NURSE 1220 FINAL EXAM 2024/2025 NCLEX STYLE QUESTIONS AND
CORRECT ANSWERS (VERIFIED ANSWERS )WITH RATIONALES
ALREADY GRADED .PASS GUARANTEED .
For which symptom or symptoms will the nurse assess in an older
adult client who is suspected of having pneumonia? Select all that
apply.
A. Fever
B. Cough
C. Confusion
D. Weakness
E. Diarrhea
F. Hypotension - ANSWER-ANSWER: A, B, C, D, F
Fever, cough, confusion, and weakness are common symptoms of
pneumonia. Elderly clients may first exhibit only altered mental status
and dehydration (hypotension, tachycardia, decreased urine output)
due to a blunted immune response. Diarrhea is not associated with
pneumonia.
A client with COPD who smokes 1 PPD presents for a routine
appointment. Which client statement causes the nurse to suspect an
increase in dyspnea?
A. "I prop myself up at night to sleep."
B. "I decided to put on some makeup today."
,C. "I have a productive cough in the morning."
D. "I have gained weight since I was here last." - ANSWER-ANSWER:
A
Clients with COPD, who smoke, may have a productive morning
cough. Weight loss (not gain) often occurs when dyspnea is
increased due to the increased metabolic demand. A disheveled
appearance may indicate an increase in dyspnea, if the client doesn't
feel well enough to perform ADLs. Sleeping propped up indicates that
breathing may be worse while lying down.
For which symptom will the nurse assess in an older adult client who
is suspected of having pneumonia? Select all that apply
A. Fever
B. Cough
C. Confusion
D. Weakness
E. Tuberculin Skin Testing (TST) induration - ANSWER-ANSWER: A,
B, C, D
The older adult with pneumonia often has fever, cough, weakness,
fatigue, lethargy, confusion, and poor appetite. TST induration is
associated with tuberculosis; not pneumonia.
,A nursing student is teaching a 72-year-old client about the
importance of the pneumonia vaccination. Which teaching will the
nurse provide?
A. "You will need two vaccines to best protect yourself."
B. "There are two vaccines available, and you can choose just one."
C. "If you have had the PCV13 vaccine, then you will not need the
PPSV23 vaccine."
D. "Since you are over 64 years old, only the flu vaccine is
suggested." - ANSWER-ANSWER: A
There are two pneumonia vaccines: pneumococcal polysaccharide
vaccine (PPSV23) and pneumococcal conjugate vaccine (PCV13) for
prevention of pneumonia (Phillips & Swanson, 2016). The CDC
recommends that adults older than 65 years be vaccinated with both,
first with PCV13 followed by PPSV23 about 6 to 12 months later.
Adults who have already received the PPSV23 should have PCV13
about a year or more later. These recommendations also apply to
adults between 19 and 64 years of age who have specific risk factors
such as chronic illnesses (CDC, 2018b). Because pneumonia often
follows influenza, especially among older adults, urge all adults to
receive the seasonal vaccination annually.
While applying compression stockings and pneumatic compression
devices, a client questions the purpose of these devices. What is the
appropriate nursing response?
, A. "These will help to prevent blood clots."
B. "They make your legs feel more comfortable."
C. "These prevent skin breakdown from immobility."
D. "The use of these right after surgery makes is easier to start to
ambulate." - ANSWER-ANSWER: A
VTE prophylaxis may involve devices and drug therapy, depending on
a specific patient's evaluated risk. Devices may be used during and
after surgery along with leg exercises and early ambulation to
promote venous return.
As the nurse evaluates a laboratory report for a client scheduled for
surgery, which finding requires nursing intervention?
A. Hemoglobin 10.4 g/dL
B. Serum potassium 2.5 mEq/L
C. Serum sodium level 145 mEq/L
D. Fasting blood glucose 110 mg/dL - ANSWER-ANSWER: B
Although all the laboratory results listed are not within normal ranges,
the presence of hypokalemia (normal serum potassium levels should
be between 3.0 and 5.5 mEq/L) increases the risk for toxicity if the
patient is taking digoxin, slows recovery from anesthesia, and
increases cardiac irritability. Potassium problems must be corrected
before the surgery.
CORRECT ANSWERS (VERIFIED ANSWERS )WITH RATIONALES
ALREADY GRADED .PASS GUARANTEED .
For which symptom or symptoms will the nurse assess in an older
adult client who is suspected of having pneumonia? Select all that
apply.
A. Fever
B. Cough
C. Confusion
D. Weakness
E. Diarrhea
F. Hypotension - ANSWER-ANSWER: A, B, C, D, F
Fever, cough, confusion, and weakness are common symptoms of
pneumonia. Elderly clients may first exhibit only altered mental status
and dehydration (hypotension, tachycardia, decreased urine output)
due to a blunted immune response. Diarrhea is not associated with
pneumonia.
A client with COPD who smokes 1 PPD presents for a routine
appointment. Which client statement causes the nurse to suspect an
increase in dyspnea?
A. "I prop myself up at night to sleep."
B. "I decided to put on some makeup today."
,C. "I have a productive cough in the morning."
D. "I have gained weight since I was here last." - ANSWER-ANSWER:
A
Clients with COPD, who smoke, may have a productive morning
cough. Weight loss (not gain) often occurs when dyspnea is
increased due to the increased metabolic demand. A disheveled
appearance may indicate an increase in dyspnea, if the client doesn't
feel well enough to perform ADLs. Sleeping propped up indicates that
breathing may be worse while lying down.
For which symptom will the nurse assess in an older adult client who
is suspected of having pneumonia? Select all that apply
A. Fever
B. Cough
C. Confusion
D. Weakness
E. Tuberculin Skin Testing (TST) induration - ANSWER-ANSWER: A,
B, C, D
The older adult with pneumonia often has fever, cough, weakness,
fatigue, lethargy, confusion, and poor appetite. TST induration is
associated with tuberculosis; not pneumonia.
,A nursing student is teaching a 72-year-old client about the
importance of the pneumonia vaccination. Which teaching will the
nurse provide?
A. "You will need two vaccines to best protect yourself."
B. "There are two vaccines available, and you can choose just one."
C. "If you have had the PCV13 vaccine, then you will not need the
PPSV23 vaccine."
D. "Since you are over 64 years old, only the flu vaccine is
suggested." - ANSWER-ANSWER: A
There are two pneumonia vaccines: pneumococcal polysaccharide
vaccine (PPSV23) and pneumococcal conjugate vaccine (PCV13) for
prevention of pneumonia (Phillips & Swanson, 2016). The CDC
recommends that adults older than 65 years be vaccinated with both,
first with PCV13 followed by PPSV23 about 6 to 12 months later.
Adults who have already received the PPSV23 should have PCV13
about a year or more later. These recommendations also apply to
adults between 19 and 64 years of age who have specific risk factors
such as chronic illnesses (CDC, 2018b). Because pneumonia often
follows influenza, especially among older adults, urge all adults to
receive the seasonal vaccination annually.
While applying compression stockings and pneumatic compression
devices, a client questions the purpose of these devices. What is the
appropriate nursing response?
, A. "These will help to prevent blood clots."
B. "They make your legs feel more comfortable."
C. "These prevent skin breakdown from immobility."
D. "The use of these right after surgery makes is easier to start to
ambulate." - ANSWER-ANSWER: A
VTE prophylaxis may involve devices and drug therapy, depending on
a specific patient's evaluated risk. Devices may be used during and
after surgery along with leg exercises and early ambulation to
promote venous return.
As the nurse evaluates a laboratory report for a client scheduled for
surgery, which finding requires nursing intervention?
A. Hemoglobin 10.4 g/dL
B. Serum potassium 2.5 mEq/L
C. Serum sodium level 145 mEq/L
D. Fasting blood glucose 110 mg/dL - ANSWER-ANSWER: B
Although all the laboratory results listed are not within normal ranges,
the presence of hypokalemia (normal serum potassium levels should
be between 3.0 and 5.5 mEq/L) increases the risk for toxicity if the
patient is taking digoxin, slows recovery from anesthesia, and
increases cardiac irritability. Potassium problems must be corrected
before the surgery.
