NCLEX-RN Exam Part 11 (751-825)

NCLEX-RN Exam Part 11

QUESTION 751

A 23-year-old female client is brought to the emergency room by her roommate for repeatedly making superficial cuts on her wrists and experiencing wide mood swings. She is very angry and hostile. Her medical diagnosis is adjustment disorder versus borderline personality disorder. The client comments to the nurse, “Nobody in here seems to really

care about the clients. I thought nurses cared about people!” The client is exhibiting the ego defense mechanism:

A. Reaction formation

1. Rationalization
2. Splitting
3. Sublimation

 

QUESTION 752

A 38-year-old female client with a history of chronic schizophrenia, paranoid type, is currently an outpatient at the local mental health and mental retardation clinic. The client comes in once a week for medication evaluation and/or refills. She self-administers haloperidol 5 mg twice a day and benztropine 1 mg once a day. During a recent clinic visit, she says to the nurse, “I can’t stay still at night. I toss and turn and can’t fall asleep.” The nurse suspects that she may be experiencing:

1. Akathisia
2. Akinesia
3. Dystonia
4. Opisthotonos

 

QUESTION 753

Which of the following nursing orders has the highest priority for a child with epiglottitis?

A. Vital signs every shift

B. Tracheostomy set at bedside

C. Intake and output

D. Specific gravity every shift

 

 

QUESTION 754

Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack

A. Fresh fruit

B. A milkshake

C. Saltine crackers and peanut butter

D. A ham and cheese sandwich

 

QUESTION 755

Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?

A. Fresh fruit

B. A milkshake

C. Saltine crackers and peanut butter

D. A ham and cheese sandwich

 

QUESTION 756

Which of the following physician’s orders would the nurse question on a client with chronic arterial insufficiency?

A. Neurovascular checks every 2 hours

B. Elevate legs on pillows

C. Arteriogram in the morning

D. No smoking

 

QUESTION 757

 

In planning daily care for a client with multiple sclerosis, the nurse would take into consideration that multiple sclerosis:

A. Becomes progressively debilitating without remission

B. Has unpredictable remissions and exacerbations

C. Is rapidly fatal

D. Responds quickly to antimicrobial therapy

 

QUESTION 758

The nurse assesses a postoperative mastectomy client and notes that breath sounds are diminished in both posterior bases. The nurse’s action should be to:

A. Encourage coughing and deep breathing each hour

B. Obtain arterial blood gases

C. Increase O2 from 2–3 L/min

D. Remove the postoperative dressing to check for bleeding

 

QUESTION 759

A 6-year-old child returned to the surgical floor 20 hours ago after an appendectomy for a gangrenous appendix. His mother tells the nurse that he is becoming more restless and is anxious. Assessment findings indicate that the child has atelectasis. Appropriate nursing actions would include:

A. Allowing the child to remain in the position of comfort, preferably semi-or high-Fowler position B. Administering analgesics as ordered

C. Having the child turn, cough, and deep breathe every 1–2 hours

D. Remaining with the child and keeping as calm and quiet as possible

 

QUESTION 760

Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following statements by the client would validate an understanding of his medication?

A. “I would notify my physician immediately if I experience nausea, vomiting, and double vision.” B. “I could stop taking this medication when I begin to feel better.”

 

C. “I should only take the medication if my heart rate is greater than 100 bpm.” D. “I should always take this medication with an antacid.”

 

QUESTION 761

Cystic fibrosis is transmitted as an autosomal recessive trait. This means that:

A. Mothers carry the gene and pass it to their sons

B. Fathers carry the gene and pass it to their daughters

C. Both parents must have the disease for a child to have the disease

D. Both parents must be carriers for a child to have the disease

 

QUESTION 762

On the third postpartum day, the nurse would expect the lochia to be:

1. Rubra
2. Serosa
3. Alba
4. Scant

 

QUESTION 763

The mother of a preschooler reports to the nurse that he frequently tells lies. The admission assessment of the child indicates possible child abuse. The nurse knows that his:

A. Behavior is not normal, and a child psychiatrist should be consulted.

B. Mother is lying to protect herself.

C. Lying is normal behavior for a preschool child who is learning to separate fantasy from reality.

D. Behavior indicates a developmental delay, because preschoolers should be able to tell right from wrong.

 

QUESTION 764

The initial focus when providing nursing care for a child with rheumatic fever during the acute phase of the illness should be to:

A. Maintain contact with her parents

B. Provide for physical and psychological rest

C. Provide a nutritious diet

 

D. Maintain her interest in school

 

QUESTION 765

A 30-year-old client has been admitted to the psychiatric service with the diagnosis of schizophreni

 

A. He tells the nurse that when the woman he had been dating broke up with him, the CIA had replaced her with an identical twin. The client is experiencing:

 

A. Grandiose delusions

B. Paranoid delusions

C. Auditory hallucinations

D. Visual hallucinations

 

QUESTION 766

The mother of a client is apprehensive about taking home her 2 year old who was diagnosed with asthma after being admitted to the emergency room with difficulty breathing and cyanosis. She asks the nurse what symptoms she should look for so that this problem will not happen again. The nurse instructs her to watch for the following early symptoms:

A. Fever, runny nose, and hyperactivity

B. Changes in breathing pattern, moodiness, fatigue, and edema of eyes

 

C. Fatigue, dark circles under the eyes, changes in breathing pattern, glassy eyes, and moodiness

 D. Fever, cough, paleness, and wheezing

 

QUESTION 767

 

During the active phase of rheumatic fever, the nurse teaches parents of a child with acute rheumatic fever to assist in minimizing joint pain and promoting healing by:

A. Putting all joints through full range-of-motion twice daily

B. Massaging the joints briskly with lotion or liniment after bath

C. Immobilizing the joints in functional position using splints, rolls, and pillows

D. Applying warm water bottle or heating pads over involved joints

 

QUESTION 768

To prevent transmission of bacterial meningitis, the nurse would instruct an infected baby’s mother to:

A. Avoid touching the baby while in the room.

B. Stay outside of the baby’s room.

C. Wear a gown and gloves and wash her hands before and after leaving the room.

D. Wear a mask while in the room.

 

QUESTION 769

A female client is started on warfarin (Coumadin) 5 mg po bid. To adequately evaluate the effectiveness of the warfarin therapy, the nurse must know that this medication:

A. Dissolves any clots already formed in the arteries

B. Prevents the conversion of prothrombin to thrombin

C. Interferes with the synthesis of vitamin K-dependent clotting factors

D. Stimulates the manufacturing of platelets

 

QUESTION 770

A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements?

A. “When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices.”

B. “If I have any side effects from my medicines, I will take an extra dose of Cogentin.”

C. “When I get home, I should be able to taper myself off the Haldol because the voices are gone now.”

D. “As soon as I leave here, I’m throwing away my medicines. I never thought I needed them anyway.”

 

QUESTION 771

A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains of severe abdominal pain. Assessment reveals abdominal rigidity and distention, increased temperature, and tachycardi

 

A. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has developed:

1. Gastritis
2. Evisceration
3. Peritonitis
4. Pulmonary embolism

 

QUESTION 772

A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching concerning the warfarin therapy?

 

A. “If you forget to take your morning dose, double the night time dose.”

B. “You should take aspirin instead of acetaminophen (Tylenol) for headaches.”

C. “Carry a medications alert card with you at all times.”

D. “You should use a straight-edge razor when shaving your arms and legs.”

 

QUESTION 773

A client tells the nurse that he has been hearing voices that tell him to kill his girlfriend because she is a spy. He further states that he is having difficulty not obeying the voices because, if he does not, his house will be burned down. The highest priority nursing diagnosis for him at this time is:

1. Sensory-perceptual alteration: auditory command hallucinations
2. Alteration in thought processes: paranoid delusions
3. Potential for violence directed at others
4. Impaired verbal communication: loose associations

 

QUESTION 774

The physician orders medication for a client’s unpleasant side effects from the haloperidol. The most appropriate drug at this time is:

1. Lorazepam
2. Triazolam (Halcion)
3. Benztropine
4. Thiothixene

 

QUESTION 775

The nurse is admitting a client with folic acid deficiency anemi

A. Which of the following questions is most important for the nurse to ask the client?

A. “Do you take aspirin on a regular basis?”

B. “Do you drink alcohol on a regular basis?”

C. “Do you eat red meat?”

D. “Have your stools been normal?”

QUESTION 776

Forty-eight hours after a thyroidectomy, a female client complains of numbness and tingling of the toes and

fingers. The nurse notes upper arm and facial twitching. The nurse needs to:

A. Report the findings to the physician

B. Assist the client to do range of motion exercises

C. Check the client’s potassium level

D. Administer the as-needed dose of phenytoin (Dilantin)

QUESTION 777

 

Parents should be taught not to prop the bottle when feeding their infants. In addition to the risk of choking, it puts the infant at risk for:

A. Otitis media

1. Asthma
2. Conjunctivitis
3. Tonsillitis

 

QUESTION 778

 

A pregnant client is having a nonstress test (NST). It is noted that the fetal heart beat rises 20 bpm, lasting 20 seconds, every time the fetus moves. The nurse explains that:

A. The test is inconclusive and should be repeated

B. Further testing is needed

C. The test is normal and the fetus is reacting appropriately

D. The fetus is distressed

 

QUESTION 779

 

The nurse is teaching a client how to perform monthly testicular self-examination (TSE) and states that it is best to perform the procedure right after showering. This statement is made by the nurse based on the knowledge that:

A. The client is more likely to remember to perform the TSE when in the nude

B. When the scrotum is exposed to cool temperatures, the testicles become large and bulky

 

C. The scrotum will be softer and more relaxed after a warm shower, making the testicles easier to palpate D. The examination will be less painful at this time

 

QUESTION 780

 

When assessing a client, the nurse notes the typical skin rash seen with systemic lupus erythematosus. Which of the following descriptions correctly describes this rash?

 

A. Small round or oval reddish brown macules scattered over the entire body

B. Scattered clusters of macules, papules, and vesicles over the body

C. Bright red appearance of the palmar surface of the hands

D. Reddened butterfly shaped rash over the cheeks and nose

 

QUESTION 781

 

The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the client’s chief complaint?

A. “I’ve been having a dull pain at the upper left shoulder.” B. “My legs have been numb for three months.”

C. “I’ve only been urinating three times a day lately.”

D. “I don’t remember anything in particular, I just haven’t felt well.”

 

QUESTION 782

Which of the following nursing care goals has the highest priority for a child with epiglottitis?

A. Sleep or lie quietly 10 hr/day.

B. Consume foods from all four food groups.

C. Be afebrile throughout her hospital stay.

D. Participate in play activities 4 hr/day.

 

QUESTION 783

 

The nurse notes multiple bruises on the arms and legs of a newly admitted client with lupus. The client states, “I get them whenever I bump into anything.” The nurse would expect to note a decrease in which of the following laboratory tests?

A. Number of platelets

B. WBC count

C. Hemoglobin level

D. Number of lymphocytes

 

QUESTION 784

When preparing insulin for IV administration, the nurse identifies which kind of insulin to use?

A. NPH

B. Human or pork

1. Regular
2. Long acting

 

QUESTION 785

 

A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating include:

A. Administering diazepam (Valium) 10–15 mg po q4h and q1h prn for hyperventilating episode B. Keeping the temperature in the client’s room at a high level to reduce respiratory stimulation

 

C. Having the client hold her breath or breathe into a paper bag when hyperventilation episodes occur

D. Using distraction to help control the client’s hyperventilation episodes

 

QUESTION 786

Which of the following lab data is representative of a client with aplastic anemia?

A. Hemoglobin 9.2, hematocrit 27, red blood cells 3.2 million

B. White blood cells 4000, erythrocytes 2.5 million, thrombocytes 100,000

C. White blood cells 3000, hematocrit 27, red blood cells 2.8 million

D. Red blood cells 1 million, white blood cells 1500, thrombocytes 16,000

 

QUESTION 787

 

The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 1– 2 hours if needed. The most likely rationale for this order is:

A. The client will settle down more quickly if he thinks the staff is medicating him B. The medication will sedate the client until the physician arrives

QUESTION 788

During the assessment, the nurse observes a client scratching his skin. He has been admitted to rule out

Laennec’s cirrhosis of the liver. The nurse knows the pruritus is directly related to:

A. A loss of phagocytic activity

B. Faulty processing of bilirubin

C. Enhanced detoxification of drugs

D. The formation of collateral circulation

 

QUESTION 789

Nursing assessment of early evidence of septic shock in children at risk includes:

A. Fever, tachycardia, and tachypnea

B. Respiratory distress, cold skin, and pale extremities

C. Elevated blood pressure, hyperventilation, and thready pulses

D. Normal pulses, hypotension, and oliguria

 

QUESTION 790

When assessing a female child for Turner’s syndrome, the nurse observes for which of the following symptoms?

A. Tall stature

B. Amenorrhea

C. Secondary sex characteristics

D. Gynecomastia

 

QUESTION 791

A 2-year-old toddler is hospitalized with epiglottitis. In assessing the toddler, the nurse would expect to find:

A. A productive cough

B. Expiratory stridor

1. Drooling
2. Crackles in the lower lobes

 

QUESTION 792

 

A client is receiving IV morphine 2 days after colorectal surgery. Which of the following observations indicate that he may be becoming drug dependent?

 

A. The client requests pain medicine every 4 hours.

B. He is asleep 30 minutes after receiving the IV morphine.

C. He asks for pain medication although his blood pressure and pulse rate are normal.

D. He is euphoric for about an hour after each injection.

 

QUESTION 793

 

The nurse is teaching a child’s parents how to protect the child from lead poisoning. The nurse knows that a common source of lead poisoning in children is:

A. Dandelion leaves

1. Pencils
2. Old paint
3. Stuffing from toy animals

 

QUESTION 794

 

A family by court order undergoes treatment by a family therapist for child abuse. The nurse, who is the child’s case manager knows that treatment has been effective when:

A. The child is removed from the home and placed in foster care

B. The child’s parents identify the ways in which he is different from the rest of the family

C. The child’s father is arrested for child abuse

D. The child’s parents can identify appropriate behaviors for children in his age group

 

QUESTION 795

 

A 4 year old has an imaginary playmate, which concerns the mother. The nurse’s best response would be:

A. “I understand your concern and will assist you with a referral.”

B. “Try not to worry because you will just upset your child.”

C. “Just ignore the behavior and it should disappear by age 8.”

D. “This is appropriate behavior for a preschooler and should not be a concern.”

 

QUESTION 796

 

A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She has been admitted to the pediatric unit after surgical repair of the cleft lip. Which of the following nursing interventions would be appropriate during the first 24 hours?

A. Position on side or abdomen.

B. Maintain elbow restraints in place unless she is being directly supervised.

C. Clean suture line every shift.

 

QUESTION 797

 

In discussing the plan of care for a child with chronic nephrosis with the mother, the nurse identifies that the purpose of weighing the child is to:

A. Measure adequacy of nutritional management

B. Check the accuracy of the fluid intake record

C. Impress the child with the importance of eating well

D. Determine changes in the amount of edema

 

QUESTION 798

 

A client had a cardiac catheterization with angiography and thrombolytic therapy with streptokinase. The nurse should initiate which of the following interventions immediately after he returns to his room?

A. Place him on NPO restriction for 4 hours.

B. Monitor the catheterization site every 15 minutes.

C. Place him in a high Fowler position.

D. Ambulate him to the bathroom to void.

 

QUESTION 799

 

A child has a nursing diagnosis of fluid volume excess related to compromised regulatory mechanisms. Which of the following nursing interventions is the most accurate measure to include in his care?

A. Weigh the child twice daily on the same scale.

B. Monitor intake and output.

C. Check urine specific gravity of each voiding.

 

D. Observe for edem

 

QUESTION 800

Loss of appetite for a child with leukemia is a major recurrent problem. The plan of care should be designed to:

E. Reinforce attempts to eat

F. Help the child gain weight

G. Increase his appetite

H. Make mealtimes pleasant

 

QUESTION 801

A client develops complications following a hysterectomy. Blood cultures reveal Pseudomonas aeruginos

A. The nurse expects that the physician would order an appropriate antibiotic to treat P. aeruginosa such as:

A. Cefoperazone (Cefobid)

B. Clindamycin (Cleocin)

C. Dicloxacillin (Dycill)

D. Erythromycin (Erythrocin)

 

QUESTION 802

 

A 45-year-old client diagnosed with major depression is scheduled for electroconvulsive therapy (ECT) in the morning. Which of the following medications are routinely administered either before or during ECT?

A. Thioridazine (Mellaril), lithium, and benztropine

B. Atropine, sodium brevitol, and succinylcholine chloride (Anectine)

C. Sodium, potassium, and magnesium

D. Carbamazepine (Tegretol), haloperidol, and trihexyphenidyl (Artane)

 

QUESTION 803

 

A 25-year-old client is admitted for a tonsillectomy. She tells the nurse that she has had episodes of muscle cramps, weakness, and unexplained temperature elevation. Many years ago her father died shortly after surgery after developing a high fever. She further tells the nurse that her surgeon is having her take dantrolene sodium (Dantrium) prophylactically prior to her tonsillectomy. Dantrolene sodium is ordered preoperatively to reduce the risk or prevent:

A. Infection postoperatively

B. Malignant hyperthermia

C. Neuroleptic malignant syndrome

D. Fever postoperatively

 

QUESTION 804

A 3-year-old child is in the burn unit following a home accident. The first sign of sepsis in burned children is:

1. Disorientation
2. Low-grade fever
3. Diarrhea
4. Hypertension

 

QUESTION 805

The parents of a 9-year-old child with acute lymphocytic leukemia expressed concern about his alopecia from

cranial irradiation. The nurse explains that:

A. Alopecia is an unavoidable side effect.

B. There are several wig makers for children.

C. Most children select a favorite hat to protect their heads.

D. His hair will grow back in a few months.

 

QUESTION 806

 

The family member of a child scheduled for heart surgery states, “I just don’t understand this open-heart or closed-heart business. I’m so confused! Can you help me understand it?” The nurse explains that patent ductus arteriosus repair is:

A. Open-heart surgery. The child will be placed on a heart-lung machine while the surgery is being performed. B. Closed-heart surgery. It does not require that the child be placed on the heart-lung machine while the surgery is being performed.

 

C. A pediatric version of the coronary artery bypass graft surgery performed on adults. It is an open-heart surgery.

 

D. A pediatric version of percutaneous transluminal coronary angioplasty performed on adults. It is a closed-heart surgery.

 

QUESTION 807

 

A child with celiac disease is being discharged from the hospital. The mother demonstrates knowledge of nutritional needs of her child when she is able to state the foods which are included in a:

1. Lactose-restricted diet
2. Gluten-restricted diet
3. Phenylalanine-restricted diet
4. Fat-restricted diet

 

QUESTION 808

 

The pediatric nurse charts that the parents of a 4-yearold child are very anxious. Which observation would indicate to the nurse unhealthy coping by these parents:

A. Discussing their needs with the nursing staff

B. Discussing their needs with other family members

C. Seeking support from their minister

D. Refusing to participate in the child’s care

 

QUESTION 809

 

A client with a head injury asks why he cannot have something for his headache. The nurse’s response is based on the understanding that analgesics could:

A. Counteract the effects of antibiotics

B. Elevate the blood pressure

C. Mask symptoms of increasing intracranial pressure

D. Stimulate the central nervous system

 

QUESTION 810

 

Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis?

A. Urine output 22 mL/hr for 2 hours

B. Serum potassium level of 3.7

C. Small T wave of ECG

D. Serum glucose level of 180

 

QUESTION 811

 

A male client is considering having laser abdominal surgery and asks the nurse if there is any advantage in having this type of surgery? The nurse will respond based on the knowledge that laser surgery:

A. Has a smaller postoperative infection rate than routine surgery

B. Will eliminate the need for preoperative sedation

C. Will result in less operating time

D. Generally eliminates problems with complications

 

QUESTION 812

 

The physician decides to prescribe both a short-acting insulin and an intermediate-acting insulin for a newly diagnosed 8-year-old diabetic client. An example of a short-acting insulin is:

A. Novolin Regular

B. Humulin NPH

C. Lente Beef

D. Protamine zinc insulin

 

QUESTION 813

 

A male client is scheduled to have angiography of his left leg. The nurse needs to include which of the following when preparing the client for this procedure?

A. Validate that he is not allergic to iodine or shellfish.

B. Instruct him to start active range of motion of his left leg immediately following the procedure.

C. Inform him that he will not be able to eat or drink anything for 4 hours after the procedure.

D. Inform him that vital signs will be taken every hour for 4 hours after the procedure.

 

QUESTION 814

The nurse will be alert to the most potentially lifethreatening side effect associated with the administration of monoamine oxidase (MAO) inhibitor. This is:

A. Oculogyric crisis

B. Hypertensive crisis

C. Orthostatic hypotension

D. Tardive dyskinesia

 

QUESTION 815

A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and kill her. The best verbal response to the client by the nurse at this time is:

A. “I understand that the voices are real to you, but I want you to know I don’t hear them. They are a symptom of your illness.”

B. “Just don’t pay attention to the voices. They’ll go away after some medication.”

C. “You can’t leave here. This unit is locked and the doctor has not ordered your discharge.”

D. “We will have to put you in seclusion and restraints for a while. You could hurt someone with thoughts like that.”

 

QUESTION 816

Discharge teaching for the client who has a total gastrectomy should include which of the following?

A. Need for the client to increase fluid intake to 3000 mL/day

B. Follow-up visits every 3 weeks for the first 6 months

C. B12 injections needed for the rest of the client’s life

D. Need to eat three full meals with plenty of fiber per day

 

QUESTION 817

The nurse is collecting a nutritional history on a 28- year-old female client with iron-deficiency anemia and learns that the client likes to eat white chalk. When implementing a teaching plan, the nurse should explain that this practice:

A. Will bind calcium and therefore interfere with its metabolism B. Will cause more premenstrual cramping

C. Interferes with iron absorption because the iron precipitates as an insoluble substance D. Causes competition at iron-receptor sites between iron and vitamin B1

 

QUESTION 818

The nurse knows that children are more susceptible to respiratory tract infections owing to physiological differences. These childhood differences, when compared to an adult, include:

A. Fewer alveoli, slower respiratory rate

B. Diaphragmatic breathing, larger volume of air

C. Larger number of alveoli, diaphragmatic breathing

D. Rounded shape of chest, smaller volume of air

 

QUESTION 819

A client delivered a stillborn male at term. An app