NCLEX-RN Practice Quiz Test Bank #4 (75 Questions) 2023

NCLEX-RN Practice Quiz Test Bank #4 (75 Questions) NCLEXRN-04-001 Question Tag: delegation Question Category: Safe and Effective Care Environment, Management of Care Which action (s) should you delegate to the experienced nursing assistant when caring for a patient with a thrombotic stroke with residual left-sided weakness? Select all that apply.  A. Assist the patient to reposition every 2 hours.  B. Reapply pneumatic compression boots.  C. Remind the patient to perform active ROM.  D. Check extremities for redness and edema. Correct Answer: A, B, & C. The experienced nursing assistant would know how to reposition the patient and how to reapply compression boots, and would remind the patient to perform activities he has been taught to perform.  Option D: Assessing for redness and swelling (signs of deep venous thrombosis {DVT}) requires additional education and is still appropriate to the professional nurse. NCLEXRN-04-002 Question Tag: stroke Question Category: Safe and Effective Care Environment, Management of Care The patient who had a stroke needs to be fed. What instruction should you give to the nursing assistant who will feed the patient?  A. Position the patient sitting up in bed before you feed her.  B. Check the patient’s gag and swallowing reflexes.  C. Feed the patient quickly because there are three more waiting.  D. Suction the patient’s secretions between bites of food. Correct Answer: A. Position the patient sitting up in bed before you feed her. Positioning the patient in a sitting position decreases the risk of aspiration.  Option B: The nursing assistant is not trained to assess gag or swallowing reflexes.  Option C: The patient should not be rushed during feeding.  Option D: A patient who needs to be suctioned between bites of food is not handling secretions and is at risk for aspiration. This patient should be assessed further before feeding. NCLEXRN-04-003 Question Tag: bacterial meningitis Question Category: Physiological Integrity, Physiological Adaptation You have just admitted a patient with bacterial meningitis to the medical-surgical unit. The patient complains of a severe headache with photophobia and has a temperature of 102.60 F orally. Which collaborative intervention must be accomplished first?  A. Administer codeine 15 mg orally for the patient’s headache.  B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection.  C. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever.  D. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure. Correct Answer: B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection. Untreated bacterial meningitis has a mortality rate approaching 100%, so rapid antibiotic treatment is essential.  Option A: Pain medications may be given after treating the infection that is most probably causing it.  Option C: Acetaminophen should be given to decrease the fever after administering the antibiotics first.  Option D: Furosemide will help reduce CNS stimulation and irritation and should be implemented as soon as possible. NCLEXRN-04-004 Question Tag: meningococcal meningitis Question Category: Physiological Integrity, Management of Care You are mentoring a student nurse in the intensive care unit (ICU) while caring for a patient with meningococcal meningitis. Which action by the student requires that you intervene immediately?  A. The student enters the room without putting on a mask and gown.  B. The student instructs the family that visits are restricted to 10 minutes.  C. The student gives the patient a warm blanket when he says he feels cold.  D. The student checks the patient’s pupil response to light every 30 minutes. Correct Answer: A. The student enters the room without putting on a mask and gown. Meningococcal meningitis is spread through contact with respiratory secretions so use of a mask and gown is required to prevent spread of the infection to staff members or other patients. The other actions may not be appropriate but they do not require intervention as rapidly.  Option B: The presence of a family member at the bedside may decrease patient confusion and agitation.  Option C: Patients with hyperthermia frequently complain of feeling chilled, but warming the patient is not an appropriate intervention.  Option D: Checking the pupil response to light is appropriate, but it is not needed every 30 minutes and is uncomfortable for a patient with photophobia. Focus: Prioritization NCLEXRN-04-005 Question Tag: delegation Question Category: Safe and Effective Care Environment, Management of Care A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient’s care will be best to delegate to an LPN/LVN whom you are supervising? Select all that apply.  A. Document the onset time, nature of seizure activity, and postictal behaviors for all seizures.  B. Administer phenytoin (Dilantin) 200 mg PO daily.  C. Teach the patient about the need for good oral hygiene.  D. Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation.  E. Gather information about the seizure activity Correct Answer: B & E Administration of medications that are not high risk is included in LPN education and scope of practice. Collection of data about the seizure activity may be accomplished by an LPN/LVN who observes initial seizure activity. An LPN/LVN would know to call the supervising RN immediately if a patient started to seize.  Option A: Documentation is a nursing responsibility.  Option C: Patient education must be accomplished by the registered nurse because it is within their scope of practice.  Option D: Planning of care is a complex activity that requires RN level education and scope of practice. NCLEXRN-04-006 Question Tag: seizure disorder Question Category: Physiological Integrity, Physiological Adaptation While working in the ICU, you are assigned to care for a patient with a seizure disorder. Which of these nursing actions will you implement first if the patient has a seizure?  A. Place the patient on a non-rebreather mask will the oxygen at 15 L/minute.  B. Administer lorazepam (Ativan) 1 mg IV.  C. Turn the patient to the side and protect the airway.  D. Assess level of consciousness during and immediately after the seizure. Correct Answer: C. Turn the patient to the side and protect the airway. The priority action during a generalized tonic-clonic seizure is to protect the airway.  Option B: Administration of lorazepam should be the next action, since it will act rapidly to control the seizure.  Option A: Although oxygen may be useful during the postictal phase, the hypoxemia during tonic-clonic seizures is caused by apnea.  Option D: Checking the level of consciousness is not appropriate during the seizure, because generalized tonic-clonic seizures are associated with a loss of consciousness. NCLEXRN-04-007 Question Tag: phenytoin Question Category: Physiological Integrity, Pharmacological and Parenteral therapies A patient recently started on phenytoin (Dilantin) to control simple complex seizures is seen in the outpatient clinic. Which information obtained during his chart review and assessment will be of greatest concern?  A. The gums appear enlarged and inflamed.  B. The white blood cell count is 2300/mm3.  C. Patient occasionally forgets to take the phenytoin until after lunch.  D. Patient wants to renew his driver’s license next month. Correct Answer: B. The white blood cell count is 2300/mm3. Leukopenia is a serious adverse effect of phenytoin and would require discontinuation of the medication.  Option A: Inflammation of the gums should be reported to the physician, but it does not require immediate attention.  Option C: The nurse should include in the patient teaching the importance of taking medications on time to avoid episodes of seizure.  Option D: Driving is prohibited for a client with seizure disorder. This should be included in the patient’s teaching, but will not require a change in medical treatment for the seizures. NCLEXRN-04-008 Question Tag: prioritization Question Category: Safe and Effective Care Environment,Management of Care After receiving a change-of-shift report at 7:00 AM, which of these patients will you assess first?  A. A 23-year-old with a migraine headache who is complaining of severe nausea associated with retching.  B. A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching.  C. A 59-year-old with Parkinson’s disease who will need a swallowing assessment before breakfast.  D. A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank pain. Correct Answer: D. A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank pain. Urinary tract infections are a frequent complication in patients with multiple sclerosis because of the effect on bladder function. The elevated temperature and decreased breath sounds suggest that this patient may have pyelonephritis. The physician should be notified immediately so that antibiotic therapy can be started quickly.  Option A: This patient needs further assessment, but does not require immediate attention. A migraine can cause severe throbbing pain or a pulsing sensation, usually on one side of the head. It’s often accompanied by nausea, vomiting, and extreme sensitivity to light and sound. Migraine attacks can last for hours to days, and the pain can be so severe that it interferes with daily activities.  Option B: Preoperative teaching must be done but it is not the nurse’s priority. A craniotomy is the surgical removal of part of the bone from the skull to expose the brain. Specialized tools are used to remove the section of bone called the bone flap. The bone flap is temporarily removed, then replaced after the brain surgery has been done.  Option C: The patient should be assessed soon, but does not have an urgent need. In MS, the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problems between your brain and the rest of your body. Eventually, the disease can cause permanent damage or deterioration of the nerves. NCLEXRN-04-009 Question Tag: delegation Question Category: Safe and Effective Care Environment, Management of Care All of these nursing activities are included in the care plan for a 78-year-old man with Parkinson’s disease who has been referred to your home health agency. Which ones will you delegate to a nursing assistant (NA)? Select all that apply.  A. Check for orthostatic changes in pulse and blood pressure.  B. Monitor for improvement in tremor after levodopa (L-dopa) is given.  C. Remind the patient to allow adequate time for meals.  D. Monitor for abnormal involuntary jerky movements of extremities.  E. Assist the patient with prescribed strengthening exercises.  F. Adapt the patient’s preferred activities to his level of function. Correct Answer: A, C, and E NA education and scope of practice includes taking pulse and blood pressure measurements. In addition, NAs can reinforce previous teaching or skills taught by the RN or other disciplines, such as speech or physical therapists.  Option B: Evaluation of patient response to medication requires the knowledge of an experienced RN.  Option D: Development and individualizing the plan of care require RN-level education and scope of practice. NCLEXRN-04-010 Question Tag: delegation Question Category: Safe and Effective Care Environment, Management of Care As the manager in a long-term-care (LTC) facility, you are in charge of developing a standard plan of care for residents with Alzheimer’s disease. Which of these nursing tasks is best to delegate to the LPN team leaders working in the facility?  A. Check for improvement in resident memory after medication therapy is initiated.  B. Use the Mini-Mental State Examination to assess residents every 6 months.  C. Assist residents to the toilet every 2 hours to decrease the risk for urinary intolerance.  D. Develop individualized activity plans after consulting with residents and family. Correct Answer: A. Check for improvement in resident memory after medication therapy is initiated. LPN education and team leader responsibilities include checking for the therapeutic and adverse effects of medications. Changes in the residents’ memory would be communicated to the RN supervisor, who is responsible for overseeing the plan of care for each resident.  Option B: Assessment for changes on the Mini-Mental State Examination is a RN responsibility.  Option C: Assisting residents with personal care and hygiene would be delegated to nursing assistants working the LTC facility.  Option D: Developing an activity plan should be done by a RN. NCLEXRN-04-011 Question Tag: Alzheimer’s disease Question Category: Physiological Integrity, Basic Care and Comfort A patient who has been admitted to the medical unit with new-onset angina also has a diagnosis of Alzheimer’s disease. Her husband tells you that he rarely gets a good night’s sleep because he needs to be sure she does not wander during the night. He insists on checking each of the medications you give her to be sure they are the same as the ones she takes at home. Based on this information, which nursing diagnosis is most appropriate for this patient?  A. Decreased Cardiac Output related to poor myocardial contractility  B. Caregiver Role Strain related to continuous need for providing care  C. Ineffective Therapeutic Regimen Management related to poor patient memory  D. Risk for Falls related to patient wandering behavior during the night Correct Answer: B. Caregiver Role Strain related to continuous need for providing care The husband’s statement about lack of sleep and anxiety over whether the patient is receiving the correct medications are behaviors that support this diagnosis.  Option A: There is no evidence that the patient’s cardiac output is decreased. Alzheimer′s disease and HF often occur together and thus increase the cost of care and health resource utilization; this highlights the need to investigate the relationship between these two conditions. Impaired cognition in HF patients leads to significantly more frequent hospital readmissions and increases mortality rates.  Option C: Ineffective Therapeutic Regimen Management is not a priority as based on the statement.  Option D: Risk for falls is not the priority at this time. Falls are a leading cause of broken hips and other serious injuries in the elderly, and those with Alzheimer’s are at particularly high risk of falling. Problems with vision, perception and balance increase as Alzheimer’s advances, making the risk of a fall more likely. NCLEXRN-04-012 Question Tag: glioblastoma Question Category: Physiological Integrity, Pharmacological and Parenteral therapies You are caring for a patient with a recurrent glioblastoma who is receiving dexamethasone (Decadron) 4 mg IV every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns you the most?  A. The patient does not recognize family members.  B. The blood glucose level is 234 mg/dL.  C. The patient complains of a continued headache.  D. The daily weight has increased by 1 kg. Correct Answer: A. The patient does not recognize family members. The inability to recognize a family member is a new neurologic deficit for this patient, and indicates a possible increase in intracranial pressure (ICP). This change should be communicated to the physician immediately so that treatment can be initiated.  Option B: Increased blood glucose levels is an expected side effect but not an emergency.  Option C: The continued headache also indicates that the ICP may be elevated, but it is not a new problem.  Option D: Weight gain is a common adverse effect of dexamethasone that may require treatment, but is not an emergency. NCLEXRN-04-013 Question Tag: lethargy Question Category: Safe and Effective Care Environment, Management of Care A 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence is admitted to the hospital ED. His wife tells you that he fell down the stairs about a month ago, but “he didn’t have a scratch afterward.” She feels that he has become gradually less active and sleepier over the last 10 days or so. Which of the following collaborative interventions will you implement first?  A. Place on the hospital alcohol withdrawal protocol.  B. Transfer to radiology for a CT scan.  C. Insert a retention catheter to straight drainage.  D. Give phenytoin (Dilantin) 100 mg PO. Correct Answer: B. Transfer to radiology for a CT scan. The patient’s history and assessment data indicate that he may have a chronic subdural hematoma. The priority goal is to obtain a rapid diagnosis and send the patient to surgery to have the hematoma evacuated.  Option A: This can be done after the treatment for any intracranial lesion has been implemented.  Option C: This intervention should be done but is not the priority.  Option D: Administration of phenytoin should be implemented as soon as possible, but the initial nursing activities should be directed toward treatment of any intracranial lesion. NCLEXRN-04-014 Question Tag: delegation Question Category: Safe and Effective Care Environment, Management of Care Which of these patients in the neurologic ICU will be best to assign to an RN who has floated from the medical unit?  A. A 26-year-old patient with a basilar skull structure who has clear drainage coming out of the nose.  B. A 42-year-old patient admitted several hours ago with a headache and diagnosed with a ruptured berry aneurysm.  C. A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due.  D. A 65-year-old patient with an astrocytoma who has just returned to the unit after having a craniotomy. Correct Answer: C. A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due. This patient is the most stable of the patients listed. An RN from the medical unit would be familiar with administration of IV antibiotics.  Option A: This patient may need the attention of an experienced neurologic RN.  Option B: A rupture of an aneurysm is fatal and should be assigned to a more experienced RN.  Option D: This patient requires assessment and care from RNs more experienced in caring for patients with neurologic diagnoses. NCLEXRN-04-015 Question Tag: migraine Question Category: Physiological Integrity, Physiological Adaptation What is the priority nursing diagnosis for a patient experiencing a migraine headache?  A. Acute pain related to biologic and chemical factors  B. Anxiety related to change in or threat to health status  C. Hopelessness related to deteriorating physiological condition  D. Risk for Side effects related to medical therapy Correct Answer: A. Acute pain related to biologic and chemical factors The priority for interdisciplinary care for the patient experiencing a migraine headache is pain management.  Option B: Anxiety is a correct diagnosis, but it is not the priority. Tension headaches are common for people that struggle with severe anxiety or anxiety disorders. Tension headaches can be described as a heavy head, migraine, head pressure, or feeling like there is a tight band wrapped around their head. These headaches are due to a tightening of the neck and scalp muscles.  Option C: Hopelessness should be addressed as part of the nursing care plan, but it does not require urgency. Hopelessness can result when someone is going through difficult times or unpleasant experiences. A person may feel overwhelmed, trapped, or insecure, or may have a lot of self-doubts due to multiple stresses and losses. He or she might think that challenges are unconquerable or that there are no solutions to the problems and may not be able to mobilize the energy needed to act on his or her own behalf.  Option D: The risk for side effects is accurate, but it is not as urgent as the issue of pain, which is often incapacitating. Focus: Prioritization NCLEXRN-04-016 Question Tag: sigmoid colostomy Question Category: Physiological Integrity, Reduction of Risk Potential Nurse Michelle should know that the drainage is normal four (4) days after a sigmoid colostomy when the stool is:  A. Green liquid  B. Solid formed  C. Loose, bloody  D. Semiformed Correct Answer: C. Loose, bloody Normal bowel function and soft-formed stool usually do not occur until around the seventh day following surgery. The stool consistency is related to how much water is being absorbed.  Option A: Food, medicines, and other things ingested can affect the consistency or color of the stool.  Option B: A formed stool may occur a week after the surgery.  Option D: The stool from a colostomy can be thin or thick liquid, or semiformed. NCLEXRN-04-017 Question Tag: right-sided brain attack, hemianopsia Question Category: Physiological Integrity, Physiological Adaptation Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left homonymous hemianopsia?  A. On the client’s right side  B. On the client’s left side  C. Directly in front of the client  D. Where the client like Correct Answer: A. On the client’s right side The client has left visual field blindness. The client will see only from the right side. Homonymous hemianopsia is a condition in which a person sees only one side―right or left―of the visual world of each eye. The person may not be aware that the vision loss is happening in both eyes, not just one. An injury to the right part of the brain produces loss of the left side of the visual world of each eye.  Option B: The client would not be able to see the call light on his right side because he can only see the left side.  Option C: Only the right half of the visual world can be seen by the client.  Option D: The most ideal place to put the call light is on the client’s right side to avoid any injuries. NCLEXRN-04-018 Question Tag: accident Question Category: Physiological Integrity, Physiological Adaptation A male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse?  A. Check respiration, circulation, neurological response  B. Align the spine, check pupils, and check for hemorrhage  C. Check respirations, stabilize the spine and check the circulation  D. Assess level of consciousness and circulation Correct Answer: C. Check respirations, stabilize the spine and check the circulation Checking the airway would be the priority, and a neck injury should be suspected. Airway patency and adequate respiratory effort are both essential for normal oxygenation and ventilation within the body so that normal physiological processes can proceed without metabolic derangement.  Option A: These assessments should be made, but keeping the spine stable is also a priority since the patient has been in an accident.  Option B: The first priority is always to check the airway, then the rest of the assessments would follow. Patency is assessed through the presence/absence of obstructive symptoms or findings suggesting an airway that may become obstructed.  Option D: The level of consciousness and circulation can be assessed after securing a patent airway. NCLEXRN-04-019 Question Tag: nitroglycerin Question Category: Physiological Integrity, Pharmacological and Parenteral therapies ADVERTISEMENTS In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and relieves angina by:  A. Increasing contractility and slowing heart rate  B. Increasing AV conduction and heart rate  C. Decreasing contractility and oxygen consumption  D. Decreasing venous return through vasodilation Correct Answer: D. Decreasing venous return through vasodilation. The significant effect of nitroglycerin is vasodilation and decreased venous return, so the heart does not have to work hard.  Option A: Nitroglycerin does not increase contractility. Cardiac work is decreased by venodilation, reducing anginal symptoms secondary to demand ischemia.  Option B: AV conduction is not increased through nitroglycerin, and an increased heart may increase the blood pressure, which is contrary to the desired effects of nitroglycerin,  Option C: Contractility is not significantly affected by nitroglycerin. The desired vasodilatory effect increases perfusion, and does not directly reduce oxygen consumption. NCLEXRN-04-020 Question Tag: myocardial infarction Question Category: Physiological Integrity, Physiological Adaptation Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse’s next action?  A. Call for help and note the time  B. Clear the airway  C. Give two sharp thumps to the precordium, and check the pulse  D. Administer two quick blows Correct Answer: A. Call for help and note the time. Having established, by stimulating the client, that the client is unconscious rather than sleep, the nurse should immediately call for help. This may be done by dialing the operator from the client’s phone and giving the hospital code for cardiac arrest and the client’s room number to the operator, or if the phone is not available, by pulling the emergency call button. Noting the time is important baseline information for cardiac arrest procedure.  Option B: A patent airway has been established the moment the nurse declares that the client is unconscious and calls for help.  Option C: This action can be done if there is an unwitnessed, unmonitored, unstable ventricular tachycardia when a defibrillator is not immediately available.  Option D: Administering two quick blows to the precordium is less effective and its use is more limited ideally. NCLEXRN-04-021 Question Tag: gastrointestinal bleeding Question Category: Physiological Integrity, Physiological Adaptation Nurse Monett is caring for a client recovering from gastrointestinal bleeding. The nurse should:  A. Plan care so the client can receive 8 hours of uninterrupted sleep each night.  B. Monitor vital signs every 2 hours.  C. Make sure that the client takes food and medications at prescribed intervals.  D. Provide milk every 2 to 3 hours. Correct Answer: C. Make sure that the client takes food and medications at prescribed intervals. Food and drug therapy will prevent the accumulation of hydrochloric acid, or will neutralize and buffer the acid that does accumulate.  Option A: Uninterrupted sleep for 8 hours is good, but it does not directly affect the production of acid.  Option B: Monitoring vital signs every 2 hours is unnecessary. It can be monitored every shift or every 4 hours.  Option D: Milk could aggravate the production of hydrochloric acid. The nutrients in milk, particularly fat, may stimulate the stomach to produce more acid. NCLEXRN-04-022 Question Tag: heparin Question Category: Physiological Integrity, Pharmacological and Parenteral therapies A male client was on warfarin (Coumadin) before admission and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do?  A. Stop the I.V. infusion of heparin and notify the physician.  B. Continue treatment as ordered.  C. Expect the warfarin to increase the PTT.  D. Increase the dosage, because the level is lower than normal. Correct Answer: B. Continue treatment as ordered. The effects of heparin are monitored by the PTT is normally 30 to 45 seconds; the therapeutic level is 1.5 to 2 times the normal level.  Option A: There is no need to stop the infusion since the PTT is at therapeutic level. In patients receiving concomitant heparin and warfarin therapy, PTT reflects the combined effects of both drugs. Because of the marked effect of warfarin on the PTT, decreasing heparin dose in response to a high PTT frequently results in subtherapeutic heparin levels.  Option C: The PTT is not used to monitor warfarin therapy, but PTT may be prolonged by warfarin at high doses.  Option D: The level is correct; increasing the dosage is unnecessary. Warfarin markedly affects PTT, for each increase of 1.0 in the international normalized ratio, the PTT increases 16 seconds. NCLEXRN-04-023 Question Tag: ileostomy, stoma Question Category: Physiological Integrity, Physiological Adaptation A client underwent an ileostomy, when should the drainage appliance be applied to the stoma?  A. 24 hours later, when edema has subsided  B. In the operating room  C. After the ileostomy begins to function  D. When the client is able to begin self-care procedures Correct Answer: B. In the operating room The stoma drainage bag is applied in the operating room. Drainage from the ileostomy contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short time becomes reddened, painful, and excoriated.  Option A: If the application of the drainage appliance is delayed after surgery, the skin around the stoma would be most likely irritated and damaged due to the digestive enzymes present in the secretions of the drainage.  Option C: An ileostomy needs a drainage bag before it starts to function so that the secretions from the drainage would be caught up by the bag, preventing contamination of the skin.  Option D: The client would have irritated, damaged skin once the drainage comes out from the stoma and comes into contact with the skin. NCLEXRN-04-024 Question Tag: spinal anesthesia Question Category: Physiological Integrity, Reduction of Risk Potential A client has undergone spinal anesthetic, it will be important that the nurse immediately position the client in:  A. On the side, to prevent obstruction of the airway by the tongue  B. Flat on back  C. On the back, with knees flexed 15 degrees  D. Flat on the stomach, with the head turned to the side Correct Answer: B. Flat on back To avoid the complication of a painful spinal headache that can last for several days, the client is kept in a flat supine position for approximately 4 to 12 hours postoperatively. Headaches are believed to be caused by the seepage of cerebrospinal fluid from the puncture site. By keeping the client flat, cerebral spinal fluid pressures are equalized, which avoids trauma to the neurons.  Option A: The client may experience a severe headache if kept in a side lying position. Spinal headaches are caused by leakage of spinal fluid through a puncture hole in the tough membrane (dura mater) that surrounds the spinal cord.  Option C: A supine position for 4 to 12 hours would prevent seepage of cerebrospinal fluid from the puncture site. There is no need to flex the knees.  Option D: Lying on his stomach would be uncomfortable to a postoperative patient, and would cause a painful spinal headache from the spinal anesthesia. . NCLEXRN-04-025 Question Tag: increased intracranial pressure Question Category: Physiological Integrity, Physiological Adaptation While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure?  A. Blood pressure has decreased from 160/90 to 110/70.  B. Pulse is increased from 87 to 95, with an occasional skipped beat.  C. The client is oriented when aroused from sleep and goes back to sleep immediately.  D. The client refuses dinner because of anorexia. Correct Answer: C. The client is oriented when aroused from sleep and goes back to sleep immediately. This finding suggests that the level of consciousness is decreasing.  Option A: A blood pressure level of 110/70 mmHg is within normal limits. Increased intracranial pressure is caused by an increase in blood pressure.  Option B: A pulse rate of 95 bpm is within the normal range. When arterial blood pressure exceeds the intracranial pressure, blood flow to the brain is restored. The increased arterial blood pressure caused by the CNS ischemic response stimulates the baroreceptors in the carotid bodies, thus slowing the heart rate drastically often to the point of bradycardia.  Option D: Anorexia is not related to increased intracranial pressure. Anorexia is an eating disorder characterized by an abnormally low body weight, an intense fear of gaining weight and a distorted perception of weight. NCLEXRN-04-026 Question Tag: pneumonia Question Category: Physiological Integrity, Physiological Adaptation Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first?  A. Altered mental status and dehydration  B. Fever and chills  C. Hemoptysis and Dyspnea  D. Pleuritic chest pain and cough Correct Answer: A. Altered mental status and dehydration Elderly clients may first appear with only an altered mental status and dehydration due to a blunted immune response.  Option B: Fever and chills are classic signs of pneumonia that may appear later in the elderly. The inflammatory response results in a proliferation of neutrophils. This can damage lung tissue, leading to fibrosis and pulmonary edema, which also impairs lung expansion.  Option C: Hemoptysis is a late sign of pneumonia. Bleeding in the lungs may originate from bronchial arteries, pulmonary arteries, bronchial capillaries, and alveolar capillaries. Dyspnea may occur early, especially among the elderly. Swelling and mucus can make it harder to move air through the airways, making it harder to breathe. This leads to shortness of breath, difficulty of breathing, and feeling more tired than normal.  Option D: Cough and pleuritic chest pain are the common symptoms of pneumonia. The air sacs may fill with fluid or pus, causing cough with phlegm or ous, fever, chills, and difficulty breathing. NCLEXRN-04-027 Question Tag: tuberculosis Question Category: Physiological Integrity, Physiological Adaptation A male client has active tuberculosis (TB). Which of the following symptoms will be exhibited?  A. Chest and lower back pain  B. Chills, fever, night sweats, and hemoptysis  C. Fever of more than 104°F (40°C) and nausea  D. Headache and photophobia Correct Answer: B. Chills, fever, night sweats, and hemoptysis Typical signs and symptoms are chills, fever, night sweats, and hemoptysis.  Option A: Chest pain may be present from coughing but isn’t usual. Pleurisy is a condition where there is inflammation or irritation of the lining of the lungs and chest. There is a sharp pain felt when breathing, coughing, or sneezing.  Option C: Clients with TB typically have low-grade fevers, not higher than 102°F (38.9°C). Fever typically develops in the late afternoon or evening in 68% of the cases, and this typical fever is significantly more common in patients less than 60 years of age.  Option D: Nausea, headache, and photophobia aren’t usual TB symptoms. Typical symptoms include a cough that lasts for more than 3 weeks, loss of appetite and unintentional weight loss, fever, chills, and night sweats. NCLEXRN-04-028 Question Tag: asthma Question Category: Physiological Integrity, Physiological Adaptation Mark, a 7-year-old client, is brought to the emergency department. He’s tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has a nonproductive cough. He recently had a cold. From this history; the client may have which of the following conditions?  A. Acute asthma  B. Bronchial pneumonia  C. Chronic obstructive pulmonary disease (COPD)  D. Emphysema Correct Answer: A. Acute asthma Based on the client’s history and symptoms, acute asthma is the most likely diagnosis.  Option B: Bronchial pneumonia most often exhibits a productive cough. It is the type of pneumonia that affects the bronchi in the lungs. This condition commonly results from a bacterial infection, but viral and fungal infections can also cause it.  Option C: COPD commonly occurs in middle-aged people, mostly over the age of 40. Chronic obstructive pulmonary disease is a chronic inflammatory lung disease that causes obstructed airflow from the lungs.  Option D: Emphysema is most common in men between the ages of 50 and 70. It is a lung condition that causes shortness of breath. The air sacs in the lungs are damaged. Over time, the inner walls of the air sacs weaken and rupture-creating larger air spaces instead of many small ones. NCLEXRN-04-029 Question Tag: morphine Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might have which of the following reactions?  A. Asthma attack  B. Respiratory arrest  C. Seizure  D. Wake up on her own Correct Answer: B. Respiratory arrest Narcotics can cause respiratory arrest if given in large quantities.  Option A: The client’s respiratory system is most likely being suppressed, so an acute asthma attack would be unlikely. In an asthma attack, the airways become swollen and inflamed. The muscles around the airways contract and the airways produce extra mucus, causing the breathing (bronchial) tubes to narrow.  Option C: A seizure is not likely to occur in the situation. Seizures are mostly caused by paroxysmal discharges from groups of neurons, which arise as a result of excessive excitation or loss of inhibition.  Option D: The client’s respiratory rate is too low and she might be going into a respiratory arrest. Respiratory depression happens when the lungs fail to exchange carbon dioxide and oxygen efficiently. This dysfunction leads to a buildup of carbon dioxide in the body, which can result in health complications. NCLEXRN-04-030 Question Tag: elective knee surgery Question Category: Health Promotion and Maintenance A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging?  A. Increased elastic recoil of the lungs  B. Increased number of functional capillaries in the alveoli  C. Decreased residual volume  D. Decreased vital capacity Correct Answer: D. Decreased vital capacity Reduction in vital capacity is a normal physiologic change including decreased elastic recoil of the lungs, fewer functional capillaries in the alveoli, and an increase in residual volume.  Option A: Elastic recoil in the lungs of the elderly is decreased. There is homogenous degeneration of the elastic fibers around the alveolar duct starting around 0 years of age resulting in enlargement of air spaces.  Option B: There are fewer functional capillaries in the alveoli as one ages. The alveoli can lose their shape and become baggy.  Option C: Decreases in the measures of lung function such as the vital capacity occurs as part of the age-related changes. NCLEXRN-04-031 Question Tag: lidocaine Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies Nurse John is caring for a male client receiving lidocaine I.V. Which factor is the most relevant to the administration of this medication?  A. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter.  B. Increase in systemic blood pressure  C. Presence of premature ventricular contractions (PVCs) on a cardiac monitor  D. Increase in intracranial pressure (ICP) Correct Answer: C. Presence of premature ventricular contractions (PVCs) on a cardiac monitor. Lidocaine drips are commonly used to treat clients whose arrhythmias haven’t been controlled with oral medication and who are having PVCs that are visible on the cardiac monitor.  Option A: This should be reported to the physician but it is not the priority in this situation.  Option B: An increase in the blood pressure is also significant, but does not need immediate attention.  Option D: Increase in ICP is an important factor but isn’t as significant as PVCs in the situation. NCLEXRN-04-032 Question Tag: anticoagulant Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to:  A. Report incidents of diarrhea  B. Avoid foods high in vitamin K  C. Use a straight razor when shaving  D. Take aspirin for pain relief Correct Answer: B. Avoid foods high in vitamin K. The client should avoid consuming large amounts of vitamin K because vitamin K can interfere with anticoagulation.  Option A: The client may need to report diarrhea but it doesn’t have the effect of taking an anticoagulant.  Option C: An electric razor-not a straight razor-should be used to prevent cuts that cause bleeding.  Option D: Aspirin may increase the risk of bleeding; acetaminophen should be used for pain relief. NCLEXRN-04-033 Question Tag: I.V. catheter Question Category: Physiological Integrity, Reduction of Risk Potential Nurse Lynette is preparing a site for the insertion of an I.V. catheter. The nurse should treat excess hair at the site by:  A. Leaving the hair intact  B. Shaving the area  C. Clipping the hair in the area  D. Removing the hair with a depilatory Correct Answer: C. Clipping the hair in the area. Hair can be a source of infection and should be removed by clipping.  Option A: Leaving the hair intact can cause infections.  Option B: Shaving the area can cause skin abrasions.  Option D: Depilatories can irritate the skin. NCLEXRN-04-034 Question Tag: osteoporosis Question Category: Health Promotion and Maintenance Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication:  A. Bone fracture  B. Loss of estrogen  C. Negative calcium balance  D. Dowager’s hump Correct Answer: A. Bone fracture Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increases the fragility of bones.  Option B: Estrogen deficiencies result from menopause and not osteoporosis.  Option C: Calcium and vitamin D supplements may be used to support normal bone metabolism, But a negative calcium balance isn’t a complication of osteoporosis.  Option D: Dowager’s hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature. NCLEXRN-04-035 Question Tag: BSE Question Category: Health Promotion and Maintenance Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the purpose of performing the examination is to discover:  A. Cancerous lumps  B. Areas of thickness or fullness  C. Changes from previous examinations  D. Fibrocystic masses Correct Answer: C. Changes from previous examinations. Women are instructed to examine themselves to discover changes that have occurred in the breast.  Option A: Lumps may be detected through BSE, but it does not diagnose whether it is benign or cancerous.  Option B: Only a physician can diagnose areas of thickness or fullness that signal the presence of a malignancy.  Option D: Only a physician can diagnose masses that are fibrocystic as opposed to malignant. NCLEXRN-04-036 Question Tag: hyperthyroidism Question Category: Physiological Integrity, Basic Care and Comfort When caring for a female client who is being treated for hyperthyroidism, it is important to:  A. Provide extra blankets and clothing to keep the client warm.  B. Monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy.  C. Balance the client’s periods of activity and rest.  D. Encourage the client to be active to prevent constipation. Correct Answer: C. Balance the client’s periods of activity and rest. A client with hyperthyroidism needs to be encouraged to balance periods of activity and rest. Many clients with hyperthyroidism are hyperactive and complain of feeling very warm.  Option A: One of the signs of hyperthyroidism is increased sensitivity to heat. So extra blankets and clothing would be unnecessary.  Option B: Restlessness, sweating, and unintentional weight loss are common signs of hyperthyroidism.  Option D: There should be equal moments of activity and rest for the client. NCLEXRN-04-037 Question Tag: atherosclerosis Question Category: Health Promotion and Maintenance Nurse Kris is teaching a client with a history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to:  A. Avoid focusing on his weight  B. Increase his activity level  C. Follow a regular diet  D. Continue leading a high-stress lifestyle. Correct Answer: B. Increase his activity level. The client should be encouraged to increase his activity level. ADVERTISEMENTS  Option A: Clients with atherosclerosis should be vigilant about their weight and maintain the ideal number of kilograms/pounds.  Option C: The client should be following a low cholesterol, low sodium diet.  Option D: Avoiding stress is an important factor in decreasing the risk of atherosclerosis. NCLEXRN-04-038 Question Tag: logroll Question Category: Physiological Integrity, Physiological Adaptation Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client following a:  A. Laminectomy  B. Thoracotomy  C. Hemorrhoidectomy  D. Cystectomy Correct Answer: A. Laminectomy The client who has had spinal surgery, such as laminectomy, must be log rolled to keep the spinal column straight when turning.  Option B: Thoracotomy clients may turn themselves or may be assisted into a comfortable position.  Option C: Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery.  Option D: A client who has undergone cystectomy would be able to turn themselves or may need minimal assistance. NCLEXRN-04-039 Question Tag: intraocular lens implant Question Category: Health Promotion and Maintenance A 55-year old client underwent cataract removal with intraocular lens implant. Nurse Oliver is giving the client discharge instructions. These instructions should include which of the following?  A. Avoid lifting objects weighing more than 5 lb (2.25 kg)  B. Lie on your abdomen when in bed  C. Keep rooms brightly lit  D. Avoiding straining during a bowel movement or bending at the waist Correct Answer: D. Avoiding straining during bowel movement or bending at the waist. The client should avoid straining, lifting heavy objects, and coughing harshly because these activities increase intraocular pressure.  Option A: Typically, the client is instructed to avoid lifting objects weighing more than 15 lb (7kg) – not 5lb.  Option B: Instruct the client when lying in bed to lie on either the side or back.  Option C: The client should avoid bright light by wearing sunglasses. NCLEXRN-04-040 Question Tag: testicular exams Question Category: Health Promotion and Maintenance George should be taught about testicular examinations during:  A. When sexual activity starts  B. After age 69  C. After age 40  D. Before age 20 Correct Answer: D. Before age 20. Testicular cancer commonly occurs in men between ages 20 and 30. A male client should be taught how to perform testicular self-examination before age 20, preferably when he enters his teens.  Option A: Sexual activity is not an accurate indicator on when to start testicular exams.  Option B: The age of 69 would be too old to start on testicular exams. Most elderly men may have testicular problems at this age.  Option C: The age 40 is not an ideal age to start the testicular exams. It might be too late to detect a problem at this stage. NCLEXRN-04-041 Question Tag: wound dehiscence Question Category: Physiological Integrity, Physiological Adaptation A male client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. Nurse Trish first response is to:  A. Call the physician  B. Place a saline-soaked sterile dressing on the wound  C. Take blood pressure and pulse  D. Pull the dehiscence closed Correct Answer: B. Place a saline-soaked sterile dressing on the wound. The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection.  Option A: After placing a saline-soaked gauze, the nurse should call the physician.  Option C: After notifying the physician, the nurse should take the client’s vital signs.  Option D: The dehiscence needs to be surgically closed, so the nurse should never try to close it. NCLEXRN-04-042 Question Tag: Cheyne-Stokes respirations Question Category: Physiological Integrity, Physiological Adaptation Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. During routine assessment, the nurse notices Cheyne- Stokes respirations. Cheyne-stokes respirations are:  A. Progressively deeper breath followed by shallower breaths with apneic periods.  B. Rapid, deep breathing with abrupt pauses between each breath.  C. Rapid, deep breathing and irregular breathing without pauses.  D. Shallow breathing with an increased respiratory rate. Correct Answer: A. Progressively deeper breaths followed by shallower breaths with apneic periods. Cheyne-Stokes respirations are breaths that become progressively deeper followed by more shallow respirations with apneic periods.  Option B: Biot’s respirations are rapid, deep breathing with abrupt pauses between each breath, and equal depth between each breath.  Option C: Kussmaul’s respirations are rapid, deep breathing without pauses.  Option D: Tachypnea is shallow breathing with increased respiratory rate. NCLEXRN-04-043 Question Tag: heart failure Question Category: Physiological Integrity, Physiological Adaptation Nurse Bea is assessing a male client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:  A. Tracheal  B. Fine crackles  C. Coarse crackles  D. Friction rubs Correct Answer: B. Fine crackles Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure.  Option A: Tracheal breath sounds are auscultated over the trachea.  Option C: Coarse crackles are caused by secretion accumulation in the airways.  Option D: Friction rubs occur with pleural inflammation. NCLEXRN-04-044 Question Tag: acute asthma Question Category: Physiological Integrity, Physiological Adaptation The nurse is caring for Kenneth experiencing an acute asthma attack. The client stops wheezing and breath sounds aren’t audible. The reason for this change is that:  A. The attack is over.  B. The airways are so swollen that no air cannot get through.  C. The swelling has decreased.  D. Crackles have replaced wheezes. Correct Answer: B. The airways are so swollen that no air cannot get through. During an acute attack, wheezing may stop and breath sounds become inaudible because the airways are so swollen that air can’t get through.  Option A: Breath sounds should still be audible even if the attack is over.  Option C: A decrease in swelling does not cause diminished breath sounds.  Option D: Crackles do not replace wheezes during an acute asthma attack. NCLEXRN-04-045 Question Tag: seizure Question Category: Safe & Effective Care Environment, Safety and infection Control Mike with epilepsy is having a seizure. During the active seizure phase, the nurse should:  A. Place the client on his back, remove dangerous objects, and insert a bite block.  B. Place the client on his side, remove dangerous objects, and insert a bite block.  C. Place the client on his back, remove dangerous objects, and hold down his arms.  D. Place the client on his side, remove dangerous objects, and protect his head. Correct Answer: D. Place the client on his side, remove dangerous objects, and protect his head. During the active seizure phase, initiate precautions by placing the client on his side, removing dangerous objects, and protecting his head from injury.  Option A: Do not insert anything on a client’s mouth during an active seizure because it may damage the teeth. Placing the client on his back may cause obstruction of the airway.  Option B: A bite block should never be inserted during the active seizure phase. Insertion can break the teeth and lead to aspiration.  Option C: The client should be placed in a side-lying position to facilitate drainage of secretions and prevent aspiration. NCLEXRN-04-046 Question Tag: chest tube, pneumothorax Question Category: Physiological Integrity,Reduction of Risk Potential After insertion of a chest tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for?  A. Infection of the lung  B. Kinked or obstructed chest tube  C. Excessive water in the water-seal chamber  D. Excessive chest tube drainage Correct Answer: B. Kinked or obstructed chest tube Kinking and blockage of the chest tube is a common cause of a tension pneumothorax.  Option A: Infection of the lung won’t cause a tension pneumothorax. A tension pneumothorax is a life-threatening condition that develops when air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary function.  Option C: Excessive water won’t affect the chest tube drainage. The main purpose of the water seal is to allow air to exit from the pleural space on exhalation and prevent air from entering the pleural cavity or mediastinum on inhalation.  Option D: An excessive chest tube drainage cannot cause tension pneumothorax. Chest tubes drain blood, fluid, or air from around the lungs, heart, or esophagus. The tube around the lung is placed between the ribs and into the space between the inner lining and the outer lining of the chest cavity. NCLEXRN-04-047 Question Tag: choking Question Category: Safe & Effective Care Environment, Safety and infection Control Nurse Maureen is talking to a male client, the client begins choking on his lunch. He’s coughing forcefully. The nurse should:  A. Stand him up and perform the abdominal thrust maneuver from behind.  B. Lay him down, straddle him, and perform the abdominal thrust maneuver.  C. Leave him to get assistance.  D. Stay with him but not intervene at this time. Correct Answer: D. Stay with him but not intervene at this time. If the client is coughing, he should be able to dislodge the object or cause complete obstruction. If a complete obstruction occurs, the nurse should perform the abdominal thrust maneuver with the client standing.  Option A: This would only be applicable if there is a complete obstruction, in which the client would not be able to cough anymore.  Option B: If the client is unconscious, she should lay him down.  Option C: A nurse should never leave a choking client alone. NCLEXRN-04-048 Question Tag: health history Question Category: Health Promotion and Maintenance Nurse Ron is taking the health history of an 84-year-old client. Which information will be most useful to the nurse for planning care?  A. General health for the last 10 years  B. Current health promotion activities  C. Family history of diseases  D. Marital status Correct Answer: B. Current health promotion activities Recognizing an individual’s positive health measures is very useful.  Option A: General health in the previous 10 years is important, however, the current activities of an 84-year-old client are most significant in planning care.  Option C: Family history of disease for a client in later years is of minor significance.  Option D: Marital status information may be important for discharge planning but is not as significant for addressing the immediate medical problem. NCLEXRN-04-049 Question Tag: oral care Question Category: Physiological Integrity, Physiological Adaptation When performing oral care on a comatose client, Nurse Krina should:  A. Apply lemon glycerin to the client’s lips at least every 2 hours.  B. Brush the teeth with a client lying supine.  C. Place the client in a side-lying position, with the head of the bed lowered.  D. Clean the client’s mouth with hydrogen peroxide. Correct Answer: C. Place the client in a side-lying position, with the head of the bed lowered. The client should be positioned in a side-lying position with the head of the bed lowered to prevent aspiration. A small amount of toothpaste should be used and the mouth swabbed or suctioned to remove pooled secretions.  Option A: Lemon glycerin can be drying if used for extended periods.  Option B: Brushing the teeth with the client lying supine may lead to aspiration.  Option D: Hydrogen peroxide is caustic to tissues and should not be used. NCLEXRN-04-050 Question Tag: pneumonia Question Category: Physiological Integrity, Physiological Adaptation A 77-year-old male client is admitted with a diagnosis of dehydration and change in mental status. He’s being hydrated with L.V. fluids. When the nurse takes his vital signs, she notes he has a fever of 103°F (39.4°C) , a cough producing yellow sputum and pleuritic chest pain. The nurse suspects this client may have which of the following conditions?  A. Adult respiratory distress syndrome (ARDS)  B. Myocardial infarction (MI)  C. Pneumonia  D. Tuberculosis Correct Answer: C. Pneumonia Fever, productive cough, and pleuritic chest pain are common signs and symptoms of pneumonia.  Option A: The client with ARDS has dyspnea and hypoxia with worsening hypoxia over time, if not treated aggressively.  Option B: Pleuritic chest pain varies with respiration, unlike the constant chest pain during an MI; so this client most likely isn’t having an MI.  Option D: The client with TB typically has a cough producing bloodtinged sputum. A sputum culture should be obtained to confirm the nurse’s suspicions. NCLEXRN-04-051 Question Tag: tuberculosis Question Category: Health Promotion and Maintenance Nurse Oliver is working in an outpatient clinic. He has been alerted that there is an outbreak of tuberculosis (TB). Which of the following clients entering the clinic today is most likely to have TB?  A. A 16-year-old female high school student  B. A 33-year-old daycare worker  C. A 43-year-old homeless man with a history of alcoholism  D. A 54-year-old businessman Correct Answer: C. A 43-year-old homeless man with a history of alcoholism Clients who are economically disadvantaged, malnourished, and have reduced immunity, such as a client with a history of alcoholism, are at extremely high risk for developing TB.  Option A: The high school student may be at low risk of developing TB, and she does not exhibit any signs and symptoms.  Option B: The daycare worker may have a lesser risk of developing TB than the homeless man with alcoholism.  Option D: A businessman probably has a much lower risk of contracting TB. NCLEXRN-04-052 Question Tag: Mantoux test Question Category: Physiological Integrity, Reduction of Risk Potential Virgie with a positive Mantoux test result will be sent for a chest X-ray. The nurse is aware that which of the following reasons this is done?  A. To confirm the diagnosis  B. To determine if a repeat skin test is needed  C. To determine the extent of lesions  D. To determine if this is a primary or secondary infection Correct Answer: C. To determine the extent of lesions If the lesions are large enough, the chest X-ray will show their presence in the lungs.  Option A: Sputum culture confirms the diagnosis. It is a test to detect and identify bacteria or fungi that infect the lungs or breathing passages.  Option B: There can be false-positive and false-negative skin test results. False positive results happen with the skin test because the person has been infected with a different type of bacteria, rather than the one that causes TB. It can also happen because the person has been vaccinated with the BCG vaccine. A false negative result may happen if the immune function is compromised by chronic medical conditions, cancer chemotherapy, or AIDS.  Option D: A chest X-ray can’t determine if this is a primary or secondary infection. In active pulmonary TB, infiltrates or consolidations and/or cavities are often seen in the upper lungs with or without mediastinal or hilar lymphadenopathy. NCLEXRN-04-053 Question Tag: acute asthma Question Category: Physiological Integrity, Physiological Adaptation Kennedy with acute asthma showing inspiratory and expiratory wheezes and a decreased forced expiratory volume should be treated with which of the following classes of medication right away?  A. Beta-adrenergic blockers  B. Bronchodilators  C. Inhaled steroids  D. Oral steroids Correct Answer: B. Bronchodilators Bronchodilators are the first line of treatment for asthma because bronchoconstriction is the cause of reduced airflow.  Option A: Beta-adrenergic blockers aren’t used to treat asthma and can cause bronchoconstriction.  Option C: Inhaled steroids are not ideal for emergency cases because of their slow onset.  Option D: Oral steroids may be given to reduce the inflammation but aren’t used for emergency relief. NCLEXRN-04-054 Question Tag: bronchitis Question Category: Physiological Integrity, Physiological Adaptation Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two packs of cigarettes per day has a chronic cough producing thick sputum, peripheral edema, and cyanotic nail beds. Based on this information, he most likely has which of the following conditions?  A. Adult respiratory distress syndrome (ARDS)  B. Asthma  C. Chronic obstructive bronchitis  D. Emphysema Correct Answer: C. Chronic obstructive bronchitis Because of this extensive smoking history and symptoms, the client most likely has chronic obstructive bronchitis.  Option A: Clients with ARDS have acute symptoms of hypoxia and typically need large amounts of oxygen.  Option B: Clients with asthma do not exhibit a chronic cough. Symptoms of asthma include shortness of breath, chest tightness or pain, wheezing when exhaling, and coughing or wheezing attacks.  Option D: Clients with emphysema tend not to have a chronic cough or peripheral edema. The main symptom of emphysema is shortness of breath, which usually begins gradually. NCLEXRN-04-055 Question Tag: chronic lymphocytic anemia Question Category: Physiological Integrity, Reduction of Risk Potential Situation: Francis, age 46 is admitted to the hospital with diagnosis of Chronic Lymphocytic Leukemia. The treatment for patients with leukemia is bone marrow transplantation. Which statement about bone marrow transplantation is not correct?  A. The patient is under local anesthesia during the procedure.  B. The aspirated bone marrow is mixed with heparin.  C. The aspiration site is the posterior or anterior iliac crest.  D. The recipient receives cyclophosph