Anda di halaman 1dari 56

NCLEX PN Practice Exam

1. The nurse is caring for a client following an appendectomy. The


client reports nausea and complains of surgical site pain at a 6 on a
0 to 10 scale. The client's employer is present in the room and
states he is paying for the insurance and wants to know what pain
medication has been prescribed by the physician. Which of the
following is the appropriate nurse response?
A. Answer any questions the employer may have as he pays for the
insurance.
B. Tell the employer his question is inappropriate and that the information is
none of his business.
C. Explain to the employer that you cannot release private information and
ask the employer to step out while you conduct your assessment of the
client.
D. Ask the employer to leave and wait until the client returns home to visit.
2. The nurse is caring for a client with a history of advanced chronic
obstructive pulmonary disease (COPD). The client had conventional
gallbladder surgery 2 days previously. Which intervention has
priority for preventing respiratory complications?
A. Incentive spirometry every 4 hours.
B. Coughing and deep breathing four times daily.
C. Getting the client out of bed 4 times daily as ordered by the physician.
D. Giving oxygen at 4 L/minute according to the physician's order.
3. A nurse is developing a care plan for a client with acute mania.
Place the following behaviors in the order in which they occur as the
client develops acute mania. Use all of the options.
A. Delusions of grandeur.
B. Relevant, calm speech patterns.
C. Highly productive and competitive in work and leisure activities.
D. Easily irritated.
E. Poor judgment and impulse control.
4. When educating a pregnant client about home safety, which of
the following information is appropriate for the nurse to include in
the teaching plan? Select all that apply.

A. When taking a shower, place a non-skid mat on the floor of the tub or
shower.
B. Avoid climbing stairs.
C. Avoid wearing high heels.
D. Use non-slip rugs on the floors.
5. A client had a C5 spinal cord contusion that resulted in
quadriplegia. Two days after the injury occurred, the nurse sees his
mother crying in the waiting room. The mother asks the nurse
whether her son will ever play football again. Which of the following
is the best initial response?
A. "Given time and motivation, your son can return to normal function."
B. "I'm not sure, but I'll call the physician to talk to you right away."
C. "What do you know about your son's injury?"
D. "Getting upset isn't in you son's best interest."
6. The nurse is caring for a client who will undergo surgical repair of
a detached retina. Which of the following is the most likely
preoperative nursing diagnosis for this client?
A. Anxiety related to loss of vision and potential failure to regain vision.
B. Deficient knowledge (preoperative and postoperative activities) related to
lack of information.
C. Acute pain related to tissue injury and decreased circulation to the eye.
D. Risk for infection related to the eye injury.
7. When assessing a client with glaucoma, a nurse expects which of
the following findings?
A. Complaints of double vision.
B. Complaints of halos around lights.
C. Intraocular pressure of 15 mm Hg.
D. Soft globe on palpation.
8. A client had a Caesarean delivery and is postpartum day 1. She
asks for pain medication when the nurse enters the room to do her
shift assessment. The client states that her pain level is an 8 on a
scale of 1 to 10. What should be the nurse's priority of care?
A. Give the pain medication and return in an hour for further assessment to
allow time for the medication to work.
B. Complete the postpartum assessment and then give the client pain
2

medication.
C. Give the pain medication first, do a quick assessment while administering
the medication to ensure the pain is not caused by a complication, and
return for the full assessment after the client's pain has subsided.
D. Instruct the patient to do relaxation exercises to relieve her discomfort.
9. The nurse is preparing to teach a client about the effects of
isoniazid (INH). Which information is important for the client to
understand?
A. Isoniazid should be taken on an empty stomach.
B. Prolonged use of isoniazid produces poorly concentrated urine.
C. Taking aluminum hydroxide (Maalox) with isoniazid minimizes
gastrointestinal upset.
D. Drinking alcohol daily can increase the incidence of drug-induced
hepatitis.
10. A one-month old infant in the neonatal intensive care unit is
dying. The parents request that the nurse administer an opioid
analgesic to their infant, who is crying weakly. The infant's heart
rate is 68 beats per minute and the respiratory rate is 18 breaths
per minute. The infant is on room air and the oxygen saturation is
92%. The nurse's response is based on which of the following
principles?
A. Providing analgesia during the last days and hours is an ethicallyappropriate nursing action.
B. Withholding the opioid analgesia during the last days and hours is an
ethical duty because administering it would represent assisted suicide.
C. Administering analgesia during the last days and hours is the parent's
ethical decision.
D. Withholding the opioid analgesia is clinically appropriate because it will
hasten the infant's death.
11. While undergoing hemodialysis, the client becomes restless and
tells the nurse he has a headache and feels nauseous. Which of the
following complications does the nurse suspect?
A. Infection.
B. Disequilibrium syndrome.
C. Air embolus.
D. Acute hemolysis.

12. An elderly couple is speaking to the nurse about their


ambivalence related to sending the client, their adult, dualdiagnosed (bipolar and drug addict) son, into residential placement.
They tell the nurse that neither keeping their son at home nor
sending him to a facility is a satisfactory solution for them. What
information should the nurse keep in mind when discussing this
dilemma with the family? Select all that apply.
A. Implement what is best for the couple.
B. Suggest another psychiatric evaluation for the son.
C. Look for all potential options for care.
D. Review the client's treatment history.
E. Consult legal authorities for information.
13. The nurse is caring for a 44-year-old client diagnosed with
hypoparathyroidism. Which electrolyte imbalance is closely
associated with hypoparathyroidism?
A. Hypocalcemia.
B. Hyponatremia.
C. Hyperkalemia.
D. Hypophosphatemia.
14. The nurse is caring for a client diagnosed with end-stage liver
disease. The client has completed an advance directive and a donot-resuscitate (DNR) document and wishes to receive palliative
care. Which of the following would correspond to the client's wish
for comfort care?
A. Positioning frequently to prevent skin breakdown and providing pain
management and other comfort measures.
B. Carrying out vigorous resuscitation efforts if the client were to stop
breathing, but no resuscitation if the heart stops beating.
C. Providing intravenous fluids when the client becomes dehydrated.
D. Providing total parenteral nutrition (TPN) if the client is not able to eat.
15. The nurse is caring for a client receiving warfarin therapy
(Coumadin) following a stroke. The client's PT/INR was completed
at 7:00 A.M. prior to the morning meal with an INR reading of 4.0.
Which of the following is the nurse's first priority?
A. Call the physician to request an increase in the Coumadin dose.
B. Administer a vitamin K injection IM and notify the physician of the results.
4

C. Assess the client for bleeding around the gums or in the stool and notify
the physician of the lab results and latest dose of Coumadin.
D. Notify the next shift to hold the daily dose of Coumadin scheduled for
5:00 pm.
16. The nurse is checking laboratory values on a patient who has
crackling rales in the lower lobes, 2+ pitting edema, and dyspnea
with minimal exertion. Which of the following laboratory values
does the nurse expect to be abnormal?
A. Potassium.
B. B-type natriuretic peptide (BNP).
C. C-reactive protein (CRP).
D. Platelets.
17. A 12-year-old boy has been receiving aggressive treatment for
leukemia for the past year. His condition has continued to
deteriorate, and the prognosis is poor. The parents would like to
implement a "Do Not Resuscitate" plan but inform the nurse that
they cannot bring themselves to discuss it with their child and ask
the nurse to discuss it with the child instead. When approaching the
subject with the child, the nurse must assess which of the following
first?
A. What the child knows about the disease and his prognosis.
B. How the child would like to handle the plan of care.
C. What interventions the child would like in the event of cardiac or
respiratory arrest.
D. What the child believes about death.
18. The nurse is advising a client with a colostomy. The client
reports problems with flatus. Which of the following foods should
the nurse recommend?
A. High fiber foods, such as bran.
B. Cruciferous vegetables, such as cabbage, broccoli, and kale.
C. Carbonated beverages.
D. Yogurt.
19. The nurse is reviewing self-care measures for a client with
peripheral vascular disease. Which of the following statements
indicates proper self-care measures?

A. "I like to soak my feet in the hot tub everyday."


B. "I walk to the mailbox in my bare feet."
C. "I stopped smoking and only use chewing tobacco."
D. "I have my wife examine the soles of my feet each day."
20. A nurse is taking the health history of an 85-year-old client.
Which of the following physical findings is consistent with normal
aging?
A. Increase in subcutaneous fat.
B. Diminished cough reflex.
C. Long-term memory loss.
D. Myopia.

Answer Key
1. Correct answer: C
Explaining to the employer that the nurse cannot release information and
asking the employer to step out while conducting an assessment allows the
6

client privacy while still being respectful of the employer. Although the
employer is paying for the insurance, this does not given him a right to
confidential information. Providing information to the client's employer
without permission is a violation of the right to privacy under HIPAA.
Speaking rudely to a visitor by saying something is "none of his business" is
never appropriate. Asking the person to leave and to wait until the client
returns home to visit wrongly assumes the nurse has the right to speak for
the patient.
2. Correct answer: C
Getting the client out of bed prevents pooling of secretions in the lungs and
promotes better lung expansion. An incentive spirometer (a device that
measures air movement into the lungs and encourages the client to breathe
deeply), coughing, and deep breathing are important, but the client needs to
perform these more frequently (every 1 to 2 hours) instead of every 4 hours
or 4 times daily. Giving oxygen at 4 L/minute could decrease the client's
respiratory drive.
3. Correct answer:
Symptoms of acute mania occur in the following sequence:
B. Relevant, calm speech patterns.
C. Highly productive and competitive in work and leisure activities.
D. Easily irritated.
A. Delusions of grandeur.
E. Poor judgment and impulse control.
Relevant and calm speech patterns are indicative of normal behavior. Once
mania begins, the client may become highly productive and competitive in
all activities. Sleep is not a priority. As mania progresses, emotional
manifestations heighten and the client is easily irritated, begins to have
delusions of grandeur, and may require medication to reduce restlessness
and agitation. Client safety is the primary goal due to poor judgment and
impulse control
4. Correct answer: A, C, and D
A woman's center of gravity changes during pregnancy, increasing her risk of
falls. She should use a non-skid mat in the tub or shower. Wearing high heels
will increase unbalance and can contribute to falls. Non-slip rugs will prevent
tripping and falling. There is no reason that a pregnant woman in good
health should avoid climbing stairs; in fact, stair climbing is good exercise.
7

5. Correct answer: C
Asking the mother what she knows about her son's injury is a good way to
encourage the mother to express her feelings. It also allows the nurse to
gather more data about the mother's understanding of the injury. Providing
reassurance that the woman's son will return to normal function may be
incorrect because, in many cases, spinal cord contusion results in permanent
loss of function. A definitive prognosis isn't possible so soon after a spinal
cord contusion, so referring the mother to the doctor would not be helpful.
The mother needs to be allowed to voice her concerns without being made to
feel guilty.
6. Correct answer: A
A client who perceives a threat to vision, such as a sudden loss of sight, is
likely to be anxious about the possibility of permanent blindness. Because
severe anxiety impairs the client's ability to process new information, this
anxiety must be addressed before teaching is possible. The nurse should
encourage the client to talk about her understanding of the surgery and the
expected outcomes. A detached retina is not characterized by acute pain
and there is little preoperative risk of infection.
7. Correct answer: B
A complaint of halos around lights is a common finding in a client with
glaucoma. Symptoms of glaucoma don't include double vision but can
include loss of peripheral vision or blind spots, reddened sclera, firm globe,
decreased accommodation, and occasional eye pain, but clients may be
asymptomatic until permanent damage to the optic nerve and retina has
occurred. Normal intraocular pressure is 10 to 21 mm Hg.
8. Correct answer: C
Pain management is a priority, so the nurse should immediately bring pain
medication. However, the nurse should do a quick assessment while
administering the medication to ensure that a complication, such a
hemorrhage, hasn't caused the increased pain. A complete assessment can
wait until the pain subsides. Control of pain will enable the client to move,
eliminating other potential complications of delivery. Bonding with the infant
will be facilitated as well if the client is without discomfort. Relaxation
techniques can act as an adjunct therapy but by themselves are not usually
useful for pain management during the early post-Caesarean period.

9. Correct answer: D
Drinking alcohol can induce isoniazid-related hepatitis. If hepatic damage
occurs, the client's urine may become dark and appear concentrated. GI
upset frequently occurs when isoniazid is taken on an empty stomach, so
taking this drug with meals decreases GI upset. The client should avoid
taking aluminum-containing antacids, such as aluminum hydroxide, with
isoniazid as it may decrease the drug's effects.
10. Correct answer: A
All clients, regardless of age, have the right to die with dignity and be free
from pain. The parents have the right to request an opioid to relieve the
child's distress. Assisted suicide requires some action on the part of the
client, and this is not possible for a 1-month old infant. Both the nurse and
the parents have an ethical duty to the child. Withholding the opioid
analgesic from a dying child is not appropriate because of fear it may hasten
death, as opioids can hasten death with dying patients at any age, and this is
not considered a contraindication for administration of analgesia.
11. Correct answer: B
Disequilibrium syndrome is caused by a rapid reduction in urea, sodium, and
other solutes from the blood. This may lead to cerebral edema and increased
intracranial pressure (ICP). Signs and symptoms of increased ICP include
headache, nausea, and restlessness as well as vomiting, confusion,
twitching, and seizures. Fever and an elevated white blood cell count may
indicate infection. Popping or ringing in the ears, chest pain, dizziness, or
coughing suggests an air embolus. Chest pain, dyspnea, burning at the
access site, and cramping suggest acute hemolysis.
12. Correct answers: C and D
One of the steps in ethical decision-making is to consider all possible options
of care, such as outpatient programs, along with the potential results of each
option. A review of the client's treatment history is part of the first step in
gathering the background information, as this helps to create a clear picture
of the client's situation. The nurse would not tell the elderly couple to
implement what is best for them since they are concerned about what action
is in the best interests of their son, and the nurse's responsibility is to the
client. Since the son is dual-diagnosed, he has had a psychiatric evaluation,
and another evaluation will not address the couple's dilemma. There is no
reason to consult legal authorities.
9

13. Correct answer: A


The parathyroid glands are responsible for maintaining calcium levels at 8.8
to 10.2 mg/dL. In hypoparathyroidism, parathyroid hormone levels are
insufficient to maintain adequate calcium levels. The nurse should monitor
clients with hypoparathyroidism for signs and symptoms of hypocalcemia,
including muscle spasms, anxiety, seizures, hypotension, and congestive
heart failure. Hyponatremia and hyperkalemia aren't associated with
hypoparathyroidism. Hyperphosphatemia, not hypophosphatemia, may be
seen in the client with hypoparathyroidism as calcium levels decrease.
14. Correct answer: A
Palliative care includes measures to prevent skin breakdown, pain
management, management of other symptoms that cause discomfort, and
encouraging contact with family and friends. A DNR request precludes all
resuscitative efforts related to respiratory or cardiac arrest. Dehydration is a
normal part of the dying process, so intravenous fluids are inappropriate.
Total parenteral nutrition (TPN) is an invasive procedure meant to prolong life
and is not part of palliative care.
15. Correct answer: C
For a client taking Coumadin following a stroke, the INR should be between
2.0 and 3.0. The elevated INR level should be communicated to the physician
along with assessment data regarding possible bleeding. An increased dose
of Coumadin would increase the risk of bleeding. Administration of
medications, such as warfarin and vitamin K, requires a physician's order.
The nurse should notify the physician and receive an order prior to holding
the Coumadin scheduled for another shift.
16. Correct answer: B
The client's symptoms suggest heart failure. BNP is a neurohormone that is
released from the ventricles when the ventricles experience increased
pressure and stretch, such as in heart failure. A BNP level greater than 51
pg/mL is often associated with mild heart failure; and, as the BNP level
increases, the severity of heart failure increases. Potassium levels are not
affected by heart failure. CRP is an indicator of inflammation. It is used to
help predict the risk of coronary artery disease. There is no indication that
the client has an increased CRP. There is no indication that the client is
experiencing bleeding or clotting abnormalities, such as those seen with an
abnormal platelet count.
10

17. Correct answer: A


When discussing the child's wishes for future care, it is important for the
nurse to first identify what the child knows about the disease and his
prognosis. Factors such as the perceived severity of the illness will be
significant in planing for end-of-life care. If the child does not understand the
disease process or prognosis, the plan of care would not be effective or
realistic. In addition, asking a child about desired interventions in the event
of cardiac or respiratory arrest would not be an appropriate initial area of
questioning. If the child does not understand the disease process, these
questions may seem frightening or threatening. While exploring the child's
belief about death would be important, it would not be the initial area of
discussion and should be guided by the child rather than the nurse.
18. Correct answer: D
The client should include yogurt in her diet to reduce gas formation. Other
helpful foods include crackers and toast. High-fiber foods, such as bran,
stimulate peristalsis and increase flatulence. Cruciferous vegetables tend to
increase gas formation, as do beans. The client should also be advised that
smoking, chewing gum, and drinking carbonated fluids, and drinking fluids
with a straw can increase gas formation.
19. Correct answer: D
A client with peripheral vascular disease should examine his feet daily for
redness, dryness, or cuts. If he isn't able to do this, then a caregiver or family
member should help him. Hot tubs should be avoided since the client may
have decreased sensation in his feet and may not feel when the water is too
hot. The client should always wear shoes or slippers on his feet when he is
out of bed to help minimize trauma to the feet. Any type of nicotine, either
from cigarettes or smokeless tobacco, can cause vasoconstriction and further
decrease blood supply to the extremities.
20. Correct answer: B
Diminished cough reflex is consistent with normal aging, putting older adults
at increased risk for aspiration and atelectasis. A decrease in subcutaneous
fat increases risk for pressure ulcers. Long-term memory is usually intact
unless the client suffers from dementia, but short-term memory is often
impaired. Presbyopia (far-sightedness) is common with aging. Those who
have had myopia (near-sightedness) may find their vision improving with
age.
11

NCLEX PN Practice Test II


1. Which type of evaluation occurs continuously throughout the
teaching and learning process?
A. Formative.
B. Retrospective.
C. Summative.
D. Informative.
2. A client with chest pain arrives in the emergency room and
receives nitroglycerin, morphine, oxygen, and aspirin. The client is
diagnosed with acute coronary syndrome and suspected myocardial
infarction. The client arrives on the unit, and his vital signs are
stable and he has no complaints of pain. The nurse is reviewing the
physician's orders. In addition to the medications given, which other
medication does the nurse expect the physician to order?
A. A -blocker, such as carvedilol (Coreg).
B. Digoxin (Lanoxin).
C. Furosemide (Lasix).
D. Nitroprusside.
3. The nurse is caring for a client after a lung lobectomy. The nurse
notes fluctuating water levels in the water-seal chamber of the
client's chest tube. What action should the nurse take?

12

A. Do nothing, but continue to monitor the client.


B. Call the physician immediately.
C. Check the chest tube for a loose connection.
D. Add more water to the water-seal chamber.
4. A hospice program director was examining various activities
related to client care with the intent of improving quality. The
director determined that many are clients were being admitted on
service without an advanced directive. The director along with a
team of individuals developed a plan including goals, objectives,
and a timeline to address the issue. This is an example of which of
the following approaches?
A. Risk management project.
B. Performance improvement project.
C. Client care initiative.
D. Palliative care project.
5. The nurse is making a teaching plan for a client with Parkinson's
disease to help him understand the implications of beginning
treatment with levodopa. Which of the following instructions should
the nurse include?
A. Change positions slowly.
B. Increase intake of foods with vitamin B6.
C. Increase the dose if twitching worsens.
D. Call the physician if symptoms don't improve in 1 week.
6. The nurse is preparing to administer an I.M. injection in a client
with a spinal cord injury that has resulted in paraplegia. Which of
the following muscles is best site for the injection in this case?
A. Deltoid.
B. Dorsal gluteal.
C. Vastus lateralis.
D. Ventral gluteal.
7. The nurse is evaluating treatment effectiveness indicators for a
client who is being discharged from the intensive outpatient drug
and alcohol clinic. Which client behavior would the nurse evaluate
as a positive treatment outcome?

13

A. The client is following a regular sleeping routine.


B. The client is participating in scheduled group meetings.
C. The client is planning to engage in social activities.
D. The client is applying the clinic rules to others.
8. The nurse is caring for a client with heart failure. Which of the
following statements by the client suggests that the client has leftsided heart failure?
A. "I sleep on three pillows each night."
B. "My feet are bigger than normal."
C. "My pants don't fit around my waist."
D. "I have to get up three times during the night to urinate."
9. A client with type 2 diabetes has a hemoglobin A1C level of 8.8
after 6 months of oral therapy with metformin (Glucophage). The
client tells the nurse that she often forgets to take her medication
and doesn't really follow her diet. Which of the following is the
nurse's best first response?
A. "If you don't get control of your blood sugar, you'll need to take insulin."
B. "It can be hard to get used to having a disease like diabetes. What are
some of the things you find challenging about it?"
C. "Uncontrolled diabetes can lead to eye problems and kidneys problems."
D. "Many people have diabetes."
10. The nurse is reviewing laboratory values of a client diagnosed
with hyperlipidemia 6 months previously. Which results indicate
that the client has been following his therapeutic regime?
A. Total cholesterol level increases from 250 mg/dL to 275 mg/dL.
B. Low-density lipoproteins (LDL) increase from 180 mg/dL to 190 mg/dL.
C. High-density lipoproteins (HDL) increase from 25 mg/dL to 40 mg/dL.
D. Triglycerides increase from 225 mg/dL to 250 mg/dL.
11. The nurse is assessing a client with aortic stenosis. Which of the
following best describes the murmur associated with aortic
stenosis?
A. High-pitched and blowing.
B. Loud and rough during systole.
C. Low-pitched, rumbling during diastole.
D. Low-pitched and blowing.
14

12. The nurse is preparing to discharge an adolescent with sickle


cell disease. Which of the following should the nurse stress during
teaching? Select all that apply.
A. Infection prevention and management.
B. Pain management.
C. Fluid restriction.
D. Effective emotional coping skills.
13. Which type of nursing intervention does the nurse perform when
she administers oral care to a client?
A. Psychomotor.
B. Educational.
C. Maintenance.
D. Supervisory.
14. The nurse is caring for a client with pulmonary edema. Which of
the following orders should the nurse clarify?
A. Dobutamine 5 mcg/kg/minute I.V.
B. 0.9% normal saline solution I.V. at 150 mL/hour.
C. Morphine I.V. 2 mg every 2 hours P.R.N. dyspnea.
D. Furosemide I.V. 40 mg every 6 hours.
15. The nurse is teaching a client newly diagnosed with type 1
diabetes how to self-administer subcutaneous insulin injections.
How does the nurse best evaluate the effectiveness of her teaching?
A. Have the client repeat the steps back to the nurse.
B. Give the client a written test on self-administration of insulin.
C. Ask the client to write out the steps for self-administration of insulin
injections.
D. Ask the client to give a return demonstration of self-administration of
insulin.
16. The nurse is assessing a female client who reports infrequent,
irregular menstrual periods. Which of the following signs and
symptoms suggests to the nurse that the client may have polycystic
ovarian syndrome (POS)?
A. Muscle wasting and nervousness.
B. Hypotension.
15

C. Poor appetite and weight loss.


D. Obesity and hirsutism with excessive facial hair.
17. A nurse is caring for a client returning from an x-ray. The
nursing assistant is helping transfer the client back to bed. Which
transfer technique by the nurse uses appropriate ergonomic
principles?
A. Lowering the bed for transfer and then raising the bed before leaving the
room, making sure to place the call light is within reach.
B. Maintaining a narrow base of support during transfer and encouraging the
client to hold onto her if afraid during transfer.
C. Raising the bed for transfer, maintaining a wide base of support during
transfer, and lowering the bed before leaving the room.
D. Explaining the procedure to the client and grabbing the client underneath
the arms to pull her over to the bed.
18. The nurse in the Emergency Department is caring for a client
who has acute heart failure. The physician is writing orders for
pharmacological management, including diuretics. Which laboratory
value is most important for the nurse to check before administering
medications to treat heart failure?
A. Platelet count.
B. Potassium.
C. Calcium.
D. White blood cell count.
19. The nurse is writing the teaching plan for a client undergoing a
radioactive iodine uptake test to study thyroid function. Which of
the following instructions should the nurse include?
A. "You need to stay at least 4 feet (1.2 m) away from other people after the
test because you'll be radioactive."
B. "You need to lie very still on a stretcher that is placed in a long tube for
the scan"
C. "Don't take any iodine or thyroid medication before the test."
D. "Schedule the bone scans before your radioactive iodine uptake test."
20. The nurse is assessing a client hospitalized with type 2 diabetes
mellitus. Which assessment finding leads the nurse to suspect
hyperosmolar hyperglycemic nonketotic syndrome (HHNS) in this
client?
16

A. Kussmaul's respirations.
B. Metabolic acidosis.
C. Serum glucose of 1,200 mg/dL.
D. Dependent edema.

Answer Key
1. Correct answer: A
Formative (or concurrent) evaluation occurs continuously throughout the
teaching and learning process. It includes assessing needs, process,
implementation and potential outcomes. One benefit is that the nurse can
adjust teaching strategies as necessary to enhance learning. Retrospective
or summative evaluation occurs at the conclusion of teaching and learning
sessions and often evaluates how a group has done. It includes outcomes
assessment, cost-effectiveness, and impact. Informative isn't a type of
evaluation.
17

2. Correct answer: A
A patient who is admitted with suspected myocardial infarction should
receive aspirin, nitroglycerin, morphine, and a -blocker, such as carvedilol.
Digoxin in indicated for arrhythmia rather than acute coronary syndrome.
Furosemide would be used if the client had signs of heart failure, such as
peripheral or pulmonary edema, but this is not evident. Nitroprusside is used
to increase blood pressure, but the client has stable vital signs and is not
hypotensive.
3. Correct answer: A
Fluctuation in the water-seal chamber is a normal finding that occurs as the
client breathes. No action is required except for continued monitoring of the
client. The nurse doesn't need to notify the physician. Continuous bubbling in
the water-seal chamber indicates an air leak in the chest tube system, such
as from a loose connection in the chest tube tubing. The water-seal chamber
should be filled initially to the 2 cm line, and no more water should be added.
4. Correct answer: B
Performance improvement projects are an approach to design, measure,
assess, and improve organizational performance. Risk management differs in
that it is a planned program of loss prevention and liability control. Although
this is an initiative that involves client care, the span of the issue extends
beyond direct care providers. Advanced directives are important in the
context of palliative care, but assuring that all patients have them relates
more closely to organizational performance.
5. Correct answer: A
Because levodopa can cause orthostatic hypotension, the client should be
cautioned to change positions slowly to avoid dizziness, light-headedness, or
fainting. The client should avoid foods high in vitamin B6 and vitamin B6
supplements because they can reverse the effects of levodopa. Increased
twitching may be a sign of drug overdose and should be reported to the
physician. Other signs of overdose include palpitations, eye spasms,
arrhythmias, and hypertension. When a client is started on levodopa, it may
take several weeks for symptoms to improve, so the client should not expect
immediate improvement.
6. Correct answer: A

18

I.M. injections should be given in the deltoid muscle in the client with a spinal
cord injury. Paraplegia involves paralysis and lack of sensation in the lower
trunk and lower extremities. Clients with spinal cord injuries exhibit reduced
use of and consequently reduced blood flow to muscles in the buttocks
(dorsal gluteal and ventral gluteal) and legs (vastus lateralis). Decreased
blood flow results in impaired drug absorption and increases the risk of local
irritation and trauma, which could result in ulceration of the tissue.
7. Correct answer: B
A client with a drug and alcohol problem who is participating in the
scheduled group sessions is making an effort to learn lifestyle changes,
coping skills, and ways to maintain a clean and sober life. Although it is
healthy to follow a regular sleep pattern, this behavior is not a specific
indicator of drug and alcohol treatment effectiveness. Plans to engage in
social activities may be repeating patterns of the people, places, and things
that triggered drug use; therefore, this action could be a negative treatment
outcome. Applying the clinic rules to others is a form of distraction that
prevents the client from focusing on personal treatment goals.
8. Correct answer: A
Orthopnea is a classic sign of left-sided heart failure. The client often sleeps
on several pillows at night to help facilitate breathing because of pulmonary
edema. Peripheral edema is indicative or right-sided failure. Ascites is a late
symptom of right-sided heart failure and can increase girth. Nocturia is
common with right-sided failure as peripheral edema decreases when the
feet are not dependent, increasing urinary output.
9. Correct answer: B
Acknowledging that the client is going through changes and allowing her to
express her concerns will help the nurse assess her needs. Hemoglobin AIC
shows the average blood glucose levels over a 3-month period. Diabetes
should maintain the AIC <7%. Lecturing, threatening and comparing the
clients to others belittles the client and discourages discussion, but the
patient must be provided adequate information in order to make informed
decisions about self-care.
10. Correct answer: C
HDL levels have an inverse relationship with coronary artery disease and
should be greater than 35 mg/dL. The goal of treating hyperlipidemia is to
19

decrease total cholesterol and LDL levels, while increasing HDL levels. Total
cholesterol levels are recommended to be below 200 mg/dL. LDL levels
should be less than 160 mg/dL. In clients with known coronary artery disease
or diabetes, the LDL level should be less than 70 mg/dL. Triglyceride level
has a direct relationship a LDL level and an inverse relationship with HDL
level. Triglyceride levels should be between 100 and 200 mg/dL.
11. Correct answer: B
An aortic murmur is loud and rough and is heard over the aortic area during
systole. Aortic insufficiency has a high-pitched and blowing murmur and is
heard at the third or fourth intercostal space at the left sternal border. Mitral
stenosis has a low-pitched rumbling murmur heard at the apex. Mitral
insufficiency has a high-pitched, blowing murmur at the apex. There is no
specific condition associated with a low-pitched, blowing murmur.
12. Correct answers: A, B, and D
The goals of sickle cell management include preventing crisis and managing
pain and issues of self-esteem. This requires teaching the client how to avoid
infection and follow protocols for antibiotics as infections can trigger crisis.
Pain management may include analgesics as well as relaxation techniques
and other comfort measures, such as heat application. Sickle cell disease, as
with all chronic diseases, can affect an adolescent's feelings of self esteem,
so coping skills include allowing the client as much independence in care as
possible. Dehydration poses the risk of sickle cell crisis and blood clots, so
the client must stay well hydrated.
13. Correct answer: C
Oral care is an example of a maintenance nursing intervention. Other
examples of maintenance nursing interventions include skin care and
hygiene. Psychomotor interventions include positioning the client.
Educational nursing interventions include the nurse demonstrating and
teaching a skill to the client. Supervisory nursing interventions occur when
the nurse supervises other health care providers performing a task.
14. Correct answer: B
An I.V. rate of 150 mL/hour would further increase the fluid overload and
worsen the pulmonary edema. Pulmonary edema is due to an increased
blood volume in the lungs. This blood volume causes an increased
hydrostatic pressure, which forces fluid from the pulmonary capillaries into
20

the interstitial space and alveoli. The fluid in the alveoli blocks the air
exchange, causing impaired gas exchange. The priority treatment for these
patients is to improve their gas exchange and decrease volume overload.
Dobutamine is a positive inotrope, which helps the heart pump more
effectively, reducing the amount of blood pooling in the lungs. Morphine
helps decrease venous pressure, which helps decrease the pressure in the
lungs and the movement of fluid into the lungs, relieving dyspnea.
Furosemide is a diuretic and helps remove some of the extra fluid from the
lungs.
15. Correct answer: D
Asking the client to give a return demonstration of his injection technique is
the best way to assess whether the client can perform the procedure. It also
gives the nurse the opportunity to provide feedback. Asking the client to
recite the steps, pass a written test, or write out the steps shows the nurse
whether the client is able to recall the steps but doesn't show that he has the
necessary motor skills or the ability to perform the procedure.
16. Correct answer: D
Polycystic ovarian syndrome (POS) is a constellation of symptoms including
amenorrhea, hirsutism on the face, chest and limbs but thinning hair on the
scalp, and obesity. Additionally, clients often exhibit insulin resistance (Type 2
diabetes mellitus). Muscle wasting and nervousness are not characteristic of
POS, but depression is common. Hypertension may occur in some women.
Increased appetite leads to weight gain.
17. Correct answer: C
Raising the bed during transfer and maintaining a wide base of support
reduces the risk of back injury, and the bed should always be left in the low
position to reduce danger from falls. Transferring the patient with the bed in
low position strains the lower back. The client should not grab or hold onto
staff members during transfers as this can interfere with the transfer and
cause the nurse injury. The nurse should not grab the client under the arms,
as this can cause the client shoulder injury or nerve damage. In addition,
pulling a client during transfers places the client at risk for skin shear
injuries.
18. Correct answer: B

21

Diuretics, such as furosemide (Lasix) are commonly used to treat acute


heart failure. Most diuretics increase the renal excretion of potassium. The
nurse should check the potassium level before administering diuretics and
obtain an order to replace potassium if the level is low. Other medications
commonly used to treat heart failure include angiotensin converting
enzymes, digoxin, and -adrenergic blockers. While checking the platelet
count, calcium level, and white blood cell count is important, these results
would not affect the administration of medications to treat acute heart
failure.
19. Correct answer: C
Medications such as iodine, contrast media, and antithyroid and thyroid
drugs can affect the test results and should be withheld by the client for a
week or longer, as directed by the physician. During a radioactive iodine
uptake test, the client receives radioactive iodine by mouth or I.V. in small
doses and doesn't require isolation. During magnetic resonance imaging--not
radioactive iodine uptake testing--a client needs to lie still inside a long tube.
Any test, such as a bone scan, that requires iodine contrast media should be
scheduled after the radioactive iodine uptake test because the iodinated
contrast medium can decrease uptake.
20. Correct answer: C
Serum glucose levels in HHNS are greater than 800 mg/dL and may be as
high as 2,000 mg/dL. By comparison, serum glucose levels in diabetic
ketoacidosis are 300 to 800 mg/dL. In HHNS the body produces enough
insulin to prevent diabetic ketoacidosis but not enough to prevent
hyperglycemia, diuresis, and dehydration. Metabolic acidosis and Kussmaul's
respirations (deep, rapid breathing) occur with diabetic ketoacidosis. In the
client with HHNS, respirations may be normal or rapid and shallow, without
any fruity odor. The osmotic diuresis that occurs in HHNS leads to profound
dehydration, so dependent edema doesn't occur.

22

NCLEX PN Practice Test III


1. The nurse is caring for a client with cirrhosis of the liver. The
client has developed ascites and requires a paracentesis. Which of
the following symptoms is associated with ascites and should be
relieved by the paracentesis?
A. Pruritus.
B. Dyspnea.
C. Jaundice.
D. Peripheral neuropathy.
2. The nurse is doing a physical assessment and electrocardiogram
on an elderly client. Which finding during the nurse's assessment of
the cardiac system is of most concern and warrants prompt further
investigation?
A. S4 heart sound.
B. Increased PR interval.
C. Orthostatic hypotension.
D. Irregularly irregular heart rate.

23

3. A client is admitted to the medical-surgical floor with a diagnosis


of acute pancreatitis. His blood pressure is 136/76 mm Hg, pulse 96
beats/minute, respirations 22 breaths/minute, temperature 99F
(38.3C), and he has been experiencing severe vomiting for 24
hours. His past medical history reveals hyperlipidemia and alcohol
abuse. The physician prescribes a nasogastric (NG) tube for the
client. Which of the following is the primary purpose for insertion of
the NG tube?
A. Empty the stomach of fluids and gas to relieve vomiting.
B. Prevent spasms at the sphincter of Oddi.
C. Prevent air from forming in the small and large intestines.
D. Remove bile from the gallbladder.
4. The nurse is caring for a client who requires a nasogastric (NG)
tube for feeding. What should the nurse do immediately after
inserting an NG tube for enteral feedings?
A. Aspirate for gastric secretions with a syringe.
B. Begin feeding slowly to prevent cramping.
C. Get an X-ray of the tip of the tube within 24 hours.
D. Clamp off the tube until the feedings begin.
5. The nurse is caring for a client with a history of cardiac disease
and type 2 diabetes. The nurse is closely monitoring the client's
blood glucose level because of his other medication. Which other
medication is the client most likely taking?
A. Procainamide (Procan).
B. Carvedilol (Coreg).
C. Amiodarone (Cordarone).
D. Diltiazem (Cardizem).
6. A client is experiencing an acute episode of ulcerative colitis.
Which of the following is the most important nursing action for this
client?
A. Replace lost fluid and sodium.
B. Monitor for increased serum glucose level from steroid therapy.
C. Restrict the dietary intake of foods high in potassium.
D. Note any change in the color and consistency of stools.

24

7. A client with a history of long-term use of non-steroidal antiinflammatory drugs (NSAIDs) has dark, tarry and sometimes foulsmelling stools. The nurse knows that this may indicate bleeding in
which part of the gastrointestinal tract?
A. Upper colon (ascending and transverse).
B. Lower colon (descending).
C. Stomach or proximal part of small intestine.
D. Distal part of small intestine.
8. A client admitted with peritonitis is under a nothing-by-mouth
order. The client is complaining of dry mouth and thirst. Which of
the following actions by the nurse is most appropriate?
A. Increase the I.V. infusion rate.
B. Use diversion activities.
C. Provide frequent mouth care.
D. Give ice chips every 15 minutes.
9. A client who is 24 hours post-partum is assessed by the nurse.
Which client behavior warrants further investigation?
A. The client is quiet and spends time gazing at her infant in wonderment.
B. The client does not hold her child and allows the nurse to perform all of
the infant care.
C. The client is nervous and voices concerns with her abilities to "handle
everything."
D. The client frequently contacts the nursery to ask for assistance and
supervision when performing infant care.
10. A client with a history of a seizure disorder is attempting to
conceive a baby. The client asks the nurse for information
concerning preconception care to increase her chances of having a
healthy baby. What information should be provided to the client?
A. The client should reduce the amount of anticonvulsant medication being
taken to promote her ability to conceive.
B. The client should increase intake of folic acid.
C. The client should discontinue anticonvulsant therapy until pregnancy is
confirmed.
D. The client should increase the amount of exercise.

25

11. The nurse is caring for a client who is newly diagnosed with
asthma. When teaching the client how to reduce exposure to
allergens, which of the following actions should the nurse suggest?
A. Maintaining indoor humidity around 80%.
B. Working outdoors in the early morning.
C. Washing sheets and pillowcases in cold water.
D. Covering pillows and mattresses in plastic cases.
12. A client underwent a colostomy for a ruptured diverticulum. He
did well throughout the surgery and returned to the medicalsurgical floor in stable condition. The nurse assesses the client's
colostomy stoma 2 days after surgery. Which assessment finding
should the nurse report immediately to the physician?
A. Blanched stoma.
B. Edematous stoma.
C. Reddish-pink stoma.
D. Brownish-black stoma.
13. A 37-year-old forklift operator presents with shakiness,
sweating, anxiety, and palpitations and tells the nurse he has type 1
diabetes mellitus. Which of the follow actions should the nurse do
first?
A. Inject 1 mg of glucagon subcutaneously.
B. Administer 50 mL of 50% glucose I.V.
C. Give 4 to 6 oz (118 to 177 mL) of orange juice.
D. Give the client four to six glucose tablets.
14. A client with cirrhosis of the liver develops ascites. Which of the
following orders would the nurse expect?
A. Restrict fluid to 1000 mL per day.
B. Ambulate 100 ft. three times per day.
C. High-sodium diet.
D. Maalox 30 ml P.O. BID.
15. A client who recently underwent cranial surgery develops
syndrome of inappropriate antidiuretic hormone (SIADH). Which of
the following symptoms should the nurse anticipate?

26

A. Edema and weight gain.


B. Excessive urinary output.
C. Fluid loss and dehydration.
D. Low urine specific gravity.
16. A client who underwent abdominal surgery now has a gaping
open incision due to delayed wound healing. The nurse must irrigate
the wound with a piston syringe and sterile normal saline and
provide wound care. Which of the following procedures is correct?
A. Rapidly instill a stream of irrigating solution into the wound to flush out
debris.
B. Apply a wet-to-dry dressing to the wound after the irrigation.
C. Moisten the area around the wound with normal saline solution after the
irrigation.
D. Irrigate slowly and continuously until the solution becomes clear or all of
the solution is used.
17. The nurse is doing teaching with the family of a client with liver
failure. Which of the following foods should the nurse advise them
to limit in the client's diet?
A. Meats and beans.
B. Butter and gravies.
C. Potatoes and pasta.
D. Cakes and pastries.
18. The nurse is evaluating a client's knowledge of miotic eye drop
self-administration for the treatment of glaucoma. Which statement
best demonstrates the client's understanding of miotic eye drop
use?
A. "The drops should go directly in the middle of the eye so they'll go into the
pupil."
B. "The eyedrops must be stored in the refrigerator so they don't grow
germs."
C. "I need to use the drops daily for the rest of my life."
D. "As soon as I recover from this glaucoma, I can stop using the drops."
19. A client comes into the clinic during a spring break beach trip
complaining of right ear pain. The nurse suspects acute otitis
externa. Which other assessment findings by the nurse supports
this diagnosis?
27

A. Cultures taken from the ear canal are positive for Pseudomonas
aeruginosa.
B. The tympanic membrane has perforated.
C. The client is experiencing fever and chills.
D. The right external auditory canal is narrowed and erythematous.
20. A client returns from the operating room after extensive
abdominal surgery. He has 1,000 mL of lactated Ringer's solution
infusing via a central venous catheter. The physician orders the I.V.
fluid to be infused at 125 mL/hour plus the total output of the
previous hour. The drip factor of the tubing is 15 gtt/mL and the
output for the previous hour was 75 mL via Foley catheter, 50 mL via
nasogastric tube, and approximately 10 mL via Jackson Pratt tube
Which of the following I.V. flow rates is needed to deliver the correct
amount of fluid?
A. 100 gtt/minute.
B. 65 gtt/minute.
C. 45 gtt/minute.
D. 80 gtt/minute.

28

Answer Key
1. Correct answer: B
Ascites (fluid buildup in the abdomen) puts pressure on the diaphragm,
resulting in difficulty breathing and dyspnea. Paracentesis (surgical puncture
of the abdominal cavity to aspirate fluid) is done to remove fluid from the
abdominal cavity and thus reduce pressure on the diaphragm in order to
relieve the dyspnea. Pruritus, jaundice, and peripheral neuropathy are signs
of cirrhosis that aren't relieved or treated by paracentesis.
2. Correct answer: D
An irregularly irregular heart rate is indicative of atrial fibrillation and should
be investigated further. Older adults may have a prolonged systole, causing
an S4 heart sound. Older adults also often have slowed conduction, causing
an increased PR interval. As a person ages, it is normal for the baroreceptors
in the body to decrease their response to changes in body position, so the
client may experience orthostatic hypotension and dizziness when standing.
3. Correct answer: A
An NG tube is no longer routinely inserted to treat pancreatitis, but if the
client has protracted vomiting, the NG tube is inserted to drain fluids and gas
and relieve vomiting. An NG tube doesn't prevent spasms at the sphincter of
Oddi (a valve in the duodenum that controls the flow of digestive enzymes)
or prevent air from forming in the small and large intestine. The common bile
duct connects to the pancreas and the gall bladder, and a T tube rather than
an NG tube would be used to collect bile drainage from the common bile
duct.
4. Correct answer: A

29

Before starting a feeding, it's essential to ensure that the tube is in the
proper location. Aspirating for stomach contents confirms correct placement.
While initial feedings should be given slowly, giving the feeding without
confirming proper placement puts the client at risk for aspiration. Clamping
the tube provides no information about tube placement. If an X-ray is
ordered, it should be done immediately, not in 24 hours.
5. Correct answer: B
Blood glucose levels need to be monitored closely in type 2 diabetics when
the client is taking -adrenergic blockers, such as carvedilol. -adrenergic
blockers may mask the signs of hypoglycemia, such as tachycardia and
sweating. The QRS duration should be monitored in clients taking
procainamide. Amiodarone may cause pulmonary fibrosis, and pulmonary
function should be closely monitored in clients taking that drug. Diltiazem
may cause increased PR interval or bradycardia.
6. Correct answer: A
Diarrhea due to an acute episode of ulcerative colitis leads to fluid and
electrolyte losses, so fluid and sodium replacement is necessary. There is no
need to restrict foods high in potassium, but potassium may need to be
replaced. If the client is taking steroid medications, the nurse should monitor
his glucose levels, but this isn't the highest priority. Noting changes in stool
consistency is important, but fluid replacement takes priority.
7. Correct answer: C
Melena is the passage of dark, tarry stools that contain a large amount of
digested blood. It occurs with bleeding from the upper GI tract (stomach or
proximal part of the small intestine). Passage of dark red blood from the
rectum indicates lower GI (distal small intestine, colon, and rectum) bleeding.
Bleeding in the lower colon or rectum would cause bright red blood in the
stool.
8. Correct answer: C
Frequent mouth care, such as swabbing the mouth with moist sponge swabs
and rinsing the mouth, helps relieve dry mouth and the sensation of thirst.
Increasing the I.V. infusion rate isn't appropriate to relieve dry mouth and
may cause fluid overload. Diversion activities aren't specific and are not
likely to distract a person from feeling thirst. Because the client has a
nothing-by-mouth order, she can't have ice chips, which are a form of liquid.
30

9. Correct answer: B
The client who does not interact with her child and allows the nurse to
provide all care will require further observation to evaluate bonding. Mothers
who spend time gazing at their babies are normal. It is not unusual for a new
mother to have numerous questions and experience feelings of uncertainty,
especially if this is her first child. This gives the nurse the opportunity for
teaching.
10. Correct answer: B
Many anticonvulsants reduce absorption of folic acid. A reduction of folic acid
is associated with neural tube defects, so the client should increase intake.
Making changes in the prescribed dosages of any anticonvulsant is
dangerous without close physician supervision; however, some
anticonvulsant medications are teratogenic, so the prescribing physician
should be consulted before the client becomes pregnant, as her medication
may need to be changed. Increasing exercise is not a factor in the client's
preconception care.
11. Correct answer: D
Because dust and dust mites found in pillows and mattresses can trigger
acute asthma attacks, the nurse should teach the client to cover them with
plastic cases. Maintaining indoor humidity between 40% and 50% helps
reduce the client's exposure to mold and pollen. Allergen levels are highest
outdoors in the early morning, so the client should avoid working outdoors
during this time. Sheets and pillowcases should be washed in hot water to
reduce the client's exposure to allergens.
12. Correct answer: D
A brownish-black stoma indicates a lack of blood flow to the stoma, and
necrosis is likely. Two days postoperatively, the stoma should still be
edematous and reddish-pink in color. A blanched or pale stoma indicates
possible decreased blood flow and should be assessed regularly. Stomas
should be assessed for color, size, characteristics (mucosa should be moist),
shape, and protrusion (should be slightly above skin level).
13. Correct answer: C
Because the client is awake and complaining of symptoms, the nurse should
first give him 15 grams of carbohydrate to treat hypoglycemia. This could be
31

4 to 6 oz of fruit juice, five to six hard candies such as Lifesavers, or 1


tablespoon of sugar. When a client has worsening symptoms of
hypoglycemia or is unconscious, treatment includes 1 mg of glucagon
subcutaneously or intramuscularly, or 50 mL of 50% glucose I.V. The nurse
may also give two to three glucose tablets for a hypoglycemic reaction.
14. Correct answer: A
Fluid restriction is a primary treatment for ascites. Restricting fluids
decreases the amount of fluid present in the body, thereby decreasing the
fluid that accumulates in the peritoneal space. A high sodium diet would
increase fluid retention. Physical activities are usually restricted until ascites
is relieved. Loop diuretics (such as furosemide) are usually ordered, and
Maalox (a bismuth subsalicylate) may interfere with the action of the
diuretics.
15. Correct answer: A
Syndrome of inappropriate antidiuretic hormone (SIADH) results in an
abnormally high release of antidiuretic hormone, which causes water
retention as serum sodium levels fall, leading to edema and weight gain.
Because of fluid retention, urine output is low. Fluid is restricted to prevent
fluid overload rather than replaced. As the urine becomes more
concentrated, the specific gravity increases. Other symptoms include
nausea, vomiting, seizures, altered mentation, and coma. SIADH is most
common with diseases of the hypothalamus but can also occur with heart
failure, Guillain-Barr syndrome, meningitis, encephalitis, head trauma, or
brain tumors. It may also be triggered by medications.
16. Correct answer: D
To wash away tissue debris and drainage effectively, the nurse should slowly
irrigate the wound until the solution becomes clear or all the solution is used.
Irrigating solution should always be instilled slowly and gently, as rapid or
forceful instillation can damage tissues. After the irrigation, the area around
the wound should be dried, as moistening it promotes microorganism growth
and skin irritation. When the area is dry, sterile dressing rather than a wet-todry dressing should be applied.
17. Correct answer: A
Meats and beans are high-protein foods and are restricted with liver failure.
In liver failure, the liver is unable to metabolize protein adequately, causing
32

protein by-products to build up in the body rather than be excreted. This


causes problems such as hepatic encephalopathy (neurologic syndrome that
develops as a result of rising blood ammonia levels). Although other
nutrients, such as fat and carbohydrates, may be regulated, it's most
important to limit protein in the diet of the client with liver failure.
18. Correct answer: C
Glaucoma is a chronic condition of the eye, so therapy for glaucoma must
continue for life to prevent damage to the optic nerve and retinal cells. Miotic
eye drops increase drainage of the aqueous humor by constricting the pupil
and contracting the ciliary muscle. The client needs to use the eyedrops daily
to control intraocular pressure. Eyedrops are best put in the lower part of the
eyelid, instilled into the conjunctival sac as this prevents leakage or
misapplication. Miotic eye drops do not require refrigeration.
19. Correct answer: D
Acute otitis externa is characterized by inflammation or infection of the
external auditory canal. It has a variety of possible causes, including
bacterial infection caused by water retention after swimming. Though
Pseudomonas aeruginosa and Staphylococcus aureus are the most common
pathogens, cultures are usually unnecessary unless the client is refractory to
treatment. The client's tympanic membrane would remain intact. Fever and
chills are unlikely findings with acute otitis externa.
20. Correct answer: B
First, the volume to be infused (in milliliters) is calculated:
75 mL + 50 mL + 10 mL = 135 mL total output for the previous hour.
135 mL + 125 mL ordered as a constant flow = 260 mL to be infused over
the next hour

33

NCLEX PN Test IV
1. A gravida 2, para 0 client at 39 weeks gestation presents to the
labor room with complaints of abdominal cramping. The nurse
performs an assessment and data collection. Which of the following
findings most supports the onset of true labor?
A. The client is experiencing nausea and centrally-located abdominal pains
with varying frequency.
B. The client is experiencing abdominal cramps that radiate from the back
around to the abdomen.
C. The client reports fatigue and mild abdominal cramping.
D. The client reports abdominal pain that is only relieved with rest.

34

2. The nurse is caring for a client following gastric bypass surgery.


The physician has encouraged the client to increase mobility as
soon as possible. The nurse notes edema of the right leg with skin
color changes (pallor) to the right lower extremity. The client
reports pain at 3 on a 0 to 10 scale to the incision site and pain in
the right calf at 7 on a 0 to 10 scale. Which of the following is the
most likely cause of the leg pain?
A. Compression of the sciatic nerve.
B. Deep vein thrombosis.
C. Surgical infection and referred pain.
D. Postoperative dehiscence.
3. The nurse is preparing to administer medications to two clients
with the same last name. The nurse checks the medication three
times before entering the room to administer medications to the
first client. While leaving the room following administration, the
nurse realizes she did not check the identification of the client prior
to administering medication. Which of the following actions should
the nurse complete first?
A. Return to the room to check the client identification and complete a
variance report if an error was made.
B. Administer the remaining medication to the other client and check the
client identification.
C. Alert the charge nurse that a medication error has been committed.
D. Document completion of the variance report and the medication error in
the client's chart and notify the physician
4. A nurse is providing education regarding injury prevention to the
parents of an 8-year-old child. The parents admit that they keep a
gun in their home. Which statement made by the nurse would be
most important?
A. "The gun should be kept in a discreet location out of the child's sight."
B. "Your child should attend a gun safety program in the community."
C. "It is a good idea to keep the gun on hand, reminding the child that only a
parent can touch the gun."
D. "The gun should be stored in a locked cabinet with the ammunition
secured in a separate location."

35

5. The nurse is assessing a client with chronic bronchospasm, which


is treated with oral theophylline. Which of the following serum
theophylline levels requires immediate nursing action?
A. 8 g/mL.
B. 12 g/mL.
C. 20 g/mL.
D. 25 g/mL.
6. After an abdominal resection for colon cancer, the client returns
to her room with a Jackson-Pratt drain in place. The client's spouse
asks the nurse what the purpose of the drain is. Which of the
following is the nurse's best response?
A. "To irrigate the incision with a saline solution."
B. "To prevent bacterial infection of the incision."
C. "To measure the amount of fluid lost after surgery."
D. "To prevent accumulation of drainage in the wound."
7. The nurse is teaching a client with asthma about the proper use
of a metered-dose inhaler. Which statement by the client indicates
that the teaching was effective?
A. "I'll flex my head forward and breathe out forcefully before inhaling the
drug."
B. "As I press down on the canister, I'll inhale slowly over 10 seconds."
C. "I'll hold my breath for 5 seconds after inhaling the drug to allow the drug
to reach my lungs."
D. "I'll wait one minute between puffs."
8. A client returns to the clinic 48 hours after receiving a Mantoux
skin test. The area of induration at the injection site measures 18
mm. The client has not previously had a reaction to this test. Which
of the following actions should the nurse do next?
A. Move the client to a negative pressure room.
B. Have the client put on a facemask.
C. Prepare the client to have a chest x-ray.
D. Draw a blood sample to check his CBC for an elevated white blood cell
count.
9. A client is admitted with acute pancreatitis. Which of the
following laboratory results is expected for this client?
36

A. Serum creatinine of 4.3 mg/dL


B. Alanine aminotransferase (ALT) of 125 IU/L.
C. Serum amylase of 306 IU/L.
D. Troponin T level of 3.5 g/L.
10. The nurse is caring for a client who fell from a scaffold 20 feet (6
m) to the ground. He was admitted to the emergency department
with multiple abrasions and complaints of shortness of breath. The
client's chest X-ray reveals a right pneumothorax. Which of the
following actions should the nurse complete first?
A. Help the client turn, cough, and deep breathe.
B. Prepare a chest drainage system.
C. Prepare the client for a computed tomography (CT) scan.
D. Administer a sedative.
11. The nurse is caring for a client diagnosed with respiratory
failure. Which of the following orders should the nurse question for
this client because of the possibility of adverse effects?
A. Antibiotics.
B. Sedatives.
C. Bronchodilators.
D. Oxygen therapy.
12. A client is admitted with hyperosmolar hyperglycemic nonketotic
syndrome (HHNS). His serum glucose level is 926 mg/dL. The nurse
observes the client for which complication of HHNS?
A. Dehydration.
B. Hemorrhage.
C. Infection.
D. Pneumonia.
13. An elderly client is recently diagnosed with hypothyroidism. He
lives in his own apartment in a community development designed
for the elderly. He asks the nurse for advice about his condition.
What is the best advice for the nurse to give the client?
A. "Stop attending group activities."
B. "Increase fiber and fluids in your diet."
C. "Stop taking your self-prescribed daily aspirin."
D. "Keep the temperature in your apartment cooler than usual."
37

14. The nurse is caring for a client with bacterial pneumonia. Of the
following, which nursing diagnosis takes top priority?
A. Activity intolerance related to altered respiratory function.
B. Risk for fluid volume deficit related to fever and dyspnea.
C. Ineffective airway clearance related to copious tracheobronchial
secretions.
D. Altered nutrition with less than body requirements related to anorexia and
dyspnea.
15. The nurse is faxing client information to a nursing home. Which
is the appropriate action for the nurse to take before faxing the
record?
A. Determine that the client has signed a record release.
B. Make sure the client's name and birth date are displayed on the fax cover
sheet.
C. Read all information to the client before faxing.
D. Obtain a written order to fax the information from the client's primary
physician.
16. A nurse is having difficulty setting up humidified oxygen at 40%
per Venturi mask and does not know how many liters of flow she
should use. Which of the following actions is most appropriate to
ensure safe oxygen administration?
A. Consult with a respiratory therapist.
B. Look at the package directions and try to figure it out.
C. Ask the nursing assistant how to set it up.
D. Use a regular oxygen mask.
17. An 8-year old girl presents to the office for a routine
examination. Considering the child's developmental level, which of
the following actions is most appropriate?
A. Allowing the child to change into a gown while you are not in the room.
B. Allowing the child to play with the medical equipment prior to the
examination.
C. Asking the parents to leave the room during the examination.
D. Encouraging the child to hold a stuffed animal during the examination.
18. The nurse is providing care needed to support the respiratory
function of a client with thick secretions. Which measure is most
38

effective in helping a client with thick secretions mobilize and


expectorate them?
A. Drinking salty fluids such as broth and bouillon.
B. Drinking 3 to 4 L of water per day.
C. Inhaling cool mist from a vaporizer daily.
D. Sitting in a tub of warm water three times a day.
19. A client is obtaining a psychiatric evaluation and counseling as a
requirement for care while on a mental health, short-term disability
leave. The client signs an information release form and requests
that the evaluation and counseling records be emailed to the human
resource representative at her company. Which of the following is
an appropriate response by the nurse?
A. "The administrative policy must be reviewed with the agency director
before records can be released."
B. "It is best not to send your records via the Internet, as this may jeopardize
your right to privacy."
C. "Think about if you want your entire counseling record to be released to
the company where you work."
D. "Before disability related records are released, they must be reviewed by
the treatment team."
20. A client suddenly becomes short of breath. Which position is
most beneficial for a client experiencing respiratory difficulty?
A. Dorsal recumbent.
B. Lithotomy.
C. Semi-Fowler's.
D. Sims'.

39

Answer Key
1. Correct answer: B
Abdominal cramping that radiates from the back to the abdomen is most
indicative of true labor. Fatigue is associated with the discomforts of later
pregnancy but does not signal labor. Nausea may be present during the later
weeks of pregnancy but is not a sign of true labor. Centrally located
abdominal pain is not a clear sign of labor, and true labor is not relieved by
rest.
2. Correct answer: B
Unilateral edema, skin color changes, and calf pain are all possible signs of a
deep vein thrombosis, a possible complication of postoperative immobility.
Compression of the sciatic nerve would cause pain to radiate down the hip.
Surgical infection would not cause referred pain to the calf, and dehiscence
would occur at the incision site (abdominal area).
3. Correct answer: A
The nurse should immediately return to the room to compare the client's
identification and the medication administration record to ensure the correct
client received the medication. If an error was made, the nurse must
complete a variance report per the facility policy. The variance report is used
to report injury or high-risk events. In this case, failure to follow correct
procedure put the client at risk. The nurse should check the remaining
medication for the second client prior to administration. The charge nurse
should be notified of any variance or medical error. Completion of a variance
report for a medical error is not documented on the client's medical record.
4. Correct answer: D

40

The gun must be kept in a locked cabinet, and it's safest to store the
ammunition separately. Keeping the gun out of the child's sight would not be
sufficient as the child may be able to locate the gun. A school-aged child
should not be referred to a gun safety program. Even if taught gun safety,
young children lack an adequate concept of cause and effect and often act
impetuously, so the gun should not be kept on hand with the understanding
that the child can be trusted not to touch it.
5. Correct answer: D
Serum theophylline levels are therapeutic when they fall between 10 to 20
g/mL. A serum theophylline level of 25 g/ml is in the toxic range and can
lead to severe adverse reactions, which may be life threatening. The nurse
should withhold the next dose of theophylline and notify the physician
immediately. A theophylline level of 8 g/ml is below the therapeutic range;
the physician should be notified, but this level doesn't require immediate
nursing action. Theophylline levels of 12 g/ml and 20 g/ml are within the
therapeutic range.
6. Correct answer: D
The accumulation of fluid in a surgical wound interferes with the healing
process. A Jackson-Pratt drain promotes wound healing by allowing fluid to
escape from the wound. The drain may be placed in the client's incision, or it
may be placed in the wound and brought out to the skin surface through a
stab wound near the incision. The drain doesn't need to be irrigated. A
Jackson-Pratt drain doesn't prevent infection. Fluid from the drain is absorbed
into the dressings and can't be measured accurately.
7. Correct answer: D
Waiting a full minute after taking the first puff allows the second puff to
reach deeper into the client's lungs. Teach the client to tilt her head back
slightly when using an inhaler and to breathe out normally. Breathing out
forcefully can cause coughing, close the small airways, and trap air. After
pressing down on the canister the client should breathe in slowly over 3 to 5
seconds and then hold her breath for 10 seconds to let the medication reach
deep into the lungs.
8. Correct answer: B
A client with an initial positive reaction to a Mantoux test is at higher risk for
active tuberculosis. Before taking him to another room or for a procedure
41

such as a chest x-ray, he should be fitted with a mask to decrease the risk of
disease transmission to others. It is not necessary to place him in a negative
pressure room before further testing indicates the need. Drawing a CBC is
not necessary at this point.
9. Correct answer: C
The normal value for serum amylase is 30 to 100 IU/L, so a level of 306 IU/L
is indicative of pancreatitis. Pancreatitis involves activation of pancreatic
enzymes, such as amylase and lipase. Therefore, serum amylase is often at
least twice the normal level and lipase levels can be 5 times the normal level
in a client with acute pancreatitis. Serum creatinine level (normal value 0.5
to 1.2 mg/dL) is elevated with kidney dysfunction. Injury or disease of the
liver causes elevated ALT level (normal value 7 to 40 IU/L). Troponin T level
(normal value <0.2 g/L) is elevated with heart damage, such as a myocardial
infarction.
10. Correct answer: B
When a pneumothorax is diagnosed, a chest tube must be inserted to
evacuate air from the pleural space. The nurse should prepare the chest
drainage system so that it can be attached to the chest tube immediately
after insertion. A CT scan of the chest isn't used to diagnose a
pneumothorax. Turning, coughing, and deep breathing can be encouraged
after the chest tube is inserted. Sedation may be administered right before
the chest tube is inserted but after the nurse prepares the chest drainage
system.
11. Correct answer: B
In this case, an order for sedatives is questionable. Sedatives could cause
decreased respirations and shallow breathing. Giving sedatives to a client
with respiratory failure may worsen his already altered respiratory status.
Antibiotics may be used to treat respiratory infection, such as pneumonia, a
possible cause of the client's respiratory failure. Bronchodilators may be used
to open the client's bronchioles to aid breathing. Oxygen therapy is a
standard treatment for respiratory failure to relieve dyspnea.
12. Correct answer: A
Hyperglycemia (excess glucose in the blood) of 926 mg/dL causes an
increase in serum osmolality. This causes fluid to shift from the interstitial to
the intravascular space, causing osmotic diuresis and dehydration.
42

Hemorrhage isn't a complication of HHNS. While pneumonia and infection


may occur in clients with HHNS, these conditions aren't direct complications
of HHNS.
13. Correct answer: B
Clients with hypothyroidism typically have constipation. A diet high in fiber
and fluids can help prevent this. The client doesn't need to stop all group
activities, although he may need to limit them until his condition improves.
Taking aspirin isn't related to hypothyroidism management and does not
interfere with treatment. Clients with hypothyroidism have an intolerance to
cold and need an environment warmer than average.
14. Correct answer: C
With bacterial pneumonia, inflammation of the respiratory system causes
swelling of the bronchioles and bronchi with increased secretions and
production of thick yellow, brown sputum. A client with bacterial pneumonia
may have difficulty clearing secretions. Airway clearance always takes the
highest priority because the client must breathe to live. Activity intolerance
is expected with severe pneumonia because of dyspnea. Fluids and nutrition
should be monitored to ensure adequate intake, but this is not the highest
priority.
15. Correct answer: A
Client authorization is required before any confidential information may be
sent to a nursing home or other facility. The client's name, and other
protected information should never be displayed on a fax cover sheet. It is
not necessary to read the information to the client before sending it. A
physician's order does not give the nurse the right to send a client's
confidential information.
16. Correct answer: A
When a problem falls outside a nurse's experience or knowledge, it is
appropriate to consult with a specialist in that area. The respiratory therapist
is an expert at setting up oxygen delivery systems. Using package directions
is not reliable and may cause harm to the client if the nurse sets up the
oxygen improperly. A nursing assistant is not considered an expert in oxygen
delivery. Using a regular mask would not deliver the correct rate of flow to
the client and would be unacceptable.

43

17. Correct answer: A


School-aged children tend to be very modest, so the child should be allowed
to change into a gown while the health care provider is not in the room.
Additionally, the child should be allowed to leave her underwear in place.
Playing with medical equipment is characteristic of younger children. Parents
should not be asked to leave the room unless the child requests that they not
be present. The child may feel too old to hold a stuffed animal during the
examination and may feel she is being treated "like a baby."
18. Correct answer: B
Adequate fluid intake decreases the viscosity of secretions. The nurse should
encourage the client to drink 3 to 4 L of water or other fluids per day.
Consuming salty fluids can cause secretions to thicken even further. Inhaling
cool mist may help but only if done more than once a day. Sitting in a tub of
warm water may be relaxing, but it doesn't loosen secretions.
19. Correct answer: B
The client has a right to ask that her records be released, but there is an
increased risk for breach of confidentiality if personal health care records are
emailed to a place of employment. Although every health care agency has a
policy and procedure related to release of client records, the staff is required
to be informed about the policy upon employment. There is no need to
review the policy with the agency director when a client requests that
records be released. Asking the client to think about her statement is
inappropriate and could create apprehension in the client. The review of a
client's treatment goals and progress is an ongoing process; it is not initiated
when client records are requested for release to a third party.
20. Correct answer: C
Semi-Fowler's position, or sitting at about 45 degrees, facilitates lung expansion.
The dorsal recumbent (supine) position doesn't ease the work of breathing. The
lithotomy (legs up in stirrups) position is normally used for gynecologic examination
but might worsen dyspnea. Sims' position is a lateral position with the top leg flexed
toward the chest. This position inhibits lung expansion.

NCLEX PN Test V
44

1. A client is admitted with a possible bowel obstruction. Which of


the following nursing actions is most important for the nurse to
perform for a client with a bowel obstruction?
A. Obtain daily weights.
B. Measure abdominal girth.
C. Keep strict intake and output.
D. Encourage the client to increase fluids.
2. An infant is brought to the Emergency Department by the child's
parents. The infant is limp and has central cyanosis, heart rate of 60
beats per minute, respiratory rate of 12 breaths per minute. The
parents state that they have an advance directive for their infant
because he has a terminal illness. Which of the following is the most
appropriate action for the nurse?
A. Ask to see a copy of the advanced directive.
B. Provide oxygen while awaiting further physician's orders.
C. Provide palliative care for the infant and family.
D. Contact the nursing supervisor for assistance.
3. The nurse is caring for a client newly diagnosed with chronic
obstructive pulmonary disease (COPD). Which of the following
exercises is most appropriate for this client?
A. Intercostal muscle expansion exercises.
B. Isometric leg exercises.
C. Diaphragmatic and pursed-lip breathing exercises.
D. Lumbar sacral strengthening exercises.
4. Parents tell the nurse that they have not been successful in
meeting their goal for home management of their 20-year old son
with a schizoaffective disorder. They report that the client is posing
a threat to their safety. Which of the following is the best initial
recommendation?
A. Have the client be evaluated for a voluntary admission to a mental health
facility.
B. Discuss what the family can do to chemically restrain the client at home.
C. Tell the family that the client's behavior releases them from the duty of
care.
D. Arrange for respite care as the family could be aggravating the client's
condition.
45

5. A client comes to the clinic because of low-grade afternoon


fevers, night sweats, and a productive cough. The client's wife was
recently diagnosed with pulmonary tuberculosis, and the physician
suspects that the client has now contracted the disease. A positive
acid-fast bacillus sputum culture confirms the diagnosis. While
obtaining the client's history, the nurse notes that he refers to his
diagnosis as "it," never as tuberculosis, and avoids discussing the
disease. What is the nurse's best response?
A. "It won't kill you if you take your medications."
B. "Tell me how you feel about the diagnosis of tuberculosis."
C. "You shouldn't be embarrassed that you have tuberculosis."
D. "Let's not talk about the tuberculosis. How long have you been having
night sweats?"
6. The nurse is giving instructions to a parent of a 13-month-old who
weighs 18 lbs. The child is being discharged from the pediatric unit
after hospitalization for gastroenteritis. When talking to the parent
about car seat safety, the nurse knows the parent understands the
teaching when the mother states:
A. "My child can be in a front-facing car seat because he is 1 year old."
B. "My child can be in a front facing car seat as soon as he weighs 21
pounds."
C. "As long as I drive a sports utility vehicle, I can have my child rear or front
facing."
D. "My child will need to be in a rear facing care seat until her is three years
old."
7. A client with acquired immunodeficiency syndrome (AIDS)
develops Pneumocystis jiroveci pneumonia. Which nursing diagnosis
has the highest priority for the client?
A. Impaired gas exchange.
B. Impaired oral mucous membrane.
C. Imbalanced nutrition: Less than body requirements.
D. Activity intolerance.
8. The nurse is caring for a 2-year-old child admitted for long-term
treatment of a chronic illness. The nurse understands the normal
growth and development of children. Which of the following is an
important nursing action for the child?

46

A. Allow the child to sleep for at least 12 hours per night.


B. Speak with a play therapist regarding activities the child can participate
in.
C. Be sure the child is continuously isolated due to the chronic illness and
risk of infection.
D. Maintain a diet that is high in carbohydrates and low in fats.
9. During the assessment interview, a depressed 15-year-old client
states that she "can't ever sleep at night." When the nurse begins
to explore the possible contributing factors by asking the client
questions, the client changes the subject and avoids eye contact.
The client tenses noticeably when the nurse touches her as part of
the exam. Which of the following does the client's behavior
suggest?
A. Sexual abuse.
B. Age-appropriate behavior.
C. Sleep apnea.
D. Narcolepsy.
10. A client with bipolar disorder who is taking lithium carbonate is
instructed by the nurse on proper use of the drug, side effects, and
symptoms of lithium toxicity. What statement by the client indicates
that additional client teaching is required?
A. "I can still eat my favorite salty foods."
B. "When my moods fluctuate, I will increase my lithium."
C. "A good blood level means the drug is working."
D. "Eating too much watermelon will effect by lithium level."
11. The nurse is developing a care plan for a client with hepatic
encephalopathy. Which of the following treatments should the nurse
include?
A. Administering a lactulose enema as ordered.
B. Encouraging a protein-rich diet.
C. Administering sedatives as necessary.
D. Encouraging ambulation at least four times a day.
12. A client is admitted to the medical-surgical floor with an
exacerbation of myasthenia gravis. Which intervention is important
for the nurse to include in the plan of care for this client?

47

A. Encouraging independent activities of daily living.


B. Helping the client cope with mood swings.
C. Scheduling the client's care around periods of rest.
D. Encouraging warm baths before exercise.
13. A client is admitted to the Emergency Department after a threecar accident. He's exhibiting early signs of increased intracranial
pressure. Which of the following groups of symptoms is the nurse
most likely to observe?
A. Decreasing pulse, increasing respiratory rate, and decreasing blood
pressure.
B. Decreasing pulse, decreasing respiratory rate, and increasing systolic
pressure.
C. Increasing pulse, decreasing respiratory rate, and increasing pulse
pressure.
D. Decreasing pulse, increasing respiratory rate, and increasing pulse
pressure.
14. The nurse is caring for a child who was in a house fire that killed
7 people, including his parents. He is the only survivor. The local
newspapers and television stations are at the hospital and are
trying to receive information regarding his condition. Which of the
following is the correct action for the nurse?
A. The nurse does not give out any information regarding the child's
condition.
B. The nurse does not give the name, only the condition of the patient.
C. The nurse gives a statement about how sad she is for the family and
friends of the little boy.
D. The nurse contacts an attorney because of the legal issues regarding
caring for the child.
15. The nurse is leading a discussion on home safety to a group of
parents with toddler-age children. Which of the following is
important to emphasize?
A. Most deaths that occur regarding toddlers are accidental.
B. Overdose of medications is the leading cause of death in toddlers.
C. All children over the age of one can be in a front facing car seat.
D. The risk of injury for toddlers is the same as for adults.

48

16. The nurse is caring for a client diagnosed with a stroke. Because
of the stroke, the client has dysphagia (difficulty swallowing). Which
intervention by the nurse is best for preventing aspiration?
A. Placing the client in high Fowler's position to eat.
B. Offering liquids and solids together.
C. Keeping liquids thinned.
D. Placing food on the affected side of the mouth.
17. The nurse is explaining medication benefits and side effects to a
client with a history of psychosis. The client's brother states to the
nurse, "You are wasting your time explaining things to him." Based
on the nurse's understanding of informed consent, which of the
following statements serves as the best guide for the nurse's
response?
A. Informed consent does not apply to clients who experience psychosis.
B. The nurse can assume that the client understands at least some of the
information.
C. A third party is necessary when informing clients about treatment
options.
D. The use of informed consent is an important part of effective client care
for all clients, regardless of age or condition.
18. The nurse is caring for a client who suddenly develops a tonicclonic seizure. Which nursing action is most appropriate during a
seizure?
A. Forcing a padded tongue blade into the client's mouth.
B. Restraining the client's limbs.
C. Placing the client in a supine position.
D. Loosening constrictive clothing.
19. The nurse is caring for a 19-month-old with mild dehydration
and weight loss. The parent states: "My son doesn't like to eat, and I
hate to make him." Which of the following nursing actions is
appropriate?
A. Contact the social worker on duty and give her information on the
situation.
B. Contact the physician to have the child referred to a gastroenterologist.
C. Contact the dietitian and have him come to talk to the parent about

49

toddlers and nutrition.


D. Contact the local police for suspected child abuse.
20. An obese client has returned to the unit after receiving sedation
and electroconvulsive therapy. The nurse requests assistance
moving the client from the stretcher to the bed. There are 2 people
available to assist. Which of the following is the best method of
transfer for this patient?
A. Carry lift.
B. Sliding board.
C. Lift sheet transfer.
D. Hydraulic lift.

Answer Key
1. Correct answer: B

50

With a bowel obstruction, abdominal distention occurs. Measuring abdominal


girth provides quantitative information about increases or decreases in the
amount of distention. Monitoring daily weights provides information about
fluid status. An increase in daily weight usually indicates fluid retention.
Measuring intake and output provides no information about abdominal
distention or the obstruction although it is to monitor output. A client with a
bowel obstruction will have a nothing-by-mouth order.
2. Correct answer: A
The nurse should ask to see a copy of the advance directive for guidance in
providing care. Advance directives for infants and children are often prepared
by the parents with the assistance of their physicians as part of planning for
end-of-life. These advance directives outline the type of care the parents
want provided for their child and are especially important to guide care if the
parents are not available when questions arise. The advance directive may
specify whether oxygen should be used as part of palliative care. Waiting for
the supervisor is not necessary since the parents are present, have an
advance directive, and can indicate their wishes.
3. Correct answer: C
Clients with COPD are taught to use their diaphragmatic muscles, not their
intercostal muscles, to breathe. Because of air trapping due to COPD,
pursed-lip breathing exercises are indicated to help expel carbon dioxide.
These exercises increase expiratory time, decrease expiratory rate, and
increase tidal volume. Isometric leg exercises and lumbar sacral
strengthening exercises don't improve breathing but may be important for
general health.
4. Correct answer: A
A voluntary admission is the preferred approach because it involves having
the client recognize the problems the family is experiencing and facilitates
the client's involvement in treatment. The client's rights would be violated by
the use of chemical restraints since the client has the right to freedom from
the use of restraints and seclusion. The duty of care is a legal relationship
that applies only to the nurse-client relationship, not to the family
relationship. In this case, the son is legally an adult, so the parents do not
have a legal obligation to care for him. Respite care is not an appropriate
recommendation at this time. The safety issue must be addressed and
effective treatment and care instituted. At a later time, it would be prudent

51

to talk to the family about caregiver burden and the option of using respite
care.
5. Correct answer: B
Asking the client how he feels about the diagnosis allows the client to
express his feelings about the diagnosis. Saying "it" won't kill the client if he
takes his medications belittles the client and reinforces the idea that he may
be at fault. Telling the client he shouldn't be embarrassed is presumptive and
judgmental. Responding with "Let's not talk about it" ignores the client's
feelings, reinforces the idea that there is something shameful about
tuberculosis, and does not help him to accept and deal with his disease.
6. Correct answer: B
Any child under one year of age and/or 20 pounds must be in a rear facing
car seat. The make or model of the car does not relate to child safety laws.
The general rule for car seat application is that the child must be over one
year of age and 20 pounds to move from a rear facing to front facing car seat
but must be in the back seat of the car. Older children must use a booster
seat until they are 7 to 8 years old, depending upon the state law.
7. Correct answer: A
Pneumocystis jiroveci is a fungus infection that can cause severe pneumonia
in those who are immunocompromised. While all these nursing diagnoses are
appropriate for the client with AIDS and P jiroveci pneumonia, impaired gas
exchange is the priority nursing diagnosis for the client as ensuring a patent
airway, breathing, and circulation are critical for life. Patients who are
severely ill often have impaired nutrition, oral mucous membranes, and
activity intolerance, but these should resolve if the causative condition is
adequately treated.
8. Correct answer: B
An important part of growth and development for a child is play. Even when a
child has a chronic illness, play should be facilitated. Consulting a play
therapist is appropriate for children with special needs. Although it is
important for children to maintain adequate sleep, it is not required that
toddlers receive 12 hours of sleep per night. Children with chronic illnesses
do not need to be continuously isolated. The child might need to be isolated
for a period of time; however, she should still have interaction with family. A
diet high in carbohydrates and low in fat is not indicated for all toddlers with
52

chronic illness, and the American Heart Association recommends that fat
intake should be 30 to 35% of the diet for a 2-year old.
9. Correct answer: A
Often a girl who is being sexually abused refuses to talk about it and changes
the subject when questioned. Avoiding eye contact can indicate feelings of
shame. While 15 year-old girls may be shy regarding their bodies, this
behavior and her reaction when touched coupled with depression suggests
abuse. Sleep apnea results in chronic fatigue although the person usually
does not have difficulty falling asleep and is often unaware of the apneic
periods. A client with narcolepsy has periods of deep sleep at night and falls
asleep even during activities in the daytime.
10. Correct answer: B
Increasing the dose of lithium without monitoring dosage through lab values
can result in lithium toxicity, overdose, and renal failure. The client must take
the medication as prescribed and discuss mood fluctuations with the
physician to determine if the dosage should be increased. Clients on lithium
must include adequate intake of both sodium and fluids. A low sodium diet
causes lithium retention. A therapeutic lithium blood level indicates that the
drug concentration has stabilized. Clients are cautioned against eating large
amounts of foods that have a diuretic effect. Some examples of these foods
are watermelon, cantaloupe, grapefruit juice, and cranberry juice.
11. Correct answer: A
Hepatic encephalopathy is a degenerative disease of the brain that is a
complication of cirrhosis. For the client with hepatic encephalopathy, the
nurse may administer the laxative lactulose (Chronulac) to reduce
ammonia levels in the colon. Protein intake is usually restricted to reduce
serum ammonia levels until the client's mental status begins to improve.
Sedatives are avoided because they can cause respiratory or circulatory
failure. Bed rest is encouraged because physical activity increases
metabolism, leading to an increased production of ammonia.
12. Correct answer: C
Classic symptoms of myasthenia gravis are weakness and fatigue, so it's
important to schedule care around periods of rest. Drastic mood changes are
a symptom of other conditions, such as Cushing's syndrome, not myasthenia
gravis. Encouraging independent activities of daily living is also important
53

but these must be done around periods of rest as well. Warm baths, which
relax the muscles, might increase the client's feeling of weakness and
fatigue.
13. Correct answer: B
In the early stages of increased intracranial pressure, the client's heart and
respiratory rates slow down. The result is an increase in systolic pressure
with further decrease in heart rate and respiratory rate, and a widening pulse
pressure. With head trauma, there may be significant swelling that decreases
perfusion, causing hypoxia and hypercapnia, triggering increased blood flow.
The increase volume when injury has impaired auto-regulation increases the
edema, which in turn increases intracranial pressure, causing further
ischemia. If the intracranial pressure is not controlled, the brain may
herniate.
14. Correct answer: A
According to HIPAA standards, one cannot give information regarding a
child's care unless permission is granted by the parents/guardian of the child
to divulge information. In this case, the guardians may not yet have been
identified. It would be inappropriate to give the name of the child, and there
is no need for the nurse to contact an attorney. Although not illegal, giving a
statement of feelings regarding the situation is not professional. In most
hospitals, a public relations officer may be directed to make a public
statement.
15. Correct answer: A
Most deaths in children are accidental. Many children are injured or killed
each year from accidents related to fire, drowning, motor vehicles, and
firearms. Generally, children of this age do not overdose on medications
unless they are accidentally given too much medication. Most state laws
require that infants remain rear-facing in a car seat until they are at least one
year old and weigh 20 pounds, but studies indicate that it is safer to remain
rear-facing for the first two years. Children are at a higher risk for injury then
adults due to the developmental level of children and their lack of knowing
right from wrong and recognizing danger signs.
16. Correct answer: A
Placing the client in high Fowler's position, such as in a chair, uses gravity to
reduce the risk of aspiration. Solids and liquids shouldn't be offered together
54

because when they're in the mouth together, the liquids can cause the solids
to be swallowed before they're properly chewed. However, water or other
fluid should be sipped after swallowing to clear the throat. Thin liquids should
be thickened. Food should be placed on the unaffected side to prevent it
from being trapped in the cheek on the affected side. Using smaller utensils
to limit bite size and doing muscle-strengthening exercises may reduce
dysphagia.
17. Correct answer: D
The use of informed consent allows the client and the nurse to work as
partners in the development and accomplishment of treatment goals. Even
clients with a history of psychosis have the right to be informed about their
treatment risks and benefits. It is not appropriate for the nurse to assume
that the client understands information given without obtaining some
feedback from the client. A third party is not required to be present unless
the client cannot give informed consent. In the case of a minor or legally
incompetent client, a legally appointed guardian or parent must give
informed consent for treatment.
18. Correct answer: D
Constrictive clothing, especially around the client's neck, can interfere with
oxygenation, so it should be loosened. One should never force anything such
as a padded tongue blade into the mouth because it could break teeth or
induce vomiting. A client who is having seizures should not be restrained, as
it can cause soft-tissue injury and musculoskeletal damage. Instead, any
dangerous objects should be removed from around the client. Because a
supine position increases the risk of aspiration, the client should be helped
into a side-lying position.
19. Correct answer: C
The parent needs assistance in maintaining her child's diet. The dietitian is a
healthcare professional that could speak to the parent regarding the diet of
the child. This is within the scope of practice for a nurse. The nurse would not
call the local police or social worker on duty. This is not a case of child abuse
or neglect. Many toddlers are picky eaters and resist eating and drinking, and
small children are less sensitive to feelings of thirst. The nurse would not call
the physician to have the child referred to a gastroenterologist, as there is no
indication that this is necessary.
20. Correct answer: B
55

Because this patient is obese and sedated, she is unable to assist with the
transfer, so the sliding board transfer is the best method of transfer as it can
be done with two to three people. The patient is turned to her side and the
sliding board placed to bridge the stretcher and the bed. The nurse can
stabilize the side opposite the bed while the other two pull the patient across
to the bed with a pull sheet. A carry lift requires 4 people but is not safe for
an obese patient. A lift sheet transfer requires at least 4 people, but if the
patient is obese up to 7 or 8 people may be needed. The hydraulic lift is not
the appropriate equipment to use with a sedated patient because the patient
cannot cooperate.

56