Exam Cram NCLEX-PN PRACTICE QUESTIONS AND ANSWERS GRADED A

would support that assessment? A. She dresses herself B. She pulls a toy behind her C. She can build a tower of eight blocks D. She can copy a horizontal or vertical line. - ANS- A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis? A. "tell me about the pain" B."what does his vomit look like?" C." Describe his usual diet." D. " have you noticed changes in his adominal size?" - ANS- C." Describe his usual diet." why? The least-helpful questions are those describing his usual diet. A, B, and D are useful in determining the extent of disease process and thus, are incorrect A 70 year old man who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggested of unilateral neglect? A. The client is observed by shaving only one side of his face B. The client is unable to distinguish between two tactile stimuli presented simultaneously C. The client is unable to complete a range a vision without turning his head side to side D. The client is unable to carry out cognitive and motor activity at the same time - ANS- A. The client is observed by shaving only one side of his face why? The client with unilateral neglect will neglect one side of the body A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for: A. Trendelenburg position B. Ice to the entire extremity C. Bucks traction D. An abduction pillow - ANS- C. Bucks traction why? The client with a fractured femur will be placed in Bucks traction to realign the leg and decrease spasms and pain. A client has been receiving cyanocobalamine (B12) injections for the past 6 weeks. Which lab finding indicates that the medication is having the desired effect? A. Neutrophil count of 60% B. Basophil count of 0.5% C. Monocyte count of 2% D. Reticlocyte count of 1% - ANS- D. Reticlocyte count of 1 % why? Cyanocolamine is a B12 medication that is used for pernicious anemia, and a reticulocyte count of 1% indicates that it is having the desired effect. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? A. Teaching how to irrigate the illeostomy B. Stopping electrolytes loss in the incisional area C. Encouraging a high fiber diet D. Facilitating perineal wound drainage - ANS- D. Facilitating perineal wound drainage why? the client with a perineal resection will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illestomy. as in answer A he will have some electrolyte loss, but treatment is not focused on preventing the loss, so answer B is incorrect A high fiber diet in answer C is not ordered at this time. A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure? A. Bradycardia B. Tachycardia C. Premature ventricular beats D. Heart block - ANS- A. Bradycardia why? Suctioning can cause a vagal response and bradycardia. A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate? A. Reinsert the protruding organ and cover with 4x4s B. Cover the wound with a sterile 4x4 and ABD dressing C. Cover the wound with a sterile saline-soaked dressing D. Apply an abdominal binder and manual pressure to the wound - ANS- C. Cover the wound with a sterile saline-soaked dressing. why? If the client eviscerates, the abdominal content should be covered with a sterile saline-soaked dressing. A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170 meq/L. What behavioral changes would be common for this client? A. Anger B. Mania C. Depression D. Pyschosis - ANS- B. Mania why? The client with serum sodium of 170 meq/L has hypernatrimia and might exhibit manic behvior. A client is admitted with a Ewing's sacroma. which symptoms would be expected due to this tumor's location? A. Hemiplegia B. Aphasia C. Nausea D. Bone Pain - ANS- D. Bone Pain why? Sacroma is a type of bone cancer, therefor, bone pain would be expected A client visits the clinic after the death of a parent. Which statement made by the client's sister signifies abnormal grieving? A. "My sister still has episodes of crying and it's been 3 months since daddy died." B. "Sally seems to have forgotten the bad things that daddy did in his lifetime." C. "She really had a hard time after daddy's funeral. She said that she had a sense of longing." D. "Sally has not been sad at all by daddy's death. She acts like nothing has happened." - ANS- D. "Sally has not been sad at all by daddy's death. She acts like nothing has happened at all." why? Abnormal grieving is exhibited by a lack of feeling sad; if the client's sister appears not to grieve, it might be abnormal grieving. This family member might be suppressing feelings of grief. A client with acute leukemia develops a low white blood cell count. In addition to the institute of isolation the nurse should: A. Request that food be served with disposable utensils B. Ask the client to wear a mask when visitors are present C. Prep IV with mild soap, water, and alcohol D. Provide foods in seal single serving packages - ANS- D. Provide foods in seal single serving packages why? Because the client is immune-suppressed, foods should be served in sealed containers, to avoid food contaminants. A client with cancer develops xerostomia. The nurse can help alleviate the discomfort associated with xerostomia by: A. Offering a hard candy B. Administering an analgesic medication C. Splinting swollen joints D. Providing saliva substitue - ANS- D. Providing saliva substitute why? Xerostomia is dry mouth, and offering the client a saliva substitute will help the most. A client with cancer is a, admitted to the oncology unit. Stat lab values revel Hgb 12.6, WBC 6500, K+1.9, uric acid 7.0, Na+136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following? A. Hypernatremia B. Hypokalemia C. Myelosuppression D. Leukocytosis - ANS- B. Hypokalemia why? Hypokalemia is evident from the lab values listed. The other laboratory findings are within normal limits. making answers A,C and D incorrect A client with caner is to undergo an intravenous pyelogram. The nurse should: A. Force fluids 24 hours before the procedure.