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NCLEX-RNNCLEX National Council Licensure Examination(NCLEX-RN) http://killexams.com/exam-detail/NCLEX-RNQuestion: 1 On the third postpartum day, the nurse would expect the lochia to be: A. RubraB. SerosaC. AlbaD. Scant Answer: A Explanation: (A) This discharge occurs from delivery through the 3rd day. There is dark red blood, placental debris, and clots.(B) This discharge occurs from days 4-10. The lochia is brownish, serous, and thin. (C) This discharge occurs fromday 10 through the 6thweek. The lochia is yellowish white. (D) This is not a classification of lochia but relates tothe amount of discharge. Question: 2 A pregnant client is having a nonstress test (NST). It is noted that the fetal heart beat rises 20 bpm, lasting 20seconds, every time the fetus moves. The nurse explains that:A. The test is inconclusive and should be repeatedB. Further testing is neededC. The test is normal and the fetus is reacting appropriatelyD. The fetus is distressed Answer: C Explanation: (A) The test results were normal, so there would be no need to repeat to determine results. (B) There are no data toindicate further tests are needed, because the result of the NST was normal. (C) An NST is reported as reactive ifthere are two to three increases in the fetal heart rate of 15 bpm, lasting at least 15 seconds during a 15-minuteperiod. (D) The NST results were normal, so there was no fetal distress. Question: 3 Which stage of labor lasts from delivery of the baby to delivery of the placenta?A. SecondB. ThirdC. FourthD. Fifth Answer: B Explanation: (A) This stage is from complete dilatation of the cervix to delivery of the fetus. (B) This is the correct stage for thedefinition. (C) This stage lasts for about 2 hours after the delivery of the placenta. (D) There is no fifth stage oflabor. Question: 4 A client develops complications following a hysterectomy. Blood cultures reveal Pseudomonas aeruginosa. Thenurse expects that the physician would order an appropriate antibiotic to treat P. aeruginosa such as:A. Cefoperazone (Cefobid)B. Clindamycin (Cleocin)C. Dicloxacillin (Dycill)D. Erythromycin (Erythrocin) Answer: A Explanation: (A) Cefoperazone is indicated in the treatment of infection withPseudomonas aeruginosa.(B) Clindamycin is notindicated in the treatment of infection withP. aeruginosa.(C) Dicloxacillin is not indicated in the treatment ofinfection withP. aeruginosa.(D) Erythromycin is not indicated in the treatment of infection withP. aeruginosa. Question: 5 A couple is experiencing difficulties conceiving a baby. The nurse explains basal body temperature (BBT) byinstructing the female client to take her temperature:A. Orally in the morning and at bedtimeB. Only one time during the day as long as it is always at the same time of dayC. Rectally at bedtimeD. As soon as she awakens, prior to any activity Answer: D Explanation: (A) Monitoring temperature twice a day predicts the biphasic pattern of ovulation. (B) Prediction of ovulationrelies on consistency in taking temperature. (C)Nightly rectal temperatures are more accurate in predictingovulation. (D) Activity changes the accuracy of basal body temperature and ability to detect the luteinizinghormone surge. Question: 6 A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriatenursing actions to help control hyperventilating include:A. Administering diazepam (Valium) 1015 mg po q4h and q1h prn for hyperventilating episodeB. Keeping the temperature in the client’s room at a high level to reduce respiratory stimulationC. Having the client hold her breath or breathe into a paper bag when hyperventilation episodes occurD. Using distraction to help control the client’s hyperventilation episodes Answer: C Explanation: (A) An adult diazepam dosage for treatment of anxiety is 210 mg PO 24 times daily. The order as written wouldplace a client at risk for overdose. (B) A high room temperature could increase hyperventilating episodes bystimulating the respiratory system. (C) Breath holding and breathing into a paper bag may be useful in controllinghyperventilation. Both measures increase CO2 retention. (D) Distraction will not prevent or controlhyperventilation caused by anxiety or fear. Question: 7 A client delivered a stillborn male at term. An appropriate action of the nurse would be to:A. State, "You have an angel in heaven."B. Discourage the parents from seeing the baby.C. Provide an opportunity for the parents to see and hold the baby for an undetermined amount of time.D. Reassure the parents that they can have other children. Answer: C Explanation: (A) This is not a supportive statement. There are also no data to indicate the family’s religious beliefs. (B) Seeingtheir baby assists the parents in the grieving process. This gives them the opportunity to say "good-bye." (C)Parents need time to get to know their baby. (D) This is not a comforting statement when a baby has died. There are also no guarantees that the couple will be able to have another child. Question: 8 A 29-year-old client is admitted for a hysterectomy. She has repeatedly told the nurses that she is worried about having this surgery, has not slept well lately, and is afraid that her husband will not find her desirable after thesurgery. Shortly into the preoperative teaching, she complains of a tightness in her chest, a feeling of suffocation,lightheadedness, and tingling in her hands. Her respirations are rapid and deep. Assessment reveals that the clientis:A. Having a heart attackB. Wanting attention from the nursesC. Suffering from complete upper airway obstructionD. Hyperventilating Answer: D Explanation: (A) Classic symptoms of a heart attack include heaviness or squeezing pain in the chest, pain spreading to the jaw,neck, and arm. Nausea and vomiting, sweating, and shortness of breath may be present. The client does not exhibitthese symptoms. (B) Clients suffering from anxiety or fear prior to surgical procedures may develophyperventilation. This client is not seeking attention. (C) Symptoms of complete airway obstruction include notbeing able to speak, and no airflow between the nose and mouth. Breath sounds are absent. (D) Tightness in thechest; a feeling of suffocation; lightheadedness; tingling in the hands; and rapid, deep respirations are signs andsymptoms of hyperventilation. This is almost always a manifestation of anxiety. Question: 9 A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains ofsevere abdominal pain. Assessment reveals abdominal rigidity and distention, increased temperature, andtachycardia. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has developed:A. GastritisB. EviscerationC. PeritonitisD. Pulmonary embolism Answer: C Explanation: (A) Assessment findings for gastritis would reveal anorexia, nausea and vomiting, epigastric fullness andtenderness, and discomfort. (B) Evisceration is the extrusion of abdominal viscera as a result of trauma or suturesfailing in a surgical incision. (C) Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ,such as the gallbladder, perforates and leaks blood and fluid into the abdominal cavity. This causes infection andirritation. (D) Assessment findings of pulmonary embolism would reveal severe substernal chest pain, tachycardia,tachypnea, shortness of breath, anxiety or panic, and wheezing and coughing often accompanied by blood-tingedsputum. Question: 10 A 35-year-old client is admitted to the hospital for elective tubal ligation. While the nurse is doing preoperativeteaching, the client says, "The anesthesiologist said she was going to give me balanced anesthesia. What exactly isthat?" The best explanation for the nurse to give the client would be that balanced anesthesia:A. Is a type of regional anesthesiaB. Uses equal amounts of inhalation agents and liquid agentsC. Does not depress the central nervous systemD. Is a combination of several anesthetic agents or drugs producing a smooth induction and minimalcomplications Answer: D Explanation: (A) Regional anesthesia does not produce loss of consciousness and is indicated for excision of moles, cysts, andendoscopic surgeries. (B) Varying amounts of anesthetic agents are used when employing balanced anesthesia.Amounts depend on age, weight, condition of the client, and surgical procedure. (C) General anesthesia is a drug-induced depression of the central nervous system that produces loss of consciousness and decreased muscleactivity. (D) Balanced anesthesia is a combination of a number of anesthetic agents that produce a smoothinduction, appropriate depth of anesthesia, and appropriate muscle relaxation with minimal complications. Question: 11 Following a gastric resection, a 70-year-old client is admitted to the postanesthesia care unit. He was extubatedprior to leaving the suite. On arrival at the postanesthesia care unit, the nurse should:A. Check airway, feeling for amount of air exchange noting rate, depth, and quality of respirationsB. Obtain pulse and blood pressure readings noting rate and quality of pulseC. Reassure the client that his surgery is over and that he is in the recovery roomD. Review physician’s orders, administering medications as ordered Answer: A Explanation: (A) Adequate air exchange and tissue oxygenation depend on competent respiratory function. Checking the airwayis the nurse’s priority action. (B) Obtaining the vital signs is an important action, but it is secondary to airwaymanagement. (C) Reorienting a client to time, place, and person after surgery is important, but it is secondary toairway and vital signs. (D) Airway management takes precedence over physician’s orders unless they specificallyrelate to airway management. Question: 12 A 25-year-old client is admitted for a tonsillectomy. She tells the nurse that she has had episodes of musclecramps, weakness, and unexplained temperature elevation. Many years ago her father died shortly after surgeryafter developing a high fever. She further tells the nurse that her surgeon is having her take dantrolene sodium(Dantrium) prophylactically prior to her tonsillectomy. Dantrolene sodium is ordered preoperatively to reduce therisk or prevent:A. Infection postoperativelyB. Malignant hyperthermiaC. Neuroleptic malignant syndromeD. Fever postoperatively Answer: B Explanation: (A, D) Dantrolene sodium is a peripheral skeletal muscle relaxant and would have no effect on a postoperativeinfection. (B) Dantrolene sodium is indicated prophylactically for clients with malignant hyperthermia or with afamily history of the disorder. The mortality rate for malignant hyperthermia is high. (C) Neuroleptic malignantsyndrome is an exercise-induced muscle pain and spasm and is unrelated to malignant hyperthermia. Question: 13 The family member of a child scheduled for heart surgery states, "I just don’t understand this open-heart or closed-heart business. I’m so confused! Can you help me understand it?" The nurse explains that patent ductus arteriosusrepair is:A. Open-heart surgery. The child will be placed on a heart-lung machine while the surgery is beingperformed.B. Closed-heart surgery. It does not require that the child be placed on the heart-lung machine while thesurgery is being performed.C. A pediatric version of the coronary artery bypass graft surgery performed on adults. It is an open-heart surgery. D. A pediatric version of percutaneous transluminal coronary angioplasty performed on adults. It is a closed-heart surgery. Answer: B Explanation: (A) Patent ductus arteriosus repair is a closed-heart procedure. The client is not placed on a heart-lung machine.(B) Patent ductus arteriosus is a ductus arteriosus that does not close shortlyafter birth but remains patent. Repairis a closed-heart procedure involving ligation of the patent ductus arteriosus. (C) Coronary artery bypass graftsurgery is an open-heart surgical procedure in which blocked coronary arteries are bypassed using vessel grafts.(D) Percutaneous transluminal coronary angioplasty is a closedheart procedure that improves coronary blood flowby increasing the lumen size of narrowed vessels. Question: 14 A child is to receive atropine 0.15 mg (1/400 g) as part of his preoperative medication. A vial containing atropine0.4 mg (1/150 g)/mL is on hand. How much atropine should be given?A. 0.06 mLB. 0.38 mLC. 2.7 mLD. Information given insufficient to determine the amount of atropine to be administered Answer: B Explanation: (A, C) Information was incorrectly placed in the formula, resulting in an incorrect answer. (B) The answer iscorrect.0.4 mg = 1 mL:0.15 mg 5 = mL0.4 x = 0.15x = 0.15/0.4x = 0.375 or 0.38 mL(D)Sufficient information is provided to determine the amount of atropine to administer. The amount of atropineavailable and the amount of atropine ordered is required to determine the amount of atropine to be given. Question: 15 A 47-year-old male client is admitted for colon surgery. Intravenous antibiotics are begun 2 hours prior to surgery.He has no known infection. The rationale for giving antibiotics prior to surgery is to:A. Provide cathartic action within the colonB. Reduce the risk of wound infection from anaerobic bacteriaC. Relieve the client’s concern regarding possible infectionD. Reduce the risk of intraoperative fever Answer: B Explanation: (A) Cathartic drugs promote evacuation of intestinal contents. (B) The client undergoing intestinal surgery is atincreased risk for infection from large numbers of anaerobic bacteria that inhabit the intestines. Administeringantibiotics prophylactically can reduce the client’s risk for infection. (C) Antibiotics are indicated in the treatmentof infections and have no effect on emotions. (D) Antipyretics are useful in the treatment of elevated temperatures.Antibiotics would have an effect on infection, which causes temperature elevation, but would not directly affectsuch an elevation. Question: 16 A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is being given digoxin. Prior to administering the medication, the nurse should: A. Not give the digoxin if the pulse is_60 B. Not give the digoxin if the pulse is_100C. Take the apical pulse for a full minuteD. Monitor for visual disturbances, a side effect of digoxin Answer: C Explanation: (A) Digoxin should not be given to adults with an apical pulse < 60 bpm. (B) Digoxin should be given to childrenwith an apical pulse > 100 bpm. With a pulse < 100 bpm, the medication should be withheld and the physiciannotified. (C) Prior to digoxin administration in both children and adults, an apical pulse should be taken for 1 fullminute. Aside from the rate per minute, the nurse should note any sudden increase or decrease in heart rate,irregular rhythm, or regularization of a chronic irregular heart rhythm. (D) Early indications of digoxin toxicity,such as visual disturbances, occur rarely as initial signs in children. Question: 17 A 35-year-old client has returned to her room following surgery on her right femur. She has an IV of D5 in onehalfnormal saline infusing at 125 mL/hr and is receiving morphine sulfate 1015 mg IM q4h prn for pain. She lastvoided 51/2 hours ago when she was given her preoperative medication. In monitoring and promoting return ofurinary function after surgery, the nurse would:A. Provide food and fluids at the client’s requestB. Maintain IV, increasing the rate hourly until the client voidsC. Report to the surgeon if the client is unable to void within 8 hours of surgeryD. Hold morphine sulfate injections for pain until the client voids, explaining to her that morphine sulfatecan cause urinary retention Answer: C Explanation: (A) Provision of food and fluid promotes bowel elimination. Nutritional needs postoperatively are determined bythe physician, not the client. (B) Increasing IV fluids postoperatively will not cause a client to void. Any change inrate of administration of IV fluids should be determined by the physician. (C) The postoperative client with normalkidney function who cannot void 8 hours after surgery is retaining urine. The client may need catheterization ormedication. The physician must provide orders for both as necessary. (D) Although morphine sulfate can causeurinary retention, withholding pain medication will not ensure that the client will void. The client with uncontrolledpain will probably not be able to void. Question: 18 A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low, intermittentsuction with orders to "Irrigate NG tube with sterile saline q1h and prn." The rationale for using sterile saline, asopposed to using sterile water to irrigate the NG tube is:A. Water will deplete electrolytes resulting in metabolic acidosis.B. Saline will reduce the risk of severe, colicky abdominal pain during NG irrigation.C. Water is not isotonic and will increase restlessness and insomnia in the immediate postoperative period.D. Saline will increase peristalsis in the bowel. Answer: A Explanation: (A) Water is a hypotonic solution and will deplete electrolytes and cause metabolic acidosis when used fornasogastric irrigation. (B) Irrigating with saline does not cause abdominal discomfort. Severe, colicky abdominalpain is a symptom of intestinal obstruction. (C) Irrigating with water will not cause restlessness or insomnia in thepostoperative client. Restlessness and insomnia can be emotional complications of surgery. (D) A nasogastric tube placed in the stomach is used to decompress the bowel. Irrigating with saline ensures a patent, well- functioning tube. Irrigating with saline will not increase peristalsis. Question: 19 The nurse writes the following nursing diagnosis for a client in acute renal failure–Impaired gas exchange related to:A. Decreased red blood cell productionB. Increased levels of vitamin DC. Increased red blood cell productionD. Decreased production of renin Answer: A Explanation: (A) Red blood cell production is impaired in renal failure owing to impaired erythropoietin production. This causesa decrease in the delivery of oxygen to the tissue and impairs gas exchange. (B) The conversion of vitamin D to itsphysiologically active form is impaired in renal failure. (C) In renal failure, a decrease in red blood cellproduction occurs owing to an impaired production of erythropoietin, leading to impaired gas exchange at thecellular level. (D) The decreased production of renin in renal failure causes an increased production ofaldosterone causing sodium and water retention. Question: 20 A 6-year-old child returned to the surgical floor 20 hours ago after an appendectomy for a gangrenous appendix.His mother tells the nurse that he is becoming more restless and is anxious. Assessment findings indicate that thechild has atelectasis. Appropriate nursing actions would include:A. Allowing the child to remain in the position of comfort, preferably semi-or high-Fowler positionB. Administering analgesics as orderedC. Having the child turn, cough, and deep breathe every 12 hours D. Remaining with the child and keepingas calm and quiet as possible Answer: C Explanation: (A) Allowing the client to remain in the position of comfort will not resolve the atelectasis. This position, if leftunchanged, over time may actually increase the atelectasis. (B) Analgesics will not resolve the atelectasis and maycontribute to it if proper nursing actions are not taken to help resolve the atelectasis. (C) Having the client turn,cough, and deep breathe every 12 hours will aid in resolving the atelectasis. Surgery clients are at risk forpostoperative respiratory complications because pulmonary function is reduced as a result of anesthesia andsurgery. (D) Remaining with the client and keeping him calm and quiet will not affect the client’s anxiety,restlessness, or help to resolve the atelectasis. The cause (atelectasis) needs to be treated, not the symptoms(anxiety and restlessness). Question: 21 A 52-year-old female client is admitted to the hospital in acute renal failure. She has been on hemodialysis for thepast 2 years. Stat arterial blood gases are drawn on the client yielding the following results: pH 7.30, PCO2 51 mmHg, HCO3, 18 mEq/L, PaO2, 84 mm Hg. The nurse would interpret these results as:A. Compensated metabolic alkalosisB. Respiratory acidosisC. Partially compensated metabolic alkalosisD. Combined respiratory and metabolic acidosis Answer: D Explanation: (A) Compensated metabolic alkalosis would be reflected by the following: pH within normal limit (7.357.45), PCO2 > 45 mm Hg, HCO3 >26 mEq/L. (B) Respiratory acidosis would be reflected by the following: pH < 7.35, PCO2 > 45 mm Hg, HCO3 within normal limits (2226 mEq/L). (C) Partially compensated metabolic alkalosiswould be reflected by the following: pH > 7.45, PCO2 > 45 mm Hg, HCO3 > 26 mEq/L. (D) Combined respiratoryand metabolicacidosis would be reflected by the following: pH < 7.35, PCO2 > 45 mm Hg, HCO3 < 22 mEq/L. Question: 22 Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. Thephysician is immediately notified and orders 50 mL of dextrose and 10 U of regular insulin IV push. The nurseadministering these drugs knows the Rationale for this therapy is to:A. Remove the potassium from the body by renin exchangeB. Protect the myocardium from the effects of hypokalemiaC. Promote rapid protein catabolismD. Drive potassium from the serum back into the cells Answer: D Explanation: (A) Sodium polystyrene sulfonate (Kayexalate), a cation exchange resin, exchanges sodium ions for potassium ionsin the large intestine reducing the serum potassium. (B) Calcium is administered to protect the myocardium fromthe adverse effects of hyperkalemia. Serum levels reflect hyperkalemia. (C)Rapid catabolism releases potassiumfrom the body tissue into the bloodstream. Infection and hyperthermia increase the process of catabolism. (D)Theadministration of dextrose and regular insulin IV forces potassium back into the cells decreasing the potassium inthe serum. Question: 23 The following nursing diagnosis is written for a comatose client with cirrhosis of the liver and secondarysplenomegaly–High risk for injury: Increased susceptibility to bleeding related to:A. Increased absorption of vitamin KB. Thrombocytopenia due to hypersplenismC. Diminished function of the Kupffer cellsD. Increased synthesis of the clotting factors Answer: B Explanation: (A) There is a decreased absorption of vitamin K with cirrhosis of the liver. This decrease impairs bloodcoagulation and the formation of prothrombin. (B) Thrombocytopenia, an increased destruction of platelets, occurssecondary to hypersplenism. (C) A diminished function of the Kupffer cells occurs with cirrhosis of the liver,causing the client to become more susceptible to infections. (D) A decrease in the synthesis of fibrinogen andclotting factors VII, IX, and X occurs with cirrhosis of the liver and increases the susceptibility to bleeding. Question: 24 During the assessment, the nurse observes a client scratching his skin. He has been admitted to rule out Laennec’scirrhosis of the liver. The nurse knows the pruritus is directly related to:A. A loss of phagocytic activityB. Faulty processing of bilirubinC. Enhanced detoxification of drugsD. The formation of collateral circulation Answer: B Explanation: (A) A loss in the phagocytic activity of the Kupffer cells occurs with cirrhosis of the liver, which increases the susceptibility to infections. (B) The faulty processing of bilirubin produces bilesalts, which are irritating to the skin. (C) The detoxification of drugs is impaired with cirrhosis of the liver. (D)Collateral circulation develops due to portal hypertension. This is manifest through the development of esophageal varices, hemorrhoids, and caputmedusae. Question: 25 Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client:increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would beappropriate for his bedtime snack?A. Fresh fruitB. A milkshakeC. Saltine crackers and peanut butterD. A ham and cheese sandwich Answer: A Explanation: (A) High levels of ammonia, a by-product of protein metabolism, can precipitate metabolic encephalopathy. Theseclients need a diet high in carbohydrates and bulk. (B) Metabolic encephalopathy of the brain associated with liverfailure is precipitated by elevated ammonia levels. Ammonia is a by-product of protein metabolism. (C, D)Metabolic encephalopathy in liver failure is precipitated by elevated ammonia levels. Ammonia is a byproduct ofprotein metabolism. Question: 26 Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client:increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would beappropriate for his bedtime snack?A. Fresh fruitB. A milkshakeC. Saltine crackers and peanut butterD. A ham and cheese sandwich Answer: B Explanation: (A) Albumin, a blood volume expander, increases the circulating blood volume by exerting an osmotic pull ontissue fluids, pulling them into the vascular system. This fluid shift causes an increase in the heart rate and bloodpressure. (B) Albumin, a blood volume expander, exerts an osmotic pull on fluids in the interstitial spaces, pullingthe fluid back into the circulatory system. This fluid shift causes an increase in the urinary output. (C) Adventitiousbreath sounds and dyspnea can occur due to circulatory overload if the albumin is infused too rapidly. (D) Chills,fever, itching, and rashes are signs of a hypersensitivity reaction to albumin. Question: 27 A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube.The rationale for this therapy is to:A. Prevent systemic infectionB. Promote diuresisC. Decrease ammonia formationD. Acidify the small bowel Answer: C Explanation: (A) Neomycin is an antibiotic, but this is not the Rationale for administering it to a client in hepatic coma. (B) Diuretics and salt-free albumin are used to promote diuresis in clients with cirrhosis of the liver. (C) Neomycin destroys the bacteria in the intestines. It is the bacteria in the bowel that break down protein into ammonia. (D) Lactulose is administered to create an acid environment in the bowel. Ammonia leaves the blood and migrates tothis acidic environment where it is trapped and excreted. Question: 28 The nurse notes multiple bruises on the arms and legs of a newly admitted client with lupus. The client states, "Iget them whenever I bump into anything." The nurse would expect to note a decrease in which of the followinglaboratory tests?A. Number of plateletsB. WBC countC. Hemoglobin levelD. Number of lymphocytes Answer: A Explanation: (A) Thrombocytopenia, a decrease in platelets, occurs in lupus and causes a decrease in blood coagulation andthrombus formation. (B) Clients with lupus will have a decrease in the WBC count decreasing their resistance toinfection. (C) Clients with lupus may have a decrease in the hemoglobin level causing anemia. (D) Leukopenia, adecrease in white blood cells, is seen in lupus and decreases resistance to infection. Question: 29 A client is started on prednisone 2.5 mg po bid. Which of the following instructions should be included in herdischarge teaching specific to this medication?A. Increase your oral intake of fluids to at least 4000 mL every day.B. Avoid contact with people who have contagious illnesses.C. Brush your teeth at least 4 times a day with a firm toothbrush.D. Immediately stop taking the prednisone if you feel depressed. Answer: B Explanation: (A) Fluid retention is a side effect of prednisone. The nurse should teach clients to weigh themselves daily and toobserve for signs of edema. If these signs of fluid retention occur, they should notify the physician. (B) Prednisone,a glucocorticoid, suppresses the normal immune response making the client more susceptible to infections. (C) Anincrease in bleeding tendencies is a side effect of prednisone therapy. The nurse should teach clients to usepreventive measures (i.e., electric razors and soft toothbrushes). (D) Depression and personality changes are sideeffects of prednisone therapy. Prednisone should never be discontinued abruptly. Question: 30 When assessing a client, the nurse notes the typical skin rash seen with systemic lupus erythematosus. Which of thefollowing descriptions correctly describes this rash?A. Small round or oval reddish brown macules scattered over the entire bodyB. Scattered clusters of macules, papules, and vesicles over the bodyC. Bright red appearance of the palmar surface of the handsD. Reddened butterfly shaped rash over the cheeks and nose Answer: D Explanation: (A) The appearance of small, round or oval reddish brown macules scattered over the entire body is characteristicof rubeola. (B) The appearance of scattered clusters of macules, papules, and vesicles throughout the body ischaracteristic of chickenpox. (C) Palmar redness is seen in clients with cirrhosis of the liver. (D) The characteristic butterfly rash over the cheek and nose and into the scalp is seen with systemic lupus erythematosus. Question: 31 Morphine sulfate 4 mg IV push q2h prn for chest pain was ordered for a client in the emergency room with severe chest pain. The nurse administering the morphine sulfate knows which of the following therapeutic actions isrelated to the morphine sulfate?A. Increased level of consciousnessB. Increased rate and depth of respirationsC. Increased peripheral vasodilationD. Increased perception of pain Answer: C Explanation: (A) Morphine sulfate, a narcotic analgesic, causes sedation and a decrease in level of consciousness. (B) The sideeffects of morphine sulfate include respiratory depression. (C) Morphine sulfate causes peripheral vasodilation,which decreases afterload, producing a decrease in the myocardial workload. (D) Morphine sulfate alters theperception of pain through an unclear mechanism. This alteration promotes pain relief. Question: 32 A client had a cardiac catheterization with angiography and thrombolytic therapy with streptokinase. The nurseshould initiate which of the following interventions immediately after he returns to his room?A. Place him on NPO restriction for 4 hours.B. Monitor the catheterization site every 15 minutes.C. Place him in a high Fowler position.D. Ambulate him to the bathroom to void. Answer: B Explanation: (A) A contrast dye, iodine, is used in this procedure. This dye is nephrotoxic. The client must be encouraged todrink plenty of liquids to assist the kidneys in eliminating the dye. (B) Streptokinase activates plasminogen,dissolving fibrin deposits. To prevent bleeding, pressure is applied at the insertion site. The client is assessed forboth internal and external bleeding. (C) The extremity used for the insertion site must be kept straight and beimmobilized because of the potential for bleeding. (D) The client is kept on bed rest for 812 hours following theprocedure because of the potential for bleeding. Question: 33 The nurse notes scattered crackles in both lungs and 1+ pitting edema when assessing a cardiac client. Thephysician is notified and orders furosemide (Lasix) 80 mg IV push stat. Which of the following diagnostic studiesis monitored to assess for a major complication of this therapy?A. Serum electrolytesB. Arterial blood gasesC. Complete blood countD. 12-Lead ECG Answer: A Explanation: (A) Furosemide, a potassium-depleting diuretic, inhibits the reabsorption of sodium and chloride from the loop ofHenle and the distal renal tubules. Serum electrolytes are monitored for hypokalemia. (B) Severe acid-baseimbalances influence the movement of potassium into and out of the cells, but arterial blood gases to not measurethe serum potassium level. (C) Furosemide is a potassium-depleting diuretic. A complete blood count does notreflect potassium levels. (D) Abnormalities in potassium (both hyperkalemia and hypokalemia) are reflected in ECG changes, but these changes do not occur until the abnormality is severe. Question: 34 Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following statements by the client would validate an understanding of hismedication?A. "I would notify my physician immediately if I experience nausea, vomiting, and double vision."B. "I could stop taking this medication when I begin to feel better."C. "I should only take the medication if my heart rate is greater than 100 bpm."D. "I should always take this medication with an antacid." Answer: A Explanation: (A) The first signs of digoxin toxicity include abdominal pain, anorexia, nausea, vomiting, and visual disturbances.The physician should be notified if any of these symptoms are experienced. (B) The positive inotropic effects ofdigoxin increase cardiac output and result in an enhanced activity tolerance. "Feeling better" indicates the drug isworking and medication therapy must be continued. (C) Clients should be taught to take their pulse prior to takingthe digoxin. If their pulse rate becomes irregular, slows significantly, or is >100 bpm the physician should benotified. (D) Antacids decrease the effectiveness of digoxin. Question: 35 A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of thefollowing should be included in her discharge teaching concerning the warfarin therapy?A. "If you forget to take your morning dose, double the night time dose."B. "You should take aspirin instead of acetaminophen (Tylenol) for headaches."C. "Carry a medications alert card with you at all times."D. "You should use a straight-edge razor when shaving your arms and legs." Answer: C Explanation: (A) Warfarin must always be taken exactly as directed. Clients should be instructed never to skip or double up ontheir dosage. (B) Aspirin decreases platelet aggregation, which would potentiate the effects of the coumadin. (C)Healthcare providers need to be aware of persons on warfarin therapy prior to the initiation of any diagnostic testsand/or surgery to help prevent bleeding complications. (D) An electric razor should be used to prevent accidentalcutting, which can lead to bleeding. Question: 36 A 40-year-old client has been admitted to the hospital with severe substernal chest pain radiating down his left arm.The nurse caring for the client establishes the following priority nursing diagnosis–Alteration in comfort, painrelated to:A. Increased excretion of lactic acid due to myocardial hypoxiaB. Increased blood flow through the coronary arteriesC. Decreased stimulation of the sympathetic nervous systemD. Decreased secretion of catecholamines secondary to anxiety Answer: A Explanation: (A) Anaerobic metabolism results because the decreased blood supply to the myocardium causes a release of lacticacid. Lactic acid is an irritant to the myocardial neural receptors, producing chest pain. (B) Chest pain is causedby a decrease in the O2 supply to the myocardial cells. Treatment modalities for chest pain are aimed towardincreasing the blood flow through coronary arteries. (C) Chest pain causes an increase in the stimulation of the sympathetic nervous system. This stimulation increases the heart rate and blood pressure, causing an increase in myocardial workload aggravating the chest pain. (D) Chest pain and anxiety cause increased secretion of catecholamines by stimulating the sympathetic nervous system. This stimulation increases chest pain by increasingthe workload of the heart. Question: 37 A female client is started on warfarin (Coumadin) 5 mg po bid. To adequately evaluate the effectiveness of thewarfarin therapy, the nurse must know that this medication:A. Dissolves any clots already formed in the arteriesB. Prevents the conversion of prothrombin to thrombinC. Interferes with the synthesis of vitamin K-dependent clotting factorsD. Stimulates the manufacturing of platelets Answer: C Explanation: (A) Thrombolytic agents (e.g., streptokinase) directly activate plasminogen, dissolving fibrin deposits, which in turndissolves clots that have already formed. (B) Heparin prevents the formation of clots by potentiating the effects ofantithrombin III and the conversion of prothrombin to thrombin. (C) Warfarin prevents the formation of clots byinterfering with the hepatic synthesis of the vitamin K-dependent clotting factors. (D) Platelets initiate thecoagulation of blood by adhering to each other and the site of injury to form platelet plugs. Question: 38 A male client is scheduled to have angiography of his left leg. The nurse needs to include which of the followingwhen preparing the client for this procedure?A. Validate that he is not allergic to iodine or shellfish.B. Instruct him to start active range of motion of his left leg immediately following the procedure.C. Inform him that he will not be able to eat or drink anything for 4 hours after the procedure.D. Inform him that vital signs will be taken every hour for 4 hours after the procedure. Answer: A Explanation: (A) Angiography, an invasive radiographic examination, involves the injection of a contrast solution (iodine)through a catheter that has been inserted into an artery. (B) The client is kept on complete bed rest for 612 hoursafter the procedure. The extremity in which the catheter was inserted must be immobilized and kept straight duringthis time. (C) The contrast dye, iodine, is nephrotoxic. The client must be instructed to drink a large quantity offluids to assist the kidneys in excreting this contrast media. (D) The major complication of this procedure ishemorrhage. Vital signs are assessed every 15 minutes initially for signs of bleeding. Question: 39 An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his left leg that startedapproximately 20 minutes ago. When performing the admission assessment, the nurse would expect to observewhich of the following:A. Both lower extremities warm to touch with 2_pedal pulsesB. Both lower extremities cyanotic when placed in a dependent positionC. Decreased or absent pedal pulse in the left legD. The left leg warmer to touch than the right leg Answer: C Explanation: (A) This statement describes a normal assessment finding of the lower extremities. (B) This assessment findingreflects problems caused by venous insufficiency. (C) Decreased or absentpedal pulses reflect a problem caused by arterial insufficiency. (D) The leg that is experiencing arterial insufficiency would be cool to touch due to the decreased circulation. Question: 40 One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is: A. Blood pressureB. Level of consciousnessC. Skin turgorD. Fluid intake Answer: B Explanation: (A) Blood pressure can remain normotensive in a state of hypovolemia. (B) Capillary refill, alterations insensorium, and urine output are the most reliable indicators for assessing hydration. (C) Skin turgor is not areliable indicator for assessing hydration in a burn client. (D) Fluid intake does not indicate adequacy of fluidresuscitation in a burn client. Question: 41 A child with celiac disease is being discharged from the hospital. The mother demonstrates knowledge ofnutritional needs of her child when she is able to state the foods which are included in a:A. Lactose-restricted dietB. Gluten-restricted dietC. Phenylalanine-restricted dietD. Fat-restricted diet Answer: B Explanation: (A) A lactose-restricted diet is prescribed for children with lactose intolerance or diarrhea. (B) A gluten-restricteddiet is the diet for children with celiac disease. (C) A phenylalaninerestricted diet is prescribed for children withphenylketonuria. (D) A fat-restricted diet is prescribed for children with disorders of the liver, gallbladder, orpancreas. Question: 42 A 3-year-old child is in the burn unit following a home accident. The first sign of sepsis in burned children is:A. DisorientationB. Low-grade feverC. DiarrheaD. Hypertension Answer: A Explanation: (A) Disorientation is the first sign of sepsis in burn children. (B) Low-grade fever is not indicative of sepsis. (C)Diarrhea is not indicative of sepsis. (D)Hypertension is not indicative of sepsis. Question: 43 Nursing assessment of early evidence of septic shock in children at risk includes:A. Fever, tachycardia, and tachypneaB. Respiratory distress, cold skin, and pale extremitiesC. Elevated blood pressure, hyperventilation, and thready pulsesD. Normal pulses, hypotension, and oliguria