PNLE NP3 Test 5 Study Guide Questions
with Guaranteed Pass Solutions 2026-
2027 Edition.
1. After a cerebrovascular accident, a 75 yr old client is admitted to the health care facility. The
client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool.
His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g/dl. Which of the following is a
priority for this client?
A. Checking stools for occult blood
B. Performing range-of-motion exercises to the left side
C. Keeping skin clean and dry
D. Elevating the head of the bed to 30 degrees - Answer ANS: D
Because the client's gag reflex is absent, elevating the head of the bed to 30 degrees helps
minimize the client's risk of aspiration. Checking the stools, performing ROM exercises, and
keeping the skin clean and dry are important, but preventing aspiration through positioning is
the priority.
2. The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small
pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action:
A. Destroys the odor-proof seal
B. Won't affect the colostomy system
C. Is appropriate for relieving the gas in a colostomy system
D. Destroys the moisture barrier seal - Answer ANS: A
Any hole, no matter how small, will destroy the odor-proof seal of a drainage bag. Removing the
bag or unclamping it is the only appropriate method for relieving gas.
3. When assessing the client with celiac disease, the nurse can expect to find which of the
following?
A. Steatorrhea
B. Jaundiced sclerae
C. Clay-colored stools
D. Widened pulse pressure - Answer ANS: A
Because celiac disease destroys the absorbing surface of the intestine, fat isn't absorbed but is
passed in the stool. Steatorrhea is bulky, fatty stools that have a foul odor. Jaundiced sclerae
,result from elevated bilirubin levels. Clay-colored stools are seen with biliary disease when bile
flow is blocked. Celiac disease doesn't cause a widened pulse pressure.
4. A client is hospitalized with a diagnosis of chronic glomerulonephritis. The client mentions
that she likes salty foods. The nurse should warn her to avoid foods containing sodium because:
A. Reducing sodium promotes urea nitrogen excretion
B. Reducing sodium improves her glomerular filtration rate
C. Reducing sodium increases potassium absorption
D. Reducing sodium decreases edema - Answer ANS: D
Reducing sodium intake reduces fluid retention. Fluid retention increases blood volume, which
changes blood vessel permeability and allows plasma to move into interstitial tissue, causing
edema. Urea nitrogen excretion can be increased only by improved renal function. Sodium
intake doesn't affect the glomerular filtration rate. Potassium absorption is improved only by
increasing the glomerular filtration rate; it isn't affected by sodium intake.
5. The nurse is caring for a client with a cerebral injury that impaired his speech and hearing.
Most likely, the client has experienced damage to the:
A. Frontal lobe
B. Parietal lobe
C. Occipital lobe
D. Temporal lobe - Answer ANS: D
The portion of the cerebrum that controls speech and hearing is the temporal lobe. Injury to the
frontal lobe causes personality changes, difficulty speaking, and disturbance in memory,
reasoning, and concentration. Injury to the parietal lobe causes sensory alterations and
problems with spatial relationships. Damage to the occipital lobe causes vision disturbances.
6. The nurse is assessing a postcraniotomy client and finds the urine output from a catheter is
1500 ml for the 1st hour and the same for the 2nd hour. The nurse should suspect:
A. Cushing's syndrome
B. Diabetes mellitus
C. Adrenal crisis
D. Diabetes insipidus - Answer ANS: D
Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in clients after
brain surgery. Cushing's syndrome is excessive glucocorticoid secretion resulting in sodium and
water retention. Diabetes mellitus is a hyperglycemic state marked by polyuria, polydipsia, and
polyphagia. Adrenal crisis is under-secretion of glucocorticoids resulting in profound
hypoglycemia, hypovolemia, and hypotension.
,7. The nurse is providing post-procedure care for a client who underwent percutaneous
lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the
renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse
should instruct the client to:
A. Limit oral fluid intake for 1 to 2 weeks
B. Report the presence of fine, sand-like particles through the nephrostomy tube.
C. Notify the physician about cloudy or foul-smelling urine
D. Report bright pink urine within 24 hours after the procedure - Answer ANS: C
The client should report the presence of foul-smelling or cloudy urine. Unless contraindicated,
the client should be instructed to drink large quantities of fluid each day to flush the kidneys.
Sand-like debris is normal because of residual stone products. Hematuria is common after
lithotripsy.
8. A client with a serum glucose level of 618 mg/dl is admitted to the facility. He's awake and
oriented, has hot dry skin, and has the following vital signs: temperature of 100.6º F (38.1º C),
heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these
assessment findings, which nursing diagnosis takes the highest priority?
A. Deficient fluid volume related to osmotic diuresis
B. Decreased cardiac output related to elevated heart rate
C. Imbalanced nutrition: Less than body requirements related to insulin deficiency
D. Ineffective thermoregulation related to dehydration - Answer ANS: A
A serum glucose level of 618 mg/dl indicates hyperglycemia, which causes polyuria and
deficient fluid volume. In this client, tachycardia is more likely to result from deficient fluid
volume than from decreased cardiac output because his blood pressure is normal. Although the
client's serum glucose is elevated, food isn't a priority because fluids and insulin should be
administered to lower the serum glucose level. Therefore, a diagnosis of Imbalanced Nutrition:
Less then body requirements isn't appropriate. A temperature of 100.6º F isn't life threatening,
eliminating ineffective thermoregulation as the top priority.
9. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with
diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose
results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U
of regular insulin. Thenurse should expect the dose's:
A. Onset to be at 2 p.m. and its peak at 3 p.m.
B. Onset to be at 2:15 p.m. and its peak at 3 p.m.
C. Onset to be at 2:30 p.m. and its peak at 4 p.m.
D. Onset to be at 4 p.m. and its peak at 6 p.m. - Answer ANS: C
, Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2
to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15
to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.
10. A client with a head injury is being monitored for increased intracranial pressure (ICP). His
blood pressure is 90/60 mmHG and the ICP is 18 mmHg; therefore, his cerebral perfusion
pressure (CPP) is:
A. 52 mm Hg
B. 88 mm Hg
C. 48 mm Hg
D. 68 mm Hg - Answer ANS: A
CPP is derived by subtracting the ICP from the mean arterial pressure (MAP). For adequate
cerebral perfusion to take place, the minimum goal is 70 mmHg. The MAP is derived using the
following formula:
MAP = ((diastolic blood pressure x 2) + systolic blood pressure) / 3
MAP = ((60 x2) + 90) / 3MAP = 70 mmHg
To find the CPP, subtract the client's ICP from the MAP; in this case, 70 mmHg - 18 mmHg = 52
mmHg.
11. A 52 yr-old female tells the nurse 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 a mobile mass
B. Nonmobile mass with irregular edges
C. Mobile mass that is oft and easily delineated
D. Nonpalpable right axillary lymph nodes - Answer ANS: B
Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. Nipple
retraction —not eversion—may be a sign of cancer. A mobile mass that is soft and easily
delineated is most often a fluid-filled benign cyst. Axillary lymph nodes may or may not be
palpable on initial detection of a cancerous mass.
12. A Client is scheduled to have a descending colostomy. He's very anxious and has many
questions regarding the surgical procedure, care of stoma, and lifestyle changes. It would be
most appropriate for the nurse to make a referral to which member of the health care team?
A. Social worker
with Guaranteed Pass Solutions 2026-
2027 Edition.
1. After a cerebrovascular accident, a 75 yr old client is admitted to the health care facility. The
client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool.
His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g/dl. Which of the following is a
priority for this client?
A. Checking stools for occult blood
B. Performing range-of-motion exercises to the left side
C. Keeping skin clean and dry
D. Elevating the head of the bed to 30 degrees - Answer ANS: D
Because the client's gag reflex is absent, elevating the head of the bed to 30 degrees helps
minimize the client's risk of aspiration. Checking the stools, performing ROM exercises, and
keeping the skin clean and dry are important, but preventing aspiration through positioning is
the priority.
2. The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small
pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action:
A. Destroys the odor-proof seal
B. Won't affect the colostomy system
C. Is appropriate for relieving the gas in a colostomy system
D. Destroys the moisture barrier seal - Answer ANS: A
Any hole, no matter how small, will destroy the odor-proof seal of a drainage bag. Removing the
bag or unclamping it is the only appropriate method for relieving gas.
3. When assessing the client with celiac disease, the nurse can expect to find which of the
following?
A. Steatorrhea
B. Jaundiced sclerae
C. Clay-colored stools
D. Widened pulse pressure - Answer ANS: A
Because celiac disease destroys the absorbing surface of the intestine, fat isn't absorbed but is
passed in the stool. Steatorrhea is bulky, fatty stools that have a foul odor. Jaundiced sclerae
,result from elevated bilirubin levels. Clay-colored stools are seen with biliary disease when bile
flow is blocked. Celiac disease doesn't cause a widened pulse pressure.
4. A client is hospitalized with a diagnosis of chronic glomerulonephritis. The client mentions
that she likes salty foods. The nurse should warn her to avoid foods containing sodium because:
A. Reducing sodium promotes urea nitrogen excretion
B. Reducing sodium improves her glomerular filtration rate
C. Reducing sodium increases potassium absorption
D. Reducing sodium decreases edema - Answer ANS: D
Reducing sodium intake reduces fluid retention. Fluid retention increases blood volume, which
changes blood vessel permeability and allows plasma to move into interstitial tissue, causing
edema. Urea nitrogen excretion can be increased only by improved renal function. Sodium
intake doesn't affect the glomerular filtration rate. Potassium absorption is improved only by
increasing the glomerular filtration rate; it isn't affected by sodium intake.
5. The nurse is caring for a client with a cerebral injury that impaired his speech and hearing.
Most likely, the client has experienced damage to the:
A. Frontal lobe
B. Parietal lobe
C. Occipital lobe
D. Temporal lobe - Answer ANS: D
The portion of the cerebrum that controls speech and hearing is the temporal lobe. Injury to the
frontal lobe causes personality changes, difficulty speaking, and disturbance in memory,
reasoning, and concentration. Injury to the parietal lobe causes sensory alterations and
problems with spatial relationships. Damage to the occipital lobe causes vision disturbances.
6. The nurse is assessing a postcraniotomy client and finds the urine output from a catheter is
1500 ml for the 1st hour and the same for the 2nd hour. The nurse should suspect:
A. Cushing's syndrome
B. Diabetes mellitus
C. Adrenal crisis
D. Diabetes insipidus - Answer ANS: D
Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in clients after
brain surgery. Cushing's syndrome is excessive glucocorticoid secretion resulting in sodium and
water retention. Diabetes mellitus is a hyperglycemic state marked by polyuria, polydipsia, and
polyphagia. Adrenal crisis is under-secretion of glucocorticoids resulting in profound
hypoglycemia, hypovolemia, and hypotension.
,7. The nurse is providing post-procedure care for a client who underwent percutaneous
lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the
renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse
should instruct the client to:
A. Limit oral fluid intake for 1 to 2 weeks
B. Report the presence of fine, sand-like particles through the nephrostomy tube.
C. Notify the physician about cloudy or foul-smelling urine
D. Report bright pink urine within 24 hours after the procedure - Answer ANS: C
The client should report the presence of foul-smelling or cloudy urine. Unless contraindicated,
the client should be instructed to drink large quantities of fluid each day to flush the kidneys.
Sand-like debris is normal because of residual stone products. Hematuria is common after
lithotripsy.
8. A client with a serum glucose level of 618 mg/dl is admitted to the facility. He's awake and
oriented, has hot dry skin, and has the following vital signs: temperature of 100.6º F (38.1º C),
heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these
assessment findings, which nursing diagnosis takes the highest priority?
A. Deficient fluid volume related to osmotic diuresis
B. Decreased cardiac output related to elevated heart rate
C. Imbalanced nutrition: Less than body requirements related to insulin deficiency
D. Ineffective thermoregulation related to dehydration - Answer ANS: A
A serum glucose level of 618 mg/dl indicates hyperglycemia, which causes polyuria and
deficient fluid volume. In this client, tachycardia is more likely to result from deficient fluid
volume than from decreased cardiac output because his blood pressure is normal. Although the
client's serum glucose is elevated, food isn't a priority because fluids and insulin should be
administered to lower the serum glucose level. Therefore, a diagnosis of Imbalanced Nutrition:
Less then body requirements isn't appropriate. A temperature of 100.6º F isn't life threatening,
eliminating ineffective thermoregulation as the top priority.
9. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with
diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose
results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U
of regular insulin. Thenurse should expect the dose's:
A. Onset to be at 2 p.m. and its peak at 3 p.m.
B. Onset to be at 2:15 p.m. and its peak at 3 p.m.
C. Onset to be at 2:30 p.m. and its peak at 4 p.m.
D. Onset to be at 4 p.m. and its peak at 6 p.m. - Answer ANS: C
, Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2
to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15
to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.
10. A client with a head injury is being monitored for increased intracranial pressure (ICP). His
blood pressure is 90/60 mmHG and the ICP is 18 mmHg; therefore, his cerebral perfusion
pressure (CPP) is:
A. 52 mm Hg
B. 88 mm Hg
C. 48 mm Hg
D. 68 mm Hg - Answer ANS: A
CPP is derived by subtracting the ICP from the mean arterial pressure (MAP). For adequate
cerebral perfusion to take place, the minimum goal is 70 mmHg. The MAP is derived using the
following formula:
MAP = ((diastolic blood pressure x 2) + systolic blood pressure) / 3
MAP = ((60 x2) + 90) / 3MAP = 70 mmHg
To find the CPP, subtract the client's ICP from the MAP; in this case, 70 mmHg - 18 mmHg = 52
mmHg.
11. A 52 yr-old female tells the nurse 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 a mobile mass
B. Nonmobile mass with irregular edges
C. Mobile mass that is oft and easily delineated
D. Nonpalpable right axillary lymph nodes - Answer ANS: B
Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. Nipple
retraction —not eversion—may be a sign of cancer. A mobile mass that is soft and easily
delineated is most often a fluid-filled benign cyst. Axillary lymph nodes may or may not be
palpable on initial detection of a cancerous mass.
12. A Client is scheduled to have a descending colostomy. He's very anxious and has many
questions regarding the surgical procedure, care of stoma, and lifestyle changes. It would be
most appropriate for the nurse to make a referral to which member of the health care team?
A. Social worker
