(Test Bank) Nclex-Rn Tesbank (Questions With 100% Correct Answers And Rationale)

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Exam 1 and Rationales 1. A client with a diagnosis of passive -aggressive personality disorder is seen at the local mental health clinic. A common characteristic of persons with passive -aggressive personality disorder is: ❍ A. Superior intelligence ❍ B. Underlying hostility ❍ C. Dependence on others ❍ D. Ability to share feelings ❍ A. A 6 - month - old ❍ B. A 4- year- old 2 Chapter 1 2. The client is admitted for evaluation of aggressive behavior and diagnosed with antisocial personality disorder. A key part of the care of such clients is: ❍ A. Setting realistic limits ❍ B. Encouraging the client to express remorse for behavior ❍ C. Minimizing interactions with other clients ❍ D. Encouraging the client to act out feelings of rage 3. An important intervention in monitoring the dietary compliance of a client with bulimia is: ❍ C. A 12- year- old ❍ D. A 13- year- old 2018 Exam 1 and Rationales ❍ A. Allowing the client privacy during mealtimes ❍ B. Praising her for eating all her meal ❍ C. Observing her for 1 –2 hours after meals ❍ D. Encouraging her to choose foods she likes and to eat in moderation 4. Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning? ❍ A. Jenny and Tommy share their toys. ❍ B. Jimmy plays with his car beside Mary, who is playing with her doll. ❍ C. Kevin plays a game of Scrabble with Kathy and Sue. ❍ D. Mary plays with a handheld game while sitting in her mother’s lap. ❍ A. Check the Babinski reflex ❍ B. Listen to the heart a nd lung sounds ❍ C. Palpate the abdomen ❍ D. Check tympanic membranes ❍ A. Think abstractly ❍ B. Use magical thinking ❍ C. Understand conservation of matter ❍ D. See things from the perspective of others ❍ A. Doesn’t understand yes and no ❍ B. Understands the meaning of words ❍ C. Able to verbalize needs ❍ D. Asks “why?” to most statements ❍ A. Administer vitamin K IM 4 Chapter 1 ❍ B. Stop the urokinase ❍ C. Reduce the urokinase and administer heparin ❍ D. Stop the urokinase and call the doctor 2018 Exam 1 and Rationales 5. Which of the following examples represents parallel 6 Chapter 1 play? 6. The nurse is ready to begin an exam on a 9 -month - old infant. The child is sitting in his mother’s lap. Which should the nurse do first? 7. In terms of cognitive development, a 2 -year-old would be expecte d to: 8. Which of the following best describes the language of a 24-month -old? 9. A client who has been receiving urokinase has a large bloody bowel movement. Which action would be best for the nurse to take immediately? 10. The client has a prescription for a calci um carbonate compound to neutralize stomach acid. The nurse should assess the client for: ❍ A. Constipation ❍ B. Hyperphosphatemia ❍ C. Hypomagnesemia ❍ D. Diarrhea 11. Heparin has been ordered for a client with pulmonary embolis. Which statement, if made by the graduate nurse, indicates a lack of understanding of the medication? ❍ A. “I will administer the medication 1 -2 inches away from the umbilicus.” ❍ B. “I will administer the medication in the abdomen.” ❍ C. “I will check the PTT before administerin g the medication.” ❍ D. “I will need to aspirate when I give Heparin.” 2018 Exam 1 and Rationales 12. The nurse is caring for a client with peripheral vascular disease. To correctly assess the oxygen saturation level, the monitor may be placed on the: ❍ A. Hip ❍ B. Ankle ❍ C. Earlo be ❍ D. Chin 13. While caring for a client with hypertension, the nurse notes the following vital signs: BP of 140/20, pulse 120, respirations 36, temperature 100.8°F. The nurse’s initial action should be to: ❍ A. Call the doctor ❍ B. Recheck the vital sign s ❍ C. Obtain arterial blood gases ❍ D. Obtain an ECG 14. The nurse is preparing a client with an axillo -popliteal bypass graft for discharge. The client should be taught to avoid: ❍ A. Using a recliner to rest ❍ B. Resting in supine position ❍ C. Sitting in a straight chair ❍ D. Sleeping in right Sim’s position ❍ A. Before rising in the morning ❍ B. With the client in a standing position ❍ C. After bathing and applying powder ❍ D. Before retiring in the evening ❍ A. The client with a history of a ce rebral aneurysm with an oxygen saturation rate of 99% ❍ B. The client three days post –coronary artery bypass graft with a temperature of 100.2°F ❍ C. The client admitted 1 hour ago with shortness of breath 8 Chapter 1 ❍ D. The client being prepared for discharge fo llowing a femoral popliteal bypass graft ❍ A. Hypothyroidism ❍ B. Diabetic ulcers ❍ C. Ulcerative colitis ❍ D. Pneumonia ❍ A. “I will have blood drawn every month.” ❍ B. “I will assess my skin for a rash.” ❍ C. “I take aspirin for a headache.” ❍ D. “I will use an electric razor to shave.” ❍ A. Pedal pulses regular ❍ B. Urinary output 20mL in the past hour ❍ C. Blood pressure 108/50 ❍ D. Oxygen saturation 97% 2018 Exam 1 and Rationales 15. The doctor has ordered antithrombolic stockings to be 10 Chapter 1 applied to the legs of the cli ent with peripheral vascular disease. The nurse knows antithrombolic stockings should be applied: 16. The nurse has just received the shift report and is preparing to make rounds. Which client should be seen first? 17. A client with a femoral popliteal bypass gra ft is assigned to a semiprivate room. The most suitable roommate for this client is the client with: 18. The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching? 19. The client returns to the recovery room following repair of an abdominal aneurysm. Which finding would require further investigation? 2018 Exam 1 and Rationales 11 20. The nurse is doing bowel and bladder retraining for the client with paraplegia. Which of the following is not a factor for the nurse to consider? 21. A 20-year-old is admitted to the rehabilitation unit following a motorcycle accident. Which would be the appropriate method for measuring the client for crutches? 22. The nurse is caring for the client following a cerebral vascular accident. Which portion of the brain is responsible for taste, smell, and hearing? 23. The client is admitted to the unit after a motor vehicle accident with a temperature of 102°F rectally. The most likely explanations for the elevated temperature is that: 24. The client is admitted to the hospital in chronic renal failure. A diet low in protein is ordered. The rationale for a low-protein diet is: ❍ A. Diet pattern ❍ B. Mobility ❍ C. Fluid intake ❍ D. Sexual function ❍ A. Measure five finger breadths under the axilla ❍ B. Measure 3 inches under the axilla ❍ C. Measure the client with the elbows flexed 10° ❍ D. Measure the client with the crutches 20 inches from the side of the foot ❍ A. Occipital ❍ B. Frontal ❍ C. Temporal ❍ D. Parietal ❍ A. There was damage to the hypothalam us. ❍ B. He has an infection from the abrasions to the head and face. ❍ C. He will require a cooling blanket to decrease the temperature. ❍ D. There was damage to the frontal lobe of the brain. ❍ A. Protein breaks down into blood urea nitrogen and other waste. ❍ B. High protein increases the sodium and potassium levels. ❍ C. A high -protein diet decreases albumin production. ❍ D. A high -protein diet depletes calcium and phosphorous. ❍ A. Buretrol ❍ B. Infusion controller ❍ C. Intravenous filter ❍ D. Three -way stop - cock 12 Chapter 1 25. The client who is admitted with thrombophlebitis has an order for heparin. The medication should be administered using a/an: 26. The nurse is taking the blood pressure of the obese client. If the blood pressure cuff is too small, the results will be: 27. A 4-year-old male is admitted to the unit with nephotic syndrome. He is extremely edematous. To decrease the discomfort associated with scrotal edema, the nurse should: 28. The client with an abdominal aor tic aneurysm is admitted in preparation for surgery. Which of the following should be reported to the doctor? 29. If the nurse is unable to elicit the deep tendon reflexes of the patella, the nurse should ask the client to: ❍ A. A false elevation ❍ B. A false low reading ❍ C. A blood pressure reading that is correct ❍ D. A subnormal finding ❍ A. Apply ice to the scrotum ❍ B. Elevate the scrotum on a small pillow ❍ C. Apply heat to the abdomin al area ❍ D. Administer an analgesic ❍ A. An elevated white blood cell count ❍ B. An abdominal bruit ❍ C. A negative Babinski reflex ❍ D. Pupils that are equal and reactive to light ❍ A. Pull against the palms ❍ B. Grimace the facial muscles ❍ C. Cross the legs at the ankles ❍ D. Perform Valsalva maneuver ❍ A. 0.25mL ❍ B. 0.5mL ❍ C. 1.0mL ❍ D. 1.25mL ❍ A. Pressure in the left ventricle ❍ B. The systolic, diastolic, and mean pressure of the pulmonary artery ❍ C. The pressure in the pulmonary veins ❍ D. The pressure in the right ventricle 2018 Exam 1 and Rationales 13 30. The physician has ordered atropine sulfate 0.4mg IM before surgery. The medication is supplied in 0.8mg per milliliter . The nurse should administer how many milliliters of the medication? 31. The nurse is evaluating the client’s pulmonary artery pressure. The nurse is aware that this test evaluates: 32. A client is being monitored using a central venous pressure monitor. If the p ressure is 2cm of water, the nurse should: 33. The nurse identifies ventricular tachycardia on the heart monitor. The nurse should immediately: 34. The doctor is preparing to remove chest tubes from the client’s left chest. In preparation for the removal, the nurs e should instruct the client to: ❍ A. Call th e doctor immediately ❍ B. Slow the intravenous infusion ❍ C. Listen to the lungs for rales ❍ D. Administer a diuretic ❍ A. Administer atropine sulfate ❍ B. Check the potassium level ❍ C. Prepare to administer an antiarrhythmic such as lidocaine ❍ D. Defibrillate at 360 joules ❍ A. Breathe normally ❍ B. Hold his breath and bear down ❍ C. Take a deep breath ❍ D. Sneeze on command ❍ A. Administer the Lasix as ordered ❍ B. Administer half the dose ❍ C. Offer the patient a potassium -rich food ❍ D. Withhold the drug and call the doctor ❍ A. Stool specimen for occult blood ❍ B. White blood cell cou nt ❍ C. Blood glucose ❍ D. Erthyrocyte count