Nclex 101 Final Test

Comprehensive Exam 1. Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? A) Checking the client's blood pressure Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. One common side effect is postural hypotension. Therefore the nurse would check the client’s blood pressure immediately before administering each dose. Checking the client’s peripheral pulses, the results of the most recent potassium level, and the intake and output for the previous 24 hours are not specifically associated with this mediation. 2. A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction? C) "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." ." Rationale: An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum by means of the use of a contrast medium. It involves swallowing a contrast medium (usually barium), which is administered in a flavored milkshake. Films are taken at intervals during the test, which takes about 30 minutes. No special preparation is necessary before a GI series, except that NPO status must be maintained for 8 hours before the test. After an upper GI series, the client is prescribed a laxative to hasten elimination of the barium. Barium that remains in the colon may become hard and difficult to expel, leading to fecal impaction. 3.A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the physician's answering service and is told that the physician is off for the night and will be available in the morning. The nurse should: B) Ask the answering service to contact the on-call physician Rationale: The nurse has a duty to protect the client from harm. A nurse who believes that a physician’s prescription may be in error is responsible for clarifying the prescription before carrying it out. Therefore the nurse would not administer the medication; instead, the nurse would withhold the medication until the dose can be clarified. The nurse would not wait until the next morning to obtain clarification. It is premature to call the nursing supervisor. 4. An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is: B) Asking the ED physician to check the client Rationale: PVCs are a result of increased irritability of ventricular cells. Peripheral pulses may be absent or diminished with the PVCs themselves because the decreased stroke volume of the premature beats may in turn decrease peripheral perfusion. Because other rhythms also cause widened QRS complexes, it is essential that the nurse determine whether the premature beats are resulting in perfusion of the extremities. This is done by palpating the carotid, brachial, or femoral artery while observing the monitor for widened complexes or by auscultating for apical heart sounds. In the situation of acute MI, PVCs may be considered warning dysrhythmias, possibly heralding the onset of ventricular tachycardia or ventricular fibrillation. Therefore the nurse would not tell the client that the PVCs are expected. Although the nurse will continue to monitor the client and document the findings, these are not the most appropriate actions of those provided. The most appropriate action would be to ask the ED physician to check the client. Test-Taking Strategy: Use the process of elimination. Recalling the significance of PVCs after acute MI and noting the strategic words "not perfusing" will direct you to the correct option. Review the significance of PVCs after acute MI if you had difficulty with this question. 5. NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should: A) Administer the antihypertensive with a small sip of water Rationale: General anesthesia is required for ECT, so NPO status is imposed for 6 to 8 hours before treatment to help prevent aspiration. Exceptions include clients who routinely receive cardiac medications, antihypertensive agents, or histamine (H2) blockers, which should be administered several hours before treatment with a small sip of water. The nurse would not administer a medication by way of a route that has not been prescribed. Test-Taking Strategy: Use the process of elimination. Use your knowledge of the principles of medication administration to help eliminate the option that involves administering the medication by way of a route other than the prescribed one. Recalling that antihypertensives must be administered on a regular schedule will assist you in eliminating the options that involve withholding the medication. Review preprocedure care for the client scheduled for ECT if you had difficulty with this question. 6. A client who recently underwent coronary artery bypass graft surgery comes to the physician's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic? A) "Tell me more about what you’re feeling." Rationale: When a client expresses feelings of depression, it is extremely important for the nurse to further explore these feelings with the client Remember to always focus on the client’s feelings. 7. A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the following actions should be the nurse’s priority? A) Contacting the physician Rationale: The FHR is assessed for at least 1 minute when the membranes rupture. The nurse also checks the quantity, color, and odor of the amniotic fluid. The fluid should be clear (often with bits of vernix) and have a mild odor. Fluid with a foul or strong odor, cloudy appearance, or yellow coloration suggests chorioamnionitis and warrants notifying the physician. A large amount of vernix in the fluid suggests that the fetus is preterm. Greenish, meconium-stained fluid may be seen in cases of postterm gestation or placental insufficiency. Checking the fluid for protein is not associated with the data in the question. Although the nurse would continue to monitor the client and the FHR and would document the findings, contacting the physician is the priority. Test-Taking Strategy: Focus on the data in the question and note the strategic word "priority." Noting the words "yellow and has a strong odor" will direct you to the correct option. 8. A nurse has assisted a physician in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the nurse immediately plans to: A) Call the radiography department to obtain a chest x-ray Rationale: One major complication associated with central venous catheter placement is pneumothorax, which may result from accidental puncture of the lung. After the catheter has been placed but before it is used for infusions, its placement must be checked with an x-ray Test-Taking Strategy: Note the strategic word “immediately.” Use the ABCs — airway, breathing, and circulation. Recalling that pneumothorax is a complication of the insertion of this type of catheter will direct you to the correct option 9. A rape victim being treated in the emergency department says to the nurse, "I’m really worried that I’ve got HIV now." What is the appropriate response by the nurse? D) "Let's talk about the information that you need to determine your risk of contracting HIV." Feedback: CORRECT Rationale: HIV is a concern of rape victims. Such concern should always be addressed, and the victim should be given the information needed to evaluate his or her risk. Pregnancy may occur as a result of rape, and pregnancy prophylaxis can be offered in the emergency department or during follow-up, once the results of a pregnancy test have been obtained.. Test-Taking Strategy: Use your knowledge of therapeutic communication 10. A client is taking prescribed ibuprofen (Motrin), 300 mg orally four times daily, to relieve joint pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and indigestion. The nurse should tell the client to: C) Take the medication with food Rationale: Ibuprofen is a nonsteroidal antiinflammatory medication. Side effects include nausea (with or without vomiting) and dyspepsia (heartburn, indigestion, or epigastric pain). If gastrointestinal distress occurs, the client should be instructed to take the medication with milk or food. 11. A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the day shift, and 650 mL on the evening shift. The client is receiving an intravenous (IV) antibiotic every 12 hours, diluted in 50 mL of normal saline solution. The nurse empties 700 mL of urine from the client's Foley catheter at the end of the day shift. Thereafter, 500 mL of urine is emptied at the end of the evening shift and 325 mL at the end of the night shift. Nasogastric tube drainage totals 155 mL for the 24-hour period, and the total drainage from the Jackson-Pratt device is 175 mL. What is the client's total intake during the 24-hour period? Type your answer in the space provided. Answer: _1670 mL Rationale: The client’s 24-hour total oral intake is 1570 mL, and the IV intake totals 100 mL (50 mL of normal saline solution every 12 hours). Therefore the 24-hour intake total is 1670 mL. Test-Taking Strategy: Focus on the subject, the client’s total intake in a 24-hour period. Add the oral intake and then note that every 12 hours the client is receiving an IV antibiotic that is diluted in 50 mL of normal saline solution. Therefore the total IV intake is 100 mL in 24 hours. Review calculation of intake and output if you had difficulty with this question. 12. Lorazepam (Ativan) 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the management of anxiety. The nurse prepares the medication as prescribed and administers the medication over a period of: A) 3 minutes Rationale: Lorazepam is a benzodiazepine. When administered by IV injection, each 2 mg or fraction thereof is administered over a period of 1 to 5 minutes. 13. A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride (Serzone). On the basis of this information, the nurse determines that the client most likely has a history of: A) Depression 14. Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the physician immediately if she experiences: D) Neck stiffness or soreness Feedback: CORRECT Rationale: Phenelzine sulfate, a monoamine oxidase inhibitor (MAOI), is an antidepressant and is used to treat depression. Hypertensive crisis, an adverse effect of this medication, is characterized by hypertension, frontally radiating occipital headache, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia, bradycardia, and constricting chest pain may also be present. The client is taught to be alert to any occipital headache radiating frontally and neck stiffness or soreness, which could be the first signs of a hypertensive crisis. Dry mouth and restlessness are common side effects of the medication. 15. Risperidone (Risperdal) is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client’s medical record would prompt the nurse to contact the prescribing physician before administering the medication? C) The client takes a prescribed antihypertensive. Rationale: Risperidone is an antipsychotic medication. Contraindications to the use of risperidone include cardiac disorders, cerebrovascular disease, dehydration, hypovolemia, and therapy with antihypertensive agents. Risperidone is used with caution in clients with a history of seizures. History of cataracts, hypothyroidism, or allergy to aspirin does not affect the administration of this medication. 16. A client who has been undergoing long-term therapy with an antipsychotic medication is admitted to the inpatient mental health unit. Which of the following findings does the nurse, knowing that long-term use of an antipsychotic medication can cause tardive dyskinesia, monitor in the client? D) Tongue protrusion Rationale: Tardive dyskinesia is a severe reaction associated with long-term use of antipsychotic medications. The clinical manifestations include abnormal movements (dyskinesia) and involuntary movements of the mouth, tongue (“flycatcher tongue”), and face. In its most severe form, tardive dyskinesia involves the fingers, arms, trunk, and respiratory muscles. When this occurs, the medication is discontinued 17. A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which of the following diagnoses, if noted on the client's record, would indicate a need to contact the physician who is scheduled to perform the ECT? A) Recent stroke Rationale: Several conditions pose risks in the client scheduled for ECT. Among them are recent myocardial infarction or stroke and cerebrovascular malformations or intracranial lesions. Hypothyroidism, glaucoma, and peripheral vascular disease are not contraindications to this treatment. 18. A client scheduled for suprapubic prostatectomy has listened to the surgeon's explanation of the surgery. The client later asks the nurse to explain again how the prostate is going to be removed. The nurse tells the client that the prostate will be removed through: A) A lower abdominal incision Rationale: A lower abdominal incision is used in suprapubic or retropubic prostatectomy. 19. A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer. Which of the following recommendations does the nurse include on the poster? Select all that apply. A) Seek medical advice if you find a skin lesion. D) Wear a hat, opaque clothing, and sunglasses when out in the sun. . Rationale: Measures to prevent skin cancer include avoiding sun exposure between 10 a.m. and 4 p.m.; using sunscreen with a high SPF; wearing a hat, opaque clothing, and sunglasses when out in the sun; and examining the body every month for possibly cancerous or precancerous lesions. The client should also seek medical advice if any changes in a skin lesion are noted. 20. A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of the breast notes documentation of the presence of peaud'orange skin. On the basis of this notation, which finding would the nurse expect to note on assessment of the client’s breast? B) ) D) B Rationale: Peaud’orange (French for “orange peel”) Correct Answer(s): 21. The mother of an adolescent with type 1 diabetes mellitus tells the nurse that her child is a member of the school soccer team and expresses concern about her child's participation in sports. The nurse, after providing information to the mother about diet, exercise, insulin, and blood glucose control, tells the mother: C) That the child should eat a carbohydrate snack about a half-hour before each soccer game Rationale: The child with diabetes mellitus who is active in sports requires additional food intake in the form of a carbohydrate snack about a half-hour before the anticipated activity. Additional food will need to be consumed, often as frequently as every 45 minutes to 1 hour, during prolonged periods of activity. If the blood glucose level is increased (240 mg/dL or more) and ketones are present before planned exercise, the activity should be postponed until the blood glucose has been controlled. Moderate to high ketone values should be reported to the physician. There is no reason for the child to avoid participating in sports. 22. A client with chronic renal failure who will require dialysis three times a week for the rest of his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter what I do if I’m never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem? B) Powerlessness Rationale: Powerlessness is present when a client believes that he or she has no control over the situation or that his or her actions will not affect an outcome in any significant way. Anxiety is a vague uneasy feeling of apprehension. Some factors in anxiety include a threat or perceived threat to physical or emotional integrity or self-concept, changes in role function, and a threat to or change in socioeconomic status. Ineffective coping is present when the client exhibits impaired adaptive abilities or behaviors in meeting the demands or roles expected. Disturbed body image is diagnosed when there is an alteration in the way the client perceives his or her own body image. Test-Taking Strategy: Use the process of elimination. Note that the statement "It doesn’t really matter what I do " implies that the client has a sense of no control of the situation. 23. A nurse is providing morning care to a client in end-stage renal failure. The client is reluctant to talk and shows little interest in participating in hygiene care. Which statement by the nurse would be therapeutic? A) "What are your feelings right now?" Rationale: Asking, "What are your feelings right now?" encourages the client to identify his or her emotions or feelings, which is a therapeutic communication technique 24. Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for thoracentesis. What characteristics of the fluid removed during thoracentesis should the nurse, assisting the physician with the procedure, expect to note? B) Thick and opaque Rationale: Empyema is the accumulation of pus in the pleural space. Empyema fluid is thick, opaque, exudative, and intensely foul-smelling. Clear and yellow, white and odorless, and clear and foul- smelling are incorrect descriptions of the fluid that occurs in this disorder. Test-Taking Strategy: Use the process of elimination. Focusing on the words "empyema" and "infected pleural effusion" 25. An emergency department nurse is told that a client with carbon monoxide poisoning resulting from a suicide attempt is being brought to the hospital by emergency medical services. Which intervention will the nurse carry out as a priority upon arrival of the client? A) Administering 100% oxygen Rationale: A client with carbon monoxide poisoning is treated with inhalation of 100% oxygen to shorten the half-life of carbon monoxide to around an hour. Hyperbaric oxygen may be required to reduce the half-life to minutes by forcing the carbon monoxide off the hemoglobin molecule Test-Taking Strategy: Note the strategic word "priority" and use the ABCs — airway, breathing, and circulation 26. A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried about how he will care financially for his wife and three small children. On the basis of the client's concern, which problem does the nurse identify? A) Anxiety Rationale: Anxiety is a vague, uneasy feeling of apprehension. Some related factors include a threat or perceived threat to physical or emotional integrity or self-concept, changes in function in one’s role, and threats to or changes in socioeconomic status. 27. A nurse, performing an assessment of a client who has been admitted to the hospital with suspected silicosis, is gathering both subjective and objective data. Which question by the nurse would elicit data specific to the cause of this disorder? C) "Have you ever worked in a mine?" Rationale: Silicosis is a chronic fibrotic disease of the lungs caused by the inhalation of free crystalline silica dust over a long period. Mining and quarrying are each associated with a high incidence of silicosis. Hazardous exposure to silica dust also occurs in foundry work, tunneling, sandblasting, pottery-making, stone masonry, and the manufacture of glass, tile, and bricks. The finely ground silica used in soaps, polishes, and filters also presents a risk. The assessment questions noted in the other options are unrelated to the cause of silicosis. 28. A physician prescribes a dose of morphine sulfate 2.5 mg stat to be administered intravenously to a client in pain. The nurse preparing the medication notes that the label on the vial of morphine sulfate solution for injection reads “4 mg/mL.” How many milliliters (mL) must the nurse draw into a syringe for administration to the client? Type the answer in the space provided. Answer: mL 0.625; .625 29. A client undergoing therapy with carbidopa/levodopa (Sinemet) calls the nurse at the clinic and reports that his urine has become darker since he started taking the medication. The nurse should tell the client: C) That this is an occasional side effect of the medication Rationale: Carbidopa/levodopa, an antiparkinson agent, may cause darkening of the urine or sweat. The client should be reassured that this is a harmless side effect of the medication and that the medication’s use should be continued. 30. A client with myasthenia gravis is taking neostigmine bromide (Prostigmin). The nurse determines that the client is gaining a therapeutic effect from the medication after noting: D) Improved swallowing function Rationale: Neostigmine bromide, a cholinergic medication that prevents the destruction of acetylcholine, is used to treat myanthenia gravis. The nurse would monitor the client for a therapeutic response, which includes increased muscle strength, an easing of fatigue, and improved chewing and swallowing function. 31. A nurse is assessing a client who has been taking amantadine hydrochloride (Symmetrel) for the treatment of Parkinson's disease. Which finding from the history and physical examination would cause the nurse to determine that the client may be experiencing an adverse effect of the medication? C) Bilateral lung wheezes Rationale: Amantadine hydrochloride is an antiparkinson agent that potentiates the action of dopamine in the central nervous system (CNS). The medication is used to treat rigidity and akinesia. Insomnia and orthostatic hypotension are side effects of the medication. Adverse effects include congestive heart failure (evidenced by bilateral lung wheezes), leukopenia, neutropenia, hyperexcitability, convulsions, and ventricular dysrhythmias. 32. A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which of the following risk factors does the nurse include in the pamphlet? Select all that apply. A) Smoking C) High alcohol intake D) White or Asian ethnicity Rationale: Osteoporosis is a chronic metabolic disease in which bone loss results in decreased density and sometimes fractures. Risk factors include being 65 years or older in women, 75 years or older in men, family history of the disorder, history of fracture after age 50, white or Asian ethnicity, low body weight and slender build, chronically low calcium intake, a history of smoking, high alcohol intake, and lack of physical exercise or prolonged immobility. 33. A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. The nurse tells the client that one food item high in calcium is: D) Sardines Rationale: Osteoporosis is a chronic metabolic disease in which bone loss results in decreased density and sometimes fractures. Foods high in calcium include milk and milk products, dark-green leafy vegetables, tofu and other soy products, sardines, and hard water. Corn, cocoa, and peaches do not contain appreciable amounts of calcium. 34. A nurse is providing information to a client with acute gout about home care. Which of the following measures does the nurse tell the client to take? Select all that apply. A) Drinking 2 to 3 L of fluid each day C) Resting and immobilizing the affected area Rationale: Gout is a systemic disease in which urate crystals are deposited in the joints and other tissues, resulting in inflammation. In acute gout, rest and immobilization are recommended until the acute attack and inflammation have subsided. Local application of cold may help relieve the pain. The application of heat is avoided because it may worsen the inflammatory process. Dietary instructions include reducing or eliminating alcohol intake and avoiding excessive intake of foods containing purines (e.g., sweetbreads, yeast, heart, herring, herring roe, sardines). The client is encouraged to drink 2 to 3 L of fluid per day to help eliminate uric acid and to prevent the formation of renal calculi. 35. A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that apply. A) Fatigue D) Low-grade fever Rationale: Rheumatoid arthritis is a chronic, progressive, systemic and inflammatory autoimmune disease process that affects the synovial joints, resulting in their destruction. Early manifestations of RA include fatigue, low-grade fever, weakness, anorexia, and paresthesias. 36. A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client’s medical record? Select all that apply. A) Fever B) Vasculitis E) Abdominal pain Rationale: Systemic lupus erythematosus is a chronic, progressive, inflammatory disorder of the connective tissue that can cause the failure of major organs and body systems. Manifestations include fever, fatigue, anorexia, weight loss, vasculitis, discoid lesions, and abdominal pain. Erythema, usually in a butterfly pattern (hence the nickname “butterfly rash”), appears over the cheeks and bridge of the nose. Other manifestations include nephritis, pericarditis, the Raynaud phenomenon, pleural effusions, joint inflammation, and myositis. 37. A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate (Parnate). Which of the following foods does the nurse tell the client to avoid while she is taking this medication? Select all that apply. A) Beer C) Yogurt E) Pickled herring Rationale: Tranylcypromine sulfate is a monoamine oxidase inhibitor (MAOI) used to treat depression. The client must follow a tyramine-restricted diet while taking the medication to help prevent hypertensive crisis, a life-threatening effect of the medication. Foods to be avoided include