NCLEX-RN Practice Quiz Test Bank #9 (75 Questions And Answers)

NCLEX-RN Practice Quiz Test Bank #9 (75 Questions) NCLEXRN-09-001 Question Tag: room assignments Question Category: Physiological Integrity, Basic Care and Comfort Which roommate would be mo st suitable for the 6-year-old male with a fractured femur in Russell’s traction? A. 16-year-old female with scoliosis B. 12-year-old male with a fractured femur C. 10-year-old male with sarcoma D. 6-year-old male with osteomyelitis Correct Answer: B. 12-year-old male with a fractured femur The 6-year-old should have a roommate as close to the same age as possible, so the 12-year-old is the best match. A bed is available and the patient gets assigned. There are certain constraints—sex, semi-private versus private, isolation issues, acuity, telemetry and specialty needs. All need to be taken into account to ensure that each patient goes to the right place and receives the proper care. But good capacity management demands that bed assignment be carefully considered and executed. Option A: The client is too old and is female. Bed assignment simply provides the proper location based on specific patient attributes like sex, isolation, telemetry, acuity and specialty needs. Option C: The 10-year-old with sarcoma has cancer and will be treated with chemotherapy that makes him immune suppressed. Bed managers aim at finding an assignment of patients to rooms that strikes a balance between patients’ preferences and comfort on the one hand, and patients’ clinical conditions and the resulting required room facilities on the other. Option D: The 6-year-old with osteomyelitis is infectious. Rooms and beds belong to the critical assets of just any hospital. They account for a considerable part of a hospital’s infrastructure, and a large amount of financial resources are invested in equipping them with medical apparatus to facilitate patient care. Furthermore, they also represent the place where most patients will spend a large part of their stay, as they recover from surgery, wait for examinations to take place, etc. NCLEXRN-09-002 Question Tag: celebrex (Celecoxib) Question Category: Health Promotion and Maintenance A client with osteoarthritis has a prescription for celebrex (Celecoxib). Which instruction should be included in the discharge teaching? A. Take the medication with milk. B. Report chest pain. C. Remain upright after taking for 30 minutes. D. Allow 6 weeks for optimal effects. Correct Answer: B. Report chest pain. Cox II inhibitors have been associated with heart attacks and strokes. Any changes in cardiac status or signs of a stroke should be reported immediately, along with any changes in bowel or bladder habits because bleeding has been linked to use of Cox II inhibitors. Like all NSAIDs, celecoxib carries an FDA boxed warning for cardiovascular risk, including the increased risk of heart attacks and strokes. As a selective COX-2 inhibitor, celecoxib also faces scrutiny for increased cardiovascular risk, since another selective COX-2 inhibitor, rofecoxib, was withdrawn from production in 2004 due to cardiovascular risk concerns. Option A: The medication can be taken with water. Celecoxib is a medication that is taken orally and comes in 50, 100, 200, and 400 mg doses. In rare cases, celecoxib can also be added to customized compounds for topical administration with or without the use of iontophoresis or other topical delivery mechanisms. It is not available via any other route of administration. Option C: The client may remain upright but not necessarily for 30 minutes. Symptoms of celecoxib overdose would likely be similar to overdoses of other NSAIDs, which include lethargy, drowsiness, nausea, vomiting, and epigastric pain. Activated charcoal may be administered for overdose treatment at the discretion of emergency medical providers if the patient presents within 4 hours of known or suspected ingestion of significant amounts of celecoxib. Option D: Allow 6 weeks for optimal effect. In the inpatient setting, as mentioned above, celecoxib is increasingly being used as part of pre-operative and post-operative multimodal pain management algorithms. Research has shown in several small randomized trials that administering celecoxib peri-operatively for elective procedures such as total hip arthroplasties, total knee arthroplasties, and other procedures with some success in reducing pain and improving functionality such as early ambulation. NCLEXRN-09-003 Question Tag: fracture, cast Question Category: Safe and Effective Care Environment,, Safety and Infection Control A client with a fractured tibia has a plaster-of-Paris cast applied to immobilize the fracture. Which action by the nurse indicates an understanding of a plaster-of-Paris cast? The nurse: A. Handles the cast with the fingertips B. Petals the cast C. Dries the cast with a hair dryer D. Allows 24 hours before bearing weight Correct Answer: D. Allows 24 hours before bearing weight A plaster-of-Paris cast takes 24 hours to dry, and the client should not bear weight for 24 hours. After the process of applying the casting material is completed, the material will start to dry in about 10 to 15 minutes. The temperature of the skin might rise as the plaster is drying because of a chemical reaction that occurs. When plaster is used, it can take from 1 to 2 days for the cast to harden completely. Option A: The cast should be handled with the palms, not the fingertips. Use the palm of hand to apply, hold, or move cast and support on pillows after application. Uneven plaster is irritating to the skin and may result in abrasions. Option B: Petaling a cast is covering the end of the cast with cast batting or a sock, to prevent skin irritation and flaking of the skin under the cast. Trim excess plaster from edges of the cast as soon as casting is completed; prevents skin breakdown caused by prolonged moisture trapped under the cast. Option C: The client should be told not to dry the cast with a hair dryer because this causes hot spots and could burn the client. This also causes unequal drying. Promote cast drying by removing bed linen, exposing it to circulating air; pressure can cause ulcerations, necrosis, or nerve palsies. Pad (petal) the edges of the cast with waterproof tape; provides an effective barrier to cast flaking and moisture. Helps prevent the breakdown of cast material at the edges and reduce skin irritation and excoriation. NCLEXRN-09-004 Question Tag: fiberglass cast Question Category: Physiological Integrity, Basic Care and Comfort The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which response would be best? A. “It will be alright for your friends to autograph the cast.” B. “Because the cast is made of plaster, autographing can weaken the cast.” C. “If they don’t use chalk to autograph, it is okay.” D. “Autographing or writing on the cast in any form will harm the cast.” Correct Answer: A. “It will be alright for your friends to autograph the cast.” There is no reason that the client’s friends should not be allowed to autograph the cast; it will not harm the cast in any way, so answers B, C, and D are incorrect. Fiberglass has several advantages compared to plaster. It weighs less, so the cast made from it will be lighter. More durable and porous, fiberglass allows air to flow in and out. Fiberglass is the better choice in case the limb must be X-rayed during the healing process. It is also available in a variety of colors. Option B: Plaster costs less than fiberglass and is more malleable (is more easily shaped) than fiberglass in certain cases. Plaster comes in strips or rolls that are moistened and rolled on over the padding. Plaster materials are made from dry muslin that is treated with starch or dextrose and calcium sulfate. Option C: Keep the cast clean and dry. A hair dryer with a cool setting may be used to dry a fiberglass cast if it becomes damp. Call a doctor if the cast does not dry or if the skin under the cast becomes wet. Avoid placing pressure or weight on the cast. If you have a leg injury and have a walking cast, make sure that the cast has hardened completely before you attempt to walk on it. Option D: Like plaster, fiberglass materials come in rolls. Strips are moistened and applied to form the cast. The cast will appear rough after it has dried. Do not place any objects inside the cast. Avoid using lotions or powders on skin underneath the cast. NCLEXRN-09-005 Question Tag: Steinmann pin Question Category: Safe and Effective Care Environment, Management of Care The nurse is assigned to care for the client with a Steinmann pin. During pin care, she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action should the nurse take at this time? A. Assisting the LPN with opening sterile packages and peroxide. B. Telling the LPN that clean gloves are allowed. C. Telling the LPN that the registered nurse should perform pin care. D. Asking the LPN to clean the weights and pulleys with peroxide. Correct Answer: A. Assisting the LPN with opening sterile packages and peroxide The nurse is performing the pin care correctly when she uses sterile gloves and Q-tips. All pins and wire sites must be cleaned daily. Basic pin care will be performed once daily by the hospital nursing staff prior to discharge from the hospital. Following discharge, the patient and family will go to the clinic for pin care teaching and instructions. Option B: During pin care, the sterile technique is utilized and sterile gloves are needed. The approach to pin care should occur in a stepwise fashion. If step one is effective there is no need to go further and pins can be wrapped with gauze. If step one is not effective, please continue until effective pin care has been achieved. Option C: A licensed practical nurse can perform pin care. Pin care is recommended during showers, after pool therapy, or swimming in the pool or ocean (ocean saltwater is good for pin sites). Ideally, pin sites are cleaned when the surrounding skin and gauze are soft. This should make removal of gauze and cleaning of pins less painful. Option D: There is no need to clean the weights. The purpose of the cleaning is to prevent the skin from attaching to the pins and wires and to clean and inspect the area to decrease the chance of infection. NCLEXRN-09-006 Question Tag: scoliosis, spica cast Question Category: Physiological Integrity, Reduction of Risk Potential A child with scoliosis has a spica cast applied. Which action specific to the spica cast should be taken? A. Check the bowel sounds B. Assess the blood pressure C. Offer pain medication D. Check for swelling Correct Answer: A. Check the bowel sounds A body cast or spica cast extends from the upper abdomen to the knees or below. Bowel sounds should be checked to ensure that the client is not experiencing a paralytic ileus. Auscultate the abdomen for bowel sounds, if bowel sounds are present, or the patient reports they are passing flatus, clear fluids can commence and aperiments can be administered. Patients must not commence oral fluids if bowel sounds are not present as this finding indicates an ileus. Option B: Checking the blood pressure is a treatment for any client. Routine post anaesthetic observations are a requirement for patient assessment and the recognition of clinical deterioration in post-operative patients; acknowledging that children are at a high risk of complications post anesthetics, surgeries and procedures. Option C: Offering pain medication is inappropriate. Patients who have had a closed reduction usually only require oral analgesia. Patients who have sustained a fracture or who have had open reduction or osteotomy will usually require an opioid infusion and/or epidural. Pain scores, interventions, and evaluation of interventions performed, should be documented in the observation flowsheet. Option D: Checking for swelling isn’t specific to the stem. Evaluate patients’ skin integrity regularly. Observe any redness, irritation or burning sensation. In the acute postoperative period swelling can occur and a tight cast can potentially cause neurovascular compromise. Children who have had an open reduction or osteotomy may have significant swelling in the groin area. Monitor swelling and plaster to ensure the cast is not too tight. NCLEXRN-09-007 Question Tag: fracture, traction Question Category: Safe and Effective Care Environment,, Safety and Infection Control The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge? A. Russell’s traction B. Buck’s traction C. Halo traction D. Crutchfield tong traction Correct Answer: C. Halo traction Halo traction will be ordered for the client with a cervical fracture. Halo-gravity traction is a way to pull the head and spine upward carefully, applying a slow stretch to the spine. Doctors do this by attaching a halo (a metal ring that surrounds the head) to a pulley system. Over several weeks, weights are added to the pulley system to slowly pull the head upward. This pulling is called “traction.” Kids stay in the hospital during halo-gravity traction. Option A: According to Oxford Reference, Russell traction is a type of skin traction used to stabilize and align the lower extremities. The patient’s leg is suspended in a sling and attached to pulleys, strings and weights, which serve to gently draw the bones into alignment. Option B: An apparatus for applying longitudinal traction on the leg by contact between the skin and adhesive tape, for maintaining the proper alignment of a leg fracture; friction between the tape and skin permits application of force through a cord over a pulley, suspending a weight; elevation of the foot of the bed allows the body to act as a counterweight; a type of traction in which a non constricting boot with weights is worn by the Pt to maintain proper alignment. Option D: Crutchfield tongs are used while in the hospital and the client is immobile. A traction device whose pins are inserted into the skull to distract and/or immobilize the neck. Crutchfield tongs are used to stabilize fractures of the cervical spine. NCLEXRN-09-008 Question Tag: continuous passive motion device Question Category: Physiological Integrity, Physiological Adaptation A client with a total knee replacement has a CPM (continuous passive motion device) applied during the postoperative period. Which statement made by the nurse indicates an understanding of the CPM machine? A. “Use of the CPM will permit the client to ambulate during the therapy.” B. “The CPM machine controls should be positioned distal to the site.” C. “If the client complains of pain during the therapy, I will turn off the machine and call the doctor.” D. “Use of the CPM machine will alleviate the need for physical therapy after the client is discharged.” Correct Answer: B. “The CPM machine controls should be positioned distal to the site.” The controller for the continuous-passive-motion device should be placed away from the client. Many clients complain of pain while having treatments with the CPM, so they might turn off the machine. The CPM flexes and extends the leg. Continuous passive motion (CPM) is a therapy in which a machine is used to move a joint without the patient having to exert any effort. A motorized device gently bends the joint back and forth to a set number of degrees, and the amount of movement and speed can be adjusted by the physical therapist. CPM machines are most commonly used on knee joints (after some types of knee surgery), but there are versions made for other joints as well. Option A: The client is in the bed during CPM therapy. The use of CPM may begin in the recovery room after surgery or on the day after surgery. Use of the CPM machine may be continuous while you are in the hospital, other than at times when you are receiving other physical therapy or are getting out of bed to use the restroom. Option C: The client will experience pain with the treatment. Recovering normal joint mobility after surgery can be a significant challenge. The stiffness of a joint can be a complication that limits outcomes and causes pain. Because of this, some surgeons use CPM to try to prevent scar tissue formation and improve range of motion. Option D: Use of the CPM does not alleviate the need for physical therapy. It may be recommended after procedures like ACL reconstruction or frozen shoulder surgery, but CPM is most likely to be prescribed after knee replacement or knee cartilage repair surgery. It may also be used after surgery to remove knee tumors in children with osteosarcoma. NCLEXRN-09-009 Question Tag: walker, fracture Question Category: Safe and Effective Care Environment,, Safety and Infection Control A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the: A. Palms rest lightly on the handles B. Elbows are flexed 0° C. Client walks to the front of the walker D. Client carries the walker Correct Answer: A. Palms rest lightly on the handles The client’s palms should rest lightly on the handles. The elbows should be flexed no more than 30° but should not be extended. Once a model of the walker has been selected, the “fit” of the walker becomes important. When holding on to the walker, the elbows should be bent in a position that feels comfortable and natural. The top of the walker should be even with the crease on the underside of the wrist when the arms are relaxed at the side. Option B: A 0° is not a relaxed angle for the elbows and will not facilitate correct walker use. Walkers that are too low cause the client to stoop over while walking, which impedes proper body mechanics. If the walker is at the wrong height, the client will be prone to aches and pains. Option C: The client should walk to the middle of the walker, not to the front of the walker. To get started, the client should push the walker slightly ahead, then step into the walker. Keep that pattern going—walker slightly ahead, then step into the walker. The walker should never be too far ahead and the client should have excellent posture as he takes steps. Also, the client should not look at feet, rather in front of him. Option D: The client should be taught not to carry the walker because this would not provide stability. If there is trouble gripping the walker, platform walkers are available that may prove to be a better option. The platform allows the client to rest the elbow and forearm, taking stress off the hands. NCLEXRN-09-010 Question Tag: prolapsed cord Question Category: Physiological Integrity, Physiological Adaptation When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should: A. Attempt to replace the cord B. Place the client on her left side C. Elevate the client’s hips D. Cover the cord with a dry, sterile gauze Correct Answer: C. Elevate the client’s hips. The client with a prolapsed cord should be treated by elevating the hips and covering the cord with a moist, sterile saline gauze. The nurse should use her fingers to push up on the presenting part until a cesarean section can be performed. Cesarean section should be performed before rupture of the membrane or the cord would slide down the vagina. Option A: The nurse should not attempt to replace the cord. Assessment of fetal heart sounds is necessary after rupture of membranes to rule out cord prolapse. If there is already complete dilatation, the physician can deliver the baby to prevent fetal anoxia. Option B: The client should not be turned to the side. The goal in therapeutic management is to relieve cord compression to avoid fetal anoxia that can be achieved through manually lifting the head of the fetal head off the cord through the vagina or placing the woman in a Trendelenburg position. Option D: The cord should be covered with a moist, sterile saline gauze. Once the cord has prolapsed and is exposed to air, drying of the umbilical cord and atrophy of the umbilical vessels would begin. Cover any exposed portion of the cord with a sterile saline compress to avoid drying. NCLEXRN-09-011 Question Tag: rosuvastatin Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies The client presents to the clinic with a serum cholesterol of 275 mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client? A. Report muscle weakness to the physician. B. Allow six months for the drug to take effect. C. Take the medication with fruit juice. D. Ask the doctor to perform a complete blood count before starting the medication. Correct Answer: A. Report muscle weakness to the physician. The client taking antilipidemics should be encouraged to report muscle weakness because this is a sign of rhabdomyolysis. The most common toxic side effect of rosuvastatin is myalgia. If the patient has mild to moderate muscle symptoms, the drug should be discontinued to evaluate for other causes of myalgia. If there is a resolution of the underlying etiology, the patient can restart the original or a lower dose of rosuvastatin; however, if symptoms reoccur for a second time, then discontinue rosuvastatin indefinitely. Switching to a different statin medication at a lower dose may relieve muscle symptoms. Option B: The medication takes effect within 1 month of beginning therapy. Dosing is individualized based on the low-density lipoprotein (LDL) levels at baseline and the goal of therapy. The patient’s response and adherence to medication is an important determinant to therapeutic success. Adjustments should be made at a regular interval of four weeks or more depending on the underlying pathology of the disease and whether the treatment is for primary versus secondary prevention. Option C: The medication should be taken with water because fruit juice, particularly grapefruit, can decrease the effectiveness. The administration of rosuvastatin is via capsule or tablet. The capsule can be administered orally or via a nasogastric tube. The oral route can be taken with or without food, at any time of the day, and should be swallowed whole. The capsule should never be crushed or chewed. If opening the capsule, it is recommended to empty the contents into one teaspoonful of applesauce and then swallow immediately without chewing. Option D: Liver function studies should be checked before beginning the medication, not after the fact, making answer D incorrect. Creatinine phosphokinase (CPK) levels should not be routinely measured; however, the clinician can base special considerations for measuring CPK on family history of statin intolerance, drug-drug interactions leading to increased risk of myopathy, or other clinical presentations that create a high index of suspicion of myopathy. NCLEXRN-09-012 Question Tag: diazoxide, hypertensive crises Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should: A. Utilize an infusion pump B. Check the blood glucose level C. Place the client in Trendelenburg position D. Cover the solution with foil Correct Answer: B. Check the blood glucose level Hyperstat is given as an IV push for hypertensive crises, but it often causes hyperglycemia. The glucose level will drop rapidly when stopped. This medication is used to treat very low blood sugar (hypoglycemia). Certain conditions (such as tumor on the pancreas, cancer, leucine sensitivity) can cause the release of too much insulin. Insulin is a natural substance that lowers blood sugar. This drug works by preventing insulin release from the pancreas, helping to return the blood sugar to normal levels. Diazoxide is a thiazide drug, but has no diuretic (“water pill”) effects like other thiazides. Option A: Diazoxide (Hyperstat) is given by IV push. Diazoxide is a potassium channel activator. Its mechanism of action revolves around enhancing cell membrane permeability to potassium ions. This action consequently elicits the relaxation of local smooth muscles. This switches off voltage-gated calcium ion channels which inhibits the generation of an action potential. Option C: The client should be placed in a dorsal recumbent position, not a Trendelenburg position. Diazoxide is used to treat low blood sugar (hypoglycemia) caused by certain cancers or other conditions that can make the pancreas release too much insulin. This medicine is for use in adults and children as young as infants. Option D: This medication does not have to be covered with foil. Store at room temperature away from moisture, heat, and light. Diazoxide is only part of a treatment program that may also include diet. Follow the doctor’s instructions very closely. NCLEXRN-09-013 Question Tag: ventral septal defect, Digitalis Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies The 6-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor? A. Blood pressure of 126/80 B. Blood glucose of 110 mg/dL C. Heart rate of 60 bpm D. Respiratory rate of 30 per minute Correct Answer: C. Heart rate of 60 bpm A heart rate of 60 in the baby should be reported immediately. The dose should be held if the heart rate is below 100 bpm. Digoxin has vagomimetic effects on the AV node. By stimulating the parasympathetic nervous system, it slows electrical conduction in the atrioventricular node, therefore, decreases the heart rate. The rise in calcium levels leads to prolongation of phase 4, and phase 0 of the cardiac action potential thus increases the refractory period of the AV node. Slower conduction through the AV node carries a decreased ventricular response. Option A: It increases the force of contraction of the heart by reversibly inhibiting the activity of the myocardial Na-K ATPase pump, an enzyme that controls the movement of ions into the heart. Digoxin induces an increase in intracellular sodium that will drive an influx of calcium in the heart and cause an increase in contractility. Cardiac output increases with a subsequent decrease in ventricular filling pressures. Option B: Electrocardiogram changes seen with digoxin demonstrate a downsloping ST-segment depression, also known as a “reverse check” sign. The ST segments may appear “scooped” without abnormal Q waves or T wave inversions. Regular intake of digoxin results in changes such as a decreased QT interval, prolongation of the PR interval and T wave inversion or flattening. In the case of overdose, the patient should receive digoxin immune fab. Option D: The prescriber needs to check levels with any recent change in medication. The kidneys excrete approximately 70% of digoxin in direct proportion to the patient’s glomerular filtration rate. The physician must request regular electrocardiograms and bloodwork to assess for renal function, and electrolytes require close monitoring. NCLEXRN-09-014 Question Tag: angina, nitroglycerin Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies The client admitted with angina is given a prescription for nitroglycerin. The client should be instructed to: A. Replenish his supply every 3 months B. Take one every 15 minutes if pain occurs C. Leave the medication in the brown bottle D. Crush the medication and take with water Correct Answer: C. Leave the medication in the brown bottle Nitroglycerine should be kept in a brown bottle (or even a special air- and water-tight, solid or plated silver or gold container) because of its instability and tendency to become less potent when exposed to air, light, or water. Store nitroglycerin pills in a dark-colored (such as brown), airtight, glass container that you cannot see through. Keep the container tightly closed. Keep nitroglycerin pills and liquid spray away from heat or moisture. Option A: The supply should be replenished every 6 months, not 3 months. Nitroglycerin is most commonly administered as a tablet that is absorbed sublingually. It is given in hospitals as well as prescribed for outpatient use. Patients may be prescribed nitroglycerin to take as prophylaxis for anginal chest pain prior to an event that may provoke anginal symptoms. They must be instructed to allow the nitroglycerin to dissolve in their mouth and allow their oral mucosa to absorb the drug. Option B: One tablet should be taken every 5 minutes until pain subsides. If the pain does not subside, the client should report to the emergency room. There currently are three doses available: 0.3 mg, 0.4 mg, and 0.6 mg. The dose is repeatable every 5 minutes until the achievement of relief. If anginal pain persists after three doses, prompt medical attention is required. After administration, the onset of vasodilatory effects occurs within 1 to 3 minutes, with a max effect occurring within 5 minutes. Option D: The medication should be taken sublingually and should not be crushed. Nitroglycerin is primarily eliminated via metabolism in the liver and has a mean half-life of approximately 2 to 3 minutes. In the event of overdose, monitoring of vital signs may be necessary to monitor the hemodynamic effects of nitroglycerin. Continuous monitoring of blood pressure, heart rate, respiratory rate, and oxygen saturation is recommended. NCLEXRN-09-015 Question Tag: cholesterol Question Category: Physiological Integrity, Basic Care and Comfort The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats? A. Macaroni and cheese B. Shrimp with rice C. Turkey breast D. Spaghetti Correct Answer: C. Turkey breast Turkey contains the least amount of fats and cholesterol. Both turkey and chicken are rich in high-quality protein. Chicken breast has slightly more protein than turkey breast, but turkey thigh is minimally higher in protein than chicken thigh. The other meat cuts provide equal amounts of protein. Option A: It’s typically high in calories because it’s made with pasta, cheese, cream, and butter, although the calorie content varies significantly between brands, ingredients, and serving size. Mac and cheese contain large amounts of fat and refined carbs, both of which contribute to its high calorie count. Eating more calories than you burn, regardless of which foods they come from, can lead to weight gain. Option B: White rice is highly processed and missing its hull (the hard protective coating), bran (outer layer), and germ (nutrient-rich core). Meanwhile, brown rice only has the hull removed. White rice is considered empty carbs since it loses its main sources of nutrients. Option D: Spaghetti is one of the most popular forms of pasta, and it’s used in dishes all around the world. Most spaghetti is made from durum wheat, so it’s high in complex carbohydrates and includes all the nutrients found in refined white flour. Liver, eggs, beef, cream sauces, shrimp, cheese, and chocolate should be avoided by the client. The client should bake meat rather than frying to avoid adding fat to the meat during cooking. NCLEXRN-09-016 Question Tag: congestive heart failure Question Category: Physiological Integrity, Reduction of Risk Potential The client is admitted with right congestive heart failure. In assessing the client for edema, the nurse should check the: A. Feet B. Neck C. Hands D. Sacrum Correct Answer: B. Neck The jugular veins in the neck should be assessed for distension. Increased blood volume, which can occur with right sided heart failure, or anything that interferes with filling of the right atrium or movement of the blood into the right ventricle, can increase the central venous pressure and the amount of jugular vein distention. Option A: Jugular vein distention is affected by the position of your body. If the height is greater than 3 to 4 centimeters when measured while you are in bed with your head elevated 45 degrees, this may signal vascular or heart disease. Smaller amounts of jugular vein distention can occur in people without heart or vascular disease. Option C: For example, jugular vein distention may be raised by a narrowing or blockage of the superior vena cava, which can interfere with blood return to the heart. Option D: It can also be caused by constrictive pericarditis (infection of the lining that surrounds the heart) and cardiac tamponade (filling of the sac around the heart with blood or other fluid), both of which restrict the volume of the heart. The other parts of the body will be edematous in right-sided congestive heart failure, not left-sided. NCLEXRN-09-017 Question Tag: central venous pressure Question Category: Physiological Integrity, Reduction of Risk Potential The nurse is checking the client’s central venous pressure. The nurse should place the zero of the manometer at the: A. Phlebostatic axis B. PMI C. Erb’s point D. Tail of Spence Correct Answer: A. Phlebostatic axis The phlebostatic axis is located at the fifth intercostal space midaxillary line and is the correct placement of the manometer. Phlebostatic axis is a point located by drawing an imaginary line from the fourth intercostal space at the sternum and finding its intersection with an imaginary line drawn down the center of the chest below the axillae. Option B: The PMI or point of maximal impulse is located at the fifth intercostal space midclavicular line. The point of maximal impulse, known as PMI, is the location at which the cardiac impulse can be best palpated on the chest wall. Frequently, this is at the fifth intercostal space at the midclavicular line. When dilated cardiomyopathy is present, this can be shifted laterally. Option C: Erb’s point is the point at which you can hear the valves close simultaneously. “Erb’s point” is also a term used in head and neck surgery to describe the point on the posterior border of the sternocleidomastoid muscle where the four superficial branches of the cervical plexus—the greater auricular, lesser occipital, transverse cervical, and supraclavicular nerves—emerge from behind the muscle. Option D: The Tail of Spence (the upper outer quadrant) is the area where most breast cancers are located and has nothing to do with the placement of a manometer. The tail of Spence (Spence’s tail, axillary process, axillary tail) is an extension of the tissue of the breast that extends into the axilla. It is actually an extension of the upper lateral quadrant of the breast. It passes into the axilla through an opening in the deep fascia called foramen of Langer. NCLEXRN-09-018 Question Tag: hypertension Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should: A. Question the order B. Administer the medications C. Administer separately D. Contact the pharmacy Correct Answer: B. Administer the medications Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix for hypertension. Studies of hypertension confirm that ACE inhibitors enhance the antihypertensive effects of diuretics, though the interaction appears more additive than synergistic. Combining diuretics with ACE inhibitors appear to be no more effective than combining them with beta blockers. Option A: Diuretics and angiotensin-converting enzyme (ACE) inhibitors are commonly used in combination, both for patients with heart failure and for those with hypertension. Option C: Diuretics activate the renin–angiotensin–aldosterone (RAAS) system that may limit the effects of diuretics on vascular tone and sodium excretion, which in turn, may limit their efficacy in reducing arterial pressure or in improving the symptoms of heart failure. ACE inhibitors can reduce plasma concentrations of angiotensin II and aldosterone, providing a theoretical rationale for use in combination with a diuretic. Option D: The order is accurate. There is no need to question the order, administer the medication separately, or contact the pharmacy. When used in combination, the thiazide diuretics and the angiotensin-converting enzyme inhibitors have been shown to improve blood pressure reduction over either drug used alone. NCLEXRN-09-019 Question Tag: edema Question Category: Physiological Integrity, Physiological Adaptation The best method of evaluating the amount of peripheral edema is: A. Weighing the client daily B. Measuring the extremity C. Measuring the intake and output D. Checking for pitting Correct Answer: B. Measuring the extremity ADVERTISEMENTS The best indicator of peripheral edema is measuring the extremity. A paper tape measure should be used rather than one of plastic or cloth, and the area should be marked with a pen, providing the most objective assessment. The circumferential method is one of the girth measurement techniques. For consistent measurements, each upper extremity or lower extremity is marked with a semi-permanent marker at a certain part with reference to the bony prominences. Option A: Weighing the client will not indicate peripheral edema. The accumulation of fluid occurs when local or systemic conditions disrupt this equilibrium, leading to increased capillary hydrostatic pressure, increased plasma volume, decreased plasma oncotic pressure (hypoalbuminemia), increased capillary permeability, or lymphatic obstruction. Option C: Measuring the intake and output will not indicate peripheral edema. The most commonly used tools to measure edema are: volume measurements (with a water volumeter); girth measurements (with a tape measure); and pitting edema assessment (based on the depth and duration of the indentation). Water displacement and ankle circumference had shown a high inter-examiner agreement (intraclass correlation coefficient 0.93, 0.96 right; 0.97, 0.97 left). Option D: Checking for pitting edema is less reliable than measuring with a paper tape measure. There are two types of edema, pitting and non- pitting edema. Pitting edema is described as an indentation that remains in the edematous area after pressure is applied. Its location, timing, and extent are determined for treatment response. It is mainly assessed on the medial malleolus, the bony portion of the tibia, and the dorsum of the foot. Non-pitting edema is seen in lymphoedema, myxedema, and lipedema. NCLEXRN-09-020 Question Tag: vaginal cancer, radioactive implant Question Category: Physiological Integrity, Physiological Integrity, Reduction of Risk Potential A client with vaginal cancer is being treated with a radioactive vaginal implant. The client’s husband asks the nurse if he can spend the night with his wife. The nurse should explain that: A. Overnight stays by family members are against hospital policy. B. There is no need for him to stay because staffing is adequate. C. His wife will rest much better knowing that he is at home. D. Visitation is limited to 30 minutes when the implant is in place. Correct Answer: D. Visitation is limited to 30 minutes when the implant is in place. Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time spent exposed to radium, putting distance between people and the radium source, and using lead to shield against the radium. Teaching family members these principles is extremely important. Internal radiation therapy uses a pill, liquid, implant or temporary source to put radiation inside the body to kill the cancer cells, and may require certain safety precautions for staff and family while the patient is in the hospital or at home, according to the National Cancer Institute Option A: Do not spend any more time in the patient’s room than is necessary to care for the patient. In particular, time at the patient’s bedside should be kept to a minimum. Specific “stay times” will be provided on the patient’s door. Option B: Visitors are allowed provided that: visitors shall be 18 years or older; the patient shall not have pregnant visitors; and visitors should remain at least 6 feet from the patients and should not stay more than 2 hours per day (unless other information is provided). Option C: The most common safety precautions related to preventing unnecessary radiation exposure are limiting time near the patient, maintaining a safe distance of three to six feet from the source of the radiation and using lead shielding to protect family and staff. NCLEXRN-09-021 Question Tag: facial stroke Question Category: Physiological Integrity, Basic Care and Comfort The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client? A. Roast beef sandwich, potato chips, pickle spear, iced tea B. Split pea soup, mashed potatoes, pudding, milk C. Tomato soup, cheese toast, Jello, coffee D. Hamburger, baked beans, fruit cup, iced tea Correct Answer: B. Split pea soup, mashed potatoes, pudding, milk The client with a facial stroke will have difficulty swallowing and chewing, and these food items mentioned provide the least amount of chewing. Consult with a speech therapist to evaluate gag reflexes; assist in teaching alternate swallowing techniques, advise the patient to take smaller boluses of food, and inform the patient of foods that are easier to swallow; provide thicker liquids or pureed diet as indicated. Option A: The patient would have difficulty in chewing meat. Observe the patient for paroxysms of coughing, food dribbling out or pooling in one side of the mouth, food retained for long periods in the mouth, or nasal regurgitation when swallowing liquids. Have the patient sit upright, preferably on a chair, when eating and drinking; advance diet as tolerated. Option C: This group would still require more chewing. Prepare for GI feedings through a tube if indicated; elevate the head of bed during feedings, check tube position before feeding, administer feeding slowly, and ensure that the cuff of the tracheostomy tube is inflated (if applicable); monitor and report excessive retained or residual feeding. Option D: The following food items would require more chewing and, thus, are incorrect. Avoid hard, chewy foods as these can be difficult to prepare, and choose a soft easy chew diet (such as pasta dishes, fish, well-cooked meats, and vegetables). Try smaller mouthfuls as these are easier to control and less likely to spill from the mouth. NCLEXRN-09-022 Question Tag: diabetes mellitus, insulin Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies The physician has prescribed Novolog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs? A. “I will make sure I eat breakfast within 10 minutes of taking my insulin.” B. “I will need to carry candy or some form of sugar with me all the time.” C. “I will eat a snack around three o’clock each afternoon.” D. “I can save my dessert from supper for a bedtime snack.” Correct Answer: A. “I will make sure I eat breakfast within 10 minutes of taking my insulin.” NovoLog insulin onsets very quickly, so food should be available within 10–15 minutes of taking the insulin. The onset of action is 1 to 3 hours. Crystalline NPH insulin administration is subcutaneous. Administration is not Intramuscular or intravenous. NPH insulin is available in a two-phase solution, which means that apart from NPH, it has a solvent or a rapid-acting insulin solution. It comes in the form of a subcutaneous suspension or suspension pen-injector. Option B: This does not address a particular type of insulin, so it is incorrect. The abdominal subcutaneous injection causes quicker absorption as compared to arms or thighs. The most significant advantage of NPH is that it can be included in premixed formulation with regular insulin. NPH in premixed formulations does not affect the potency and time-action profile of regular insulin. Exercise, massage, and local heat application increase NPH insulin absorption. Option C: NPH insulin peaks in 8–12 hours, so a snack should be eaten at the expected peak time. It may not be 3 p.m. NPH insulin pen requires adequate mixing to get complete resuspension before injecting it. It may be given once or twice daily. Since the action profile of NPH insulin does not cover 24 hours, a twice-daily dose in the morning and evening or bedtime is the recommended regimen, which applies to the premixed formulations as well. Option D: There is no need to save the dessert until bedtime. NPH insulin has a somewhat higher risk of hypoglycemia. Inadequate resuspension is thought to contribute to the high day to day variability in the pharmacodynamic and pharmacokinetic profile of NPH insulin, leading to hypoglycemia. Patients can adequately resuspend NPH by rotating the vial several times until it is uniformly cloudy. NCLEXRN-09-023 Question Tag: infant care Question Category: Health Promotion and Maintenance The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first 2 weeks of life because: A. New parents need time to learn how to hold the baby. B. The umbilical cord needs time to separate. C. Newborn skin is easily traumatized by washing. D. The chance of chilling the baby outweighs the benefits of bathing. Correct Answer: B. The umbilical cord needs time to separate. The umbilical cord needs time to dry and fall off before putting the infant in the tub. The first bath will be a sponge bath. Pick a warm room with a flat surface, like a bathroom or kitchen counter, a changing table, or a bed. Cover the surface with a thick towel. Make sure the room temperature is at least 75 degrees Fahrenheit, because babies chill easily. Option A: Taking the baby away for a bath too soon can interrupt skin-to-skin care, mother-child bonding, and early breastfeeding success. One study showed a 166% increase in hospital breastfeeding success after implementing a 12-hour delay in the baby’s first bath compared to those bathed within the first couple hours. Option C: Gentle sponge baths are perfect for the first few weeks until the umbilical cord falls off, the circumcision heals, and the navel heals completely. Once the umbilical cord falls off, and the circumcision and the navel are completely healed, it’s time to try a tub bath. Option D: Although these statements might be important, they are not the primary answer to the question. The World Health Organization (WHO) recommends delaying a baby’s first bath until 24 hours after birth—or waiting at least 6 hours if a full day isn’t possible for cultural reasons. Babies who get baths right away may be more likely to become cold and develop hypothermia. The minor stress of an early bath can also make some babies more likely to have a drop in blood sugar (hypoglycemia). NCLEXRN-09-024 Question Tag: leukemia Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies A client with leukemia is receiving Trimetrexate. After reviewing the client’s chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to: A. Treat iron-deficiency anemia caused by chemotherapeutic agents B. Create a synergistic effect that shortens treatment time C. Increase the number of circulating neutrophils D. Reverse drug toxicity and prevent tissue damage Correct Answer: D. Reverse drug toxicity and prevent tissue damage Leucovorin is the antidote for Methotrexate and Trimetrexate which are folic acid antagonists. Leucovorin is a folic acid derivative. Leucovorin is FDA indicated after high dose methotrexate therapy in osteosarcoma, to decrease the toxic effects of methotrexate or to counter the toxic effects of folate antagonists. Leucovorin is also occasionally an alternative agent used in the treatment of megaloblastic anemia when oral intake of folic acid is not possible. Option A: Leucovorin does not treat iron deficiency. Off-label uses include as neoadjuvant treatment in bladder cancer, as a cofactor in methanol toxicity, in the treatment of advanced esophageal cancer, advanced gastric cancer, advanced pancreatic cancer, prevention of hematological toxicity of pyrimethamine in patients with AIDS and the treatment of ectopic pregnancy (along with methotrexate). Option B: Leucovirin does not create a synergistic effect when taken with Trimextrate. When used as a part of chemotherapeutic regimens, leucovorin is not administered along with methotrexate. It is usually administered 24 hours after a course of methotrexate. Tissue toxicity may be permanent if leucovorin therapy gets delayed beyond 40 hours. Option C: An increase in neutrophils is not an effect of Leucovirin. Folic acid in large quantities has been shown to counteract the pharmacological actions of antiepileptics such as primidone, phenobarbital, and phenytoin. When leucovorin has been used concomitantly during the treatment of Pneumocystis jirovecii with trimethoprim-sulfamethoxazole (TMP-SMX), higher rates of treatment failure and morbidity have been reported. NCLEXRN-09-025 Question Tag: immunization Question Category: Health Promotion and Maintenance A 4-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive: A. HibTITER B. Mumps vaccine C. Hepatitis B vaccine D. MMR Correct Answer: A. HibTITER The Haemophilus influenza vaccine is given at 4 months with the polio vaccine. It protects the child from Hib disease, which can cause lifelong disability and be deadly; protects the child from the most common type of Hib disease, meningitis (an infection of the lining covering the brain and spinal cord); and keeps the child from missing school or child care, and the parents from missing work. Option B: Mumps vaccine is the best way to decrease the risk of getting mumps. It is usually given as part of a combination vaccine that protects against three diseases: measles, mumps, and rubella (MMR). This vaccine is only licensed for use in children who are 12 months through 12 years of age. Option C: Hepatitis B vaccine is given immediately after birth and for children up to 18 years. Hepatitis B vaccine is usually given as 2, 3, or 4 shots. Infants should get their first dose of hepatitis B vaccine at birth and will usually complete the series at 6 months of age (sometimes it will take longer than 6 months to complete the series). Children and adolescents younger than 19 years of age who have not yet gotten the vaccine should also be vaccinated. Option D: MMR stands for measles, mumps and rubella vaccine, which is given at 9 months old. The MMR vaccine is safe and effective. Most children don’t have any side effects from the vaccine. The side effects that do occur are usually very mild, such as a fever or rash. The first dose at 12 through 15 months of age, and the second dose at 4 through 6 years of age. Questions and rationale from N Feel free to print or share and link back to us! For more practice questions, please visit our Nursing Test Bank [