?
- • A. A 26-year-old patient with a basilar skull structure who has clear drainage coming out of the nose.
- • B. A 42-year-old patient admitted several hours ago with a headache and diagnosed with a ruptured berry aneurysm.
- • C. A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due.
- • D. A 65-year-old patient with an astrocytoma who has just returned to the unit after having a craniotomy.
Correct
Incorrect
Question 241 of 451
241. Question
1. Question Tag: migraine
Question Category: Physiological Integrity, Physiological Adaptation
What is the priority nursing diagnosis for a patient experiencing a migraine headache?
- • A. Acute pain related to biologic and chemical factors
- • B. Anxiety related to change in or threat to health status
- • C. Hopelessness related to deteriorating physiological condition
- • D. Risk for Side effects related to medical therapy
Correct
Incorrect
Question 242 of 451
242. Question
1. Question Tag: sigmoid colostomy
Question Category: Physiological Integrity, Reduction of Risk Potential
Nurse Michelle should know that the drainage is normal four (4) days after a sigmoid colostomy when the stool is:
- • A. Green liquid
- • B. Solid formed
- • C. Loose, bloody
- • D. Semiformed
Correct
Incorrect
Question 243 of 451
243. Question
1. Question Tag: right-sided brain attack, hemianopsia
Question Category: Physiological Integrity, Physiological Adaptation
Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left homonymous hemianopsia?
- • A. On the client’s right side
- • B. On the client’s left side
- • C. Directly in front of the client
- • D. Where the client like
Correct
Incorrect
Question 244 of 451
244. Question
1. Question Tag: accident
Question Category: Physiological Integrity, Physiological Adaptation
A male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse?
- • A. Check respiration, circulation, neurological response
- • B. Align the spine, check pupils, and check for hemorrhage
- • C. Check respirations, stabilize the spine and check the circulation
- • D. Assess level of consciousness and circulation
Correct
Incorrect
Question 245 of 451
245. Question
1. Question Tag: nitroglycerin
Question Category: Physiological Integrity, Pharmacological and Parenteral therapies
In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and relieves angina by:
- • A. Increasing contractility and slowing heart rate
- • B. Increasing AV conduction and heart rate
- • C. Decreasing contractility and oxygen consumption
- • D. Decreasing venous return through vasodilation
Correct
Incorrect
Question 246 of 451
246. Question
1. Question Tag: myocardial infarction
Question Category: Physiological Integrity, Physiological Adaptation
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’s next action?
- • A. Call for help and note the time
- • B. Clear the airway
- • C. Give two sharp thumps to the precordium, and check the pulse
- • D. Administer two quick blows
Correct
Incorrect
Question 247 of 451
247. Question
1. Question Tag: gastrointestinal bleeding
Question Category: Physiological Integrity, Physiological Adaptation
Nurse Monett is caring for a client recovering from gastrointestinal bleeding. The nurse should:
- • A. Plan care so the client can receive 8 hours of uninterrupted sleep each night.
- • B. Monitor vital signs every 2 hours.
- • C. Make sure that the client takes food and medications at prescribed intervals.
- • D. Provide milk every 2 to 3 hours.
Correct
Incorrect
Question 248 of 451
248. Question
1. Question Tag: heparin
Question Category: Physiological Integrity, Pharmacological and Parenteral therapies
A male client was on warfarin (Coumadin) before admission and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do?
- • A. Stop the I.V. infusion of heparin and notify the physician.
- • B. Continue treatment as ordered.
- • C. Expect the warfarin to increase the PTT.
- • D. Increase the dosage, because the level is lower than normal.
Correct
Incorrect
Question 249 of 451
249. Question
1. Question Tag: ileostomy, stoma
Question Category: Physiological Integrity, Physiological Adaptation
A client underwent an ileostomy, when should the drainage appliance be applied to the stoma?
- • A. 24 hours later, when edema has subsided
- • B. In the operating room
- • C. After the ileostomy begins to function
- • D. When the client is able to begin self-care procedures
Correct
Incorrect
Question 250 of 451
250. Question
1. Question Tag: spinal anesthesia
Question Category: Physiological Integrity, Reduction of Risk Potential
A client has undergone spinal anesthetic, it will be important that the nurse immediately position the client in:
- • A. On the side, to prevent obstruction of the airway by the tongue
- • B. Flat on back
- • C. On the back, with knees flexed 15 degrees
- • D. Flat on the stomach, with the head turned to the side
Correct
Incorrect
Question 251 of 451
251. Question
1. Question Tag: increased intracranial pressure
Question Category: Physiological Integrity, Physiological Adaptation
While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure?
- • A. Blood pressure has decreased from 160/90 to 110/70.
- • B. Pulse is increased from 87 to 95, with an occasional skipped beat.
- • C. The client is oriented when aroused from sleep and goes back to sleep immediately.
- • D. The client refuses dinner because of anorexia.
Correct
Incorrect
Question 252 of 451
252. Question
1. Question Tag: pneumonia
Question Category: Physiological Integrity, Physiological Adaptation
Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first?
- • A. Altered mental status and dehydration
- • B. Fever and chills
- • C. Hemoptysis and Dyspnea
- • D. Pleuritic chest pain and cough
Correct
Incorrect
Question 253 of 451
253. Question
1. Question Tag: tuberculosis
Question Category: Physiological Integrity, Physiological Adaptation
A male client has active tuberculosis (TB). Which of the following symptoms will be exhibited?
- • A. Chest and lower back pain
- • B. Chills, fever, night sweats, and hemoptysis
- • C. Fever of more than 104°F (40°C) and nausea
Correct
Incorrect
Question 254 of 451
254. Question
1. Question Tag: asthma
Question Category: Physiological Integrity, Physiological Adaptation
Mark, a 7-year-old client, is brought to the emergency department. He’s tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has a nonproductive cough. He recently had a cold. From this history; the client may have which of the following conditions?
- • A. Acute asthma
- • B. Bronchial pneumonia
- • C. Chronic obstructive pulmonary disease (COPD)
- • D. Emphysema
Correct
Incorrect
Question 255 of 451
255. Question
1. Question Tag: morphine
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might have which of the following reactions?
- • A. Asthma attack
- • B. Respiratory arrest
- • C. Seizure
- • D. Wake up on her own
Correct
Incorrect
Question 256 of 451
256. Question
255.Question Tag: elective knee surgery
Question Category: Health Promotion and Maintenance
A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging?
- • A. Increased elastic recoil of the lungs
- • B. Increased number of functional capillaries in the alveoli
- • C. Decreased residual volume
- • D. Decreased vital capacity
Correct
Incorrect
Question 257 of 451
257. Question
1. Question Tag: lidocaine
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
Nurse John is caring for a male client receiving lidocaine I.V. Which factor is the most relevant to the administration of this medication?
- • A. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter.
- • B. Increase in systemic blood pressure
- • C. Presence of premature ventricular contractions (PVCs) on a cardiac monitor
- • D. Increase in intracranial pressure (ICP)
Correct
Incorrect
Question 258 of 451
258. Question
257.Question Tag: anticoagulant
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to:
- • A. Report incidents of diarrhea
- • B. Avoid foods high in vitamin K
- • C. Use a straight razor when shaving
- • D. Take aspirin for pain relief
Correct
Incorrect
Question 259 of 451
259. Question
1. Question Tag: I.V. catheter
Question Category: Physiological Integrity, Reduction of Risk Potential
Nurse Lynette is preparing a site for the insertion of an I.V. catheter. The nurse should treat excess hair at the site by:
- • A. Leaving the hair intact
- • B. Shaving the area
- • C. Clipping the hair in the area
- • D. Removing the hair with a depilatory
Correct
Incorrect
Question 260 of 451
260. Question
1. Question Tag: osteoporosis
Question Category: Health Promotion and Maintenance
Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication:
- • A. Bone fracture
- • B. Loss of estrogen
- • C. Negative calcium balance
- • D. Dowager’s hump
Correct
Incorrect
Question 261 of 451
261. Question
1. Question Tag: BSE
Question Category: Health Promotion and Maintenance
Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the purpose of performing the examination is to discover:
- • A. Cancerous lumps
- • B. Areas of thickness or fullness
- • C. Changes from previous examinations
- • D. Fibrocystic masses
Correct
Incorrect
Question 262 of 451
262. Question
1. Question Tag: hyperthyroidism
Question Category: Physiological Integrity, Basic Care and Comfort
When caring for a female client who is being treated for hyperthyroidism, it is important to:
- • A. Provide extra blankets and clothing to keep the client warm.
- • B. Monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy.
- • C. Balance the client’s periods of activity and rest.
- • D. Encourage the client to be active to prevent constipation.
Correct
Incorrect
Question 263 of 451
263. Question
1. Question Tag: atherosclerosis
Question Category: Health Promotion and Maintenance
Nurse Kris is teaching a client with a history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to:
- • A. Avoid focusing on his weight
- • B. Increase his activity level
- • C. Follow a regular diet
- • D. Continue leading a high-stress lifestyle.
Correct
Incorrect
Question 264 of 451
264. Question
1. Question Tag: logroll
Question Category: Physiological Integrity, Physiological Adaptation
Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client following a:
- • A. Laminectomy
- • B. Thoracotomy
- • C. Hemorrhoidectomy
- • D. Cystectomy
Correct
Incorrect
Question 265 of 451
265. Question
1. Question Tag: intraocular lens implant
Question Category: Health Promotion and Maintenance
A 55-year old client underwent cataract removal with intraocular lens implant. Nurse Oliver is giving the client discharge instructions. These instructions should include which of the following?
- • A. Avoid lifting objects weighing more than 5 lb (2.25 kg)
- • B. Lie on your abdomen when in bed
- • C. Keep rooms brightly lit
- • D. Avoiding straining during a bowel movement or bending at the waistv
Correct
Incorrect
Question 266 of 451
266. Question
265.Question Tag: testicular exams
Question Category: Health Promotion and Maintenance
George should be taught about testicular examinations during:
- • A. When sexual activity starts
- • B. After age 69
- • C. After age 40
- • D. Before age 20
Correct
Incorrect
Question 267 of 451
267. Question
1. Question Tag: wound dehiscence
Question Category: Physiological Integrity, Physiological Adaptation
A male client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. Nurse Trish first response is to:
- • A. Call the physician
- • B. Place a saline-soaked sterile dressing on the wound
- • C. Take blood pressure and pulse
- • D. Pull the dehiscence closed
Correct
Incorrect
Question 268 of 451
268. Question
267.Question Tag: Cheyne-Stokes respirations
Question Category: Physiological Integrity, Physiological Adaptation
Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. During routine assessment, the nurse notices Cheyne- Stokes respirations. Cheyne-stokes respirations are:
- • A. Progressively deeper breath followed by shallower breaths with apneic periods.
- • B. Rapid, deep breathing with abrupt pauses between each breath.
- • C. Rapid, deep breathing and irregular breathing without pauses.
- • D. Shallow breathing with an increased respiratory rate.
Correct
Incorrect
Question 269 of 451
269. Question
1. Question Tag: heart failure
Question Category: Physiological Integrity, Physiological Adaptation
Nurse Bea is assessing a male client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:
- • A. Tracheal
- • B. Fine crackles
- • C. Coarse crackles
- • D. Friction rubs
Correct
Incorrect
Question 270 of 451
270. Question
1. Question Tag: acute asthma
Question Category: Physiological Integrity, Physiological Adaptation
The nurse is caring for Kenneth experiencing an acute asthma attack. The client stops wheezing and breath sounds aren’t audible. The reason for this change is that:
- • A. The attack is over.
- • B. The airways are so swollen that no air cannot get through.
- • C. The swelling has decreased.
- • D. Crackles have replaced wheezes.
Correct
Incorrect
Question 271 of 451
271. Question
1. Question Tag: seizure
Question Category: Safe & Effective Care Environment, Safety and infection Control
Mike with epilepsy is having a seizure. During the active seizure phase, the nurse should:
- • A. Place the client on his back, remove dangerous objects, and insert a bite block.
- • B. Place the client on his side, remove dangerous objects, and insert a bite block.
- • C. Place the client on his back, remove dangerous objects, and hold down his arms.
- • D. Place the client on his side, remove dangerous objects, and protect his head.
Correct
Incorrect
Question 272 of 451
272. Question
1. Question Tag: chest tube, pneumothorax
Question Category: Physiological Integrity,Reduction of Risk Potential
After insertion of a chest tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for?
- • A. Infection of the lung
- • B. Kinked or obstructed chest tube
- • C. Excessive water in the water-seal chamber
- • D. Excessive chest tube drainage
Correct
Incorrect
Question 273 of 451
273. Question
272.Question Tag: choking
Question Category: Safe & Effective Care Environment, Safety and infection Control
Nurse Maureen is talking to a male client, the client begins choking on his lunch. He’s coughing forcefully. The nurse should:
- • A. Stand him up and perform the abdominal thrust maneuver from behind.
- • B. Lay him down, straddle him, and perform the abdominal thrust maneuver.
- • C. Leave him to get assistance.
- • D. Stay with him but not intervene at this time
Correct
Incorrect
Question 274 of 451
274. Question
1. Question Tag: health history
Question Category: Health Promotion and Maintenance
Nurse Ron is taking the health history of an 84-year-old client. Which information will be most useful to the nurse for planning care?
- • A. General health for the last 10 years
- • B. Current health promotion activities
- • C. Family history of diseases
- • D. Marital status
Correct
Incorrect
Question 275 of 451
275. Question
1. Question Tag: oral care
Question Category: Physiological Integrity, Physiological Adaptation
When performing oral care on a comatose client, Nurse Krina should:
- • A. Apply lemon glycerin to the client’s lips at least every 2 hours.
- • B. Brush the teeth with a client lying supine.
- • C. Place the client in a side-lying position, with the head of the bed lowered.
- • D. Clean the client’s mouth with hydrogen peroxide.
Correct
Incorrect
Question 276 of 451
276. Question
1. Question Tag: pneumonia
Question Category: Physiological Integrity, Physiological Adaptation
A 77-year-old male client is admitted with a diagnosis of dehydration and change in mental status. He’s being hydrated with L.V. fluids. When the nurse takes his vital signs, she notes he has a fever of 103°F (39.4°C) , a cough producing yellow sputum and pleuritic chest pain. The nurse suspects this client may have which of the following conditions?
- • A. Adult respiratory distress syndrome (ARDS)
- • B. Myocardial infarction (MI)
- • C. Pneumonia
- • D. Tuberculosis
Correct
Incorrect
Question 277 of 451
277. Question
1. Question Tag: tuberculosis
Question Category: Health Promotion and Maintenance
Nurse Oliver is working in an outpatient clinic. He has been alerted that there is an outbreak of tuberculosis (TB). Which of the following clients entering the clinic today is most likely to have TB?
- • A. A 16-year-old female high school student
- • B. A 33-year-old daycare worker
- • C. A 43-year-old homeless man with a history of alcoholism
- • D. A 54-year-old businessman
Correct
Incorrect
Question 278 of 451
278. Question
1. Question Tag: Mantoux test
Question Category: Physiological Integrity, Reduction of Risk Potential
Virgie with a positive Mantoux test result will be sent for a chest X-ray. The nurse is aware that which of the following reasons this is done?
- • A. To confirm the diagnosis
- • B. To determine if a repeat skin test is needed
- • C. To determine the extent of lesions
- • D. To determine if this is a primary or secondary infection
Correct
Incorrect
Question 279 of 451
279. Question
1. Question Tag: acute asthma
Question Category: Physiological Integrity, Physiological Adaptation
Kennedy with acute asthma showing inspiratory and expiratory wheezes and a decreased forced expiratory volume should be treated with which of the following classes of medication right away?
- • A. Beta-adrenergic blockers
- • B. Bronchodilators
- • C. Inhaled steroids
- • D. Oral steroids
Correct
Incorrect
Question 280 of 451
280. Question
1. Question Tag: bronchitis
Question Category: Physiological Integrity, Physiological Adaptation
Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two packs of cigarettes per day has a chronic cough producing thick sputum, peripheral edema, and cyanotic nail beds. Based on this information, he most likely has which of the following conditions?
- • A. Adult respiratory distress syndrome (ARDS)
- • B. Asthma
- • C. Chronic obstructive bronchitis
- • D. Emphysema
Correct
Incorrect
Question 281 of 451
281. Question
1. Question Tag: chronic lymphocytic anemia
Question Category: Physiological Integrity, Reduction of Risk Potential
Situation: Francis, age 46 is admitted to the hospital with diagnosis of Chronic Lymphocytic Leukemia.
The treatment for patients with leukemia is bone marrow transplantation. Which statement about bone marrow transplantation is not correct?
- • A. The patient is under local anesthesia during the procedure.
- • B. The aspirated bone marrow is mixed with heparin.
- • C. The aspiration site is the posterior or anterior iliac crest.
- • D. The recipient receives cyclophosphamide (Cytoxan) for 4 consecutive days before the procedure.
Correct
Incorrect
Question 282 of 451
282. Question
1. Question Tag: disorientation
Question Category: Safe and Effective Care Environemnt
After several days of admission, Francis becomes disoriented and complains of frequent headaches. The nurse in-charge first action would be:
- • A. Call the physician
- • B. Document the patient’s status in his charts
- • C. Prepare oxygen treatment
- • D. Raise the side rails
Correct
Incorrect
Question 283 of 451
283. Question
1. Question Tag: WBC
Question Category: Physiological Integrity, Physiological Adaptation
During routine care, Francis asks the nurse, “How can I be anemic if this disease causes increased white blood cell production?” The nurse in-charge best response would be that the increased number of white blood cells (WBC) is:
- • A. Crowded red blood cells
- • B. Is not responsible for the anemia
- • C. Uses nutrients from other cells
- • D. Have an abnormally short lifespan of cells
Correct
Incorrect
Question 284 of 451
284. Question
1. Question Tag: leukocytosis
Question Category: Physiological Integrity, Reduction of Risk Potential
Diagnostic assessment of Francis would probably not reveal:
- • A. Predominance of lymphoblasts
- • B. Leukocytosis
- • C. Abnormal blast cells in the bone marrow
Correct
Incorrect
Question 285 of 451
285. Question
1. Question Tag: embolectomy
Question Category: Physiological Integrity, Reduction of Risk Potential
Robert, a 57-year-old client with acute arterial occlusion of the left leg undergoes an emergency embolectomy. Six hours later, the nurse isn’t able to obtain pulses in his left foot using Doppler ultrasound. The nurse immediately notifies the physician and asks her to prepare the client for surgery. As the nurse enters the client’s room to prepare him, he states that he won’t have any more surgery. Which of the following is the best initial response by the nurse?
- • A. Explain the risks of not having the surgery
- • B. Notifying the physician immediately
- • C. Notifying the nursing supervisor
- • D. Recording the client’s refusal in the nurses’ notes
Correct
Incorrect
Question 286 of 451
286. Question
1. Question Tag: prioritization
Question Category: Safe and Effective Care Environment, Management of Care
During the endorsement, which of the following clients should the on-duty nurse assess first?
- • A. The 58-year-old client who was admitted 2 days ago with heart failure, blood pressure of 126/76 mm Hg, and a respiratory rate of 22 breaths/minute.
- • B. The 89-year-old client with end-stage right-sided heart failure, blood pressure of 78/50 mm Hg, and a “do not resuscitate” order.
- • C. The 62-year-old client who was admitted 1 day ago with thrombophlebitis and is receiving L.V. heparin.
- • D. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. diltiazem (Cardizem).
Correct
Incorrect
Question 287 of 451
287. Question
1. Question Tag: cocaineuse
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
Honey, a 23-year old client complains of substernal chest pain and states that her heart feels like “it’s racing out of the chest”. She reports no history of cardiac disorders. The nurse attaches her to a cardiac monitor and notes sinus tachycardia with a rate of 136beats/minutes. Breath sounds are clear and the respiratory rate is 26 breaths/minutes. Which of the following drugs should the nurse question the client about using?
- • A. Barbiturates
- • B. Opioids
- • C. Cocaine
- • D. Benzodiazepines
Correct
Incorrect
Question 288 of 451
288. Question
1. Question Tag: breast lump
Question Category: Health Promotion and Maintenance
A 51-year-old female client tells the nurse-in-charge that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client’s lump is cancerous?
- • A. Eversion of the right nipple and mobile mass.
- • B. Nonmobile mass with irregular edges.
- • C. Mobile mass that is soft and easily delineated.
- • D. Nonpalpable right axillary lymph nodes.
Correct
Incorrect
Question 289 of 451
289. Question
1. Question Tag: vaginal cancer
Question Category: Physiological Integrity, Physiological Adaptation
A 35-year-old client with vaginal cancer asks the nurse, “What is the usual treatment for this type of cancer?” Which treatment should the nurse name?
- • A. Surgery
- • B. Chemotherapy
- • C. Radiation
- • D. Immunotherapy
Correct
Incorrect
Question 290 of 451
290. Question
289.Question Tag: TNM staging
Question Category: Physiological Integrity, Reduction of Risk Potential
Cristina undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, N0, M0. What does this classification mean?
- • A. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis.
- • B. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis.
- • C. Can’t assess tumor or regional lymph nodes and no evidence of metastasis.
- • D. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis.
Correct
Incorrect
Question 291 of 451
291. Question
1. Question Tag: laryngectomy, stoma
Question Category: Physiological Integrity, Reduction of Risk Potential
Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?
- • A. “Keep the stoma uncovered.”
- • B. “Keep the stoma dry.”
- • C. “Have a family member perform stoma care initially until you get used to the procedure.”
- • D. “Keep the stoma moist.”
Correct
Incorrect
Question 292 of 451
292. Question
1. Question Tag: cancer
Question Category: Physiological Integrity, Physiological Adaptation
A 37-year-old client with uterine cancer asks the nurse, “Which is the most common type of cancer in women?” The nurse replies that it’s breast cancer. Which type of cancer causes the most deaths in women?
- • A. Breast cancer
- • B. Lung cancer
- • C. Brain cancer
- • D. Colon and rectal cancer
Correct
Incorrect
Question 293 of 451
293. Question
1. Question Tag: Horner’s syndrome, lung cancer
Question Category: Physiological Integrity, Physiological Adaptation
Antonio, with lung cancer, develops Horner’s syndrome when the tumor invades the ribs and affects the sympathetic nerve ganglia. When assessing for signs and symptoms of this syndrome, the nurse should note:
- • A. Miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.
- • B. Chest pain, dyspnea, cough, weight loss, and fever.
- • C. Arm and shoulder pain and atrophy of arm and hand muscles, both on the affected side.
- • D. Hoarseness and dysphagia.
Correct
Incorrect
Question 294 of 451
294. Question
1. Question Tag: PSA
Question Category: Physiological Integrity , Reduction of Risk Potential
Vic asks the nurse what PSA is. The nurse should reply that it stands for:
- • A. Prostate-specific antigen, which is used to screen for prostate cancer.
- • B. Protein serum antigen, which is used to determine protein levels.
- • C. Pneumococcal strep antigen, which is a bacteria that causes pneumonia.
- • D. Papanicolaou-specific antigen, which is used to screen for cervical cancer.
Correct
Incorrect
Question 295 of 451
295. Question
1. Question Tag: subarachnoid block
Question Category: Physiological Integrity, Reduction of Risk Potential
What is the most important postoperative instruction that nurse Kate must give a client who has just returned from the operating room after receiving a subarachnoid block?
- • A. “Avoid drinking liquids until the gag reflex returns.”
- • B. “Avoid eating milk products for 24 hours.”
- • C. “Notify a nurse if you experience blood in your urine.”
- • D. “Remain supine for the time specified by the physician.”
Correct
Incorrect
Question 296 of 451
296. Question
1. Question Tag: colorectal cancer
Question Category: Physiological Integrity, Reduction of Risk Potential
A male client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis?
- • A. Stool Hematest
- • B. Carcinoembryonic antigen (CEA)
- • C. Sigmoidoscopy
- • D. Abdominal computed tomography (CT) scan
Correct
Incorrect
Question 297 of 451
297. Question
1. Question Tag: breast cancer
Question Category: Physiological Integrity, Physiological Adaptation
During a breast examination, which finding most strongly suggests that the Luz has breast cancer?
- • A. Slight asymmetry of the breasts.
- • B. A fixed nodular mass with dimpling of the overlying skin.
- • C. Bloody discharge from the nipple.
- • D. Multiple firm, round, freely movable masses that change with the menstrual cycle.
Correct
Incorrect
Question 298 of 451
298. Question
1. Question Tag: cancer
Question Category: Physiological Integrity, Physiological Adaptation
A female client with cancer is being evaluated for possible metastasis. Which of the following is one of the most common metastasis sites for cancer cells?
- • A. Liver
- • B. Colon
- • C. Reproductive tract
- • D. White blood cells (WBCs)
Correct
Incorrect
Question 299 of 451
299. Question
1. Question Tag: MRI
Question Category: Physiological Integrity,Reduction of Risk Potential
Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client?
- • A. The client lies still
- • B. The client asks questions
- • C. The client hears thumping sounds
- • D. The client wears a watch and wedding band
Correct
Incorrect
Question 300 of 451
300. Question
1. Question Tag: osteoporosis
Question Category: Health Promotion and Maintenance
Nurse Cecile is teaching a female client about preventing osteoporosis. Which of the following teaching points is correct?
- • A. Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss.
- • B. To avoid fractures, the client should avoid strenuous exercise.
- • C. The recommended daily allowance of calcium may be found in a wide variety of foods
- • D. Obtaining the recommended daily allowance of calcium requires taking a calcium supplement.
Correct
Incorrect
Question 301 of 451
301. Question
1. Question Tag: arthroscopy
Question Category: Physiological Integrity, Reduction of Risk Potential
Before Jacob undergoes arthroscopy, the nurse reviews the assessment findings for contraindications for this procedure. Which finding is a contraindication?
- • A. Joint pain
- • B. Joint deformity
- • C. Joint flexion of less than 50%
- • D. Joint stiffness
Correct
Incorrect
Question 302 of 451
302. Question
1. Question Tag: arthritis
Question Category: Physiological Integrity,
Mr. Rodriguez is admitted with severe pain in the knees. Which form of arthritis is characterized by urate deposits and joint pain, usually in the feet and legs, and occurs primarily in men over age 30?
- • A. Septic arthritis
- • B. Traumatic arthritis
- • C. Intermittent arthritis
- • D. Gouty arthritis
Correct
Incorrect
Question 303 of 451
303. Question
302.Question Tag: heparin
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
A heparin infusion at 1,500 units/hour is ordered for a 64-year-old client with stroke in evolution. The infusion contains 25,000 units of heparin in 500 ml of saline solution. How many milliliters per hour should be given?
- • A. 15 ml/hour
- • B. 30 ml/hour
- • C. 45 ml/hour
- • D. 50 ml/hour
Correct
Incorrect
Question 304 of 451
304. Question
1. Question Tag: stroke
Question Category: Physiological Integrity, Physiological Adaptation
A 76-year-old male client had a thromboembolic right stroke; his left arm is swollen. Which of the following conditions may cause swelling after a stroke?
- • A. Elbow contracture secondary to spasticity.
- • B. Loss of muscle contraction decreasing venous return.
- • C. Deep vein thrombosis (DVT) due to immobility of the ipsilateral side.
- • D. Hypoalbuminemia due to protein escaping from an inflamed glomerulus.
Correct
Incorrect
Question 305 of 451
305. Question
304. Question Tag: osteoarthritis
Question Category: Physiological Integrity, Physiological Adaptation
Heberden’s nodes are a common sign of osteoarthritis. Which of the following statements is correct about this deformity?
- A. It appears only in men.
- B. It appears on the distal interphalangeal joint.
- C. It appears on the proximal interphalangeal joint.
- D. It appears on the dorsolateral aspect of the interphalangeal joint.
Correct
Incorrect
Question 306 of 451
306. Question
305. Question Tag: arthritis
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following statements explains the main difference between rheumatoid arthritis and osteoarthritis?
- A. Osteoarthritis is gender-specific, rheumatoid arthritis isn’t.
- B. Osteoarthritis is a localized disease rheumatoid arthritis is systemic.
- C. Osteoarthritis is a systemic disease, rheumatoid arthritis is localized.
- D. Osteoarthritis has dislocations and subluxations, rheumatoid arthritis doesn’t.
Correct
Incorrect
Question 307 of 451
307. Question
306. Question Tag: assistive devices
Question Category: Basic Care and Comfort
Mrs. Cruz uses a cane for assistance in walking. Which of the following statements is true about a cane or other assistive devices?
- A. A walker is a better choice than a cane.
- B. The cane should be used on the affected side.
- C. The cane should be used on the unaffected side.
- D. A client with osteoarthritis should be encouraged to ambulate without the cane.
Correct
Incorrect
Question 308 of 451
308. Question
307. Question Tag: insulin
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
A male client with type 1 diabetes is scheduled to receive 30 U of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client:
- A. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).
- B. 21 U regular insulin and 9 U NPH.
- C. 10 U regular insulin and 20 U NPH.
- D. 20 U regular insulin and 10 U NPH.
Correct
Incorrect
Question 309 of 451
309. Question
308. Question Tag: gout
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
Nurse Len should expect to administer which medication to a client with gout?
- A. Aspirin
- B. Furosemide (Lasix)
- C. Colchicines
- D. Calcium gluconate (Kalcinate)
Correct
Incorrect
Question 310 of 451
310. Question
309. Question Tag: hyperaldosteronism
Question Category: Physiological Integrity, Physiological Adaptation
Mr. Domingo with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client’s hypertension is caused by excessive hormone secretion from which of the following glands?
- A. Adrenal cortex
- B. Pancreas
- C. Adrenal medulla
- D. Parathyroid
Correct
Incorrect
Question 311 of 451
311. Question
310. Question Tag: ulcer
Question Category: Health Promotion and Maintenance
For a diabetic male client with a foot ulcer, the doctor orders bed rest, a wet to- dry dressing change every shift, and blood glucose monitoring before meals and bedtime. Why are wet-to-dry dressings used for this client?
- A. They contain exudate and provide a moist wound environment.
- B. They protect the wound from mechanical trauma and promote healing.
- C. They debride the wound and promote healing by secondary intention.
- D. They prevent the entrance of microorganisms and minimize wound discomfort.
Correct
Incorrect
Question 312 of 451
312. Question
311. Question Tag: Addisonian crisis
Question Category: Physiological Integrity, Reduction of Risk Potential
Nurse Zeny is caring for a client in an acute Addisonian crisis. Which laboratory data would the nurse expect to find?
- A. Hyperkalemia
- B. Reduced blood urea nitrogen (BUN)
- ⦁ C. Hypernatremia
- ⦁ D. Hyperglycemia
Correct
Incorrect
Question 313 of 451
313. Question
312. Question Tag: SIADH
Question Category: Physiological Integrity, Physiological Adaptation
A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?
- ⦁ A. Infusing I.V. fluids rapidly as ordered.
- ⦁ B. Encouraging increased oral intake.
- ⦁ C. Restricting fluids.
- ⦁ D. Administering glucose-containing I.V. fluids as ordered.
Correct
Incorrect
Question 314 of 451
314. Question
313. Question Tag: diabetes mellitus
Question Category: Physiological Integrity, Reduction of Risk Potential
A female client tells nurse Nikki that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client’s efforts, the nurse should check:
- ⦁ A. Urine glucose level.
- ⦁ B. Fasting blood glucose level.
- ⦁ C. Serum fructosamine level.
- ⦁ D. Glycosylated hemoglobin level.
Correct
Incorrect
Question 315 of 451
315. Question
314. Question Tag: insulin
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
Nurse Trinity administered neutral protamine Hagedorn (NPH) insulin to a diabetic client at 7 a.m. At what time would the nurse expect the client to be most at risk for a hypoglycemic reaction?
- ⦁ A. 10:00 am
- ⦁ B. Noon
- ⦁ C. 4:00 pm
- ⦁ D. 10:00 pm
Correct
Incorrect
Question 316 of 451
316. Question
315. Question Tag: adrenal cortex
Question Category: Physiological Integrity, Physiological Adaptation
The adrenal cortex is responsible for producing which substances?
- ⦁ A. Glucocorticoids and androgens
- ⦁ B. Catecholamines and epinephrine
- ⦁ C. Mineralocorticoids and catecholamines
- ⦁ D. Norepinephrine and epinephrine
Correct
Incorrect
Question 317 of 451
317. Question
316. Question Tag: partial thyroidectomy
Question Category: Physiological Integrity, Physiological Adaptation
On the third day after a partial thyroidectomy, Proserfina exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
- ⦁ A. Hypocalcemia
- ⦁ B. Hyponatremia
- ⦁ C. Hyperkalemia
- ⦁ D. Hypermagnesemia
Correct
Incorrect
Question 318 of 451
318. Question
317. Question Tag: cancer
Question Category: Physiological Integrity, Reduction of Risk Potential
Which laboratory test value is elevated in clients who smoke and can’t be used as a general indicator of cancer?
- ⦁ A. Acid phosphatase level
- ⦁ B. Serum calcitonin level
- ⦁ C. Alkaline phosphatase level
- ⦁ D. Carcinoembryonic antigen level
Correct
Incorrect
Question 319 of 451
319. Question
318. Question Tag: iron-deficiency anemia
Question Category: Physiological Integrity, Physiological Adaptation
Francis with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron-deficiency anemia?
- ⦁ A. Nights sweats, weight loss, and diarrhea
- ⦁ B. Dyspnea, tachycardia, and pallor
- ⦁ C. Nausea, vomiting, and anorexia
- ⦁ D. Itching, rash, and jaundice
Correct
Incorrect
Question 320 of 451
320. Question
319. Question Tag: HIV, pregnancy
Question Category: Health Promotion and Maintenance
In teaching a female client who is HIV-positive about pregnancy, the nurse would know more teaching is necessary when the client says:
- ⦁ A. The baby can get the virus from my placenta.”
- ⦁ B. “I’m planning on starting on birth control pills.”
- ⦁ C. “Not everyone who has the virus gives birth to a baby who has the virus.”
- ⦁ D. “I’ll need to have a C-section if I become pregnant and have a baby.”
Correct
Incorrect
Question 321 of 451
321. Question
320. Question Tag: AIDS
Question Category: Health Promotion and Maintenance
When preparing Judy with acquired immunodeficiency syndrome (AIDS) for discharge to the home, the nurse should be sure to include which instruction?
- ⦁ A. “Put on disposable gloves before bathing.”
- ⦁ B. “Sterilize all plates and utensils in boiling water.”
- ⦁ C. “Avoid sharing such articles as toothbrushes and razors.”
- ⦁ D. “Avoid eating foods from serving dishes shared by other family members.”
Correct
Incorrect
Question 322 of 451
322. Question
321. Question Tag: pernicious anemia
Question Category: Physiological Integrity, Physiological Adaptation
Nurse Marie is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
- ⦁ A. Pallor, bradycardia, and reduced pulse pressure
- ⦁ B. Pallor, tachycardia, and a sore tongue
- ⦁ C. Sore tongue, dyspnea, and weight gain
- ⦁ D. Angina, double vision, and anorexia
Correct
Incorrect
Question 323 of 451
323. Question
322. Question Tag: anaphylactic shock
Question Category: Management of Care
After receiving a dose of penicillin, a client develops dyspnea and hypotension. Nurse Celestina suspects the client is experiencing anaphylactic shock. What should the nurse do first?
- ⦁ A. Page an anesthesiologist immediately and prepare to intubate the client.
- ⦁ B. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.
- ⦁ C. Administer the antidote for penicillin, as prescribed, and continue to monitor the client’s vital signs.
- ⦁ D. Insert an indwelling urinary catheter and begin to infuse I.V. fluids as ordered.
Correct
Incorrect
Question 324 of 451
324. Question
323. Question Tag: aspirin
Question Category: Physiological Integrity, Physiological Adaptation
Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:
- ⦁ A. Weight gain.
- ⦁ B. Fine motor tremors.
- ⦁ C. Respiratory acidosis.
- ⦁ D. Bilateral hearing loss.
Correct
Incorrect
Question 325 of 451
325. Question
324. Question Tag: HIV, AIDS
Question Category: Health Promotion and Maintenance
A 23-year-old client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that adaptive immunity is provided by which type of white blood cell?
- ⦁ A. Neutrophil
- ⦁ B. Basophil
- ⦁ C. Monocyte
- ⦁ D. Lymphocyte
Correct
Incorrect
Question 326 of 451
326. Question
325. Question Tag: Sjögren’s syndrome
Question Category: Physiological Integrity, Physiological Adaptation
In an individual with Sjögren’s syndrome, nursing care should focus on:
- ⦁ A. Moisture replacement.
- ⦁ B. Electrolyte balance.
- ⦁ C. Nutritional supplementation.
- ⦁ D. Arrhythmia management.
Correct
Incorrect
Question 327 of 451
327. Question
326. Question Tag: chemotherapy
Question Category: Physiological Integrity, Reduction of Risk Potential
During chemotherapy for lymphocytic leukemia, Mathew develops abdominal pain, fever, and “horse barn” smelling diarrhea. It would be most important for the nurse to advise the physician to order:
- ⦁ A. Enzyme-linked immunosuppressant assay (ELISA) test.
- ⦁ B. Electrolyte panel and hemogram.
- ⦁ C. Stool for Clostridium difficile test.
- ⦁ D. Flat plate X-ray of the abdomen.
Correct
Incorrect
Question 328 of 451
328. Question
327. Question Tag: HIV
Question Category: Physiological Integrity, Reduction of Risk Potential
A male client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:
- ⦁ A. E-rosette immunofluorescence.
- ⦁ B. Quantification of T-lymphocytes.
- ⦁ C. Enzyme-linked immunosorbent assay (ELISA).
- ⦁ D. Western blot test with ELISA.
Correct
Incorrect
Question 329 of 451
329. Question
328. Question Tag: blood count
Question Category: Physiological Integrity, Reduction of Risk Potential
A complete blood count is commonly performed before Joe goes into surgery. What does this test seek to identify?
- ⦁ A. Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels.
- ⦁ B. Low levels of urine constituents normally excreted in the urine.
- ⦁ C. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels.
- ⦁ D. Electrolyte imbalance that could affect the blood’s ability to coagulate properly.
Correct
Incorrect
Question 330 of 451
330. Question
329. Question Tag: disseminated intravascular coagulation
Question Category: Physiological Integrity, Reduction of Risk Potential
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?
- ⦁ A. Platelet count, prothrombin time, and partial thromboplastin time
- ⦁ B. Platelet count, blood glucose levels, and white blood cell (WBC) count
- ⦁ C. Thrombin time, calcium levels, and potassium levels
- ⦁ D. Fibrinogen level, WBC, and platelet count
Correct
Incorrect
Question 331 of 451
331. Question
330. Question Tag: allergen, diet
Question Category: Basic Care and Comfort
When taking a dietary history from a newly admitted female client, Nurse Len should remember which of the following foods is a common allergen?
- ⦁ A. Bread
- ⦁ B. Carrots
- ⦁ C. Orange
- ⦁ D. Strawberries
Correct
Incorrect
Question 332 of 451
332. Question
331. Question Tag: outpatient, prioritization
Question Category: Safe and Effective Care Environment, Management of Care
Nurse John is caring for clients in the outpatient clinic. Which of the following phone calls should the nurse return first?
- ⦁ A. A client with hepatitis A who states, “My arms and legs are itching.”
- ⦁ B. A client with a cast on the right leg who states, “I have a funny feeling in my right leg.”
- ⦁ C. A client with osteomyelitis of the spine who states, “I am so nauseous that I can’t eat.”
- ⦁ D. A client with rheumatoid arthritis who states, “I am having trouble sleeping.”
Correct
Incorrect
Question 333 of 451
333. Question
332. Question Tag: prioritization
Question Category: Safe and Effective Care Environment, Management of Care
Nurse Sarah is caring for clients on the surgical floor and has just received a report from the previous shift. Which of the following clients should the nurse see first?
- ⦁ A. A 35-year-old admitted three hours ago with a gunshot wound; 1.5 cm area of dark drainage noted on the dressing.
- ⦁ B. A 43-year-old who had a mastectomy two days ago; 23 ml of serosanguinous fluid noted in the Jackson-Pratt drain.
- ⦁ C. A 59-year-old with a collapsed lung due to an accident; no drainage noted in the previous eight hours.
- ⦁ D. A 62-year-old who had an abdominal-perineal resection three days ago; client complains of chills.
Correct
Incorrect
Question 334 of 451
334. Question
333. Question Tag: thyroidectomy
Question Category: Physiological Integrity, Physiological Adaptation
Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago for treatment of Grave’s disease. The nurse would be most concerned if which of the following was observed?
- ⦁ A. Blood pressure 138/82, respirations 16, oral temperature 99 degrees Fahrenheit.
- ⦁ B. The client supports his head and neck when turning his head to the right.
- ⦁ C. The client spontaneously flexes his wrist when the blood pressure is obtained.
- ⦁ D. The client is drowsy and complains of sore throat.
Correct
Incorrect
Question 335 of 451
335. Question
334. Question Tag: pain relief
Question Category: Physiological Integrity, Physiological Adaptation
Julius is admitted with complaints of severe pain in the lower right quadrant of the abdomen. To assist with pain relief, the nurse should take which of the following actions?
- ⦁ A. Encourage the client to change positions frequently in bed.
- ⦁ B. Administer Demerol 50 mg IM q 4 hours and PRN.
- ⦁ C. Apply warmth to the abdomen with a heating pad.
- ⦁ D. Use comfort measures and pillows to position the client.
Correct
Incorrect
Question 336 of 451
336. Question
335. Question Tag: peritoneal dialysis
Question Category: Physiological Integrity, Physiological Adaptation
Nurse Tina prepares a client for peritoneal dialysis. Which of the following actions should the nurse take first?
- ⦁ A. Assess for a bruit and a thrill.
- ⦁ B. Warm the dialysate solution.
- ⦁ C. Position the client on the left side.
- ⦁ D. Insert a Foley catheter
Correct
Incorrect
Question 337 of 451
337. Question
336. Question Tag: cane
Question Category: Health Promotion and Maintenance
Nurse Jannah teaches an elderly client with right-sided weakness how to use a cane. Which of the following behaviors, if demonstrated by the client to the nurse, indicates that the teaching was effective?
- ⦁ A. The client holds the cane with his right hand, moves the cane forward followed by the right leg, and then moves the left leg.
- ⦁ B. The client holds the cane with his right hand, moves the cane forward followed by his left leg, and then moves the right leg.
- ⦁ C. The client holds the cane with his left hand, moves the cane forward followed by the right leg, and then moves the left leg.
- ⦁ D. The client holds the cane with his left hand, moves the cane forward followed by his left leg, and then moves the right leg.
Correct
Incorrect
Question 338 of 451
338. Question
337. Question Tag: confusion
Question Category: Physiological Adaptation, Physiological Adaptation
An elderly client is admitted to the nursing home setting. The client is occasionally confused and her gait is often unsteady. Which of the following actions, if taken by the nurse, is most appropriate?
- ⦁ A. Ask the woman’s family to provide personal items such as photos or mementos.
- ⦁ B. Select a room with a bed by the door so the woman can look down the hall.
- ⦁ C. Suggest the woman eat her meals in the room with her roommate.
- ⦁ D. Encourage the woman to ambulate in the halls twice a day.
Correct
Incorrect
Question 339 of 451
339. Question
338. Question Tag: walker
Question Category: Health Promotion and Maintenance
Nurse Evangeline teaches an elderly client how to use a standard aluminum walker. Which of the following behaviors, if demonstrated by the client, indicates that the nurse’s teaching was effective?
- ⦁ A. The client slowly pushes the walker forward 12 inches, then takes small steps forward while leaning on the walker.
- ⦁ B. The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward.
- ⦁ C. The client supports his weight on the walker while advancing it forward, then takes small steps while balancing on the walker.
- ⦁ D. The client slides the walker 18 inches forward, then takes small steps while holding onto the walker for balance.
Correct
Incorrect
Question 340 of 451
340. Question
339. Question Tag: sensory deprivation
Question Category: Health Promotion and Maintenance
Nurse Derek is supervising a group of elderly clients in a residential home setting. The nurse knows that the elderly are at greater risk of developing sensory deprivation for what reason?
- ⦁ A. Increased sensitivity to the side effects of medications.
- ⦁ B. Decreased visual, auditory, and gustatory abilities.
- ⦁ C. Isolation from their families and familiar surroundings.
- ⦁ D. Decrease musculoskeletal function and mobility.
Correct
Incorrect

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