This chapter provides a sample NCLEX-PN exam with detailed explanations for each of the answers to help you practice.
A client hospitalized with severe depression and suicidal ideation refuses to talk with the nurse. The nurse recognizes that the suicidal client has difficulty:
Expressing feelings of low self-worth
Discussing remorse and guilt for actions
Displaying dependence on others
Expressing anger toward others
A client receiving hydrochlorothiazide is instructed to increase her dietary intake of potassium. The best snack for the client requiring increased potassium is:
The nurse is caring for a client following removal of the thyroid. Immediately post-op, the nurse should:
Maintain the client in a semi-Fowler's position with the head and neck supported by pillows
Encourage the client to turn her head side to side, to promote drainage of oral secretions
Maintain the client in a supine position with sandbags placed on either side of the head and neck
Encourage the client to cough and breathe deeply every 2 hours, with the neck in a flexed position
A client hospitalized with chronic dyspepsia is diagnosed with gastric cancer. Which of the following is associated with an increased incidence of gastric cancer?
Dairy products
Carbonated beverages
Refined sugars
Luncheon meats
A client is sent to the psychiatric unit for forensic evaluation after he is accused of arson. His tentative diagnosis is antisocial personality disorder. In reviewing the client's record, the nurse could expect to find:
A history of consistent employment
A below-average intelligence
A history of cruelty to animals
An expression of remorse for his actions
The licensed vocational nurse may not assume the primary care for a client:
In the fourth stage of labor
Two days post-appendectomy
With a venous access device
With bipolar disorder
The physician has ordered dressings with Sulfamylon cream for a client with full-thickness burns of the hands and arms. Before dressing changes, the nurse should give priority to:
Administering pain medication
Checking the adequacy of urinary output
Requesting a daily complete blood count
Obtaining a blood glucose by finger stick
The nurse is teaching a group of parents about gross motor development of the toddler. Which behavior is an example of the normal gross motor skill of a toddler?
She can pull a toy behind her.
She can copy a horizontal line.
She can build a tower of eight blocks.
She can broad-jump.
A client hospitalized with a fractured mandible is to be discharged. Which piece of equipment should be kept on the client with a fractured mandible?
Wire cutters
Oral airway
Pliers
Tracheostomy set
The nurse is to administer digoxin elixir to a 6-month-old with a congenital heart defect. The nurse auscultates an apical pulse rate of The nurse should:
Record the heart rate and call the physician
Record the heart rate and administer the medication
Administer the medication and recheck the heart rate in 15 minutes
Hold the medication and recheck the heart rate in 30 minutes
A mother of a 3-year-old hospitalized with lead poisoning asks the nurse to explain the treatment for her daughter. The nurse's explanation is based on the knowledge that lead poisoning is treated with:
Gastric lavage
Chelating agents
Antiemetics
Activated charcoal
An 18-month-old is scheduled for a cleft palate repair. The usual type of restraints for the child with a cleft palate repair are:
Elbow restraints
Full arm restraints
Wrist restraints
Mummy restraints
A client with glaucoma has been prescribed Timoptic (timolol) eyedrops. Timoptic should be used with caution in the client with a history of:
Diabetes
Gastric ulcers
Emphysema
Pancreatitis
An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help decrease the client's confusion by:
Assigning a nursing assistant to sit with him until he falls asleep
Allowing the client to room with another elderly client
Administering a bedtime sedative
Leaving a nightlight on during the evening and night shifts
Which of the following is a common complaint of the client with end-stage renal failure?
Weight loss
Itching
Ringing in the ears
Bruising
Which of the following medication orders needs further clarification?
Darvocet 65mg PO q 4–6 hrs. PRN
Nembutal 100mg PO at bedtime
Coumadin 10mg PO
Estrace 2mg PO q day
The best diet for the client with Meniere's syndrome is one that is:
High in fiber
Low in sodium
High in iodine
Low in fiber
Which of the following findings is associated with right-sided heart failure?
Shortness of breath
Nocturnal polyuria
Daytime oliguria
Crackles in the lungs
An 8-year-old admitted with an upper-respiratory infection has an order for O2 saturation via pulse oximeter. To ensure an accurate reading, the nurse should:
Place the probe on the child's abdomen
Recalibrate the oximeter at the beginning of each shift
Apply the probe and wait 15 minutes before obtaining a reading
Place the probe on the child's finger
An infant with Tetralogy of Fallot is discharged with a prescription for lanoxin elixir. The nurse should instruct the mother to:
Administer the medication using a nipple
Administer the medication using the calibrated dropper in the bottle
Administer the medication using a plastic baby spoon
Administer the medication in a baby bottle with 1oz. of water
The client scheduled for electroconvulsive therapy tells the nurse, "I'm so afraid. What will happen to me during the treatment?" Which of the following statements is most therapeutic for the nurse to make?
"You will be given medicine to relax you during the treatment."
"The treatment will produce a controlled grand mal seizure."
"The treatment might produce nausea and headache."
"You can expect to be sleepy and confused for a time after the treatment."
Which of the following skin lesions is associated with Lyme's disease?
Bull's eye rash
Papular crusts
Bullae
Plaques
Which of the following snacks would be suitable for the child with gluten-induced enteropathy?
Soft oatmeal cookie
Buttered popcorn
Peanut butter and jelly sandwich
Cheese pizza
A client with schizophrenia is receiving chlorpromazine (Thorazine) 400mg twice a day. An adverse side effect of the medication is:
Photosensitivity
Elevated temperature
Weight gain
Elevated blood pressure
Which information should be given to the client taking phenytoin (Dilantin)?
Taking the medication with meals will increase its effectiveness.
The medication can cause sleep disturbances.
More frequent dental appointments will be needed for special gum care.
The medication decreases the effects of oral contraceptives.
A client has returned to his room following an esophagoscopy. Before offering fluids, the nurse should give priority to assessing the client's:
Level of consciousness
Gag reflex
Urinary output
Movement of extremities
Which instruction should be included in the discharge teaching for the client with cataract surgery?
Over-the-counter eyedrops can be used to treat redness and irritation.
The eye shield should be worn at night.
It will be necessary to wear special cataract glasses.
A prescription for medication to control post-operative pain will be needed.
An 8-year-old is admitted with drooling, muffled phonation, and a temperature of 102°F. The nurse should immediately notify the doctor because the child's symptoms are suggestive of:
Strep throat
Epiglottitis
Laryngotracheobronchitis
Bronchiolitis
Phototherapy is ordered for a newborn with physiologic jaundice. The nurse caring for the infant should:
Offer the baby sterile water between feedings of formula
Apply an emollient to the baby's skin to prevent drying
Wear a gown, gloves, and a mask while caring for the infant
Place the baby on enteric isolation
A teen hospitalized with anorexia nervosa is now permitted to leave her room and eat in the dining room. Which of the following nursing interventions should be included in the client's plan of care?
Weighing the client after she eats
Having a staff member remain with her for 1 hour after she eats
Placing high-protein foods in the center of the client's plate
Providing the client with child-size utensils
According to Erickson's stage of growth and development, the developmental task associated with middle childhood is:
Trust
Initiative
Independence
Industry
The nurse should observe for side effects associated with the use of bronchodilators. A common side effect of bronchodilators is:
Tinnitus
Nausea
Ataxia
Hypotension
The 5-minute Apgar of a baby delivered by C-section is recorded as 9. The most likely reason for this score is:
The mottled appearance of the trunk
The presence of conjunctival hemorrhages
Cyanosis of the hands and feet
Respiratory rate of 20–28 per minute
A 5-month-old infant is admitted to the ER with a temperature of 6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
Periorbital edema
Tenseness of the anterior fontanel
Positive Babinski reflex
Negative scarf sign
A client with a bowel resection and anastamosis returns to his room with an NG tube attached to intermittent suction. Which of the following observations indicates that the nasogastric suction is working properly?
The client's abdomen is soft.
The client is able to swallow.
The client has active bowel sounds.
The client's abdominal dressing is dry and intact.
The nurse is teaching the client with insulin-dependent diabetes the signs of hypoglycemia. Which of the following signs is associated with hypoglycemia?
Tremulousness
Slow pulse
Nausea
Flushed skin
Which of the following symptoms is associated with exacerbation of multiple sclerosis?
Anorexia
Seizures
Diplopia
Insomnia
Which of the following conditions is most likely related to the development of renal calculi?
Gout
Pancreatitis
Fractured femur
Disc disease
A client with AIDS is admitted for treatment of wasting syndrome. Which of the following dietary modifications can be used to compensate for the limited absorptive capability of the intestinal tract?
Thoroughly cooking all foods
Offering yogurt and buttermilk between meals
Forcing fluids
Providing small, frequent meals
The treatment protocol for a client with acute lymphatic leukemia includes prednisone, methotrexate, and cimetadine. The purpose of the cimetadine is to:
Decrease the secretion of pancreatic enzymes
Enhance the effectiveness of methotrexate
Promote peristalsis
Prevent a common side effect of prednisone
Which of the following meal choices is suitable for a 6-month-old infant?
Egg white, formula, and orange juice
Apple juice, carrots, whole milk
Rice cereal, apple juice, formula
Melba toast, egg yolk, whole milk
The LPN is preparing to administer an injection of vitamin K to the newborn. The nurse should administer the injection in the:
Rectus femoris muscle
Vastus lateralis muscle
Deltoid muscle
Dorsogluteal muscle
The physician has prescribed Cytoxan (cyclophosphamide) for a client with nephotic syndrome. The nurse should:
Encourage the client to drink extra fluids
Request a low-protein diet for the client
Bathe the client using only mild soap and water
Provide additional warmth for swollen, inflamed joints
The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal?
Antabuse (disulfiram)
Romazicon (flumazenil)
Dolophine (methodone)
Ativan (lorazepam)
A client with insulin-dependent diabetes takes 20 units of NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at:
8 a.m.
10 a.m.
3 p.m.
5 a.m.
The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnoses should receive priority?
Alteration in comfort
Alteration in mobility
Alteration in skin integrity
Alteration in O2 perfusion
The primary purpose for using a CPM machine for the client with a total knee repair is to help:
Prevent contractures
Promote flexion of the artificial joint
Decrease the pain associated with early ambulation
Alleviate lactic acid production in the leg muscles
Which of the following statements reflects Kohlberg's theory of the moral development of the preschool-age child?
Obeying adults is seen as correct behavior.
Showing respect for parents is seen as important.
Pleasing others is viewed as good behavior.
Behavior is determined by consequences.
A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:
Determine whether the ear infection has affected her hearing
Make sure that she has taken all the antibiotic
Document that the infection has completely cleared
Obtain a new prescription in case the infection recurs
A factory worker is brought to the nurse's office after a metal fragment enters his right eye. The nurse should:
Cover the right eye with a sterile 4x4
Attempt to remove the metal with a cotton-tipped applicator
Flush the eye for 10 minutes with running water
Cover both eyes and transport the client to the ER
The nurse is caring for a client with systemic lupus erythematosis (SLE). The major complication associated with systemic lupus erythematosis is:
Nephritis
Cardiomegaly
Desquamation
Meningitis
Which diet is associated with an increased risk of colorectal cancer?
Low protein, complex carbohydrates
High protein, simple carbohydrates
High fat, refined carbohydrates
Low carbohydrates, complex proteins
The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid:
Holding the infant
Offering a pacifier
Providing a mobile
Offering sterile water
The physician has ordered Amoxil (amoxicillin) 500mg capsules for a client with esophageal varices. The nurse can best care for the client's needs by:
Giving the medication as ordered
Providing extra water with the medication
Giving the medication with an antacid
Requesting an alternate form of the medication
The nurse is providing dietary instructions for a client with iron-deficiency anemia. Which food is a poor source of iron?
Tomatoes
Legumes
Dried fruits
Nuts
The nurse is teaching a client with Parkinson's disease ways to prevent curvatures of the spine associated with the disease. To prevent spinal flexion, the nurse should tell the client to:
Periodically lie prone without a neck pillow
Sleep only in dorsal recumbent position
Rest in supine position with his head elevated
Sleep on either side but keep his back straight
The nurse is planning dietary changes for a client following an episode of pancreatitis. Which diet is suitable for the client?
Low calorie, low carbohydrate
High calorie, low fat
High protein, high fat
Low protein, high carbohydrate
A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she:
Uses an electric blanket at night
Dresses in extra layers of clothing
Applies a heating pad to her feet
Takes a hot bath morning and evening
A client has been hospitalized with a diagnosis of laryngeal cancer. Which factor is most significant in the development of laryngeal cancer?
A family history of laryngeal cancer
Chronic inhalation of noxious fumes
Frequent straining of the vocal cords
A history of alcohol and tobacco use
The nurse is completing an assessment history of a client with pernicious anemia. Which complaint differentiates pernicious anemia from other types of anemia?
Difficulty in breathing after exertion
Numbness and tingling in the extremities
A faster-than-usual heart rate
Feelings of lightheadedness
The chart of a client with schizophrenia states that the client has echolalia. The nurse can expect the client to:
Speak using words that rhyme
Repeat words or phrases used by others
Include irrelevant details in conversation
Make up new words with new meanings
Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis?
Brushing the teeth
Drinking a glass of juice
Drinking a cup of coffee
Brushing the hair
A newborn weighed 7 pounds at birth. At 6 months of age, the infant could be expected to weigh:
14 pounds
18 pounds
25 pounds
30 pounds
A client with nontropical sprue has an exacerbation of symptoms. Which meal selection is responsible for the recurrence of the client's symptoms?
Tossed salad with oil and vinegar dressing
Baked potato with sour cream and chives
Cream of tomato soup and crackers
Mixed fruit and yogurt
A client with congestive heart failure has been receiving Digoxin (lanoxin). Which finding indicates that the medication is having a desired effect?
Increased urinary output
Stabilized weight
Improved appetite
Increased pedal edema
Which play activity is best suited to the gross motor skills of the toddler?
Coloring book and crayons
Ball
Building cubes
Swing set
The physician has ordered Basalgel (aluminum carbonate gel) for a client with recurrent indigestion. The nurse should teach the client common side effects of the medication, which include:
Constipation
Urinary retention
Diarrhea
Confusion
A client is admitted with suspected abdominal aortic aneurysm (AAA). A common complaint of the client with an abdominal aortic aneurysm is:
Loss of sensation in the lower extremities
Back pain that lessens when standing
Decreased urinary output
Pulsations in the periumbilical area
A client is admitted with acute adrenal crisis. During the intake assessment, the nurse can expect to find that the client has:
Low blood pressure
Slow, regular pulse
Warm, flushed skin
Increased urination
An elderly client is hospitalized for a transurethral prostatectomy. Which finding should be reported to the doctor immediately?
Hourly urinary output of 40–50cc
Bright red urine with many clots
Dark red urine with few clots
Requests for pain med q 4 hrs.
A 9-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of polymigratory arthritis?
Irregular movements of the extremities and facial grimacing
Painless swelling over the extensor surfaces of the joints
Faint areas of red demarcation over the back and abdomen
Swelling, inflammation, and effusion of the joints
A child with croup is placed in a cool, high-humidity tent connected to room air. The primary purpose of the tent is to:
Prevent insensible water loss
Provide a moist environment with oxygen at 30%
Prevent dehydration and reduce fever
Liquefy secretions and relieve laryngeal spasm
A client is admitted with a diagnosis of hypothyroidism. An initial assessment of the client would reveal:
Slow pulse rate, weight loss, diarrhea, and cardiac failure
Weight gain, lethargy, slowed speech, and decreased respiratory rate
Rapid pulse, constipation, and bulging eyes
Decreased body temperature, weight loss, and increased respirations
Which statement describes the contagious stage of varicella?
The contagious stage is 1 day before the onset of the rash until the appearance of vesicles.
The contagious stage lasts during the vesicular and crusting stages of the lesions.
The contagious stage is from the onset of the rash until the rash disappears.
The contagious stage is 1 day before the onset of the rash until all the lesions are crusted.
A client admitted to the psychiatric unit claims to be the Son of God and insists that he will not be kept away from his followers. The most likely explanation for the client's delusion is:
A religious experience
A stressful event
Low self-esteem
Overwhelming anxiety
The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?
Reluctance to swallow
Drooling of blood-tinged saliva
An axillary temperature of 99°F
Respiratory stridor
The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort lessens when he:
Skips a meal
Rests in recumbent position
Eats a meal
Sits upright after eating
Which of the following meal selections is appropriate for the client with celiac disease?
Toast, jam, and apple juice
Peanut butter cookies and milk
Rice Krispies bar and milk
Cheese pizza and Kool-Aid
A client with hyperthyroidism is taking lithium carbonate to inhibit thyroid hormone release. Which complaint by the client should alert the nurse to a problem with the client's medication?
The client complains of blurred vision.
The client complains of increased thirst and increased urination.
The client complains of increased weight gain over the past year.
The client complains of ringing in the ears.
A 2-month-old infant has just received her first Tetramune injection. The nurse should tell the mother that the immunization:
Will need to be repeated when the child is 4 years of age
Is given to determine whether the child is susceptible to pertussis
Is one of a series of injections that protects against dpt and Hib
Is a one-time injection that protects against MMR and varicella
The nurse is caring for a client hospitalized with bipolar disorder, manic phase. Which of the following snacks would be best for the client with mania?
Potato chips
Diet cola
Apple
Milkshake
A 2-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?
"Currant jelly" stools
Projectile vomiting
"Ribbonlike" stools
Palpable mass over the flank
A client is being treated for cancer with linear acceleration radiation. The physician has marked the radiation site with a blue marking pen. The nurse should:
Remove the unsightly markings with acetone or alcohol
Cover the radiation site with loose gauze dressing
Sprinkle baby powder over the radiated area
Refrain from using soap or lotion on the marked area
The nurse is caring for a client with acromegaly. Following a transphenoidal hypophysectomy, the nurse should:
Monitor the client's blood sugar
Suction the mouth and pharynx every hour
Place the client in low Trendelenburg position
Encourage the client to cough
A client newly diagnosed with diabetes is started on Precose (acarbose). The nurse should tell the client that the medication should be taken:
1 hour before meals
30 minutes after meals
With the first bite of a meal
Daily at bedtime
A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should:
Apply a lanolin-based lotion to the skin
Wash the skin with water and pat dry
Cover the area with a petroleum gauze
Apply an occlusive dressing to the site
A client with a laryngectomy returns from surgery with a nasogastric tube in place. The primary reason for placement of the nasogastric tube is to:
Prevent swelling and dysphagia
Decompress the stomach via suction
Prevent contamination of the suture line
Promote healing of the oral mucosa
The chart indicates that a client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with:
Speaking and writing
Comprehending spoken words
Carrying out purposeful motor activity
Recognizing and using an object correctly
A camp nurse is applying sunscreen to a group of children enrolled in swim classes. Chemical sunscreens are most effective when applied:
Just before sun exposure
5 minutes before sun exposure
15 minutes before sun exposure
30 minutes before sun exposure
A post-operative client has an order for Demerol (meperidine) 75mg and Phenergan (promethazine) 25mg IM every 3–4 hours as needed for pain. The combination of the two medications produces a/an:
Agonist effect
Synergistic effect
Antagonist effect
Excitatory effect
Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:
Record the pulse rate and administer the medication
Administer the medication and monitor the heart rate
Withhold the medication and notify the doctor
Withhold the medication until the heart rate increases
What information should the nurse give a new mother regarding the introduction of solid foods for her infant?
Solid foods should not be given until the extrusion reflex disappears, at 8–10 months of age.
Solid foods should be introduced one at a time, with 4- to 7-day intervals.
Solid foods can be mixed in a bottle or infant feeder to make feeding easier.
Solid foods should begin with fruits and vegetables.
A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:
Withholding all morning medications
Ordering a CBC and CPK
Administering prescribed anti-Parkinsonian medication
Transferring the client to a medical unit
A client with human immunodeficiency syndrome has gastrointestinal symptoms, including diarrhea. The nurse should teach the client to avoid:
Calcium-rich foods
Canned or frozen vegetables
Processed meat
Raw fruits and vegetables
A 4-year-old is admitted with acute leukemia. It will be most important to monitor the child for:
Abdominal pain and anorexia
Fatigue and bruising
Bleeding and pallor
Petechiae and mucosal ulcers
A 5-month-old is diagnosed with atopic dermatitis. Nursing interventions will focus on:
Preventing infection
Administering antipyretics
Keeping the skin free of moisture
Limiting oral fluid intake
The nurse is caring for a client with a history of diverticulitis. The client complains of abdominal pain, fever, and diarrhea. Which food was responsible for the client's symptoms?
Mashed potatoes
Steamed carrots
Baked fish
Whole-grain cereal
The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client's cancer is located in:
The tail of the pancreas
The head of the pancreas
The body of the pancreas
The entire pancreas
A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is:
Weight gain
Hair loss
Sore throat
Brittle nails
The doctor has ordered Percocet (oxycodone) for a client following abdominal surgery. The primary objective of nursing care for the client receiving an opiate analgesic is to:
Prevent addiction
Alleviate pain
Facilitate mobility
Prevent nausea
Which finding is the best indication that a client with ineffective airway clearance needs suctioning?
Oxygen saturation
Respiratory rate
Breath sounds
Arterial blood gases
A client with tuberculosis has a prescription for Myambutol (ethambutol HCl). The nurse should tell the client to notify the doctor immediately if he notices:
Gastric distress
Changes in hearing
Red discoloration of bodily fluids
Changes in color vision
The primary cause of anemia in a client with chronic renal failure is:
Poor iron absorption
Destruction of red blood cells
Lack of intrinsic factor
Insufficient erythropoietin
Which of the following nursing interventions has the highest priority for the client scheduled for an intravenous pyelogram?
Providing the client with a favorite meal for dinner
Asking if the client has allergies to shellfish
Encouraging fluids the evening before the test
Telling the client what to expect during the test
The doctor has prescribed aspirin 325mg daily for a client with transient ischemic attacks. The nurse knows that aspirin was prescribed to:
Prevent headaches
Boost coagulation
Prevent cerebral anoxia
Keep platelets from clumping together
A client with tuberculosis asks the nurse how long he will have to take medication. The nurse should tell the client that:
Medication is rarely needed after 2 weeks.
He will need to take medication the rest of his life.
The course of therapy is usually 18–24 months.
He will be re-evaluated in 1 month to see if further medication is needed.
Which development milestone puts the 4-month-old infant at greatest risk for injury?
Switching objects from one hand to another
Crawling
Standing
Rolling over
A client taking Dilantin (phenytoin) for grand mal seizures is preparing for discharge. Which information should be included in the client's discharge care plan?
The medication can cause dental staining.
The client will need to avoid a high-carbohydrate diet.
The client will need a regularly scheduled CBC.
The medication can cause problems with drowsiness.
Assessment of a newborn male reveals that the infant has hypospadias. The nurse knows that:
The infant should not be circumcised.
Surgical correction will be done by 6 months of age.
Surgical correction is delayed until 6 years of age.
The infant should be circumcised to facilitate voiding.
The nurse is providing dietary teaching for a client with elevated cholesterol levels. Which cooking oil is not suggested for the client on a low-cholesterol diet?
Safflower oil
Sunflower oil
Coconut oil
Canola oil
The nurse is caring for a client with stage III Alzheimer's disease. A characteristic of this stage is:
Memory loss
Failing to recognize familiar objects
Wandering at night
Failing to communicate
The doctor has prescribed Cortone (cortisone) for a client with systemic lupus erythematosis. Which instruction should be given to the client?
Take the medication 30 minutes before eating.
Report changes in appetite and weight.
Wear sunglasses to prevent cataracts.
Schedule a time to take the influenza vaccine.
The nurse is caring for a client with an above-the-knee amputation (AKA). To prevent contractures, the nurse should:
Place the client in a prone position 15–30 minutes twice a day
Keep the foot of the bed elevated on shock blocks
Place trochanter rolls on either side of the affected leg
Keep the client's leg elevated on two pillows
The mother of a 6-month-old asks when her child will have all his baby teeth. The nurse knows that most children have all their primary teeth by age:
12 months
18 months
24 months
30 months
While caring for a client with cervical cancer, the nurse notes that the radioactive implant is lying in the bed. The nurse should:
Place the implant in a biohazard bag and return it to the lab
Give the client a pair of gloves and ask her to reinsert the implant
Use tongs to pick up the implant and return it to a lead-lined container
Discard the implant in the commode and double-flush
The nurse is preparing to discharge a client following a laparoscopic cholecystectomy. The nurse should:
Tell the client to avoid a tub bath for 48 hours
Tell the client to expect clay-colored stools
Tell the client that she can expect lower abdominal pain for the next week
Tell the client that she can resume a regular diet in the next 24 hours
A high school student returns to school following a 3-week absence due to mononucleosis. The school nurse knows it will be important for the client:
To drink additional fluids throughout the day
To avoid contact sports for 1–2 months
To have a snack twice a day to prevent hypoglycemia
To continue antibiotic therapy for 6 months
A 6-year-old with cystic fibrosis has an order for Creon. The nurse knows that the medication will be given:
At bedtime
With meals and snacks
Twice daily
Daily in the morning
The doctor has prescribed a diet high in vitamin B12 for a client with pernicious anemia. Which foods are highest in B12?
Meat, eggs, dairy products
Peanut butter, raisins, molasses
Broccoli, cauliflower, cabbage
Shrimp, legumes, bran cereals
A client with hypertension has begun an aerobic exercise program. The nurse should tell the client that the recommended exercise regimen should begin slowly and build up to:
20–30 minutes three times a week
45 minutes two times a week
1 hour four times a week
1 hour two times a week
A client with breast cancer is returned to the room following a right total mastectomy. The nurse should:
Elevate the client's right arm on pillows
Place the client's right arm in a dependent sling
Keep the client's right arm on the bed beside her
Place the client's right arm across her body
A neurological consult has been ordered for a pediatric client with suspected petit mal seizures. The client with petit mal seizures can be expected to have:
Short, abrupt muscle contraction
Quick, bilateral severe jerking movements
Abrupt loss of muscle tone
A brief lapse in consciousness
A client with schizoaffective disorder is exhibiting Parkinsonian symptoms. Which medication is responsible for the development of Parkinsonian symptoms?
Zyprexa (olanzapine)
Cogentin (benzatropine mesylate)
Benadryl (diphenhydramine)
Depakote (divalproex sodium)
Which activity is best suited to the 12-year-old with juvenile rheumatoid arthritis?
Playing video games
Swimming
Working crossword puzzles
Playing slow-pitch softball
The glycosylated hemoglobin of a 40-year-old client with diabetes mellitus is 2.5%. The nurse understands that:
The client can have a higher-calorie diet.
The client has good control of her diabetes.
The client requires adjustment in her insulin dose.
The client has poor control of her diabetes.
The physician has ordered Stadol (butorphanol) for a post-operative client. The nurse knows that the medication is having its intended effect if the client:
Is asleep 30 minutes after the injection
Asks for extra servings on his meal tray
Has an increased urinary output
States that he is feeling less nauseated
The mother of a child with cystic fibrosis tells the nurse that her child makes "snoring" sounds when breathing. The nurse is aware that many children with cystic fibrosis have:
Choanal atresia
Nasal polyps
Septal deviations
Enlarged adenoids
A client is hospitalized with hepatitis A. Which of the client's regular medications is contraindicated due to the current illness?
Prilosec (omeprazole)
Synthroid (levothyroxine)
Premarin (conjugated estrogens)
Lipitor (atorvastatin)
The nurse has been teaching the role of diet in regulating blood pressure to a client with hypertension. Which meal selection indicates that the client understands his new diet?
Cornflakes, whole milk, banana, and coffee
Scrambled eggs, bacon, toast, and coffee
Oatmeal, apple juice, dry toast, and coffee
Pancakes, ham, tomato juice, and coffee
An 18-month-old is being discharged following hypospadias repair. Which instruction should be included in the nurse's discharge teaching?
The child should not play on his rocking horse.
Applying warm compresses to decrease pain.
Diapering should be avoided for 1–2 weeks.
The child will need a special diet to promote healing.
An obstetrical client calls the clinic with complaints of morning sickness. The nurse should tell the client to:
Keep crackers at the bedside for eating before she arises
Drink a glass of whole milk before going to sleep at night
Skip breakfast but eat a larger lunch and dinner
Drink a glass of orange juice after adding a couple of teaspoons of sugar
The nurse has taken the blood pressure of a client hospitalized with methicillin-resistant staphylococcus aureus. Which action by the nurse indicates an understanding regarding the care of clients with MRSA?
The nurse leaves the stethoscope in the client's room for future use.
The nurse cleans the stethoscope with alcohol and returns it to the exam room.
The nurse uses the stethoscope to assess the blood pressure of other assigned clients.
The nurse cleans the stethoscope with water, dries it, and returns it to the nurse's station.
The physician has discussed the need for medication with the parents of an infant with congenital hypothyroidism. The nurse can reinforce the physician's teaching by telling the parents that:
The medication will be needed only during times of rapid growth.
The medication will be needed throughout the child's lifetime.
The medication schedule can be arranged to allow for drug holidays.
The medication is given one time daily every other day.
A client with diabetes mellitus has a prescription for Glucotrol XL (glipizide). The client should be instructed to take the medication:
At bedtime
With breakfast
Before lunch
After dinner
The nurse is caring for a client admitted with suspected myasthenia gravis. Which finding is usually associated with a diagnosis of myasthenia gravis?
Visual disturbances, including diplopia
Ascending paralysis and loss of motor function
Cogwheel rigidity and loss of coordination
Progressive weakness that is worse at the day's end
The nurse is teaching the parents of a newborn with osteogenesis imperfecta. The nurse should tell the parents:
That the baby will need daily calcium supplements
To lift the baby by the buttocks when diapering
That the condition is a temporary one
That only the bones are affected by the disease
Physician's orders for a client with acute pancreatitis include the following: strict NPO, NG tube to low intermittent suction. The nurse recognizes that these interventions will:
Reduce the secretion of pancreatic enzymes
Decrease the client's need for insulin
Prevent secretion of gastric acid
Eliminate the need for analgesia
A client with diverticulitis is admitted with nausea, vomiting, and dehydration. Which finding suggests a complication of diverticulitis?
Pain in the left lower quadrant
Boardlike abdomen
Low-grade fever
Abdominal distention
The diagnostic work-up of a client hospitalized with complaints of progressive weakness and fatigue confirms a diagnosis of myasthenia gravis. The medication used to treat myasthenia gravis is:
Prostigmine (neostigmine)
Atropine (atropine sulfate)
Didronel (etidronate)
Tensilon (edrophonium)
A client with AIDS complains of a weight loss of 20 pounds in the past month. Which diet is suggested for the client with AIDS?
High calorie, high protein, high fat
High calorie, high carbohydrate, low protein
High calorie, low carbohydrate, high fat
High calorie, high protein, low fat
The nurse is caring for a 4-year-old with cerebral palsy. Which nursing intervention will help ready the child for rehabilitative services?
Patching one of the eyes to strengthen the muscles
Providing suckers and pinwheels to help strengthen tongue movement
Providing musical tapes to provide auditory training
Encouraging play with a video game to improve muscle coordination
At the 6-week check-up, the mother asks when she can expect the baby to sleep all night. The nurse should tell the mother that most infants begin to sleep all night by age:
1 month
2 months
3–4 months
5–6 months
Which of the following pediatric clients is at greatest risk for latex allergy?
The child with a myelomeningocele
The child with epispadias
The child with coxa plana
The child with rheumatic fever
The nurse is teaching the mother of a child with cystic fibrosis how to do postural drainage. The nurse should tell the mother to:
Use the heel of her hand during percussion
Change the child's position every 20 minutes
Do percussion after the child eats and at bedtime
Use cupped hands during percussion
The nurse calculates the amount of an antibiotic for injection to be given to an infant. The amount of medication to be administered is 1.25mL. The nurse should:
Divide the amount into two injections and administer in each vastus lateralis muscle
Give the medication in one injection in the dorsogluteal muscle
Divide the amount in two injections and give one in the ventrogluteal muscle and one in the vastus lateralis muscle
Give the medication in one injection in the ventrogluteal muscle
A client with schizophrenia is receiving depot injections of Haldol Deconate (haloperidol decanoate). The client should be told to return for his next injection in:
1 week
2 weeks
4 weeks
6 weeks
A 3-year-old is immobilized in a hip spica cast. Which discharge instruction should be given to the parents?
Keep the bed flat, with a small pillow beneath the cast
Provide crayons and a coloring book for play activity
Increase her intake of high-calorie foods for healing
Tuck a disposable diaper beneath the cast at the perineal opening
The nurse is caring for a client following the reimplantation of the thumb and index finger. Which finding should be reported to the physician immediately?
Temperature of 100°F
Coolness and discoloration of the digits
Complaints of pain
Difficulty moving the digits
When assessing the urinary output of a client who has had extracorporeal lithotripsy, the nurse can expect to find:
Cherry-red urine that gradually becomes clearer
Orange-tinged urine containing particles of calculi
Dark red urine that becomes cloudy in appearance
Dark, smoky-colored urine with high specific gravity
The physician has prescribed Cognex (tacrine) for a client with dementia. The nurse should monitor the client for adverse reactions, which include:
Hypoglycemia
Jaundice
Urinary retention
Tinnitus
The physician has ordered a low-potassium diet for a child with acute glomerulonephritis. Which snack is suitable for the child with potassium restrictions?
Raisins
Oranges
Apricots
Bananas
The physician has ordered a blood test for H. pylori. The nurse should prepare the client by:
Withholding intake after midnight
Telling the client that no special preparation is needed
Explaining that a small dose of radioactive isotope will be used
Giving an oral suspension of glucose 1 hour before the test
The nurse is preparing to give an oral potassium supplement. The nurse should:
Give the medication without diluting it
Give the medication with 4oz. of juice
Give the medication with water only
Give the medication on an empty stomach
The physician has ordered cultures for cytomegalovirus (CMV). Which statement is true regarding collection of cultures for cytomegalovirus?
Stool cultures are preferred for definitive diagnosis.
Pregnant caregivers may obtain cultures.
Collection of one specimen is sufficient.
Accurate diagnosis depends on fresh specimens.
A pediatric client with burns to the hands and arms has dressing changes with Sulfamylon (mafenide acetate) cream. The nurse is aware that the medication:
Will cause dark staining of the surrounding skin
Produces a cooling sensation when applied
Can alter the function of the thyroid
Produces a burning sensation when applied
The physician has ordered Dilantin (phenytoin) for a client with generalized seizures. When planning the client's care, the nurse should:
Maintain strict intake and output
Check the pulse before giving the medication
Administer the medication 30 minutes before meals
Provide oral hygiene and gum care every shift
A client receiving chemotherapy for breast cancer has an order for Zofran (ondansetron) 8mg PO to be given 30 minutes before induction of the chemotherapy. The purpose of the medication is to:
Prevent anemia
Promote relaxation
Prevent nausea
Increase neutrophil counts
The physician has ordered cortisporin ear drops for a 2-year-old. To administer the ear drops, the nurse should:
Pull the ear down and back
Pull the ear straight out
Pull the ear up and back
Leave the ear undisturbed
A client with schizophrenia has been taking Thorazine (chlorpromazine) 200mg four times a day. Which finding should be reported to the doctor immediately?
The client complains of thirst
The client has gained 4 pounds in the past 2 months
The client complains of a sore throat
The client naps throughout the day
A client with iron-deficiency anemia is taking an oral iron supplement. The nurse should tell the client to take the medication with:
Orange juice
Water only
Milk
Apple juice
A client is admitted with burns of the right arm, chest, and head. According to the Rule of Nines, the percent of burn injury is:
A client who was admitted with chest pain and shortness of breath has a standing order for oxygen via mask. Standing orders for oxygen mean that the nurse can apply oxygen at:
2L per minute
6L per minute
10L per minute
12L per minute
The nurse is caring for a client with an ileostomy. The nurse should pay careful attention to care around the stoma because:
Digestive enzymes cause skin breakdown.
Stools are less watery and contain more solid matter.
The stoma will heal more slowly than expected.
It is difficult to fit the appliance to the stoma site.
The physician has ordered aspirin therapy for a client with severe rheumatoid arthritis. A sign of acute aspirin toxicity is:
Anorexia
Diarrhea
Tinnitus
Pruritis
A client is admitted to the emergency room with symptoms of delirium tremens. After admitting the client to a private room, the priority nursing intervention is to:
Obtain a history of his alcohol use
Provide seizure precautions
Keep the room cool and dark
Administer thiamine and zinc
The nurse is providing dietary teaching for a client with gout. Which dietary selection is suitable for the client with gout?
Broiled liver, macaroni and cheese, spinach
Stuffed crab, steamed rice, peas
Baked chicken, pasta salad, asparagus casserole
Steak, baked potato, tossed salad
A newborn has been diagnosed with exstrophy of the bladder. The nurse should position the newborn:
Prone
Supine
On either side
With the head elevated
The mother of a 3-month-old with esophageal reflux asks the nurse what she can do to lessen the baby's reflux. The nurse should tell the mother to:
Feed the baby only when he is hungry
Burp the baby after the feeding is completed
Place the baby supine with head elevated
Burp the baby frequently throughout the feeding
A child is hospitalized with a fractured femur involving the epiphysis. Epiphyseal fractures are serious because:
Bone marrow is lost through the fracture site.
Normal bone growth is affected.
Blood supply to the bone is obliterated.
Callus formation prevents bone healing.
Before administering a nasogastric feeding to a client hospitalized following a CVA, the nurse aspirates 40mL of residual. The nurse should:
Replace the aspirate and administer the feeding
Discard the aspirate and withhold the feeding
Discard the aspirate and begin the feeding
Replace the aspirate and withhold the feeding
A client has an order for Dilantin (phenytoin) .2g orally twice a day. The medication is available in 100mg capsules. For the morning medication, the nurse should administer:
1 capsule
2 capsules
3 capsules
4 capsules
The LPN is reviewing the lab results of an elderly client when she notes a specific gravity of 1. The nurse recognizes that:
The client has impaired renal function.
The client has a normal specific gravity.
The client has mild to moderate dehydration.
The client has diluted urine from fluid overload.
A client with pancreatitis has requested pain medication. Which pain medication is indicated for the client with pancreatitis?
Demerol (meperidine)
Toradol (ketorolac)
Morphine (morphine sulfate)
Codeine (codeine)
A client with a hiatal hernia has been taking magnesium hydroxide for relief of heartburn. Overuse of magnesium-based antacids can cause the client to have:
Constipation
Weight gain
Anorexia
Diarrhea
When performing a newborn assessment, the nurse measures the circumference of the neonate's head and chest. Which assessment finding is expected in the normal newborn?
The head and chest circumference are the same.
The head is 2cm larger than the chest.
The head is 3cm smaller than the chest.
The head is 4cm larger than the chest.
A client with a history of emboli is receiving Lovenox (enoxaparin). Which drug is given to counteract the effects of enoxaparin?
Calcium gluconate
Aquamephyton
Methergine
Protamine sulfate
The nurse is formulating a plan of care for a client with a cognitive disorder. Which activity is most appropriate for the client with confusion and short attention span?
Taking part in a reality-orientation group
Participating in unit community goal setting
Going on a field trip with a group of clients
Meeting with an assertiveness training group
The mother of a child with hemophilia asks the nurse which over-the-counter medication is suitable for her child's joint discomfort. The nurse should tell the mother to purchase:
Advil (ibuprofen)
Tylenol (acetaminophen)
Aspirin (acetylsalicytic acid)
Naproxen (naprosyn)
Which home remedy is suitable to relieve the itching associated with varicella?
Dusting the lesions with baby powder
Applying gauze saturated in hydrogen peroxide
Using cool compresses of normal saline
Applying a paste of baking soda and water
A newborn male has been diagnosed with hypospadias with chordee. The nurse understands that the infant will have altered patterns of urination because:
The urinary meatus is on the dorsum of the penis.
The ureters will reflux urine into the kidneys.
The urinary meatus is on the top of the penis.
The bladder lies outside the abdominal cavity.
The recommended time for administering Zantac (ranitidine) is:
Before breakfast
Midafternoon
After dinner
At bedtime
Which statement best describes the difference between the pain of angina and the pain of myocardial infarction?
Pain associated with angina is relieved by rest.
Pain associated with myocardial infarction is always more severe.
Pain associated with angina is confined to the chest area.
Pain associated with myocardial infarction is referred to the left arm.
The nurse is developing a bowel-retraining plan for a client with multiple sclerosis. Which measure is likely to be least helpful to the client:
Limiting fluid intake to 1000mL per day
Providing a high-roughage diet
Elevating the toilet seat for easy access
Establishing a regular schedule for toileting
The nurse is providing dietary teaching for a client with Meniere's disease. Which statement indicates that the client understands the role of diet in triggering her symptoms?
"I can expect to see more problems with tinnitus if I eat a lot of dairy products."
"I need to limit foods that taste salty or that contain a lot of sodium."
"I can help control problems with vertigo if I avoid breads and cereals."
"I need to eat fewer foods that are high in potassium, such as raisins and bananas."
The nurse is assessing a multigravida, 36 weeks gestation for symptoms of pregnancy-induced hypertension and preeclampsia. The nurse should give priority to assessing the client for:
Facial swelling
Pulse deficits
Ankle edema
Diminished reflexes
An adolescent with borderline personality is hospitalized with suicidal ideation and self-mutilation. Which goal is both therapeutic and realistic for this client?
The client will remain in her room when feeling overwhelmed by sadness.
The client will request medication when feeling loss of emotional control.
The client will leave group activities to pace when feeling anxious.
The client will seek out a staff member to verbalize feelings of anger and sadness.
A client with angina has an order for nitroglycerin ointment. Before applying the medication, the nurse should:
Apply the ointment to the previous application
Obtain both a radial and an apical pulse
Remove the previously applied ointment
Tell the client he will experience pain relief in 15 minutes
The nurse is caring for a client who is unconscious following a fall. Which comment by the nurse will help the client become reoriented when he regains consciousness?
"I am your nurse and I will be taking care of you today."
"Can you tell me your name and where you are?"
"I know you are confused right now, but everything will be alright."
"You were in an accident that hurt your head. You are in the hospital."
Following a generalized seizure, the nurse can expect the client to:
Be unable to move the extremities
Be drowsy and prone to sleep
Remember events before the seizure
Have a drop in blood pressure
A client with oxylate renal calculi should be taught to avoid eating:
Strawberries
Oranges
Apples
Pears
A 6-year-old is diagnosed with Legg-Calve Perthes disease of the right femur. An important part of the child's care includes instructing the parents:
To increase the amount of dietary protein
About exercises to strengthen affected muscles
About relaxation exercises to minimize pain in the joints
To prevent weight bearing on the affected leg
The nurse is assessing an infant with Hirschsprung's disease. The nurse can expect the infant to:
Weigh less than expected for height and age
Have a scaphoid-shaped abdomen
Exhibit clubbing of the fingers and toes
Have hyperactive deep tendon reflexes
The physician has prescribed supplemental iron for a prenatal client. The nurse should tell the client to take the medication with:
Milk, to prevent stomach upset
Tomato juice, to increase absorption
Oatmeal, to prevent constipation
Water, to increase serum iron levels
The nurse is teaching a client with a history of obesity and hypertension regarding dietary requirements during pregnancy. Which statement indicates that the client needs further teaching?
"I need to reduce my daily intake to 1,200 calories a day."
"I need to drink at least a quart of milk a day."
"I shouldn't add salt when I am cooking."
"I need to eat more protein and fiber each day."
An elderly client is admitted to the psychiatric unit from the nursing home. Transfer information indicates that the client has become confused and disoriented, with behavioral problems. The client will also likely show a loss of ability in:
Speech
Judgment
Endurance
Balance
The physician has ordered an external monitor for a laboring client. If the fetus is in the left occipital posterior (LOP) position, the nurse knows that the ultrasound transducer will be located:
Near the symphysis pubis
Near the umbilicus
Over the fetal back
Over the fetal abdomen
A client develops tremors while withdrawing from alcohol. Which medication is routinely administered to lessen physiological effects of alcohol withdrawal?
Dolophine (methodone)
Klonopin (clonazepam)
Narcan (Naloxone)
Antabuse (disulfiram)
A client with Type II diabetes has an order for regular insulin 10 units SC each morning. The client's breakfast should be served within:
15 minutes
20 minutes
30 minutes
45 minutes
A 10-year-old has an order for Demerol (meperidine) 35mg IM for pain. The medication is available as Demerol 50mg per ml. How much should the nurse administer?
Which intervention would be recommended to the parents of a child experiencing nocturnal enuresis?
Use small night lights, so your child can easily find the way between the bedroom and bathroom. Encourage regular toilet use throughout the day. During the day and evening, suggest that your child urinate every two hours or so, or at least often enough to avoid a feeling of urgency. Prevent rashes.Which intervention would the plan of care include during the acute phase of a child diagnosed with nephrotic syndrome?
Nursing interventions for a child with nephrotic syndrome are: Monitoring fluid intake and output. Accurately monitor and document intake and output; weigh the child at the same time every day, on the same scale in the same clothing; measure the child's abdomen daily at the level of the umbilicus.When examining a postpartum woman the nurse should immediately report?
The nurse must report a PPH immediately and prepare for the insertion of a large-bore intravenous catheter, if one is not already present, and the administration of intravenous fluids and oxygen. In the case of an early PPH caused by damage to the birth canal, surgical repair is usually necessary.When explaining to the parents the optimal time for repair of hypospadias the nurse should indicate which as the age of choice?
Hypospadias is generally repaired for functional and cosmetic reasons. Surgical repair is desirable between the ages of 6 and 18 months.