200question NCLEX exam review (QUETIONS AND ANSWERS)

200question NCLEX exam Question 1 See full question A client is scheduled to have a graded exercise test. The nurse explains to the client that the test will determine how: You Selected: well the body reacts to controlled exercise stress. Correct response: well the body reacts to controlled exercise stress. Explanation: Graded exercise testing is a diagnostic and prognostic tool used to determine the physiologic responses to controlled exercise stress. Information gained from a graded exercise test can achieve diagnostic, functional, and therapeutic objectives for the client. Graded exercise tests involve the use of a treadmill, stationary bicycle, or arm ergometry. The information obtained from this test is not used to set the incline on the treadmill, and measuring the distance walked and the duration of the walk are not the purpose of a graded exercise test. Remediation: Electrocardiography, exercise Question 2 See full question A nurse should include which discharge instruction for clients receiving tricyclic antidepressants? You Selected: Restrict fluid and sodium intake while using this medication. Correct response: Don't consume alcohol while using this medication. Explanation:Drinking alcohol can potentiate the sedating action of tricyclic antidepressants. Dry mouth and blurred vision are normal adverse effects of tricyclic antidepressants. Fluid and sodium intake must be monitored during lithium treatment, not during treatment with tricyclic antidepressants. Safe use of tricyclic antidepressants during pregnancy and breast-feeding hasn't been established. Remediation: Amitriptyline hydrochloride Clomipramine hydrochloride Question 3 See full question The nurse prepares to administer promethazine 35 mg IM as prescribed PRN for a client with cholecystitis who has nausea. The ampule label reads that the medication is available in 25 mg/mL. How many milliliters should the nurse administer? Record your answer using one decimal place. Your Response: 0.7 Correct response: 1.4 Explanation: The following formula is used to calculate the correct dosage: 35 mg/X = 25 mg/1 mL X = (35/25) mL X = 1.4 mL. Question 4 See full question Levothyroxine 0.2 mg orally has been prescribed for a client diagnosed with hypothyroidism. The nurse has available 0.05-mg tablets. How many tablets should the nurse prepare to give the client? You Selected: two tablets Correct response: four tablets Explanation: 0.2 mg/x tablet = 0.05 mg/1 tablet. x = 4 tablets. Remediation: Levothyroxine sodium Question 5 See full question What is the nurse’s priority intervention for a toddler who has just had a hip-spica cast applied? You Selected: Assess sensation, circulation, and motion of the child’s feet and toes Correct response: Assess sensation, circulation, and motion of the child’s feet and toes Explanation: Assessing sensation, circulation, and motion is necessary in all children with a cast. Fluids should be encouraged, and careful diapering and padding will keep the child’s cast dry. Discharge instructions are not a priority, but should be shared at a later time. Children experiencing pain should receive medication as needed. Remediation: Cast assessment and management, pediatric Casting, pediatric Question 6 See full question A child requires IV fluids to infuse at 27 ml/hr. The tubing delivers 60 gtts/ml. How many gtts/min should the nurse count to ensure that the fluid is safely infusing? You Selected:27 gtts/min Correct response: 27 gtts/min Explanation: The nurse should count 27 gtts/min. 27 ml/h x 60 gtts/ml ÷ 60 min/h = 27 gtts/min Remediation: IV infusion, dose and flow rate calculations Question 7 See full question Before placement of a ventriculoperitoneal shunt for hydrocephalus, an infant is irritable, lethargic, and difficult to feed. To maintain the infant's nutritional status, which action would be most appropriate? You Selected: Give the infant small, frequent feedings. Correct response: Give the infant small, frequent feedings. Explanation: An infant with hydrocephalus is difficult to feed because of poor sucking, lethargy, and vomiting, which are associated with increased intracranial pressure. Small, frequent feedings given at times when the infant is relaxed and calm are tolerated best. Feeding an infant before any procedure is inappropriate because the stress of the procedure may lead to vomiting. Ideally, the infant should be held in a slightly vertical position when feeding to prevent backflow of formula into the eustachian tubes and subsequent development of ear infections. Giving large, less frequently feedings allows for rest, but typically results in more vomiting. Remediation: Ventriculoperitoneal shunt placement Hydrocephalus, pediartic Question 8 See full questionA 13-year-old child has seen the school nurse several times with headache, vomiting, and difficulty walking. When calling the adolescent's mother about these symptoms, what should the nurse suggest the mother do first? You Selected: Make an appointment with the adolescent's health care provider (HCP). Correct response: Make an appointment with the adolescent's health care provider (HCP). Explanation: A child who has symptoms of vomiting, headaches, and problems walking needs to be evaluated by a health care provider (HCP) to determine the cause. Unexplained headaches and vomiting along with difficulty walking (e.g., ataxia) may suggest a brain tumor. Evaluation by an eye HCP would be appropriate once a complete medical evaluation has been accomplished. Psychological counseling may be indicated for this adolescent, but only after medical evaluation to determine that she is physically healthy. Meeting with the child’s teachers would be appropriate after medical evaluation. Remediation: Physical assessment, pediatric Question 9 See full question A client with hyperemesis gravidarum is on a clear liquid diet. The nurse should serve this client: You Selected: tea and gelatin dessert. Correct response: tea and gelatin dessert. Explanation: A clear liquid diet consists of foods that are clear liquids at room temperature or body temperature, such as ice pops, regular or decaffeinated coffee and tea, gelatin desserts, carbonated beverages, and clear juices. Milk, pasteurized eggs, egg substitutes, and oatmeal are part of a full liquid diet.Remediation: Vomiting Question 10 See full question Clozapine therapy has been initiated for a client with schizophrenia who has been unresponsive to other antipsychotics. The client states, "Why do I have to have a blood test every week?" Which response by the nurse would be most appropriate? You Selected: "Weekly blood tests are necessary to determine safe dosage and to monitor the effect of the medication on the blood." Correct response: "Weekly blood tests are necessary to determine safe dosage and to monitor the effect of the medication on the blood." Explanation: The client needs specific information about the effects of the drug, specifically that the drug can cause agranulocytosis. The statement about weekly blood tests to determine safe dosage and monitoring for effects on the blood gives the client specific information to ensure followup with the required protocol for clozapine therapy. Lack of accurate knowledge can lead to noncompliance with necessary follow-up procedures and noncompliance with medication. The supply of medication is not dependent on blood testing. Telling the client that the health care provider (HCP) wants to know the progress does not provide specific information for this client. The blood tests are not required by the drug company. Remediation: Clozapine Question 11 See full question A nurse is caring for a client who is recovering from a myocardial infarction (MI). The cardiologist refers him to cardiac rehabilitation. Which statement by the client indicates an understanding of cardiac rehabilitation? You Selected: "Rehabilitation will help me function as well as I physically can." Correct response: "Rehabilitation will help me function as well as I physically can." Explanation: The client demonstrates understanding of cardiac rehabilitation when he states that it helps the client reach his activity potential. Coronary artery disease, which typically causes an acute MI, is a chronic condition that isn't cured. Many clients who suffer an acute MI can eventually return to such activities as jogging, depending on the extent of cardiac damage. Cardiac rehabilitation involves physical activity as well as classroom education. Remediation: Myocardial infarction Myocardial Blood Flow Question 12 See full question While caring for a client who's immobile, a nurse documents the following information in the client's chart: "Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information? You Selected: Risk for impaired skin integrity related to immobility Correct response: Risk for impaired skin integrity related to immobility Explanation: The information documented in the client's chart reflects the risk for impaired skin integrity. Because the client's skin is intact, the problem is only a potential one, not an actual one, which makes the nursing diagnosis of Impaired skin integrity inappropriate. If constipation were a problem, interventions would focus on diet and activity. If body image disturbance were a problem, interventions would focus on the client's feelings about himself and his disease. Remediation: Pressure ulcer prevention Question 13 See full question A nurse is caring for an older client who has had a hemorrhagic stroke. The client has exhibited impulsive behavior and, despite reminders from the nurse, doesn't recognize his limitations. Which priority measure should the nurse implement to prevent injury? You Selected: Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed. Correct response: Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed. Explanation: The bed alarm will alert staff that the client is attempting to transfer, so they can come to assist. The nurse shouldn't encourage the family to reprimand the client. Instead, the nurse should ask the family to encourage the client to request assistance. The nurse should encourage the client to use the call light in all situations, not just emergencies. A vest and wrist restraints aren't appropriate unless less-restrictive measures have failed and the client is a danger to himself or others. Remediation: Confused patient, care of Question 14 See full question A nurse is caring for a client diagnosed with cardiomyopathy. The student nurse assigned to collaborate with the nurse begins data collection for the admission assessment. The student nurse violates information security when she: You Selected: writes the client's phone number on her clinical paperwork. Correct response: writes the client's phone number on her clinical paperwork. Explanation:Documenting identifying information taken outside the institution is violates information security. The student nurse has no need for the client's phone number on her clinical paperwork in order to provide care. Completing admission paperwork and data collection sheets is within the scope of practice for the student nurse and doesn't violate information security. Remediation: Documentation Question 15 See full question When obtaining a client's history, a nurse develops a genogram. What is the purpose of developing a genogram? You Selected: To identify genetic and familial health problems Correct response: To identify genetic and familial health problems Explanation: A genogram organizes a family's history into a diagram or flow chart. A nurse uses a genogram to identify genetic and familial health problems. A genogram doesn't identify previously undetected diseases and disorders, the client's reason for seeking care, or chronic health problems. Question 16 See full question A nurse is caring for a toddler who was diagnosed with an inoperable brain tumor. The parents are having difficulty deciding on a course of action for their child. Why is it important to have the nurse involved in an ethical discussion about a planned course of treatment? You Selected: The nurse can act as a liaison between the child, the child's parents, and the health care team. Correct response: The nurse can act as a liaison between the child, the child's parents, and the health care team. Explanation: It is important to involve the nurse because she can act as a liaison between all parties. The nurse has the most direct contact with the child and his parents, and she can listen to and communicate their wishes for treatment. She can also aid in interpreting information about the child's condition and course of treatment, helping the parents to make an informed decision. The nurse isn't viewed as the authority on ethical issues at the hospital. In fact, hospitals commonly employ ethicists to help with ethical dilemmas. Time shouldn't be a factor when it comes to helping parents make decisions about their child's care. Question 17 See full question Because antianxiety agents such as chlordiazepoxide can potentiate the effects of other drugs, the nurse should incorporate which instruction in her teaching plan? You Selected: Avoid mixing antianxiety agents with alcohol or other central nervous system (CNS) depressants. Correct response: Avoid mixing antianxiety agents with alcohol or other central nervous system (CNS) depressants. Explanation: Potentiating effect refers to a drug's ability to increase the potency of another drug if the two drugs are taken together. Therefore, the client should be instructed to avoid alcohol while taking chlordiazepoxide because alcohol potentiates the drug's CNS depressant effect. Taken at bedtime, this drug will induce sleep. Chlordiazepoxide comes in capsule form and can usually be taken with water. Aged cheese is restricted with monoamine oxidase inhibitors, not antianxiety agents. Remediation: Chlordiazepoxide hydrochloride Question 18 See full question A 30-year-old client comes to the office for a routine prenatal visit. After reading the chart entry below, the nurse would prepare the client for which test? You Selected:1-Hour glucose tolerance test Correct response: 1-Hour glucose tolerance test Explanation: A 1-hour glucose tolerance test is recommended to screen for gestational diabetes if the client is obese, has glycosuria or a family history of diabetes, or lost a fetus for unexplained reasons or gave birth to a large-for-gestational-age neonate. A triple screen tests for chromosomal abnormalities. The indirect Coombs’ test screens maternal blood for red blood cell antibodies. Amniocentesis is used to detect fetal abnormalities. Remediation: Gestational diabetes mellitus -- management guidelines Breath with fruity odor Urinalysis Question 19 See full question A client’s family just completed a care conference with the health care team. The family has decided to withdraw treatment. What is the nurse’s next step? You Selected: Document the decision in the client’s electronic record. Correct response: Document the decision in the client’s electronic record. Explanation: After a decision has been made, the nurse should document the decision in the client’s electronic record. This will alert additional members of the health care team. The client should not be transferred to a different floor. The pharmacy will receive notification from the EMR. Family members should communicate to others about the decision. The nurse should be caring for the client. Remediation: Documentation Question 20 See full question The nurse is caring for a client in labor. The nurse notes variable decelerations on the fetal monitor strip. Which of the following interventions should the nurse include in the client’s plan of care? You Selected: Repositioning the client on her side Correct response: Repositioning the client on her side Explanation: Variable decelerations are caused by umbilical cord compression. These can occur with or without a contraction. Positioning the client on her side would provide optimal oxygenation to the fetus. Discontinuing the fetal monitor would be inappropriate for a client in labor who is having variable decelerations. Calling the healthcare provider without repositioning the client first would be inappropriate. Terbutaline may discontinue the uterine contractions but may not stop the variable decelerations. Remediation: External fetal monitoring Question 21 See full question A client is has presented to the emergency department with symptoms that are suggestive of appendicitis. The client admits to the nurse, "I am very nervous because I am in the country illegally and have been for several years." What is the nurse's best response? You Selected: "We are going to give you the treatment you need. The care team does not involve ourselves with your immigration status." Correct response: "We are going to give you the treatment you need. The care team does not involve ourselves with your immigration status." Explanation:A client's immigration status is highly significant, but this variable is not the responsibility of the nurse and the other members of the healthcare team. A nurse should never counsel a client towards secrecy. Question 22 See full question A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction? You Selected: "Avoid stimulants and alcohol for 24 to 48 hours before the test." Correct response: "Avoid stimulants and alcohol for 24 to 48 hours before the test." Explanation: For 24 to 48 hours before an EEG, the client should avoid coffee, cola, tea, alcohol, and cigarettes because these may interfere with the accuracy of test results. (For the same reason, the client also should avoid antidepressants, sedatives, and anticonvulsants.) To avoid a reduced serum glucose level, which may alter test results, the client should eat normal meals before the test. The hair should be washed before an EEG because the electrodes must be applied to a clean scalp. The client's thoughts don't affect the test results. Remediation: Electroencephalography Question 23 See full question A client is in the manic phase of chronic bipolar disorder. The client has stopped taking the prescribed lithium carbonate 3 weeks ago and has not been eating or sleeping for 3 days. Which behaviors listed below will be of priority concern as the nurse begins a care plan for this client? You Selected: Hyperactivity, ignoring eating and sleeping Correct response: Hyperactivity, ignoring eating and sleeping Explanation:Safety needs are always the first priority in care planning. A client who has not eaten or slept for several days and has been extremely hyperactive may be at risk of exhaustion and malnutrition, and the implications of those states. Although thought disorder, expansive mood, and dress are important assessment information, priority interventions must center on the basic needs. Remediation: Manic episode patient care Question 24 See full question A client comes to the emergency department complaining of chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see? You Selected: Elevated ST segment Correct response: Elevated ST segment Explanation: Ischemic myocardial tissue changes cause elevation of the ST segment, an inverted T wave, and a pathological Q wave. A prolonged PR interval occurs with first-degree heart block, the least dangerous atrioventricular heart block; this disorder may arise in healthy people but sometimes results from drug toxicity, electrolyte or metabolic disturbances, rheumatic fever, or chronic degenerative disease of the conduction system. An absent Q wave is normal; an MI may cause a significant Q wave. A widened QRS complex indicates a conduction delay in the HisPurkinje system. Remediation: 15-lead electrocardiogram (ECG) Electrocardiography Myocardial infarction Question 25 See full questionA client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instructions should the nurse include in the client's discharge teaching plan? You Selected: Increase daily fluid intake to at least 2 to 3 L. Correct response: Increase daily fluid intake to at least 2 to 3 L. Explanation: A high daily fluid intake is essential for all clients who are at risk for calculi formation because it prevents urinary stasis and concentration, which can cause crystallization. Depending on the composition of the stone, the client also may be instructed to institute specific dietary measures aimed at preventing stone formation. Clients may need to limit purine, calcium, or oxalate. Urine may need to be either alkaline or acid. There is no need to strain urine regularly. Remediation: Renal calculi Question 26 See full question The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse makes which observation? You Selected: wearing of sterile gloves to bathe a neonate at 2 hours of age Correct response: wearing of sterile gloves to bathe a neonate at 2 hours of age Explanation: One of the staff members needs further instructions when the nurse observes the staff member wearing sterile gloves to bathe a neonate at 2 hours of age. Clean gloves should be worn, not sterile gloves. Sterile gloves are more expensive than clean gloves and are not necessary when bathing a neonate. Wearing protective goggles during a cesarean birth is a standard blood precaution.Bloody sheets should be placed in a designated container. Scalpel blades, needles, syringes, and other equipment used during birthing should be disposed of safely in appropriate, labeled containers. Remediation: Standard precautions Standard Precautions Question 27 See full question A client’s arterial blood gas values are shown. The nurse should monitor the client for: You Selected: metabolic alkalosis Correct response: metabolic acidosis Explanation: The pH of 7.24 indicates that the client is acidotic. The carbon dioxide level is normal, but the HCO3 - level is decreased. These findings indicate that the client is in metabolic acidosis. Remediation: Arterial blood gas analysis Question 28 See full question Which finding indicates that a client who has been raped will have future adjustment problems and need additional counseling? You Selected: Her parents show shame and suspicion about her part in the rape. Correct response: Her parents show shame and suspicion about her part in the rape. Explanation: The potential for problems in adjusting after a rape will be increased when those around the victim treat her as though she is to blame for the rape, especially when she already may feel some guilt and shame about it. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims. Remediation: Rape-trauma syndrome Question 29 See full question A client is at the end of her first postpartum day. The nurse is assessing the client's uterus. Which finding requires further evaluation? You Selected: Fundus two fingerbreadths above the umbilicus Correct response: Fundus two fingerbreadths above the umbilicus Explanation: Fundal height decreases about one fingerbreadth each postpartum day. Therefore, the fundus being two fingerbreadths above the umbilicus requires further evaluation. A firm, round uterus that's in the midline position is normal for a client who is 1 day postpartum. Remediation: Fundal assessment, postpartum Question 30 See full questionA client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33; PCO2 48 (6.4 kPa); PO2 58 (7.7 kPa); HCO3 26 (26 mmol/L). Which prescriptions should the nurse implement first? You Selected: albuterol nebulizer Correct response: albuterol nebulizer Explanation: The arterial blood gas reveals a respiratory acidosis with hypoxia. A quick-acting bronchodilator, albuterol, should be administered via nebulizer to improve gas exchange. Ipratropium is a maintenance treatment for bronchospasm that can be used with albuterol. A chest x-ray and sputum sample can be obtained once the client is stable. Remediation: Arterial puncture for blood gas analysis Albuterol sulfate Asthma Question 31 See full question The nurse notes that a client is too busy investigating the unit and overseeing the activities of other clients to eat dinner. To help the client obtain sufficient nourishment, which plan would be best? You Selected: Allow her to enter the unit kitchen for extra food as necessary. Correct response: Serve foods that she can carry with her. Explanation: Because the client is very active, it would be best to give her food she can carry with her and eat as she moves.Neither allowing the client to send out for her favorite foods nor serving food in small, attractively arranged portions will address her need to be active. Allowing the client in the unit kitchen is impractical, and she most likely would be too busy to eat anyway. Question 32 See full question A nurse is assigned to care for a client with anorexia nervosa. During the first 48 hours of treatment, which nursing intervention is most appropriate for this client? You Selected: Providing one-on-one supervision during meals and for 1 hour afterward Correct response: Providing one-on-one supervision during meals and for 1 hour afterward Explanation: Because a client with anorexia nervosa may discard food or induce vomiting in the bathroom, the nurse should provide one-on-one supervision during meals and for 1 to 2 hours afterward. Letting the client eat with other clients wouldn't be therapeutic because other clients might urge the client to eat and give this client attention for not eating. Trying to persuade the client to eat would reinforce control issues, which are central to this client's underlying psychological problem. Instead of giving the client unlimited time to eat the nurse should set limits and let the client know what is expected. Remediation: Anorexia nervosa Question 33 See full question A third-grade child is referred to the mental health clinic by the school nurse because he is fearful, anxious, and socially isolated. After meeting with the client, the nurse talks with his mother, who says, “It is that school nurse again. She has done nothing but try to make trouble for our family since my son started school. And now you are in on it.” The nurse should respond by saying: You Selected: "You sound pretty angry with the school nurse. Tell me what has happened." Correct response:"You sound pretty angry with the school nurse. Tell me what has happened." Explanation: The mother’s feelings are the priority here. Addressing the mother’s feelings and asking for her view of the situation is most important in building a relationship with the family. Ignoring the mother’s feelings will hinder the relationship. Defending the school nurse and the school puts the client’s mother on the defensive and stifles communication. Remediation: Risk for impaired parenting Conduct disorder, pediatric Question 34 See full question A charge nurse is completing day-shift client care assignments on the genitourinary floor. A new graduate is present for the first day on the unit. An agency nurse and an experienced nurse are also present. The charge nurse should assign the new graduate nurse to the care of which of the following clients? You Selected: Elderly client just admitted for an acute stroke Correct response: Middle-aged stable client with bladder cancer awaiting surgery Explanation: The charge nurse should assign the new nurse to the middle-aged client newly diagnosed with bladder cancer awaiting surgery, as this client has a condition common to the genitourinary floor and is of low acuity and stable. The charge nurse should assign the agency nurse to the client who had an ileo conduit. Their conditions have lesser acuity. The charge nurse should assign the experienced nurse to the most acute clients: the middle-age kidney-transplant recipient Remediation: Kidney cancer Question 35 See full questionWhile performing an assessment of a 75-year-old client in the emergency department, a nurse notes several areas of ecchymosis in various stages of healing on the client’s body. What is the nurse’s priority action? You Selected: Document the findings Correct response: Inquire how these bruises occurred Explanation: The nurse should obtain more information from the client first, in order to complete the initial assessment. The nurse should not assume that the bruises are a result of abuse, and she should not notify the nursing supervisor until additional facts are obtained. The nurse should inform the provider so an examination can be completed. She should follow the facility’s policy and procedure for reporting abuse and document the findings. Remediation: Assessment differences in an older adult, long-term care Suspected elder abuse assessment Question 36 See full question A nurse is instructing a client with bipolar disorder on proper use of lithium carbonate, the drug's adverse effects, and symptoms of lithium toxicity. Which client statement indicates that additional teaching is required? You Selected: "When my moods fluctuate, I'll increase my dose of lithium." Correct response: "When my moods fluctuate, I'll increase my dose of lithium." Explanation: A client who states that he'll increase his dose of lithium if his mood fluctuates requires additional teaching because increasing the dose of lithium without evaluating the client's laboratory values can cause serious health problems, such as lithium toxicity, overdose, and renal failure. Clients taking lithium don't need to limit their sodium intake. A low-sodium diet causes lithium retention. A therapeutic lithium blood level indicates that the drug concentration has stabilized. The client demonstrates effective teaching by stating his lithium levels will be affected by foods that have a diuretic effect, such as watermelon, cantaloupe, grapefruit juice, and cranberry juice. Remediation: Lithium carbonate Question 37 See full question An 8-year-old child, diagnosed with obsessive-compulsive disorder, is admitted by the nurse to a psychiatric facility. During the admission assessment, which behaviors would be characterized as compulsions? Select all that apply. You Selected: Repeatedly washing the hands. Checking and rechecking that the television is turned off before going to school. Routinely climbing up and down a flight of stairs three times before leaving the house. Correct response: Checking and rechecking that the television is turned off before going to school. Repeatedly washing the hands. Routinely climbing up and down a flight of stairs three times before leaving the house. Explanation: Compulsions involve symbolic rituals that relieve anxiety when they are performed. The disorder is caused by anxiety from obsessive thoughts, and acts are seen as irrational. Examples include repeatedly checking the television set, washing hands, or climbing stairs. An activity such as playing the same video game each night may be indicative of normal development for a school-age child. Frequent brushing of the teeth and feeding the dog a consistent meal are not abnormal. Remediation: Obsessive-compulsive disorder Obsessive-compulsive disorder Question 38 See full question A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has: You Selected: cirrhosis. Correct response: cirrhosis. Explanation: Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal. Remediation: Cirrhosis Cirrhosis Question 39 See full question A client is to be discharged with a prescription for lactulose. The nurse teaches the client and the client’s spouse how to administer this medication. Which statement would indicate that the client has understood the information? You Selected: "I will mix it with apple juice." Correct response: "I will mix it with apple juice." Explanation: The taste of lactulose is a problem for some clients. Mixing it with fruit juice, water, or milk can make it more palatable. Lactulose should not be given with antacids, which may inhibit its action. Lactulose should not be taken with a laxative because increased stooling is an adverse effect of the drug and would be potentiated by using a laxative. Lactulose comes in the form of syrup for oral or rectal administration. Remediation: Lactulose Question 40 See full question A client with suspected inhalation anthrax is admitted to the emergency department. Which action by the nurse takes the highest priority? You Selected: Suction the client as needed to obtain a sputum specimen for culture and sensitivity. Correct response: Monitor vital signs and oxygen saturation every 15 to 30 minutes. Explanation: Monitoring vital signs and oxygen saturation every 15 to 30 minutes takes priority. Suctioning the client as needed to obtain a sputum specimen may be necessary, but assessing the client for changes in his respiratory status takes priority. Assessing intake and output and providing adequate hydration are important steps for liquefying secretions; however, they don't take priority. Reassuring the client that intubation and mechanical ventilation is temporary is inappropriate. The client may not require intubation and mechanical ventilation; however, if he does, the nurse can't predict the length of time it may be necessary. Remediation: Levofloxacin Question 41 See full question A client with renal insufficiency is admitted to the hospital with pneumonia. He's being treated with gentamicin. Which laboratory value should be closely monitored? You Selected:Blood urea nitrogen (BUN) Correct response: Blood urea nitrogen (BUN) Explanation: BUN and creatinine levels should be closely monitored to detect elevations caused by nephrotoxicity. Sodium level should be routinely monitored in all hospitalized clients. Alkaline phosphatase helps evaluate liver function. The WBC count should be monitored to evaluate the effectiveness of the antibiotic; it doesn't help evaluate kidney function. Remediation: Blood urea nitrogen level test Question 42 See full question A client with an exacerbation of chronic obstructive pulmonary disease (COPD) is admitted to the hospital. Which nursing diagnosis requires the nurse to collaborate with other health team members to achieve the best outcome for the client? You Selected: Impaired gas exchange Correct response: Impaired gas exchange Explanation: Impaired gas exchange requires collaboration between the nurse, physician, and respiratory therapist to help achieve the best respiratory outcome for the client. Medications, oxygen, nebulizer treatments, and arterial blood gas analyses all require a physician's order. The respiratory therapist administers the oxygen and nebulizer treatments. The nurse assesses the client's response to medications and respiratory treatments and provides feedback to the physician and respiratory therapist. Impaired skin integrity, Activity intolerance, and Imbalanced nutrition: Less than body requirements (when applied to the client with COPD) require independent nursing interventions without collaboration with other health team members. These interventions include skin care, pacing nursing care to promote rest and minimize fatigue, and providing small, frequent meals. Remediation:Care plan preparation Question 43 See full question A client on vacation experiences severe allergy symptoms, headache, and sinusitis (without respiratory distress). This client adamantly declines any supportive medications when offered. The nurse questions the client and learns the client receives weekly acupuncture treatments for these symptoms. The nurse’s best response is: You Selected: “Let us try this until you can have acupuncture.” Correct response: “Let us try this until you can have acupuncture.” Explanation: The nurse should respect the client’s choice of alternative treatments. It is respectful to offer choices until the client can again access acupuncture treatment. Acupuncture is not experimental. The nurse is being disrespectful to offer medications when the client has declined them, and it is silly to compare acupuncture to injectable medications. Remediation: Allergic rhinitis, long-term care Question 44 See full question What should a nurse do to ensure a safe hospital environment for a toddler? You Selected: Move the equipment out of reach. Correct response: Move the equipment out of reach. Explanation: Moving the equipment out of reach ensures a safe environment because toddlers are curious and may try to play with items within their reach. Toddlers in a strange hospital environment still need the security of a crib. Stacking toys don't need to be moved out of reach because they don't present a safety hazard and are appropriate for this age-group. Padded crib rails are necessary only if seizure activity is present. Remediation: Developmental Considerations in Caring for Children: Toddlers Question 45 See full question The client attends two sessions with the dietitian to learn about diet modifications to minimize gastroesophageal reflux. The teaching would be considered successful if the client decreases the intake of which foods? You Selected: fats Correct response: fats Explanation: Fats are associated with decreased esophageal sphincter tone, which increases reflux. Obesity contributes to the development of hiatal hernia, and a low-fat diet might also aid in weight loss. Carbohydrates and foods high in sodium or calcium do not affect gastroesophageal reflux. Remediation: Gastroesophageal reflux disease Question 46 See full question A client has received an infusion of antibiotics and is now experiencing an anaphylactic reaction. What is the most important intervention by the nurse? You Selected: Maintain a patent airway Correct response: Maintain a patent airway Explanation: The first priority is to maintain a patent airway. The client will then require an epinephrine injection. If hypotension develops, a saline bolus may be given. The client’s vital signs should be monitored, but not as the first action. Remediation: Anaphylaxis emergency patient care, ambulatory care Question 47 See full question The nurse is caring for a comatose, older adult with stage III pressure ulcers over two bony prominences. Which intervention should be added to the plan of care? You Selected: Place a foam pad on the existing mattress. Correct response: Place the client on a pressure redistribution bed. Explanation: A pressure redistribution bed will allow for constant motion of the client and prevent further breakdown. A foam pad will not be sufficient to prevent further breakdown in a patient this debilitated. Turning should be at a minimum of every 2 hours, and pain medication is not indicated unless the patient is demonstrating pain. Remediation: Low-air-loss therapy bed use Question 48 See full question An older client reports episodes of severe anxiety resulting in shortness of breath, palpitations, chest pain, dizziness, and nausea. The physician prescribes lorazepam. What effect of this medication would be most important for the nurse to monitor on this client? You Selected: Hyponatremia Correct response: Sedation Explanation: Lorazepam use, especially in older adults, has a pronounced sedative effect. This puts the client at risk for injury and falls. Hyponatremia, paradoxical reactions, and sleep disturbances are less common adverse effects of lorazepam and would not be as acutely dangerous to the elderly client as sedation. Remediation: lorazepam Question 49 See full question The nurse is analyzing the arterial blood gas (AGB) results of a client diagnosed with severe pneumonia. What ABG results are most consistent with this diagnosis? You Selected: pH: 7.20, PaCO2: 65 mm Hg, HCO3–: 26 mEq/L Correct response: pH: 7.20, PaCO2: 65 mm Hg, HCO3–: 26 mEq/L Explanation: Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3– occurs. It may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg, HCO3–: 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm Hg, and HCO3–: 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.42, PaCO2: 45 mm Hg, and HCO3–: 22 mEq/L indicate a normal result/no imbalance. Remediation: Pneumonia Arterial blood gas analysis Question 50 See full questionA 26-year-old primigravida visiting the prenatal clinic for her regular visit at 34 weeks’ gestation tells the nurse that she takes mineral oil for occasional constipation. What should the nurse should instruct the client to do? You Selected: Avoid mineral oil because it interferes with the absorption of fat-soluble vitamins. Correct response: Avoid mineral oil because it interferes with the absorption of fat-soluble vitamins. Explanation: Mineral oil is a harsh laxative that is contraindicated during pregnancy because it interferes with absorption of the fat-soluble vitamins A, D, E, and K from the intestinal tract. Dietary measures, exercise, and increased fluid and fiber intake are better choices to prevent constipation. If necessary, a stool softener or mild laxative may be prescribed. Use of fruit juice is recommended for the client receiving iron supplementation to enhance its absorption. Mineral oil does not lead to vitamin C deficiency in pregnant clients. Mineral oil use is contraindicated during pregnancy and therefore should not be used. Increased fluids, fiber, and exercise are better choices to suggest for relief of constipation. Remediation: Mineral oil oral liquid Question 51 See full question A client’s blood pressure is elevated at 160/90 mm Hg. The health care provider (HCP) prescribed “clonidine 1 mg by mouth now.” The nurse sent the prescription to pharmacy at 0710, but the medication still has not arrived at 0800. The nurse should do all except: You Selected: go to the pharmacy to obtain the drug. Correct response: go to the pharmacy to obtain the drug. Explanation: Although the nurse needs to obtain and administer the medication as soon as possible, it is inappropriate for the nurse to go to the pharmacy and request the drug without first calling the pharmacy and checking to see whether the medication was delivered. The drug may have been delivered to several appropriate spots on the unit, such as the client’s drug bin, the transport system, or the delivery box. The nurse should assess the client’s blood pressure to determine the immediacy of the condition for which the medication was prescribed. Remediation: Safe medication administration practices Question 52 See full question A nurse-manager appropriately behaves as an autocrat in which situation? You Selected: Directing staff activities if a client experiences a cardiac arrest Correct response: Directing staff activities if a client experiences a cardiac arrest Explanation: In a crisis situation, the nurse-manager should take command for the benefit of the client. Planning vacation time and evaluating procedures and client resources require staff input and are actions characteristic of a democratic or participative manager. Question 53 See full question A client admitted to the inpatient psychiatric unit changes clothes eight or nine times a day, wears heavy eye makeup, is intrusive with other clients, and makes inappropriate sexual advances toward staff members. Which of the following client goals would be most appropriate? You Selected: The client will refrain from hugging other clients and change clothing only twice per day. Correct response: The client will refrain from hugging other clients and change clothing only twice per day. Explanation: The focus should be on symptom management and containment until the client recovers enough to participate in more structured nursing interventions. Small changes in hugging and wardrobe change behavior will be realistic, offer a measure of change/stability, and help decrease overall hypomanic behaviors. Recording the number of clothing changes per day is not realistic. Having staff members help the client choose appropriate dress is incorrect because this behavior will encourage continued inappropriate sexual advances. The client does not have difficulties with low self-esteem. Remediation: Manic episode patient care Question 54 See full question A nurse should monitor a client receiving lidocaine for toxicity. Which signs or symptoms in a client suggest lidocaine toxicity? You Selected: Confusion and restlessness Correct response: Confusion and restlessness Explanation: Confusion and restlessness are signs of lidocaine toxicity. Nausea and vomiting may occur with oral administration of mexiletine or tocainide — other class IB drugs. Pupillary changes and hypertension aren't signs of lidocaine toxicity, although visual changes and hypotension may occur as adverse reactions to class IB drugs. Remediation: Lidocaine hydrochloride Question 55 See full question A couple visiting the infertility clinic for the first time states that they have been trying to conceive for the past 2 years without success. After a history and physical examination of both partners, what would be the most appropriate outcome for the couple to accomplish by the end of this visit? You Selected:Describe each of the potential causes and possible treatment modalities. Correct response: Describe each of the potential causes and possible treatment modalities. Explanation: By the end of the first visit, the couple should be able to identify potential causes and treatment modalities for infertility. If their evaluation shows that a treatment or procedure may help them to conceive, the couple must then decide how to proceed, considering all of the various treatments before selecting one. Treatments can be difficult, painful, or risky. The first visit is not the appropriate time to decide on a treatment plan because the couple needs time to adjust to the diagnosis of infertility, a crisis for most couples. Although the couple may be in a hurry for definitive therapy, a thorough assessment of both partners is necessary before a treatment plan can be initiated. The success rate for achieving a pregnancy depends on both the cause and the effectiveness of the treatment, and in some cases it may be only as high as 30%. The couple may desire information about alternatives to treatment, but insufficient data are available to suggest that a specific treatment modality may not be successful. Suggesting that the couple consider adoption at this time may inappropriately imply that the couple has no other choice. If a specific therapy may result in a pregnancy, the couple should have time to consider their options. After a thorough evaluation, adoption may be considered by the couple as an alternative to the costly, time-consuming, and sometimes painful treatments for infertility. Remediation: Care plan preparation Question 56 See full question A nurse is preparing to give an average-size 9-year-old child a preoperative I.M. injection. Which size needle should the nurse use? You Selected: 22G, 1″ Correct response: 22G, 1″ Explanation:The nurse should evaluate the muscle mass and amount of subcutaneous fat and then select the correct needle size. Without more information, the nurse would select the 22G, 1″ needle, appropriate for an average-size school-age child. The 20G, 1″ needle would be unnecessarily large. The 22G, 1½″ needle would be too long. The 20G, 1½″ needle would be too long and unnecessarily large. Remediation: Intramuscular injection, pediatric Pharmacology: Intramuscular Injection Question 57 See full question The nurse is caring for a client who is a recent immigrant from China. Through the hospital interpreter, the client expresses an unwillingness to eat the fried fish that was on the meal tray, describing it as "too hot." What is the nurse's best action? You Selected: Ask the interpreter to ask the client about the specific meaning of the description of "hot." Correct response: Ask the interpreter to ask the client about the specific meaning of the description of "hot." Explanation: In many Asian cultures, foods are categorized on a continuum of cold to hot that is independent of their physical temperature. Consequently, it is important for the nurse to assess the precise meaning of the client's statement before taking further action such as changing the client's diet. It is appropriate to assess the client's food preferences, but this data should come from the client, not the interpreter. Remediation: Cultural assessment Question 58 See full question A client has a history of schizophrenia. Because he has a history of noncompliance with antipsychotic therapy, he will receive fluphenazine decanoate injections every 4 weeks. Before discharge, what should the nurse include in her teaching plan? You Selected:Sitting up for a few minutes before standing to minimize orthostatic hypotension Correct response: Sitting up for a few minutes before standing to minimize orthostatic hypotension Explanation: The nurse should teach the client how to manage common adverse reactions, such as orthostatic hypotension and anticholinergic effects. Antipsychotic effects of the drug may not become evident for several weeks. Droperidol increases the risk of extrapyramidal effects when given in conjunction with phenothiazines such as fluphenazine. Tardive dyskinesia is a possible adverse reaction and should be reported immediately. Remediation: Fluphenazine decanoate Question 59 See full question A client is admitted to the health care facility with acute chest pain. When obtaining the client's health history, which question would be most helpful for the nurse to ask? You Selected: "What were you doing when the pain started?" Correct response: "What were you doing when the pain started?" Explanation: Subjective data (data from the client) about the chest pain help the nurse determine the specific health problem. For example, asking about the setting in which the pain developed can provide helpful information about its cause. Asking about the history and medications will yield helpful information, but would not be the most helpful. Remediation: Pain management Question 60 See full questionA nurse is assessing the family of an infant and observes that the parents are argumentative and appear fatigued. They indicate that the baby is not breastfeeding well and cries through the night. What would be the nurse’s priority nursing diagnosis for this infant? You Selected: Altered nutrition (less than body requirements) related to difficulty sucking Correct response: Altered nutrition (less than body requirements) related to difficulty sucking Explanation: The nurse’s initial priority should be to address the caloric intake of the baby through health teaching and support of the parents to ensure that the baby will meet age-appropriate growth and development milestones. Remediation: Breast-feeding assistance Ineffective infant feeding pattern Question 61 See full question An elderly couple who have just relocated to a long-term care facility have been unable to obtain a shared room. A staff member at the facility states that this should not be a concern and implies that sexual activity between the couple likely ceased many years ago. How should the nurse best respond to this individual’s assertion? You Selected: "Actually it's not true that older people always stop having sexual activity when they get older." Correct response: "Actually it's not true that older people always stop having sexual activity when they get older." Explanation: Sexual activity need not be hindered by age. There is no evidence, however, that it becomes increasingly frequent in late adulthood. Question 62 See full question A nurse hears a client state, “I have had it with this marriage. It would be so much easier to just hire someone to kill my husband!” What action should the nurse take? You Selected: The nurse must start the process to warn the client’s husband. Correct response: The nurse must start the process to warn the client’s husband. Explanation: Confidentiality must be broken if there are credible threats made against another person’s safety. Confidentiality does not override the safety of other persons. Remediation: Confidentiality, maintaining Question 63 See full question A client’s nutritional status has been severely compromised through prolonged episodes of nausea and vomiting. Which nutritional therapy will be the most effective in correcting nutritional deficits before surgery? You Selected: total parenteral nutrition (TPN) for several days Correct response: total parenteral nutrition (TPN) for several days Explanation: TPN bypasses the enteral route and provides total nutrition: protein, carbohydrates, fats, vitamins, minerals, and trace elements. The client is not able to tolerate oral feedings. Enteral feedings would enter the stomach and could increase feelings of fullness, nausea, and vomiting that the client may have had. IV isotonic saline, which contains only water, sodium, and chloride, provides incomplete nutrition. Remediation: Parenteral nutrition administration Question 64 See full question A man brings his wife to the emergency department. He reports that since the death of their 7- month-old daughter 8 weeks earlier, his wife has been neglecting her housework and family, has lost 20 lb (9.1 kg), and has not left the house. Which of the following additional assessment findings would indicate to the nurse that the client may be experiencing extreme depression? Select all that apply. You Selected: Speaking in soft monotone voice Inconsolable weeping Obvious neglect of personal hygiene Correct response: Obvious neglect of personal hygiene Speaking in soft monotone voice Inconsolable weeping Explanation: Typically, a depressed client exhibits slow movements and fatigue and poor hygiene/grooming. Such a client also has difficulty interacting, speaking in a monotone voice, and avoiding eye contact. In extreme depression, the client may not communicate verbally at all, or the client may verbalize feelings of anger and lash out with irritability. Remediation: Major depression Question 65 See full questionA client tells the nurse, "Everybody smiles at me because they know that I was chosen by God for this mission." The nurse interprets this statement as which finding? You Selected: idea of reference Correct response: idea of reference Explanation: An idea of reference is a person’s view that other people recognize that she has an important characteristic or power. Thought insertion refers to a person’s belief that others, or a specific other, can put thoughts into her mind. Visual hallucinations involve seeing objects or persons not based on reality. A neologism is a word or phrase that has meaning only to the person using it. Remediation: Group work techniques Question 66 See full question A nurse is caring for a client newly diagnosed with primary hypertension. Which activity best reflects the implementation phase of the nursing process? You Selected: Collaborating with the client to set exercise goals Correct response: Providing education about documenting blood pressure readings Explanation: Implementation involves providing actual nursing care. Education is an intervention that occurs during the implementation phase. Goal setting and formulation of nursing diagnosis do not occur during the implementation phase of the nursing process. Remediation: Hypertension Hypertension Question 67 See full question An overweight adolescent has been diagnosed with type 2 diabetes. To increase the client's self-efficacy to manage their disease, the nurse should: You Selected: provide the client with a written daily food and exercise plan. Correct response: utilize a peer with type 2 diabetes to role model lifestyle changes. Explanation: Self-efficacy, or the belief that one can act in a way to produce a desired outcome, can be promoted through the observation of role models. Peers are particularly effective role models because clients can more readily identify with them and believe they are capable of similar behaviors. Providing a written plan alone does not promote self-efficacy. Having parents eliminate junk food and having the school nurse weigh the adolescent can be part of the plan, but these actions do not empower the client. Remediation: Diabetes mellitus, type 2 Question 68 See full question While receiving phototherapy, a neonate begins to have frequent, loose, watery, green stools and is very irritable. The nurse interprets this as which situation? You Selected: The neonate may have a malabsorption problem. Correct response: This is a normal adverse effect of phototherapy. Explanation: Phototherapy increases gastric motility, causing the neonate to have many green, watery stools. The increased gastric motility also causes the neonate to be irritable. There is no evidence that the neonate has a lactose intolerance or malabsorption problem, nor is there evidence that the neonate's bilirubin levels are rising to dangerous levels. Remediation: Phototherapy Question 69 See full question A hospital nurse is on the safety committee. Which should the nurse recommend to the hospital administration to reduce needle-stick injuries at the institution? Select all that apply. You Selected: Purchase safety needle devices Encourage staff to plan safe handling and disposal of needles before initiating a procedure Post signs reminding staff to dispose of needles immediately after use Correct response: Purchase safety needle devices Encourage staff to plan safe handling and disposal of needles before initiating a procedure Post signs reminding staff to dispose of needles immediately after use Remind staff to use the “scoop” technique for recapping needles Explanation: The nurse should not recap needles. Choosing safety needle devices whenever possible and appropriate; planning in advance how to handle and dispose of needles; and discarding needles, safety needle systems, and sharps in sharpsdisposal containers immediately after use are safe ways to handle sharps with less risk of needle-stick injuries. The nurse should use the one-handed needlerecapping technique only when absolutely necessary, such as when a sharpsdisposal container is not readily available. Remediation: Standard precautions Question 70 See full questionA client receiving total parenteral nutrition is ordered a 24-hour urine test. When initiating a 24-hour urine specimen, the collection time should: You Selected: start after a known voiding. Correct response: start after a known voiding. Explanation: When initiating a 24-hour urine specimen, have the client void, then start the timing. The collection should start on an empty bladder. The exact time the test starts isn't important but the test is commonly started in the morning. Remediation: 12- or 24-hour timed urine collection Question 71 See full question A nurse is working in a rural health clinic that serves a large Amish population. The nurse is developing a program to address common health promotion strategies. Which aspect would be most important for the nurse to integrate into the program to promote its success? Select all that apply. You Selected: importance of the extended family in providing support focus on being in tune with nature for health maintenance need to ask for permission before physically touching a client Correct response: importance of the extended family in providing support focus on being in tune with nature for health maintenance need to ask for permission before physically touching a client Explanation:In the Amish culture, the extended family and community play important roles in supporting the client. They have a strong extended family social structure, and caring for the community is a strong value. Family structure is patriarchal, with the husband often the family spokesperson and decision maker. The Amish believe in the importance of nature to maintain health and often use natural remedies as a major part of care. Because touch is discouraged, permission is needed before touching a client. Remediation: Amish community Question 72 See full question The health care provider (HCP) prescribes intestinal decompression with a Cantor tube for a client with an intestinal obstruction. In order to determine effectiveness of intestinal decompression, the nurse should evaluate the client to determine if: You Selected: intestinal fluid and gas have been removed. Correct response: intestinal fluid and gas have been removed. Explanation: Intestinal decompression is accomplished with a Cantor, Harris, or Miller-Abbott tube. These 6- to 10-foot (180 to 300 cm) tubes are passed into the small intestine to the obstruction. They remove accumulated fluid and gas, relieving the pressure. The client will not have an adequate bowel movement until the obstruction is removed. The pressure from the distended intestine should not obstruct urinary output. While the client may be able to more easily sit up, and the pain caused by the intestinal pressure will be less, these are not the primary indicators for successful intestinal decompression. Remediation: Nasoenteric-decompression tube management Question 73 See full question An assessment of a client on the first day after a thoracotomy shows a temperature of 100° F (37.8° C); heart rate, 96 bpm; blood pressure, 136/86 mmHg; and shallow respirations at 30 breaths/min, with rhonchi at the bases. The client is diaphoretic, anxious,