NCLEX-RN Quiz Part 13 (751-825)

NO.751 To ensure proper client education, the nurse should teach the client taking SL nitroglycerin to expect which of the following responses with administration?

A.            Stinging, burning when placed under the tongue

B.            Temporary blurring of vision

C.            Generalized urticaria with prolonged use

D.            Urinary frequency

NO.752 A 30-year-old client in the third trimester of her pregnancy asks the nurse for advice about upper respiratory discomforts. She complains of nasal stuffiness and epistaxis, most noticeable on the left side. Which reply by the nurse is correct?

A.            “It sounds as though you are coming down with a bad cold. I’ll ask the doctor to prescribe a decongestant for relief of symptoms.”

B.            “A good vaporizer will help; avoid the cool air kind. Also, try saline nose drops, and spend less time on your left side.”

C.            “These discomforts are all a result of increased blood supply; one of the pregnancy hormones, estrogen, causes them.”

D.            “This is most unusual. I’m sure your obstetrician will want you to see an ENT (ear, nose, throat) specialist.”

NO.753 A pregnant client experiences a precipitous delivery. The nursing action during a precipitous delivery is to:

A.            Control the delivery by guiding expulsion of fetus

B.            Leave the room to call the physician

C.            Push against the perineum to stop delivery

D.            Cross client’s legs tightly

NO.754 A client has received digoxin 0.25 mg po daily for 2 weeks. Which of the following digoxin levels indicates toxicity?

A.            0.5 ng/mL

B.            1.0 ng/mL

C.            2.0 ng/mL

D.            3.0 ng/mL

NO.755 A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the left side of the chest of a newly intubated client is probably due to:

A.            A left hemothorax

B.            A right hemothorax

C.            Intubation of the right mainstem bronchus

D.            An inadequate mechanical ventilator

NO.756 As a nurse in the emergency room, you receive an outside call from an elderly woman who states she has just been raped. She states, “I know I must come to the hospital, but what do I do next?” You advise her to call the police, then come to the hospital emergency room. What action by the nurse would indicate an understanding of the examination process once the victim enters the emergency room?

A.            Inform the victim not to wash, change clothes, douche, brush teeth, or eat or drink anything.

B.            Inform the victim to bring insurance information with her to the hospital so she can be properly cared for.

C.            Phone a rape counselor to begin working with the victim as soon as she enters the hospital.

D.            Do not leave the victim alone to collect her thoughts.

NO.757 A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy:

A.            Prevents the development of ophthalmia neonatorum

B.            Assists the baby’s clotting mechanism

C.            Breaks down bilirubin in the skin into substances that can be excreted in stool or urine

D.            Increases levels of unconjugated bilirubin, thereby preventing kernicterus (brain damage)

NO.758 A 38-year-old pregnant woman visits her nurse practitioner for her regular prenatal checkup. She is 30 weeks’ gestation. The nurse should be alert to which condition related to her age?

A.            Iron-deficiency anemia

B.            Sexually transmitted disease (STD)

C.            Intrauterine growth retardation

D.            Pregnancy-induced hypertension (PIH)

NO.759 The nurse needs to be aware that the most common early complication of a myocardial infarction is:

A.            Diabetes mellitus

B.            Anaphylactic shock

C.            Cardiac hypertrophy

D.            Cardiac dysrhythmia

NO.760 On a mother’s 2nd postpartum day after having a vaginal delivery, the RN is preparing to assess her perineum and anus as part of her daily assessment. The best position for the client to be placed in for this assessment is:

A.            Sims’

B.            Fowler’s

C.            Prone

D.            Any position that the RN chooses

NO.761 On admission to the inpatient unit, a 34-year-old client is able to follow simple directions, butwith great difficulty.

He is worried about how he can keep clean in such a public place and repeatedly dusts his bureau, straightens his bed, and adjusts the clothes in his closet. The client is experiencing a severe level of anxiety. Which response by the nurse would be most therapeutic in initially attempting to reduce his anxiety?

A.            “You will not be allowed to remain in your room if you continue to bother things.”

B.            “I can see how uncomfortable you are, but I would like you to walk with me so I can show you around the unit.”

C.            “Tell me why your room needs to be so clean.”

D.            “I’ve inspected this room and it is perfectly clean.”

NO.762 The day following his admission, the nurse sits down by a male client on the sofa in the dayroom. He was admitted for depression and thoughts of suicide. He looks at the nurse and says, “My life is so bad no one can do anything to help me.” The most helpful initial response by the nurse would be:

A.            “It concerns me that you feel so badly when you have so many positive things in your life.”

B.            “It will take a few weeks for you to feel better, so you need to be patient.”

C.            “You are telling me that you are feeling hopeless at this point?”

D.            “Let’s play cards with some of the other clients to get your mind off your problems for now.”

NO.763 A client is a depressed, 48-year-old salesman. A serious concern for the nurse working with depressed clients is the potential of suicide. The time that suicide is most likely to occur is:

A.            In the acutely depressed state

B.            When the depression starts to lift

C.            In the denial phase

D.            During a manic episode

NO.764 A primipara is assessed on arrival to the postpartum unit. The nurse finds her uterus to be boggy. The nurse’s first action should be to:

A.            Call the physician

B.            Assess her vital signs

C.            Give the prescribed oxytocic drug

D.            Massage her fundus

NO.765 A 68-year-old woman is admitted to the hospital with chronic obstructive pulmonary disease (COPD). She is started on an aminophylline infusion. Three days later she is breathing easier. A serum theophylline level is drawn. Which of the following values represents a therapeutic level?

A.            14 u g/mL

B.            25 u g/mL

C.            4 u g/mL

D.            30 u g/mL

NO.766 A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is ototoxic, the nurse would implement which of the following measures?

A.            Instruct the client to report any signs of tinnitus, dizziness or difficulty hearing.

B.            Advise the client to discontinue the drug at the first sign of dizziness.

C.            Order audiometric testing in order to determine if hearing loss is caused by an ototoxic drug or other cause.

D.            Instruct the client in Valsalva’s maneuver to equalize middle ear pressure and to prevent hearing loss.

NO.767 Which of the following statements relevant to a suicidal client is correct?

A.            The more specific a client’s plan, the more likely he or she is to attempt suicide.

B.            A client who is unsuccessful at a first suicide attempt is not likely to make future attempts.

C.            A client who threatens suicide is just seeking attention and is not likely to attempt suicide.

D.            Nurses who care for a client who has attempted suicide should not make any reference to the word “suicide” in order to protect the client’s ego.

NO.768 A child is to receive atropine 0.15 mg (1/400 g) as part of his preoperative medication. A vial containing atropine 0.4 mg (1/150 g)/mL is on hand. How much atropine should be given?

A.            0.06 mL

B.            0.38 mL

C.            2.7 mL

D.            Information given insufficient to determine the amount of atropine to be administered

NO.769 A new mother experiences strong uterine contractions while breast-feeding her baby. She excitedly rings for the nurse. When the nurse arrives the mother tells her, “Something is wrong. This is like my labor.” Which reply by the nurse identifies the physiological response of the client?

A.            “Your breasts are secreting a hormone that enters your bloodstream and causes your abdominal muscles to contract.”

B.            “Prolactin increases the blood supply to your uterus, and you are feeling the effects of this blood vessel engorgement.”

C.            “The same hormone that is released in response to the baby’s sucking, causing milk to flow, also causes the uterus to contract.”

D.            “There is probably a small blood clot or placental fragment in your uterus, and your uterus is contracting to expel it.”

NO.770 A client has been uncomfortable in crowds all her life. After the birth of her child, she has been housebound unless her husband can accompany her to the grocery store and for medical appointments. His schedule will not allow for this, and he has insisted that she must be more independent. Her anxiety has increased to the point of panic. The client has been diagnosed with agoraphobia. Which statement is true about this disorder?

A.            The behavior is not considered disabling.

B.            More men suffer from agoraphobia than women.

C.            The fears are persistent, and avoidance is used as the coping mechanism.

D.            Agoraphobia moves into remission when treated with chlorpromazine.

NO.771 A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will:

A.            Drink at least 8 oz of cranberry juice daily

B.            Maintain a fluid intake of at least 2000 mL daily

C.            Wash her hands before and after voiding

D.            Limit her fluid intake after 6 PM so that there is not a great deal of urine in her bladder while she sleeps

NO.772 When teaching a sex education class, the nurse identifies the most common STDs in the United States as:

A.            Chlamydia

B.            Herpes genitalis

C.            Syphilis

D.            Gonorrhea

NO.773 A 24-hours’ postpartum client complains of discomfort at the episiotomy site. On assessment, the nurse notes the episiotomy is without signs of infection. To relieve the discomfort, the nurse should first:

A.            Assist her with a sitz bath

B.            Administer the prescribed medication for pain

C.            Teach her Kegel exercises

D.            Apply an ice pack

NO.774 A male client has a history of diverticulosis. He has questions about the foods that he should eat. His nurse gives him the following information:

A.            He should be on a high-fiber diet.

B.            He should eat a low-residue diet.

C.            He should drink minimal amounts of fluids.

D.            He does not need to make any modifications.

NO.775 The nurse is planning a reality orientation program for a group of clients with organic brain syndrome at the mental health center. Props that could be used for this program are:

A.            Month-old magazines that are provided by volunteers

B.            Large maps and posters depicting area of current residence

C.            A litter of kittens for the clients to pet

D.            A library of biographical books

NO.776 The mother of a 7-year-old mental health center client reports that the client has refused to attend gymnastics for the past 2 weeks. Prior to that time, the child liked going to this class and was attending 3 times a week. In talking with the client, the nurse would:

A.            Ask her why she doesn’t like gymnastics anymore

B.            Ask her to describe how things were at gymnastics before she started refusing to go

C.            Tell her that it is OK to be afraid of this activity

D.            Reassure her that things will get better once she begins the classes again

NO.777 An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction?

A.            Boardlike, rigid abdomen

B.            Loss of the urge to defecate

C.            Liquid stool

D.            Abdominal pain

NO.778 The nurse instructs a pregnant client (G2P1) to rest in a side-lying position and avoid lying flat on her back. The nurse explains that this is to avoid “vena caval syndrome,” a condition which:

A.            Occurs when blood pressure increases sharply with changes in position

B.            Results when blood flow from the extremities is blocked or slowed

C.            Is seen mainly in first pregnancies

D.            May require medication if positioning does not help

NO.779 A murmur has been discovered during the routine physical examination of a 1-year-old child. The parent is extremely concerned about this diagnosis. Which of the following explanations by the nurse indicates understanding of this dysfunction?

A.            The blood shifts from the right to the left atrium.

B.            Surgical closure by suture or patch is recommended before school age.

C.            Most atrial septal defects close spontaneously.

D.            The child can be treated medically with antibiotics to prevent bacterial endocarditis.

NO.780 A 28-year-old client performs a long, involved ritual in getting up and preparing for the day. He became unable to get to his job before noon. His family, in desperation, has admitted him to the hospital’s psychiatric unit. On the unit, he is always late for breakfast, which is served at 8 am. The nurse identifies that the best approach to this problem is to:

A.            Allow him to eat late

 

B.            Suggest that he do the rituals after breakfast

C.            Get him up early so that he can complete the ritual before breakfast

D.            Ask him to get all the other clients up so that he will forget about his ritual

NO.781 A 78-year-old female client has a total hip arthroplasty. Her nurse should know that which of the following is contraindicated?

A.            Encourage exercises in the unaffected extremities.

B.            Encourage her to cross and uncross her legs.

C.            Check neurological and circulatory status of the affected leg hourly.

D.            Place a trochanter roll along the upper thigh of the affected leg.

NO.782 The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?

A.            Pulse rate of 50-70 bpm by her third postpartum day

B.            Diuresis by her second or third postpartum day

C.            Vaginal discharge or rubra, serosa, then rubra

D.            Diaphoresis by her third postpartum day

NO.783 The client has been in active labor for the last 12 hours. During the last 3 hours, labor has been augmented with oxytocin because of hypoactive uterine contractions. Her physician assesses her cervix as 95% effaced, 8 cm dilated, and the fetus is at 0 station. Her oral temperature is 100.2F at this time. The physician orders that she be prepared for a cesarean delivery. In preparing the client for the cesarean delivery, which one of the following physician’s orders should the RN question?

A.            Administer meperidine (Demerol) 100 mg IM 1 hour prior to the delivery.

B.            Discontinue the oxytocin infusion.

C.            Insert an indwelling Foley catheter prior to delivery.

D.            Prepare abdominal area from below the nipples to below the symphysis pubis area.

NO.784 A female client at 37 weeks’ gestation has just undergone a nonstress test. The results were two fetal movements with a corresponding increase in fetal heart rate (FHR) of 15 bpm lasting 15 seconds within a 20-minute period. Her results would be classified as:

A.            Reactive; needs follow-up contraction stress test

B.            Reactive; no contraction stress test required

C.            Non-reactive; needs follow-up contraction stress test

D.            Non-reactive; no contraction stress test required

NO.785 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

NO.786 Before giving methergine postpartum, the nurse should assess the client for:

A.            Decreased amount of lochial flow

B.            Elevated blood pressure

C.            Flushing

D.            Afterpains

NO.787 A client diagnosed with severe anemia is to receive 2 U of packed red blood cells. Prior to starting the blood transfusion, the nurse must:

A.            Take a baseline set of vital signs

B.            Hang Ringer’s lactate as the companion fluid

C.            Use microdrip tubing for the blood administration

D.            Have the registered nurse in charge assume responsibility for verifying the client and blood product information

NO.788 A 3-year-old child was hospitalized for acute laryngotracheobronchitis. During her hospitalization, the child was placed under an oxygen mist tent. The nurse’s frequent monitoring of the child’s temperature frightened her parents. Which response by the nurse would be most appropriate?

A.            Monitoring the temperature prevents undue chilling.

 B.           Rapid temperature elevations can occur in children.

C.            Checking the temperature will prevent febrile seizures.

D.            Taking the child’s temperature can prevent airway obstruction.

NO.789 A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful?

A.            Pork chop, baked acorn squash, brussel sprouts

B.            Chicken breast, rice, and green beans

C.            Roast beef, baked potato, and diced carrots

D.            Tuna casserole, noodles, and spinach

NO.790 A 45-year-old male client experiences a sense of depression because he has not yet achieved his life’s goals. His career has not been satisfying. He is still looking for the right job. His wife spends too much money, and his children seem to ignore him while being very selfish. He is tired of all of their attitudes and is considering buying a red Corvette convertible. While obtaining these data concerning the client’s feelings about his life, the nurse is able to determine he is experiencing what psychological crisis according to Erikson’s stages?

A.            Identity versus role confusion

B.            Integrity versus despair

C.            Intimacy versus isolation

D.            Generativity versus self-absorption

NO.791 A psychiatric nurse is providing an orientation to a new staff nurse. She reminds the nurse that psychiatrists often use categories of medications and that it is important that she recall that some categories of medications have synonyms. Another name used to describe minor tranquilizers is which of the following?

A.            Antipsychotic medications

B.            Antidepressant medications

C.            Antianxiety medications

D.            Antimania medication

NO.792 A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours’ postburn?

A.            Fluid volume deficit secondary to alteration in skin integrity

B.            Alteration in comfort secondary to alteration in skin integrity

C.            Alteration in sensation secondary to third-degree burn

D.            Alteration in airway integrity secondary to edema of neck and face, which in turn is secondary to alteration in skin integrity

NO.793 Which of the following nursing orders should be included in the plan of care for a client with hepatitis C?

A.            The nurse should use universal precautions when obtaining blood samples.

B.            Total bed rest should be maintained until the client is asymptomatic.

C.            The client should be instructed to maintain a low semi-Fowler position when eating meals.

D.            The nurse should administer an alcohol backrub at bedtime.

NO.794 A male client was involved in a motor vehicle accident earlier in the day. The nurse caring for him on evenings notices that on admission to the hospital, he lost a lot of blood and r