NEW Free NCLEX-RN Sample Test Questions For Nursing Review (Part 16)

Question 1
The nurse prepares for a Denver Screening of a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. What is the nurse’s best response about the purpose of the Denver?
A) "It measures a child’s intelligence."
B) "It assesses a child's development."
C) "It evaluates psychological responses."
D) " It helps to determine problems."




Review Information: The correct answer is B: "It assesses a child''s development."
The Denver Developmental Test II is a screening test to assess children from birth through 6 years in personal/social, fine motor adaptive, language and gross motor development. A child experiences the fun of play during the test.


Question 2
In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and
A) increased retention of albumin in the vascular system
B) decreased colloidal osmotic pressure in the capillaries
C) fluid shift from interstitial spaces into the vascular space
D) reduced tubular reabsorption of sodium and water


Review Information: The correct answer is B: decreased colloidal osmotic pressure in the capillaries
The increased glomerular permeability to protein causes a decrease in serum albumin, which results in decreased colloidal osmotic pressure.





Question 3
Based on principles of teaching and learning, what is the best initial approach to pre-op teaching for a client scheduled for coronary artery bypass?
A) Touring the coronary intensive unit
B) Mailing a video tape to the home
C) Assessing the client's learning style
D) Administering a written pre-test


Review Information: The correct answer is C: Assessing the client''s learning style
As with any anticipatory teaching, assess the client''s level of knowledge and learning style first.


Question 4
A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values?
A) Blood urea nitrogen
B) Acid phosphatase
C) Bilirubin
D) Sedimentation rate




Review Information: The correct answer is C: Bilirubin
In the laboratory data provided, the only elevated level expected is bilirubin. Additional liver function tests will confirm the diagnosis.








Question 5
The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to
A) Dress the child warmly to avoid chilling
B) Keep the child away from other children for the duration of the rash
C) Clean the affected areas with tepid water and detergent
D) Wrap the child's hand in mittens or socks to prevent scratching




Review Information: The correct answer is D: Wrap the child''s hand in mittens or socks to prevent scratching
A toddler with atopic dermatitis needs to have fingernails cut short and covered so the child will not be able to scratch the skin lesions, thereby causing new lesions and possibly a secondary infection.


Question 6
The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is the best approach by the nurse?
A) "Do you want to take this pretty red medicine?"
B) "You will feel better if you take your medicine."
C) "This is your medicine, and you must take it all right now."
D) "Would you like to take your medicine from a spoon or a cup?"


Review Information: The correct answer is D: "Would you like to take your medicine from a spoon or a cup?"
At 3 years of age, a child often feels a loss of control when hospitalized. Giving a choice about how to take the medicine will allow the child to express an opinion and have some control.






Question 7
Which of the actions suggested to the registered nurse (RN) by the practical nurse (PN) during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care?
A) measure head circumference
B) place in airborne isolation
C) provide passive range of motion
D) provide an over-the-crib protective top




Review Information: The correct answer is A: measure head circumference
In meningitis, assessment of neurological signs should be done frequently. Head circumference is measured because subdural effusions and obstructive hydrocephalus can develop as a complication of meningitis. The client will have already been on airborne precautions and crib top applied to the bed on admission to the unit.


Question 8
During the evaluation phase for a client, the nurse should focus on
A) All finding of physical and psychosocial stressors of the client and in the family
B) The client's status, progress toward goal achievement, and ongoing re-evaluation
C) Setting short and long-term goals to insure continuity of care from hospital to home
D) Select interventions that are measurable and achievable within selected timeframes


Review Information: The correct answer is B: The client''s status, progress toward goal achievement, and ongoing re-evaluation
The evaluation step of the nursing process focuses on the client''s status, progress toward goal achievement and ongoing re-evaluation of the plan of care. The other possible answers focus on other steps of the nursing process.






Question 9
The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet
A) high in carbohydrates and proteins
B) low in carbohydrates and proteins
C) high in carbohydrates, low in proteins
D) low in carbohydrates, high in proteins




Review Information: The correct answer is A: high in carbohydrates and proteins
Provide a high-energy diet by increasing carbohydrates, protein and fat (possibly as high as 40%). A favorable response to the supplemental pancreatic enzymes is based on tolerance of fatty foods, decreased stool frequency, absence of steatorrhea, improved appetite and lack of abdominal pain.


Question 10
The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!". What would be the most appropriate next action?
A) Leave the room and return five minutes later and give the medicine
B) Explain to the child that the medicine must be taken now
C) Give the medication to the father and ask him to give it
D) Mix the medication with ice cream or applesauce


Review Information: The correct answer is A: Leave the room and return five minutes later and give the medicine
Since the nurse gave the child a choice about taking the medication, the nurse must comply with the child''s response in order to build or maintain trust. Since toddlers do not have an accurate sense of time, leaving the room and coming back later is another episode to the toddler.





Question 11
A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child?
A) All lesions crusted
B) Elevated temperature
C) Rhinorrhea and coryza
D) Presence of vesicles


Review Information: The correct answer is A: All lesions crusted
The rash begins as a macule, with fever, and progresses to a vesicle that breaks open and then crusts over. When all lesions are crusted, the child is no longer in a communicable stage.


Question 12
The nurse is providing instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother indicates the need for additional instruction?
A) "I should position my baby completely facing me with my baby's mouth in front of my nipple."
B) "The baby should latch onto the nipple and areola areas."
C) "There may be times that I will need to manually express milk."
D) " I can switch to a bottle if I need to take a break from breast feeding."


Review Information: The correct answer is D: " I can switch to a bottle if I need to take a break from breast feeding."
Babies adapt more quickly to the breast when they are not confused about what is put into their mouths and its purpose. Artificial nipples do not lengthen and compress the way the human nipples (areola) do. The use of an artificial nipple weakens the baby''s suck as the baby decreases the sucking pressure to slow fluid flow. Babies should not be given a bottle during the learning stage of breast feeding.




Question 13
A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond?
A) With acceptance and views the victim’s comment as an indication that their marriage is in trouble
B) With fear of rejection causing increased rage toward the victim
C) With a new commitment to seek counseling to assist with their marital problems
D) With relief, and welcomes the separation as a means to have some personal time




Review Information: The correct answer is B: With fear of rejection causing increased rage toward the victim
The fear of rejection, abandonment, and loss only serve to increase the batterer’s rage at the partner.


Question 14
The nurse, assisting in applying a cast to a client with a broken arm, knows that the
A) cast material should be dipped several times into the warm water
B) cast should be covered until it dries
C) wet cast should be handled with the palms of hands
D) casted extremity should be placed on a cloth-covered surface


Review Information: The correct answer is C: wet cast should be handled with the palms of hands
Handle cast with palms of the hands and lift at 2 points of the extremity. This will prevent stress at the injury site and pressure areas on the cast.






Question 15
A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special family gatherings?" Which initial response by the nurse would be best?
A) "A recovering person has to be very careful not to lose control, therefore, confine your drinking only to family gatherings."
B) "At your next AA meeting discuss the possibility of limited drinking with your sponsor."
C) "A recovering person needs to get in touch with their feelings. Do you want a drink?"
D) "A recovering person cannot return to drinking without starting the addiction process over."


Review Information: The correct answer is D: "A recovering person cannot return to drinking without starting the addiction process over."
Recovery requires total abstinence from all drugs.


Question 16
The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as the cause of the findings?
A) Decreased cardiac output
B) Tissue hypoxia
C) Cerebral edema
D) Reduced oxygen saturation




Review Information: The correct answer is B: Tissue hypoxia
When the hemoglobin falls sufficiently to produce clinical manifestations, the findings are directly attributable to tissue hypoxia, resulting from a decrease in the oxygen carrying capacity of the blood.






Question 17
A nurse is assigned to a client who is newly admitted for treatment of a frontal lobe brain tumor. Which history offered by the family members would be recognized by the nurse as associated with the diagnosis, and communicated to the provider?
A) "My partner's breathing rate is usually below 12."
B) "I find the mood swings and the change from a calm person to being angry all the time hard to deal with."
C) "It seems our sex life is nonexistent over the past 6 months."
D) "In the morning and evening I hear complaints that reading is next to impossible from blurred print."




Review Information: The correct answer is B: "I find the mood swings and the change from a calm person to being angry all the time hard to deal with."
The frontal lobe of the brain controls affect, judgment and emotions. Dysfunction in this area results in findings such as emotional lability, changes in personality, inattentiveness, flat affect and inappropriate behavior.


Question 18
Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner’s injuries by
A) seeking medical help for the victim's injuries
B) minimizing the episode and underestimating the victim’s injuries
C) contacting a close friend and asking for help
D) being very remorseful and assisting the victim with medical care


Review Information: The correct answer is B: minimizing the episode and underestimating the victim’s injuries
Many batterers lack an understanding of the effects of their behavior on the victim and use excessive minimization and denial.




Question 19
The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should
A) review the medications the client is receiving
B) increase the formula infusion rate
C) increase the amount of water used to flush the tube
D) attach a rectal bag to protect the skin




Review Information: The correct answer is A: review the medications the client is receiving
Antibiotics and medications containing sorbitol may induce diarrhea.
.

Question 20
A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should be what focus?
A) Discuss with the mother sharing parenting responsibilities
B) Set time aside to get the mother to express her feelings and concerns
C) Arrange for the parents to attend infant care classes
D) Talk with the father and help him accept the wife's decision


Review Information: The correct answer is B: Set time aside to get the mother to express her feelings and concerns
Non-judgmental support for expressed feelings may lead to resolution of competitive feelings in a new family. Cultural influences may also be clarified.






Question 21
The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct?
A) May drink as much milk as desired
B) Can have milk mixed with other foods
C) Will benefit from fat-free cow's milk
D) Should be limited to 3-4 cups of milk daily




Review Information: The correct answer is D: Should be limited to 3-4 cups of milk daily
More than 32 ounces of milk a day considerably limits the intake of solid foods, resulting in a deficiency of dietary iron, as well as other nutrients.


Question 22
Which of these parents’ comments about a newborn would most likely reveal an initial finding of a suspected pyloric stenosis?
A) "I noticed a little lump a little above the belly button."
B) "The baby seems hungry all the time."
C) "Mild vomiting turned into vomiting that shot across the room."
D) "We notice irritation and spitting up immediately after feedings."


Review Information: The correct answer is C: "Mild vomiting turned into vomiting that shot across the room."
Mild regurgitation or emesis that progresses to projectile vomiting is a pattern associated with pyloric stenosis as an initial finding. The other findings are present, though not immediately.







Question 23
The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." The client’s remarks most likely indicate
A) neologisms
B) flight of ideas
C) loose associations
D) word salad




Review Information: The correct answer is C: loose associations
Though the client’s statements are not typical of logical communication, remarks 2 and 3 contain elements of the preceding sentence (moon, walk). Option A refers to making up words that have personal meaning to the client, and option B – flight of ideas defines nearly continuous flow of speech, jumping from one unconnected topic to another. Option D – word salad refers to stringing together real words into nonsense “sentences” that have no meaning for the listener.


Question 24
The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate?
A) Retractions in the intercostal tissues of the thorax
B) Chest pain aggravated by respiratory movement
C) Cyanosis and mottling of the skin
D) Rapid, shallow respirations


Review Information: The correct answer is A: Retractions in the intercostal tissues of the thorax
Slight intercostal retractions are normal, however in disease states, especially in severe airway obstruction, retractions become extreme.





Question 25
A Hispanic client in the postpartum period refuses the hospital food because it is "cold." The best initial action by the nurse is to
A) have the unlicensed assistive personnel (UAP) reheat the food if the client wishes
B) ask the client what foods are acceptable or are unacceptable
C) encourage her to eat for healing and strength
D) schedule the dietitian to meet with the client as soon as possible




Review Information: The correct answer is B: ask the client what foods are acceptable or are unacceptable
Many Hispanic women subscribe to the balance of hot and cold foods in the post partum period. What defines "cold" can best be explained by the client or family.


Question 26
The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended?
A) Seizures
B) Withdrawal
C) Craving
D) Marked tolerance


Review Information: The correct answer is B: Withdrawal
The early signs of alcohol withdrawal develop within a few hours after cessation or reduction of alcohol intake. Seizure activity is one withdrawal symptom but there are many others, like nausea and tremor.







Question 27
The nurse is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy. The parents are anxious and concerned about the child's reaction to impending surgery. Which nursing intervention would best prepare the child?
A) Introduce the child to all staff the day before surgery
B) Explain the surgery 1 week prior to the procedure
C) Arrange a tour of the operating and recovery rooms
D) Encourage the child to bring a favorite toy to the hospital




Review Information: The correct answer is B: Explain the surgery 1 week prior to the procedure
A 5 year-old can understand the surgery, and should be prepared well before the procedure. Most of these procedures are "same day" surgeries and do not require an overnight stay.


Question 28
The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M. and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the frequency of the contractions?
A) 14 minutes
B) 10 minutes
C) 15 minutes
D) Nine minutes


Review Information: The correct answer is C: 15 minutes
Frequency is the time from the beginning of one contraction to the beginning of the next contraction.






Question 29
The nurse is assigned to a client who has heart failure . During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first?
A) Take the client's vital signs
B) Place the client in a sitting position with legs dangling
C) Contact the health care provider
D) Administer the PRN antianxiety agent




Review Information: The correct answer is B: Place the client in a sitting position with legs dangling
Place the client in a sitting position with legs dangling to pool the blood in the legs. This helps to diminish venous return to the heart and minimize the pulmonary edema. The result will enhance the client’s ability to breathe. The next actions would be to contact the heath care provider, then take the vital signs and then the administration of the antianxiety agent.


Question 30
A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client should
A) eat foods high in sodium to increase sputum liquefaction
B) use oxygen during meals to improve gas exchange
C) perform exercise after respiratory therapy to enhance appetite
D) cleanse the mouth of dried secretions to reduce risk of infection


Review Information: The correct answer is B: use oxygen during meals to improve gas exchange
Clients with emphysema breathe easier when using oxygen while eating.





Question 31
A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is
A) transparent film dressing
B) wet dressing with debridement granules
C) wet to dry with hydrogen peroxide
D) moist saline dressing


Review Information: The correct answer is D: moist saline dressing
This wound is a stage III pressure ulcer. The wound is red (granulation tissue) and does not require debridement. The wound must be protected for granulation tissue to proliferate. A moist dressing allows epithelial tissues to migrate more rapidly.


Question 32
The father of an 8 month-old infant asks the nurse if his child's vocalizations are normal for his age. Which of the following would the nurse expect at this age?
A) Cooing
B) Imitation of sounds
C) Throaty sounds
D) Laughter


Review Information: The correct answer is B: Imitation of sounds
Imitation of sounds such as "da-da" is expected at this time.








Question 33
A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age?
A) Jumping rope
B) Tying shoelaces
C) Riding a tricycle
D) Playing hopscotch




Review Information: The correct answer is C: Riding a tricycle
Coordination is gained through large muscle use. A child of 3 has the ability to ride a tricycle.


Question 34
An 18 month-old has been brought to the emergency room with irritability, lethargy over 2 days, dry skin, and increased pulse. Based upon the evaluation of these initial findings, the nurse would assess the child for additional findings of
A) septicemia
B) dehydration
C) hypokalemia
D) hypercalcemia




Review Information: The correct answer is B: dehydration
Clinical findings of dehydration include lethargy, irritability, dry skin, and increased pulse.








Question 35
In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding?
A) Age 40 years
B) Lactose intolerance
C) Family history of breast cancer
D) Use of cocaine on weekends


Review Information: The correct answer is D: Use of cocaine on weekends
Binge use of cocaine can be just as harmful to the breast fed newborn as regular use.


Question 36
The school nurse suspects that a third grade child might have attention deficit hyperactivity disorder (ADHD). Prior to referring the child for further evaluation, the nurse should
A) observe the child's behavior on at least 2 occasions
B) consult with the teacher about how to control impulsivity
C) compile a history of behavior patterns and developmental accomplishments
D) compare the child's behavior with classic signs and symptoms


Review Information: The correct answer is C: compile a history of behavior patterns and developmental accomplishments
A complete behavioral, and developmental history plays an important role in determining the diagnosis.







Question 37
In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant?
A) Increased 10% in height
B) 2 deciduous teeth
C) Tripled the birth weight
D) Head > chest circumference


Review Information: The correct answer is C: Tripled the birth weight
The infant usually triples his birth weight by the end of the first year of life. Height usually increases by 50% from birth length. A 12 month- old child should have approximately 6 teeth. ( estimate number of teeth by subtracting 6 from age in months, ie 12 – 6 = 6). By 12 months of age, head and chest circumferences are approximately equal.


Question 38
A client who has been drinking for five years states that he drinks when he gets upset about "things" such as being unemployed or feeling like life is not leading anywhere. The nurse understands that the client is using alcohol as a way to deal with
A) recreational and social needs
B) feelings of anger
C) life’s stressors
D) issues of guilt and disappointment




Review Information: The correct answer is C: life’s stressors
Alcohol is used by some people to manage anxiety and stress. The overall intent is to decrease negative feelings and increase positive feelings, but substance abuse itself eventually increases negative feelings.







Question 39
A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor when a client is receiving this medication?
A) Potassium level
B) Arterial blood gasses
C) Blood urea nitrogen
D) Thiocyanate




Review Information: The correct answer is D: Thiocyanate
Thiocyanate levels rise with the metabolism if nitroprusside is taken, and this can cause cyanide toxicity. Thiocyanate should not be over 1 millimole/liter.


Question 40
A nurse is doing preconception counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome?
A) "I understand that a glass of wine with dinner is healthy."
B) "Beer is not really hard alcohol, so I guess I can drink some."
C) "If I drink, my baby may be harmed before I know I am pregnant."
D) "Drinking with meals reduces the effects of alcohol."


Review Information: The correct answer is C: "If I drink, my baby may be harmed before I know I am pregnant."
Alcohol has the greatest teratogenic effect during organogenesis, in the first weeks of pregnancy. Therefore women considering a pregnancy should not drink.

NEW Free NCLEX-RN Sample Test Questions For Nursing Review (Part 15)

Question 1
At the geriatric day care program a client is crying and repeating "I want to go home. Call my daddy to come for me." The nurse should
A) Inform the client that she must wait until the program ends at 5:00 pm to leave
B) Give the client simple information about what she will be doing
C) Tell the client you will call someone to come for her and suggest joining the exercise group while she waits
D) Firmly direct the client to her assigned group activity


Review Information: The correct answer is C: Tell the client you will call someone to come for her and suggest joining the exercise group while she waits
Comforting and distraction, key approaches in validation therapy are the kindest and most effective for clients who have advancing dementia. The distressed, disoriented client should be gently oriented to reduce fear and increase the sense of safety and security, but reorientation often is ineffective when the client has moderate dementia and/or is upset. Environmental changes provoke stress and fear, especially in clients suffering from Alzheimer’s disease.


Question 2
At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these developmental achievements would the nurse anticipate that the child would be able to perform?
A) Say 2 words
B) Pull up to stand
C) Sit without support
D) Drink from a cup


Review Information: The correct answer is C: Sit without support
The age at which the normal child develops the ability to sit steadily without support is 8 months.



Question 3
A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to "see old buddies." The nurse understands that the client’s behaviors are warning signs to indicate that the client may be
A) headed for relapse
B) feeling hopeless
C) approaching recovery
D) in need of increased socialization


Review Information: The correct answer is A: headed for relapse
It takes 9 to 15 months to adjust to a lifestyle free of chemical use, thus it is important for clients to acknowledge that relapse is a possibility and to identify early signs of relapse.


Question 4
A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling sad and hopeless, the nurse would assess for
A) Anxiety, unconscious anger, and hostility
B) Guilt, indecisiveness, poor self-concept
C) Psychomotor retardation or agitation
D) Meticulous attention to grooming and hygiene


Review Information: The correct answer is C: Psychomotor retardation or agitation
Somatic or physiologic symptoms of depression include: fatigue, psychomotor retardation or psychomotor agitation, chronic generalized or local pain, sleep disturbances, disturbances in appetite, gastrointestinal complaints and impaired libido.






Question 5
A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response?
A) "There is a probability of life-long complications."
B) "Cystic fibrosis results in nutritional concerns that can be dealt with."
C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis."
D) "You will work with a team of experts and also have access to a support group that the family can attend."




Review Information: The correct answer is C: "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis."
All of the options will be concerns with cystic fibrosis, however the respiratory threats are the major concern. Other information of interest is that cystic fibrosis is an autosomal recessive disease. For these parents there is a 25% chance that each pregnancy will result in a child with cystic fibrosis.


Question 6
A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child?
A) Cartoon stickers
B) Large wooden puzzle
C) Blunt scissors and paper
D) Beach ball




Review Information: The correct answer is B: Large wooden puzzle
Appropriate toys for this child''s age include items such as push-pull toys, blocks, pounding board, toy telephone, puppets, wooden puzzles, finger paint, and thick crayons.






Question 7
Post-procedure nursing interventions for electroconvulsive therapy include
A) applying hard restraints if seizure occurs
B) permitting client to sleep for 4 to 6 hours
C) remaining with client until oriented
D) expecting long-term memory loss




Review Information: The correct answer is C: remaining with client until oriented
The client awakens post-procedure 20-30 minutes after treatment and appears groggy and confused. The nurse remains with the client until the client is oriented and able to engage in self care. The time frame will vary, but it will not take several hours.


Question 8
A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly “bothers” other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client?
A) Reading
B) Checkers
C) Cards
D) Ping-pong


Review Information: The correct answer is D: Ping-pong
This provides an outlet for physical energy and requires limited attention. The other options would over-tax the client’s level of self-control.






Question 9
The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?
A) Widening pulse pressure
B) Pleural friction rub
C) Distended neck veins
D) Bradycardia


Review Information: The correct answer is C: Distended neck veins
In cardiac tamponade, intrapericardial pressures rise to a point at which venous blood cannot flow into the heart. As a result, venous pressure rises and the neck veins become distended.


Question 10
First-time parents bring their 5 day-old infant to the pediatrician's office because they are extremely concerned about its breathing pattern. The nurse assesses the baby and finds that the breath sounds are clear with equal chest expansion. The respiratory rate is 38-42 breaths per minute with occasional periods of apnea lasting 10 seconds in length. What is the correct analysis of these findings?
A) The pediatrician must examine the baby
B) Emergency equipment should be available
C) This breathing pattern is normal
D) A future referral may be indicated


Review Information: The correct answer is C: This breathing pattern is normal
Respiratory rate in a newborn is 30-60 breaths/minute and periods of apnea often occur, lasting up to 15 seconds. The nurse should reassure the parents that this is normal to allay their anxiety.






Question 11
A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief system, the nurse would explain that illness is attributed to the
A) Yang, the positive force that represents light, warmth, and fullness
B) Yin, the negative force that represents darkness, cold, and emptiness
C) use of improper hot foods, herbs and plants
D) a failure to keep life in balance with nature and others




Review Information: The correct answer is B: Yin, the negative force that represents darkness, cold, and emptiness
Chinese folk medicine proposes that health is regulated by the opposing forces of yin and yang. Yin is the negative female force characterized by darkness, cold and emptiness. Excessive yin predisposes one to nervousness.


Question 12
Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis?
A) Assess for generalized edema
B) Monitor for increased urinary output
C) Encourage rest during hyperactive periods
D) Note patterns of increased blood pressure


Review Information: The correct answer is D: Note patterns of increased blood pressure
Evaluation for hypertension is a key assessment in the course of the disease.






Question 13
What is the most important aspect to include when developing a home care plan for a client with severe arthritis?
A) Maintaining and preserving function
B) Anticipating side effects of therapy
C) Supporting coping with limitations
D) Ensuring compliance with medications




Review Information: The correct answer is A: Maintaining and preserving function
To maintain quality of life, the plan for care must emphasize preserving function. Proper body positioning and posture, and active and passive range of motion exercises are important interventions for maintaining function of affected joints.


Question 14
The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?
A) Stand on 1 foot
B) Catch a ball
C) Skip on alternate feet
D) Ride a bicycle




Review Information: The correct answer is A: Stand on 1 foot
At this age, gross motor development allows a child to balance on 1 foot.








Question 15
A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn't really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation?
A) The alveoli will degenerate
B) Chronic bronchoconstriction of the large airways will occur
C) Lung remodeling and permanent changes in lung function will result
D) The client will experience frequent bouts of pneumonia




Review Information: The correct answer is C: Lung remodeling and permanent changes in lung function will result
While an asthma attack is an acute event from which lung function essentially returns to normal, chronic under-treated asthma can lead to lung remodeling and permanent changes in lung function. Increased bronchial vascular permeability leads to chronic airway edema which leads to mucosal thickening and swelling of the airway. Increased mucous secretion and viscosity may plug airways, leading to airway obstruction. Changes in the extracellular matrix in the airway wall may also lead to airway obstruction. These long-term consequences should help reinforce the need for daily management of the disease whether or not the client "feels better."


Question 16
A nurse is conducting a community wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning?
A) 9 month-old who stays with a sitter 5 days a week
B) 20 month-old who has just learned to climb stairs
C) 10 year-old who occasionally stays at home unattended
D) 15 year-old who likes to repair bicycles


Review Information: The correct answer is B: 20 month-old who has just learned to climb stairs
Toddlers are at most risk for poisoning because they are increasingly mobile, need to explore and engage in autonomous behavior.


Question 17
When teaching adolescents about sexually transmitted diseases, what should the nurse emphasize that is the most common infection?
A) Gonorrhea
B) Chlamydia
C) Herpes
D) HIV


Review Information: The correct answer is B: Chlamydia
Chlamydia has the highest incidence of any sexually transmitted disease in this country. Prevention is similar to safe sex practices taught to prevent any STD: use of a condom and spermicide for protection during intercourse.


Question 18
The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be most effective in meeting the growth and development needs for persons in this age group?
A) Aerobic exercise classes
B) Transportation for shopping trips
* C) Reminiscence groups
D) Regularly scheduled social activities


Review Information: The correct answer is C: Reminiscence groups
According to Erikson''s theory, older adults need to find and accept the meaningfulness of their lives, or they may become depressed, angry, and fear death. Reminiscing contributes to successful adaptation by maintaining self-esteem, reaffirming identity, and working through loss. Erikson identifies this developmental challenge of elders as ego integrity vs despair.






Question 19
Which of the following nursing assessments for an infant is most valuable in identifying serious visual defects?
A) Red reflex test
B) Visual acuity
C) Pupil response to light
D) Cover test




Review Information: The correct answer is A: Red reflex test
A brilliant, uniform red reflex is an important sign because it virtually rules out almost all serious defects of the cornea, aqueous chamber, lens, and vitreous chamber.


Question 20
The nurse assesses a client who has been re-admitted to the psychiatric inpatient unit for schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment?
A) Stressors in the home
B) Medication compliance
C) Exposure to hot temperatures
D) Alcohol use




Review Information: The correct answer is B: Medication compliance
Prolixin is an antipsychotic / neuroleptic medication useful in managing the symptoms of schizophrenia. Compliance with daily doses is a critical assessment finding.








Question 21
A mother asks the nurse if she should be concerned about her child’s tendency to stutter. What assessment data will be most useful in counseling the parent?
A) Age of the child
B) Sibling position in family
C) Stressful family events
D) Parental discipline strategies


Review Information: The correct answer is A: Age of the child
During the preschool period children are using their rapidly growing vocabulary faster than they can produce their words. This failure to master sensorimotor integrations results in stuttering. This dysfluency in speech pattern is a normal characteristic of language development. Therefore, knowing the child''s age is most important in determining if any true dysfunction might be occurring.


Question 22
Which type of accidental poisoning would the nurse expect to occur in children under age 6?
A) Oral ingestion
B) Topical contact
C) Inhalation
D) Eye splashes


Review Information: The correct answer is A: Oral ingestion
The greatest risk for young children is from oral ingestion. While children under age 6 may come in contact with other poisons or inhale toxic fumes, these are not common.







Question 23
The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure?
A) Standing and sitting
B) In both arms
C) After exercising
D) Supine position




Review Information: The correct answer is B: In both arms
Blood pressure should be taken in both arms due to the fact that one subclavian artery may be stenosed, causing a false high in that arm.


Question 24
The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be included in the plan of care?
A) Monitor for hyperkalemia
B) Place in protective isolation
C) Precautions with position changes
D) Administer diuretics as ordered


Review Information: The correct answer is C: Precautions with position changes
Because multiple myeloma is a condition in which neoplastic plasma cells infiltrate the bone marrow resulting in osteoporosis, clients are at high risk for pathological fractures.







Question 25
A client is experiencing hallucinations that are markedly increased at night. The client is very frightened by the hallucinations. The client’s partner asked to stay a few hours beyond the visiting time, in the client’s private room. What would be the best response by the nurse demonstrating emotional support for the client?
A) "No, it would be best if you brought the client some reading material that she could read at night."
B) "No, your presence may cause the client to become more anxious."
C) "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety."
D) "Yes, would you like to spend the night when the client’s behavior indicates that she is frightened?"




Review Information: The correct answer is C: "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety."
Encouraging the family or a close friend to stay with the client in a quiet surrounding can help increase orientation and minimize confusion and anxiety.


Question 26
A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4 cm by 7 cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound?
A) transparent dressing
B) dry sterile dressing with antibiotic ointment
C) wet to dry dressing
D) occlusive moist dressing


Review Information: The correct answer is D: occlusive moist dressing
This wound has granulation tissue present and must be protected. The use of a moisture retentive dressing is the best choice because moisture supports wound healing.





Question 27
During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be most concerned about which statement by the mother?
A) "My child has lost 3 pounds in the last month."
B) "Urinary output seemed to be less over the past 2 days."
C) "All the pants have become tight around the waist."
D) "The child prefers some salty foods more than others."




Review Information: The correct answer is C: "All the pants have become tight around the waist."
Parents often recognize the increasing abdominal girth first. This is an early sign of Wilm''s tumor, a malignant tumor of the kidney.


Question 28
The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate?
A) Schedule the therapy thirty minutes after meals
B) Teach the child not to cough during the treatment
C) Confine the percussion to the rib cage area
D) Place the child in a prone position for the therapy




Review Information: The correct answer is C: Confine the percussion to the rib cage area
Percussion (clapping) should be only done in the area of the rib cage.







Question 29
In a child with suspected coarctation of the aorta, the nurse would expect to find
A) strong pedal pulses
B) diminishing carotid pulses
C) normal femoral pulses
D) bounding pulses in the arms




Review Information: The correct answer is D: bounding pulses in the arms
Coarctation of the aorta, a narrowing or constriction of the descending aorta, causes increased blood flow to the upper extremities resulting in increased pressure and pulses.


Question 30
The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this assessment?
A) Activity intolerance caused by fatigue related to chronic tissue hypoxia
B) Impaired mobility related to chronic obstructive pulmonary disease
C) Self care deficit caused by fatigue related to dyspnea
D) Ineffective airway clearance related to increased bronchial secretions


Review Information: The correct answer is A: Activity intolerance caused by fatigue related to chronic tissue hypoxia
Activity intolerance describes a condition in which the client''s physiological capacity for activities is compromised.






Question 31
The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care?
A) Increase fluid intake to prevent dehydration
B) Place client on a pressure reducing support surface
C) Use skin care products designed for use with incontinence
D) Increase caloric intake to aid healing




Review Information: The correct answer is B: Place client on a pressure reducing support surface
This client is at greatest risk for skin breakdown because of immobility and decreased sensation. The first action should be to choose and then place the client on the best support surface to relieve pressure, shear and friction forces.


Question 32
A mother wants to switch her 9 month-old infant from an iron-fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse?
A) Change the baby to whole milk
B) Add chocolate syrup to the bottle
C) Continue with the present formula
D) Offer fruit juice frequently


Review Information: The correct answer is C: Continue with the present formula
The recommended age for switching from formula to whole milk is 12 months. Switching to cow''s milk before the age of 1 can predispose an infant to allergies and lactose intolerance.
.




Question 33
A victim of domestic violence states to the nurse, "If only I could change and be how my companion wants me to be, I know things would be different." Which would be the best response by the nurse?
A) "The violence is temporarily caused by unusual circumstances, don’t stop hoping for a change."
B) "Perhaps, if you understood the need to abuse, you could stop the violence."
C) "No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?"
D) "Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do."


Review Information: The correct answer is D: "Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do."
Only the perpetrator has the ability to stop the violence. A change in the victim’s behavior will not cause the abuser to become nonviolent.


Question 34
A pre-term newborn is to be fed breast milk through nasogastric tube. Breast milk is preferred over formula for premature infants because it
A) contains less lactose
B) is higher in calories/ounce
C) provides antibodies
D) has less fatty acid


Review Information: The correct answer is C: provides antibodies
Breast milk is ideal for the preterm baby who needs additional protection against infection through maternal antibodies. It is also much easier to digest, therefore less residual is left in the infant''s stomach.





Question 35
The parents of a 15 month-old child asks the nurse to explain their child's lab results and how they show the child has iron deficiency anemia. The nurse's best response is
A) "Although the results are here, your doctor will explain them later."
B) "Your child has fewer red blood cells that carry oxygen."
C) "The blood cells that carry nutrients to the cells are too large."
D) "There are not enough blood cells in your child's circulation."




Review Information: The correct answer is B: "Your child has fewer red blood cells that carry oxygen."
The results of a complete blood count in clients with iron deficiency anemia will show decreased red blood cell levels, low hemoglobin levels and microcytic, hypochromic red blood cells. A simple but clear explanation is appropriate.


Question 36
A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0-to-10 scale. The client refuses all pain medication other than Motrin, which does not relieve his pain. The next action for the nurse to take is to
A) ask the client about the refusal of certain pain medications
B) talk with the client's family about the situation
C) report the situation to the primary care provider
D) document the situation in the notes




Review Information: The correct answer is A: ask the client about the refusal of certain pain medications
Beliefs regarding pain are one of the oldest culturally-related research areas in health care. Astute observations and careful assessments must be completed to determine the level of pain a person can tolerate. Health care practitioners must investigate the meaning of pain to each person within a cultural explanatory framework.




Question 37
A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect when assessing this client?
A) Hyperextension of the neck with passive shoulder flexion
B) Flexion of the hip and knees with passive flexion of the neck
C) Flexion of the legs with rebound tenderness
D) Hyperflexion of the neck with rebound flexion of the legs


Review Information: The correct answer is B: Flexion of the hip and knees with passive flexion of the neck
This is known as a positive Brudzinski’s sign (flexion of hip and knees with passive flexion of the neck). A positive Kernig’s sign, the inability to extend the knee to more than 135 degrees without pain behind the knee while the hip is flexed, usually establishes the diagnosis of meningitis.


Question 38
The nurse is talking to parents about nutrition in school aged children. Which of the following is the most common nutritional disorder in this age group?
A) Bulimia
B) Anorexia
C) Obesity
D) Malnutrition


Review Information: The correct answer is C: Obesity
Many factors contribute to the high rate of obesity in school aged children. These include heredity, sedentary lifestyle, social and cultural factors and poor knowledge of balanced nutrition.





Question 39
Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice?
A) When a family member offers information about their loved one
B) When the client threatens self-harm and harm to others
C) When the provider decides the family has a right to know the client's diagnosis
D) When a visitor insists that the visitor has been given permission by the client


Review Information: The correct answer is B: When the client threatens self-harm and harm to others
Privacy and confidentiality of all client information is protected with the exception of the client who threatens self harm or endangering the public. (Tarasoff decision,1974)


Question 40
At the day treatment center a client diagnosed with schizophrenia - paranoid type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client's behavior most likely indicates
A) Feelings of increasing anxiety related to paranoia
B) Social isolation related to altered thought processes
C) Sensory perceptual alteration related to withdrawal from environment
D) Impaired verbal communication related to impaired judgment


Review Information: The correct answer is B: Social isolation related to altered thought processes
Hostile alertness and absence of involvement with people are findings supporting a diagnosis of social isolation. Her psychiatric diagnosis and her idea about the purpose of medication suggest altered thinking processes.

NEW Free NCLEX-RN Sample Test Questions For Nursing Review (Part 14)

The nurse is participating in a community health fair. As part of the assessments, the nurse should conduct a mental status examination when
A) an individual displays restlessness
B) there are obvious signs of depression
C) conducting any health assessment
D) the resident reports memory lapses


Review Information: The correct answer is C: conducting any health assessment
A mental status assessment is a critical part of baseline information, and should be a part of every examination.


Question 2
The nurse is teaching a client with dysrhythmia about the electrical pathway of an impulse as it travels through the heart. Which of these describes the normal pathway?
A) AV node, SA node, Bundle of His, Purkinje fibers
B) Purkinje fibers, SA node, AV node, Bundle of His
C) Bundle of His, Purkinje fibers, SA node , AV node
D) SA node, AV node, Bundle of His, Purkinje fibers


Review Information: The correct answer is D: SA node, AV node, Bundle of His, Purkinje fibers
This is the pathway of a normal electrical impulse through the heart.







Question 3
Clients taking which of the following drugs are at risk for depression?
A) Steroids
B) Diuretics
C) Folic acid
D) Aspirin


Review Information: The correct answer is A: Steroids
Adverse medication effects can cause a syndrome that may or may not remit when the medication is discontinued. Examples of drugs that can lead to ongoing side effects include: phenothiazines, corticosteroids, and reserpine.


Question 4
A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find?
A) S3 heart sound
B) Thready pulse
C) Flattened neck veins
D) Hypoventilation


Review Information: The correct answer is A: S3 heart sound
Auscultation of an S3 heart sound. This is an early sign of volume overload (or CHF) because during the first phase of diastole, when blood enters the ventricles, an extra sound is produced due to the presence of fluid left in the ventricles.








Question 5
While teaching a client about their medications, the client asks how long it will take before the therapeutic effects of lithium occur. What is the best response of the nurse?
A) Immediately
B) Several days
C) 2 weeks
D) 1 month


Review Information: The correct answer is C: 2 weeks
Lithium is started immediately to treat bipolar disorder because it is quite effective in controlling mania. Lithium takes approximately 2 weeks to effect change in a client’s symptoms.


Question 6
The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is
A) pain
B) impaired gas exchange
C) cardiac output altered: decreased
D) fluid volume excess


Review Information: The correct answer is C: cardiac output altered: decreased
All nursing interventions should be focused on improving cardiac output. Increasing cardiac output is the primary goal of therapy. Comfort will improve as the client improves and the respiratory status will improve as cardiac output increases.








Question 7
In order to enhance a client's response to medication for chest pain from acute angina, the nurse should emphasize
A) learning relaxation techniques
B) limiting alcohol use
C) eating smaller meals
D) avoiding passive smoke


Review Information: The correct answer is A: learning relaxation techniques
The only factor that can enhance the client''s response to pain medication for angina is reducing anxiety through relaxation methods. Anxiety can be great enough to make the pain medication totally ineffective.


Question 8
When a client is having a general tonic clonic seizure, the nurse should
A) hold the client's arms at their side
B) place the client on their side
C) insert a padded tongue blade in client's mouth
D) elevate the head of the bed


Review Information: The correct answer is B: place the client on their side
This position keeps the airway patent and prevents aspiration.










Question 9
When making a home visit to a client with chronic pyelonephritis, which nursing action has the highest priority?
A) follow-up on lab values before the visit
B) observe client findings for the effectiveness of antibiotics
C) ask for a log of urinary output
D) ask for the log of the oral intake


Review Information: The correct answer is C: ask for a log of urinary output
The nurse must monitor the urine output as a priority because it is the best indictor of renal function. The other options would be appropriate after an evaluation of the urine output.


Question 10
Parents of a 7 year-old child call the clinic nurse because their daughter was sent home from school because of a rash. The child had been seen the day before by the provider and diagnosed with Fifth Disease (erythema infectiosum). What is the most appropriate action by the nurse?
A) Tell the parents to bring the child to the clinic for further evaluation
B) Refer the school officials to printed materials about this viral illness
C) Inform the teacher that the child is receiving antibiotics for the rash
D) Explain that this rash is not contagious and does not require isolation




Review Information: The correct answer is D: Explain that this rash is not contagious and does not require isolation
Fifth Disease is a viral illness with an uncertain period of communicability (perhaps 1 week prior to and 1 week after onset). Isolation of the child with Fifth Disease is not necessary except in cases of hospitalized children who are immunosuppressed or having aplastic crises. The parents may need written confirmation of this from the provider.


Question 11
The nurse is caring for a post myocardial infarction client in an intensive care unit. It is noted that urinary output has dropped from 60 -70 ml per hour to 30 ml per hour. This change is most likely due to
A) dehydration
B) diminished blood volume
C) decreased cardiac output
D) renal failure


Review Information: The correct answer is C: decreased cardiac output
Cardiac output and urinary output are directly correlated. The nurse should suspect a drop in cardiac output if the urinary output drops.


Question 12
In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing?
A) White patches
B) Green drainage
C) Reddened tissue
D) Eschar development


Review Information: The correct answer is C: Reddened tissue
As the wound granulates, redness indicates healing.








Question 13
Clients with mitral stenosis would likely manifest findings associated with congestion in the
A) pulmonary circulation
B) descending aorta
C) superior vena cava
D) bundle of His




Review Information: The correct answer is A: pulmonary circulation
Congestion occurs in the pulmonary circulation due to the inefficient emptying of the left ventricle and the lack of a competent valve to prevent back-flow into the pulmonary vein.


Question 14
The nurse caring for a 14 year-old boy with severe Hemophilia A, who was admitted after a fall while playing basketball. In understanding his behavior and in planning care for this client, the nurse should understand that adolescents with hemophilia _______.
A) must have structured activities
B) often take part in active sports
C) explain limitations to peer groups
D) avoid risks after bleeding episodes




Review Information: The correct answer is B: often take part in active sports
An age-appropriate treatment goal is to establish an age-appropriate safe environment. Adolescent hemophiliacs should be aware that contact sports may trigger bleeding. However, developmental characteristics of this age group such as impulsivity, inexperience and peer pressure, place adolescents in unsafe environments.






Question 15
A depressed client who has recently been acting suicidal is now more social and energetic than usual. Smilingly he tells the nurse "I’ve made some decisions about my life." What should be the nurse’s initial response?
A) "You’ve made some decisions."
B) "Are you thinking about killing yourself?"
C) "I’m so glad to hear that you’ve made some decisions."
D) "You need to discuss your decisions with your therapist."




Review Information: The correct answer is B: "Are you thinking about killing yourself?"
Sudden mood elevation and energy may signal increased risk of suicide. The nurse must validate suicidal ideation as a beginning step in evaluating seriousness of risk.


Question 16
The nurse is assessing a client on admission to a community mental health center. The client discloses that she has been thinking about ending her life. The nurse's best response would be
A) "Do you want to discuss this with your pastor?"
B) "We will help you deal with those thoughts."
C) "Is your life so terrible that you want to end it?"
D) "Have you thought about how you would do it?"


Review Information: The correct answer is D: "Have you thought about how you would do it?"
This response provides an opening to discuss intent and means of committing suicide. It helps in assessing the severity of the risk, since clients who have formulated a suicide plan are closer to suicidal behavior than those who have had vague, non-specific thoughts.






Question 17
The nurse understands that one reason domestic violence remains extensively undetected is
A) few battered victims seek medical care
B) there is typically a series of minor, vague complaints
C) expenses due to police and court costs are prohibitive
D) very little knowledge is currently known about batterers and battering relationships


Review Information: The correct answer is B: there is typically a series of minor, vague complaints
Signs of abuse may not be clearly manifested and include a series a minor complaints such as headache, abdominal pain, insomnia, back pain, and dizziness. These may be covert indications of abuse that go undetected. Victim complaints may be vague reflecting their ambivalence about disclosing the abuse.


Question 18
The nurse is teaching a smoking cessation class and notices there are 2 pregnant women in the group. Which information is a priority for these women?
A) Low tar cigarettes are less harmful during pregnancy
B) There is a relationship between smoking and low birth weight
C) The placenta serves as a barrier to nicotine
D) Moderate smoking is effective in weight control


Review Information: The correct answer is B: There is a relationship between smoking and low birth weight
Nicotine reduces placental blood flow, and may contribute to fetal hypoxia or placenta previa, decreasing the growth potential of the fetus.






Question 19
The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first
A) assess the client's airway
B) call for help
C) establish that the client is unresponsive
D) see if anyone saw the client fall




Review Information: The correct answer is C: establish that the client is unresponsive
The first step in CPR is to establish responsiveness. The second is to call for help, and the third is to ensure an open airway.


Question 20
A new nurse on the unit notes that the nurse manager seems to be highly respected by the nursing staff. The new nurse is surprised when one of the nurses states: "The manager makes all decisions and rarely asks for our input." The best description of the nurse manager's management style is
A) Participative or democratic
B) Ultraliberal or communicative
C) Autocratic or authoritarian
D) Laissez faire or permissive




Review Information: The correct answer is C: Autocratic or authoritarian
Autocratic leadership style is suggested in this situation. It is appropriate for groups with little education and experience who need strong direction, while a participative or democratic style is usually more successful on nursing units






Question 21
The nurse is caring for a newborn who has just been diagnosed with hypospadias. When discussing the defect with the parents, the nurse should communicate that
A) circumcision can be performed at any time
B) initial repair is delayed until 6-8 years of age
C) post-operative appearance will be normal
D) surgery will be performed in stages




Review Information: The correct answer is D: surgery will be performed in stages
Hypospadias, a condition in which the urethral opening is located on the ventral surface or below the penis, is corrected in stages as soon as the infant can tolerate surgery.


Question 22
The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis?
A) observe for edema proximal to the site
B) irrigate with 5 ml of 0.9% Normal Saline
C) palpate for a thrill over the fistula
D) check color and warmth in the extremity


Review Information: The correct answer is C: palpate for a thrill over the fistula
To assess for patency in a fistula or graft, the nurse auscultates for a bruit and palpates for a thrill. The other options are not related to evaluation of patency.








Question 23
A client has received her first dose of fluphenazine (Prolixin) 2 hours ago. She suddenly experiences torticollis and involuntary spastic muscle movement. In addition to administering the ordered anticholinergic drug, what other measure should the nurse implement?
A) Have respiratory support equipment available
B) Immediately place her in the seclusion room
C) Assess the client for anxiety and agitation
D) Administer prn dose of IM antipsychotic medication


Review Information: The correct answer is A: Have respiratory support equipment available
Persons receiving neuroleptic medication experiencing torticollis and involuntary muscle movement are demonstrating side effects that could lead to respiratory failure.


Question 24
When an autistic client begins to eat with her hands, the nurse can best handle the problem by
A) placing the spoon in the client’s hand and stating, "Use the spoon to eat your food."
B) commenting, "I believe you know better than to eat with your hand."
C) jokingly stating, "Well I guess fingers sometimes work better than spoons."
D) removing the food and stating, "You can’t have anymore food until you use the spoon."


Review Information: The correct answer is A: placing the spoon in the client’s hand and stating, "Use the spoon to eat your food."
This response identifies instruction and verbal expectation with adaptive behavior.







Question 25
The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include
A) pointing out inconsistencies in speech patterns to correct thought disorders
B) accepting client and the client's behavior unconditionally
C) encouraging dependency in order to develop ego controls
D) consistent limit-setting enforced 24 hours per day




Review Information: The correct answer is D: consistent limit-setting enforced 24 hours per day
Treatment approaches that include restructuring the personality, assisting the person with advancing developmental level and setting limits for maladaptive behavior such as acting out.


Question 26
A neonate born 12 hours ago to a methadone maintained woman is exhibiting a hyperactive MORO reflex and slight tremors. The newborn passed one loose, watery stool. Which of these is a nursing priority?
A) Hold the infant at frequent intervals.
* B) Assess for neonatal withdrawal syndrome
C) Offer fluids to prevent dehydration
D) Administer paregoric to stop diarrhea




Review Information: The correct answer is B: Assess for neonatal withdrawal syndrome
Neonatal withdrawal syndrome is a cluster of findings that signal the withdrawal of the infant from the opiates. The findings seen in methadone withdrawal are often more severe than for other substances. Initial signs are central nervous system hyper irritability and gastro-intestinal symptoms. If withdrawal signs are severe, there is an increased mortality risk. Scoring the infant ensures proper treatment during the period of withdrawal.




Question 27
A 2 year-old child is being treated with Amoxicillin suspension, 200 milligrams per dose, for acute otitis media. The child weighs 30 lb. (15 kg) and the daily dose range is 20-40 mg/kg of body weight, in three divided doses every 8 hours. Using principles of safe drug administration, what should the nurse do next?
A) Give the medication as ordered
B) Call the provider to clarify the dose
C) Recognize that antibiotics are over-prescribed
D) Hold the medication as the dosage is too low


Review Information: The correct answer is A: Give the medication as ordered
Amoxicillin continues to be the drug of choice in the treatment of acute otitis media. The dose range is 20-40 mg/kg/day divided every 8 hours. 15kg x 40mg = 600mg, divided by 3 = 200 mg per dose. The prescribed dose is correct and should be given as ordered.


Question 28
While planning care for a preschool aged child, the nurse takes developmental needs into consideration. Which of the following would be of the most concern to the nurse?
A) Playing imaginatively
B) Expressing shame
C) Identifying with family
D) Exploring the playroom




Review Information: The correct answer is B: Expressing shame
Erikson describes the stage of the preschool child as being the time when there is normally an increase in initiative. The child should have resolved the sense of shame and doubt in the toddler stage.





Question 29
After talking with her partner, a client voluntarily admitted herself to the substance abuse unit. After the second day on the unit the client states to the nurse, "My husband told me to get treatment or he would divorce me. I don’t believe I really need treatment, but I don’t want my husband to leave me." Which response by the nurse would assist the client?
A) "In early recovery, it's quite common to have mixed feelings, but unmotivated people can’t get well."
B) "In early recovery, it’s quite common to have mixed feelings, but I didn’t know you had been pressured to come."
C) "In early recovery it’s quite common to have mixed feelings, perhaps it would be best to seek treatment on an outpatient basis."
D) "In early recovery, it’s quite common to have mixed feelings. Let’s discuss the benefits of sobriety for you."




Review Information: The correct answer is D: "In early recovery, it’s quite common to have mixed feelings. Let’s discuss the benefits of sobriety for you."
This response gives the client the opportunity to decrease ambivalent feelings by focusing on the benefits of sobriety. Dependency issues are significant for the client, fostering ambivalence.


Question 30
The nurse is performing a developmental assessment on an 8 month-old. Which finding should be reported to the provider?
A) Lifts head from the prone position
B) Rolls from abdomen to back
C) Responds to parents' voices
D) Falls forward when sitting


Review Information: The correct answer is D: Falls forward when sitting
Sitting without support is expected at this age.





Question 31
What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero?
A) The disease will incubate longer and progress more slowly in this infant
B) The infant is very susceptible to infections
C) Growth and development patterns will proceed at a normal rate
D) Careful monitoring of renal function is indicated


Review Information: The correct answer is B: The infant is very susceptible to infections
HIV infected children are susceptible to opportunistic infections due to a compromised immune system.


Question 32
The nurse is caring for a 12 year-old with an acute illness. Which of the following indicates the nurse understands common sibling reactions to hospitalization?
A) Younger siblings adapt very well
B) Visitation is helpful for both
C) The siblings may enjoy privacy
D) Those cared for at home cope better


Review Information: The correct answer is B: Visitation is helpful for both
Contact with the ill child helps siblings understand the reasons for hospitalization and maintains their relationships.







Question 33
The nurse asks a client with a history of alcoholism about recent drinking behavior. The client states "I didn’t hurt anyone. I just like to have a good time, and drinking helps me to relax." The client is using which defense mechanism?
A) Denial
B) Projection
C) Intellectualization
D) Rationalization




Review Information: The correct answer is D: Rationalization
Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations for unacceptable actions. Both the teller and the listener find the rationalizations more satisfactory than the reality.


Question 34
When assessing a client who has just undergone a cardioversion, the practical nurse (LPN) finds the respirations are 12/minute. Which action should the nurse take first?
A) Try to vigorously stimulate normal breathing
B) Ask the RN to assess the vital signs
C) Measure the pulse oximetry
D) Continue to monitor respirations


Review Information: The correct answer is D: Continue to monitor respirations
12 respirations per minute is tolerated post-operatively. A range from 8 to 10 gives cause for concern. At that point pulse oximetry is taken to determine whether that rate is providing sufficient oxygenation. Vigorous stimulation is not indicated beyond deep breathing and coughing. It is not necessary to ask the registered nurse (RN) to check the findings.






Question 35
Which therapeutic communication skill used by the nurse is most likely to encourage a depressed client to vent feelings?
A) Direct confrontation
B) Reality orientation
C) Projective identification
D) Active listening


Review Information: The correct answer is D: Active listening
Use of therapeutic communication skills such as silence and active listening encourages verbalization of feelings.


Question 36
What is the best way for the nurse to obtain the health history of a 14 year-old client?
A) Have the mother present to verify information
B) Allow an opportunity for the teen to express feelings
C) Use the same type of language as the adolescent
D) Focus the discussion of risk factors in the peer group


Review Information: The correct answer is B: Allow an opportunity for the teen to express feelings
Adolescents need to express their feelings. Generally, they talk freely when given an opportunity and some privacy to do so.








Question 37
The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance?
A) Arterial septal defect
B) Patent ductus arteriosus
C) Aortic stenosis
D) Ventricular septal defect


Review Information: The correct answer is D: Ventricular septal defect
While assessments for conduction disturbance should be included following repair of any defect, it is a priority for this condition. A ventricular septal defect is an abnormal opening between the right and left ventricles. The atrioventricular bundle (bundle of His), is a part of the electrical conduction system of the heart. It extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening. Either method involves manipulation of the ventricular septum, thereby increasing risk of interrupting the conduction pathway. Consequently, postoperative complications include conduction disturbances.


Question 38
The nurse is caring for a client 2 hours after a right lower lobectomy. During the evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles constantly in the water seal chamber. On inspection of the chest dressing and tubing, the nurse does not find any air leaks in the system. The next best action for the nurse is to
A) check for subcutaneous emphysema in the upper torso
B) reposition the client to improve the level of comfort
C) call the provider as soon as possible
D) check for any increase in the amount of thoracic drainage


Review Information: The correct answer is A: check for subcutaneous emphysema in the upper torso
Continuous bubbling in the water seal chamber is an abnormal finding 2 hours after a lobectomy. Further assessment of appropriate factors was done by the nurse to rule out an air leak in the system. Thus the conclusion is that the problem is one of an air leak in the lung. This client may need to be returned to surgery to deal with the sustained air leak. Action by the provider is required to prevent further complications.


Question 39
Following a cocaine high, the user commonly experiences an extremely unpleasant feeling called
A) craving
B) crashing
C) outward bound
D) nodding out


Review Information: The correct answer is B: crashing
Following cocaine use, the intense pleasure is replaced by an equally unpleasant feeling referred to as crashing.


Question 40
A client has been receiving lithium (Lithane) for the past two weeks for the treatment of bipolar illness. When planning client teaching, what is most important for the nurse to emphasize?
A) Maintain a low sodium diet
B) Take a diuretic with lithium and avoid excessive fluids
C) Don't be overly concerned if feelings of depression occur
D) Come in for evaluation of serum lithium levels regularly


Review Information: The correct answer is D: Come in for evaluation of serum lithium levels regularly
This is especially important during hot weather, which may cause excessive perspiration, a loss of sodium and consequently an increase in serum lithium concentration. Diuretics should be avoided, as they could result in an increased serum lithium level. Excessive thirst is a common early finding that subsides over time but may recur. Initiation of treatment for elevated mood at times results in onset of a depressive episode that can be accompanied by risk for self-harm. Clients should be cautioned to report any symptoms of mood instability.

NEW Free NCLEX-RN Sample Test Questions For Nursing Review (Part 13)

The nurse is assessing a client with delayed wound healing. Which of the following risk factors is most important in this situation?
A) Glucose level of 120
B) History of myocardial infarction
C) Long term steroid usage
D) Diet high in carbohydrates




Review Information: The correct answer is C: Long term steroid usage
Steroid dependency tends to delay wound healing. If the client also smokes, the risk is increased.


Question 2
A client continually repeats phrases that others have just said. The nurse recognizes this behavior as
A) autistic
B) echopraxis
C) echolalic
D) catatonic




Review Information: The correct answer is C: echolalic
Echolalia is repeating words or phrases heard before.








Question 3
The nurse has been assigned to four clients in the emergency room, each experiencing one of these conditions. Which client condition would the nurse check first?
A) Viral pneumonia with atelectasis
B) Spontaneous pneumothorax with a respiratory rate of 38
C) Tension pneumothorax with slight tracheal deviation to the right
D) Acute asthma with episodes of bronchospasm




Review Information: The correct answer is C: Tension pneumothorax with slight tracheal deviation to the right
Tracheal deviation indicates a significant volume of air being trapped in the chest cavity with a mediastinal shift. In tension pneumothorax the tracheal deviation is away from the affected side. The affected side is the side where the air leak is in the lung. This situation also results in sudden air hunger, agitation, hypotension, pain in the affected side, and cyanosis with a high risk of cardiac tamponade and cardiac arrest.


Question 4
A schizophrenic client talks animatedly but the staff are unable to understand what the client is communicating. The client is observed mumbling to herself and speaking to the radio. A desirable outcome for this client’s care will be
A) expresses feelings appropriately through verbal interactions
B) accurately interprets events and behaviors of others
C) demonstrates improved social relationships
D) engages in meaningful and understandable verbal communication


Review Information: The correct answer is D: engages in meaningful and understandable verbal communication
The outcome must be related to the diagnosis and supporting data. Data support impaired verbal communication deficit as a nursing diagnosis. No direct data are presented related to feelings or to thinking processes, though disorganized verbalizations are typically taken to indicate disorganized thinking.





Question 5
A client was admitted to the psychiatric unit after refusing to get out of bed. In the hospital the client talks to unseen people and voids on the floor. The nurse could best handle the problem of voiding on the floor by
A) requiring the client to mop the floor
B) restricting the client’s fluids throughout the day
C) withholding privileges each time the voiding occurs
D) toileting the client more frequently with supervision


Review Information: The correct answer is D: toileting the client more frequently with supervision
With a client suffering from altered thought processes, the most appropriate nursing approach to change this behavior is by taking an active role in attending to the physical need.


Question 6
The parents of a 7 year-old tell the nurse their child has started to "tattle" on siblings. In interpreting this new behavior, how should the nurse explain the child's actions to the parents?
A) The ethical sense and feelings of justice are developing
B) Attempts to control the family use new coping styles
C) Insecurity and attention getting are common motives
D) Complex thought processes help to resolve conflicts




Review Information: The correct answer is A: The ethical sense and feelings of justice are developing
The child is developing a sense of justice and a desire to do what is right. At seven, the child is increasingly aware of family roles and responsibilities. They also do what is right because of parental direction or to avoid punishment.




Question 7
When counseling parents of a child who has recently been diagnosed with hemophilia, what must the nurse know about the offspring of a normal father and a carrier mother?
A) It is likely that all sons are affected
B) There is a 50% probability that sons will have the disease
C) Every daughter is likely to be a carrier
D) There is a 25% chance a daughter will be a carrier


Review Information: The correct answer is D: There is a 25% chance a daughter will be a carrier
Hemophilia A is a sex-linked recessive trait seen almost exclusively in males. With a normal father and carrier mother, affected individuals are male. There is a 25% chance of having an affected male, 25% chance of having a carrier female, 25% chance of having a normal female and 25% chance of having a normal male.















Question 8
Which of the following statements describes what the nurse must know in order to provide anticipatory guidance to parents of a toddler about readiness for toilet training?
A) The child learns voluntary sphincter control through repetition
B) Myelination of the spinal cord is completed by this age
C) Neuronal impulses are interrupted at the base of the ganglia
D) The toddler can understand cause and effect


Review Information: The correct answer is B: Myelination of the spinal cord is completed by this age
Voluntary control of the sphincter muscles can be gradually achieved due to the complete myelination of the spinal cord, sometime between the ages of 18 to 24 months of age.


Question 9
During seizure activity which observation is the priority to enhance further direction of treatment?
A) Observe the sequence or types of movement
B) Note the time from beginning to end
C) Identify the pattern of breathing
D) Determine if loss of bowel or bladder control occurs


Review Information: The correct answer is A: Observe the sequence or types of movement
It is a priority to note, and then record, what movements are seen during a seizure because the diagnosis and subsequent treatment often rests solely on the seizure description.






Question 10
The charge nurse on the eating disorder unit instructs a new staff member to weigh each client in his or her hospital gown only. What is the rationale for this nursing intervention?
A) To reduce the risk of the client feeling cold due to decreased fat and subcutaneous tissue
B) To cover the bony prominence and areas where there is skin breakdown
C) The client knows what type of clothing to wear when weighed
D) To reduce the tendency of the client to hide objects under his or her clothing




Review Information: The correct answer is D: To reduce the tendency of the client to hide objects under his or her clothing
The client may conceal weights on their body to create the illusion of increased weight gain.


Question 11
A 2 year-old child has recently been diagnosed with cystic fibrosis. The nurse is teaching the parents about home care for the child. Which of the following information is appropriate for the nurse to include?
A) Allow the child to continue normal activities
B) Schedule frequent rest periods
C) Limit exposure to other children
D) Restrict activities to inside the house


Review Information: The correct answer is A: Allow the child to continue normal activities
Physical activity is important in a two year-old who is developing autonomy. Physical activity is a valuable adjunct to chest physical therapy. Exercise tends to stimulate mucus secretion and helps develop normal breathing patterns.






Question 12
A nurse who travels with an agency is uncertain about what tasks can be performed when working in a different state. It would be best for the nurse to check which resource?
A) The state nurse practice act in which the assignment is made
B) With a nurse colleague who has worked in that state 2 years ago
C) The policies and procedures of the assigned agency in that state
D) The Nursing Social Policy Statement within the United States




Review Information: The correct answer is A: The state nurse practice act in which the assignment is made
The state nurse practice act is the governing document of the scope of practice in the given state.


Question 13
At a routine clinic visit, parents express concern that their 4 year-old is wetting the bed several times a month. What is the nurse's best response?
A) "This is normal at this time of day."
B) "How long has this been occurring?"
C) "Do you offer fluids at night?"
D) "Have you tried waking her to urinate?"


Review Information: The correct answer is B: "How long has this been occurring?"
Nighttime control should be present by this age, but may not occur until age 5. Involuntary voiding may occur due to infectious, anatomical and/or physiological reasons.





Question 14
The nurse is teaching parents of an infant about introduction of solid food to their baby. What is the first food they can add to the diet?
A) Vegetables
B) Cereal
C) Fruit
D) Meats


Review Information: The correct answer is B: Cereal
Cereal is usually introduced first because it is well tolerated, easy to digest, and contains iron.


Question 15
The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention?
A) Piercing the plastic of the ostomy pouch with a pin to vent the flatus
B) Opening the bottom of the pouch, allowing the flatus to be expelled
C) Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape
D) Assisting the client to ambulate to reduce the flatus in the pouch


Review Information: The correct answer is B: Opening the bottom of the pouch, allowing the flatus to be expelled
The only correct way to vent the flatus from a 1 piece drainable ostomy pouch is to instruct the client to obtain privacy (the release of the flatus will cause odor), and to open the bottom of the pouch, release the flatus and close the bottom of the pouch.






Question 16
A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and she expectorates large amounts of pink frothy sputum. The first action of the nurse would be which of the following?
A) Call the health care provider
B) Check vital signs
C) Position in high Fowler's
D) Administer oxygen




Review Information: The correct answer is D: Administer oxygen
When dealing with a medical emergency, the rule is airway first, then breathing, and then circulation. Starting oxygen is the priority.


Question 17
A 3 year-old child is treated in the emergency department after ingestion of 1 ounce of a liquid narcotic. What action should the nurse perform first?
A) Provide the ordered humidified oxygen via mask
B) Suction the mouth and the nose
C) Check the mouth and radial pulse
D) Start the ordered intravenous fluids


Review Information: The correct answer is C: Check the mouth and radial pulse
The first step in treatment of a toxic exposure or ingestion is to assess the airway, breathing and circulation, then stabilize the client. The other nursing actions would follow.







Question 18
The nurse measures the head and chest circumferences of a 20 month-old infant. After comparing the measurements, the nurse finds that they are approximately the same. What action should the nurse take?
A) Notify the provider
B) Palpate the anterior fontanel
C) Feel the posterior fontanel
D) Record these normal findings




Review Information: The correct answer is D: Record these normal findings
The rate of increase in head circumference slows by the end of infancy, and the head circumference is usually equal to chest circumference at 1 to 2 years of age.


Question 19
When teaching a client with chronic obstructive pulmonary disease about oxygen by cannula, the nurse should also instruct the client's family to
A) avoid smoking near the client
B) turn off oxygen during meals
C) adjust the liter flow to 10 as needed
D) remind the client to keep mouth closed


Review Information: The correct answer is A: avoid smoking near the client
Since oxygen supports combustion, there is a risk of fire if anyone smokes near the oxygen equipment.


Question 20
In teaching parents to associate prevention with the lifestyle of their child with sickle cell disease, the nurse should emphasize that a priority for their child is to
A) avoid overheating during physical activities
B) maintain normal activity with some restrictions
C) be cautious of others with viruses or temperatures
D) maintain routine immunizations


Review Information: The correct answer is A: avoid overheating during physical activities
Fluid loss caused by overheating and dehydration can trigger a crisis.


Question 21
The nurse is caring for a client with benign prostatic hypertrophy (BPH). Which of the following assessments would the nurse anticipate finding?
A) Large volume of urinary output with each voiding
B) Involuntary voiding with coughing and sneezing
C) Frequent urination
D) Urine is dark and concentrated


Review Information: The correct answer is C: Frequent urination
Clients with BPH have overflow incontinence with frequent urination in small amounts day and night.


Question 22
A parent has numerous questions regarding normal growth and development of a 10 month-old infant. Which of the following parameters is of most concern to the nurse?
A) 50% increase in birth weight
B) Head circumference greater than chest
C) Crying when the parents leave
D) Able to stand up briefly in play pen


Review Information: The correct answer is A: 50% increase in birth weight
Birth weight should be doubled at 6 months of age, tripled at 1 year, and quadrupled by 18 months.







Question 23
The nurse is caring for a post-op colostomy client. The client begins to cry, saying "I'll never be attractive again with this ugly red thing." What should be the first action taken by the nurse?
A) Arrange a consultation with a sex therapist experienced in working with colostomy clients
B) Suggest sexual positions that hide the colostomy
C) Invite the partner to participate in colostomy care after viewing an instructional video
D) Encourage the client to discuss her feelings about the colostomy


Review Information: The correct answer is D: Encourage the client to discuss her feelings about the colostomy
One of the greatest fears of colostomy clients is the fear that sexual intimacy is no longer possible. However, the client’s personal feelings about the stoma and colostomy care, as well as the client''s specific concerns, need to be assessed to accurately identify the problem(s) to be solved. An assessment should occur before specific suggestions for dealing with the sexual concerns are given.


Question 24
Which of these principles should the nurse apply when performing a nutritional assessment on a 2 year-old client?
A) An accurate measurement of intake is not reliable
B) The food pyramid is not used in this age group
C) A serving size at this age is about 2 tablespoons
D) Total intake varies greatly each day


Review Information: The correct answer is C: A serving size at this age is about 2 tablespoons
In children, a general guide to serving sizes is 1 tablespoon of solid food per year of age. Understanding this, the nurse can assess adequacy of intake.





Question 25
The nurse is preparing to perform a physical examination on an 8 month-old who is sitting contentedly on his mother's lap. Which of the following should the nurse do first?
A) Elicit reflexes
B) Measure height and weight
C) Auscultate heart and lungs
D) Examine the ears




Review Information: The correct answer is C: Auscultate heart and lungs
The nurse should auscultate the heart and lungs during the first quiet moment with the infant so as to be able to hear sounds clearly. Other assessments may follow in any order.


Question 26
The nurse is performing an assessment on a client with pneumococcal pneumonia. Which finding would the nurse anticipate?
A) bronchial breath sounds in outer lung fields
B) decreased tactile fremitus
C) hacking, nonproductive cough
D) hyper-resonance of areas of consolidation


Review Information: The correct answer is A: bronchial breath sounds in outer lung fields
Pneumonia causes a marked increase in interstitial and alveolar fluid. Consolidated lung tissue transmits bronchial breath sounds to outer lung fields.







Question 27
A client is unconscious following a tonic-clonic seizure. What should the nurse do first?
A) check the pulse
B) administer Valium
C) place the client in a side-lying position
D) place a tongue blade in the mouth




Review Information: The correct answer is C: place the client in a side-lying position
Place the client in a side-lying position to maintain an open airway, drain secretions, and prevent aspiration if vomiting occurs.


Question 28
A school nurse is advising a class of unwed pregnant high school students. What is the most important action they can perform to deliver a healthy child?
A) Maintain good nutrition
B) Stay in school
C) Keep in contact with the child's father
D) Get adequate sleep


Review Information: The correct answer is A: Maintain good nutrition
Nurses can serve a pivotal role in providing nutritional education and case management interventions. Weight gain during pregnancy is one of the strongest predictors of infant birth weight. Specifically, teens need to increase their intake of protein, vitamins, and minerals including iron. Pregnant teens who gain between 26 and 35 pounds have the lowest incidence of low-birth-weight babies.






Question 29
The nurse is caring for a 14 month-old just diagnosed with cystic fibrosis. The parents state this is the first child in either family with this disease, and ask about the risk to future children. What is the best response by the nurse?
A) 1in 4 chance for each child to carry that trait
B) 1in 4 risk for each child to have the disease
C) 1in 2 chance of avoiding the trait and disease
D) 1in 2 chance that each child will have the disease




Review Information: The correct answer is B: 1in 4 risk for each child to have the disease
Cystic fibrosis has an autosomal recessive transmission pattern. In this situation, both parents must be carriers of the trait for the disease since neither one of them has the disease. Therefore, for each pregnancy, there is a 25% chance of the child having the disease, 50% chance of carrying the trait and a 25% chance of having neither the trait or the disease.


Question 30
A client is admitted for hemodialysis. Which abnormal lab value would the nurse anticipate not being improved by hemodialysis?
A) Low hemoglobin
B) Hypernatremia
C) High serum creatinine
D) Hyperkalemia


Review Information: The correct answer is A: Low hemoglobin
Although hemodialysis improves or corrects electrolyte imbalances it has no effect on improving anemia.






Question 31
In providing care to a 14 year-old adolescent with scoliosis, which of the following will be most difficult for this client?
A) Compliance with treatment regimens
B) Looking different from their peers
C) Lacking independence in activities
D) Reliance on family for their social support




Review Information: The correct answer is B: Looking different from their peers
Conformity to peer influences peaks at around age 14. Since many persons view any disability as deviant, the client will need help in learning how to deal with reactions of others. Treatment of scoliosis is long-term and involves bracing and/or surgery.


Question 32
An anxious parent of a 4 year-old consults the nurse for guidance in how to answer the child's question, "Where do babies come from?" What is the nurse's best response to the parent?
A) "When a child asks a question, give a simple answer."
B) "Children ask many questions, but are not looking for answers."
C) "This question indicates interest in sex beyond this age."
D) "Full and detailed answers should be given to all questions."


Review Information: The correct answer is A: "When a child asks a question, give a simple answer."
During discussions related to sexuality, honesty is very important. However, honesty does not mean imparting every fact of life associated with the question. When children ask 1 question, they are looking for 1 answer. When they are ready, they will ask for more detailed information.






Question 33
The nurses on a unit are planning for stoma care for clients who have a stoma for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown
A) Ileostomy
B) Transverse colostomy
C) Ileal conduit
D) Sigmoid colostomy


Review Information: The correct answer is A: Ileostomy
Ileostomy output contains gastric and enzymatic agents that when present on skin can denuded skin in several hours. Because of the caustic nature of this stoma output adequate peristomal skin protection must be delivered to prevent skin breakdown.


Question 34
The nurse is teaching a client who has a hip prosthesis following total hip replacement. Which of the following should be included in the instructions for home care?
A) Avoid climbing stairs for 3 months
B) Ambulate using crutches only
C) Sleep only on your back
D) Do not cross your legs


Review Information: The correct answer is D: Do not cross your legs
When the client is immediately post-op, hip flexion should not exceed 60 degrees, and after discharge it should not exceed 90 degrees.







Question 35
A 7 year-old child is hospitalized following a major burn to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse informs the child and family that the most important reason for this diet is to
A) Promote healing and strengthen the immune system
B) Provide a well balanced nutritional intake
C) Stimulate increased peristalsis absorption
D) Spare protein catabolism to meet metabolic needs




Review Information: The correct answer is D: Spare protein catabolism to meet metabolic needs
Because of the burn injury, the child has increased metabolism and catabolism. By providing a high carbohydrate diet, the breakdown of protein for energy is avoided. Proteins are then used to restore tissue.


Question 36
Which of the following nursing assessment findings require immediate discontinuance of an antipsychotic medication?
A) Involuntary rhythmic stereotypic movements and tongue protrusion
B) Cheek puffing, involuntary movements of extremities and trunk
C) Agitation, constant state of motion
D) Hyperpyrexia, severe muscle rigidity, malignant hypertension


Review Information: The correct answer is D: Hyperpyrexia, severe muscle rigidity, malignant hypertension
Hyperpyrexia, sever muscle rigidity, and malignant hypertension are assessment signs indicative of NMS (neuroleptic malignant syndrome).






Question 37
The nurse understands that during the "tension building" phase of a violent relationship, when the batterer makes unreasonable demands, the battered victim may experience feelings of
A) anger
B) helplessness
C) calm
D) explosiveness




Review Information: The correct answer is B: helplessness
Battered individuals internalize appropriate anger of the batterer’s unfairness. They feel depressed, with a sense of helplessness when their partner explodes, in spite of their best efforts to please the batterer.


Question 38
The nurse is assessing a 4 year-old for possible developmental dysplasia of the right hip. Which finding would the nurse expect?
A) Pelvic tip downward
B) Right leg lengthening
C) Ortolani sign
D) Characteristic limp


Review Information: The correct answer is D: Characteristic limp
Developmental dysplasia produces a characteristic limp in children who are walking.







Question 39
The nurse is caring for a 7 year-old child who is being discharged following a tonsillectomy. Which of the following instructions is appropriate for the nurse to teach the parents?
A) Report a persistent cough to the health care provider
B) The child can return to school in 4 days
C) Administer chewable aspirin for pain
D) The child may gargle with saline as necessary for discomfort




Review Information: The correct answer is A: Report a persistent cough to the health care provider
Persistent coughing should be reported to the health care provider as this may indicate bleeding.


Question 40
A client with HIV infection has a secondary herpes simplex type 1 (HSV-1) infection. The nurse knows that the most likely reason for the HSV-1 infection in this client is
A) immunosuppression
B) emotional stress
C) unprotected sexual activities
D) contact with saliva


Review Information: The correct answer is A: immunosuppression
The decreased immunity leads to frequent secondary infections. Herpes simplex virus type 1 is an opportunistic infection. The other options may result in HSV-1. However, they are not the most likely causes in clients with HIV.