NCLEX-RN Quiz Part 4 (151-200)

NO.151 A 29-year-old client delivered her fifth child by the Lamaze method and developed a postpartal hemorrhage in the recovery room. What are the initial symptoms of shock that she may experience?

A.            Marked elevation in blood pressure, respirations, and pulse

B.            Decreased systolic pressure, cold skin, and anuria

C.            Rapid pulse; narrowed pulse pressure; cool, moist skin

D.            No urinary output, tachycardia, and restlessness

NO.152 A successful executive left her job and became a housewife after her marriage to a plastic surgeon. She started doing volunteer work for a charity organization. She developed pain in her legs that advanced to the point of paralysis. Her physicians can find no organic basis for the paralysis. The client’s behavior can be described as:

A.            Housework phobia

B.            Malingering

C.            Conversion reaction

D.            Agoraphobia Answer: C Explanation:

NO.153 A pregnant client experiences spontaneous rupture of membranes. The first nursing action is to:

A.            Assess the client’s respirations

B.            Notify the physician

C.            Auscultate fetal heart rate

D.            Transfer to delivery suite

NO.154 A client’s wife is concerned over his behavior in recent months. He has been diagnosed with Parkinson’s disease, and she is telling his nurse that he has been doing “strange things.” The nurse reassures the wife that the following behavior is normal with Parkinson’s disease:

A.            “Your husband will experience some periods of muscle flaccidity. Be sure to make him sit down during these periods.”

B.            “Your husband may move his hands in motions that look like he is rolling a pill between his fingers.”

C.            “Twitching of the muscles is to be expected and can occur at any time during the day.”

D.            “Parkinson’s disease causes severe pain in the joints. You should give your husband Tylenol at those times.”

NO.155 A 22-year-old single woman was admitted to the psychiatric hospital by her mother, who reported bizarre behavior. Except for going to work, she spends all her time in her room and expresses concern over neighbors spying on her. She has fears of the telephone being “bugged.” Her diagnosis is schizophrenia. One nurse per shift is assigned to work with the client. The primary reason for this plan would be to:

A.            Protect her from suicide

B.            Enable her to develop trust

C.            Supervise her medication regimen

D.            Involve her in groups for social interaction

NO.156 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.”

NO.157 A 26-year-old male client is brought by his wife to the emergency department (ED) unconscious. Blood is drawn for a stat blood count (CBC), fasting blood sugar level, and electrolytes. An indwelling urinary catheter is inserted. He has a history of type 1 diabetes (insulindependent diabetes mellitus [IDDM]). A diagnosis of ketoacidosis is made. Stat lab values reveal a blood sugar level of 520 mg/dL. Which of the following should the nurse expect to administer in the ER?

A.            D50W by IV push

B.            NPH insulin SC

C.            Regular insulin by IV infusion

D.            Sweetened grape juice by mouth

NO.158 A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular disorder. She arrives in her

room via stretcher and requires assistance to move to her bed. The nurse notes that her left leg is cold to touch. She complains of having recently experienced muscle spasms in that leg. To determine if these muscle spasms are indicative of intermittent claudication, the nurse would begin her assessment with the following question:

A.            “Would you describe the intensity, duration, and symptoms associated with your pain?”

B.            “Do you experience swelling at the end of the day in the affected and unaffected leg?”

C.            “Have you had any lesions of the affected leg that have been difficult to heal?”

D.            “Do your muscle spasms occur following rest, walking, or exercising?”

NO.159 A client’s behavior is annoying other clients on the unit. He is meddling with their belongings and dominating the group. The best approach by the nurse is to:

A.            Seclude him in his room.

B.            Set limits on his behavior.

C.            Have his medication increased.

D.            Ignore him and tell the other clients that these behaviors are due to his illness and that they should understand.

NO.160 A behavioral modification program is recommended by the multidisciplinary team working with a 15-year-old client with anorexia nervosa. A nursing plan of care based on this modality would include:

 A.           Role playing the client’s eating behaviors

B.            Restriction to the unit until she has gained 2 lb

C.            Encouraging her to verbalize her feelings concerning food and food intake

D.            Provision for a high-calorie, high-protein snack between meals

NO.161 An alcoholic client who is completing the inpatient segment of a substance abuse program was placed on disulfiram (Antabuse) drug therapy. What should the nurse include in the discharge instructions?

A.            If disulfiram is taken and alcohol ingested, the client experiences nausea, vomiting and elevated blood pressure.

B.            Disulfiram is most effective when prescribed as late as possible in a recovery program.

C.            Disulfiram works on the desensitization principle.

D.            The effects of disulfiram can be triggered by alcohol 5 days to 2 weeks after the drug is discontinued.

NO.162 The postpartum nurse should include which of the following instructions to breast-feeding mothers?

A.            Limit feeding times for several days to avoid nipple soreness.

B.            Wash the nipples with soap and water before and after each feeding.

C.            Daily caloric intake should be increased by 500 cal.

D.            Breast milk is totally digestible by the baby because it contains lactose.

NO.163 At her monthly prenatal visit, a client reports experiencing heartburn. Which nursing measure should be included in her plan of care to help alleviate it?

A.            Restrict fluid intake.

B.            Use Alka-Seltzer as necessary.

C.            Eat small, frequent bland meals.

D.            Lie down after eating.

NO.164 A type I diabetic client is diagnosed with cellulitis in his right lower extremity. The nurse would expect which of the following to be present in relation to his blood sugar level?

A.            A normal blood sugar level

B.            A decreased blood sugar level

C.            An increased blood sugar level

D.            Fluctuating levels with a predawn increase

NO.165 An 8-year-old boy has been diagnosed with hemophilia. Which of the following diagnostic blood studies is characteristically abnormal in this disorder?

A.            Partial thromboplastin time

B.            Platelet count

C.            Complete blood count

D.            Bleeding time

NO.166 The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be a reaction to which of the following medications if applied in large amounts?

 A.           Neosporin sulfate

B.            Mafenide acetate

C.            Silver sulfadiazine

D.            Povidone-iodine

NO.167 Nursing care for the parents of a child with a congenital heart defect would include:

A.            Encouraging the parents not to tell the child about the seriousness of the congenital heart defect, so the child will function as normally as possible

B.            Acknowledging the fear and concern surrounding their child’s health and assisting the parents through the grieving process as they mourn the loss of their fantasized healthy child

C.            Identifying anger and resentment as destructive emotions that serve no purpose

D.            Expressing to the parents after the corrective surgery has been completed successfully that all their grief feelings will resolve

NO.168 Three hours postoperatively, a 27-year-old client complains of right leg pain after knee reduction. The first action by the nurse will be to:

A.            Assess vital signs

B.            Elevate the extremity

C.            Perform a lower extremity neurovascular check

D.            Remind the client that he has a client-controlled analgesic pump, and reinstruct him on its use

NO.169 A 28-year-old multigravida has class II heart disease. At her prenatal visit at 34 weeks’ gestation, all of the following observations are made. Which would require intervention?

A.            Weight gain of 2 kg in 4 weeks

B.            Blood pressure of 128/78

C.            Subjective data: shortness of breath after showering

D.            Ankle edema reported present in late afternoon and evenings

NO.170 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

B.            Pencils

C.            Old paint

D.            Stuffing from toy animals

NO.171 A 79-year-old client with Alzheimer’s disease is exhibiting significant memory impairment, cognitive impairment, extremely impaired judgment in social situations, and agitation when placed in a new situation or around unfamiliar people. The nurse should include the following strategy in the client’s care:

A.            Maintain routines and usual structure and adhere to schedules.

B.            Encourage the client to attend all structured activities on the unit, whether she wants to or not.

C.            Ask the client to go to an activity once. If she gives no response right away, change the question around, asking the same thing.

D.            Give the client two or three choices to decide what she wants to do.

NO.172 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

NO.173 A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self-mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by:

A.            Placing her in seclusion until the behavior is under control

B.            Walking up to the client and touching her on the arm to get her attention

C.            Communicating a desire to assist the client to regain control, offering a one-to-one session in a quiet area

D.            Confronting the client, letting her know the consequences for getting angry and disrupting the unit

NO.174 A female client is concerned that she is in a “high-risk” group for the development of acquired immunodeficiency syndrome (AIDS). She wants to know about the advisability of donating blood. Which of the following responses is correct?

 A.           “Individuals who donate blood are at risk of getting the AIDS virus. You should not donate.”

B.            “It’s OK for you to donate because the blood bank has a test that is 100% effective.”

C.            “You should not donate since it takes time to develop antibodies to the AIDS virus. If you donate blood before you develop the antibody, you could pass it on in the blood.”

D.            “It is not a good idea for you to donate. If you have AIDS, the information is made public and could destroy your personal life.”

NO.175 A 56-year-old client is admitted to the psychiatric unit in a state of total despair. She feels hopeless and worthless, has a flat affect and very sad appearance, and is unable to feel pleasure from anything. Her husband has been assisting her at home with the housework and cooking; however, she has not been eating much, lies around or sits in a chair most of the day, and is becoming confused and thinks her family does not want her around anymore. In assessing the client, the nurse determines that her behavior is consistent with:

A.            Transient depression

B.            Mild depression

C.            Moderate depression

D.            Severe depression

NO.176 A client had a ruptured abdominal aortic aneurysm that was repaired surgically. Her postoperative recovery progressed without complications, and she is ready for discharge. Client education in preparation for discharge began 7 days ago on her admission to the nursing unit.

Evaluation of nursing care related to client education is based on evaluation of expected outcomes. Which statement made by the client would indicate that she is ready for discharge?

A.            “I will not drive but ride in the front seat of the car with a seat belt on for my first doctor’s appointment.”

B.            “When I bathe tomorrow morning, I will be very careful not to get soap on my incision.”

C.            “I am allowed to exercise by walking for short periods.”

D.            “Teach my husband about the diet. He’ll be doing all the cooking now.”

NO.177 In caring at home for a child who just ingested a caustic alkali, the nurse would immediately tell the mother to:

A.            Give vinegar, lemon juice, or orange juice

B.            Phone the doctor

C.            Take the child to the emergency room

D.            Induce vomiting

NO.178 A 1000-mL dose of lactated Ringer’s solution is to be infused in 8 hours. The drop factor for the tubing is 10 gtt/mL. How many drops per minute should the nurse administer?

A.            125 gtt/min

B.            48 gtt/min

C.            20 gtt/min

D.            21 gtt/min

NO.179 Home-care instructions for the child following a cardiac catheterization should include:

 A.           Notify the physician if a slight bruise develops around the insertion site.

B.            Use sponge bathing until stitches are removed.

C.            Give aspirin if the child complains of pain at the insertion site.

D.            Keep a clean, dry dressing on the insertion site for 2 days.

NO.180 A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5’4″ and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:

A.            Obtain an accurate weight

B.            Search the client’s purse for pills

C.            Assess vital signs

D.            Assign her to a room with someone her own age

NO.181 A couple is experiencing difficulties conceiving a baby. The nurse explains basal body temperature (BBT) by instructing the female client to take her temperature:

A.            Orally in the morning and at bedtime

B.            Only one time during the day as long as it is always at the same time of day

C.            Rectally at bedtime

D.            As soon as she awakens, prior to any activity

NO.182 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

NO.183 A postoperative TURP client returns from the recovery room to the general surgery unit and is in stable condition. One hour later the nurse assesses him and finds him to be confused and disoriented. She recognizes that this is most likely caused by:

A.            Hypovolemic shock

B.            Hypokalemia

C.            Hypernatremia

D.            Hyponatremia

NO.184 A 6-month-old infant who was diagnosed at 4 weeks of age with a ventricular septal defect, was admitted today with a diagnosis of failure to thrive. His mother stated that he had not been eating well for the past month. A cardiac catheterization reveals congestive heart failure. All of the following nursing diagnoses are appropriate. Which nursing diagnosis should have priority?

A.            Altered nutrition: less than body requirements related to inability to take in adequate calories

B.            Altered growth and development related to decreased intake of food

C.            Activity intolerance related to imbalance between oxygen supply and demand

D.            Decreased cardiac output related to ineffective pumping action of the heart

NO.185 A 35-year-old client has returned to her room following surgery on her right femur. She has an IV of D5 in onehalf normal saline infusing at 125 mL/hr and is receiving morphine sulfate 10-15 mg IM q4h prn for pain. She last voided 51/2 hours ago when she was given her preoperative medication. In monitoring and promoting return of urinary function after surgery, the nurse would:

A.            Provide food and fluids at the client’s request

B.            Maintain IV, increasing the rate hourly until the client voids

C.            Report to the surgeon if the client is unable to void within 8 hours of surgery

D.            Hold morphine sulfate injections for pain until the client voids, explaining to her that morphine sulfate can cause urinary retention

NO.186 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

NO.187 The nurse observes that a client has difficulty chewing and swallowing her food. A nursing response designed to reduce this problem would include:

A.            Ordering a full liquid diet for her

B.            Ordering five small meals for her

 C.           Ordering a mechanical soft diet for her

D.            Ordering a pureed diet for her

NO.188 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 tachycardia. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has developed:

A.            Gastritis

B.            Evisceration

C.            Peritonitis

D.            Pulmonary embolism

NO.189 Hypoxia is the primary problem related to near-drowning victims. The first organ that sustains irreversible damage after submersion in water is the:

A.            Kidney (urinary system)

B.            Brain (nervous system)

C.            Heart (circulatory system)

D.            Lungs (respiratory system)

NO.190 A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period was February 16, with 3 days of spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to be:

A.            November 23rd

B.            December 26th

C.            September 14th

D.            December 9th

NO.191 Following a fracture of the left femur, a client develops symptoms of osteomyelitis. During the acute phase of osteomyelitis, nursing care is directed toward:

A.            Moving or turning the client’s left leg carefully to minimize pain and discomfort

B.            Allowing the client out of bed only in a wheelchair or gurney to minimize weight bearing on the left leg

C.            Providing the client with a high-protein, high-fiber diet to promote healing

D.            Instituting physical therapy to ensure restoration of optimal functioning of the leg

NO.192 After several days, an IDDM client’s serum glucose stabilizes, and the registered nurse continues client teaching in preparation for his discharge. The nurse helps him plan an American Diabetes Association diet and explains how foods can be substituted on the exchange list. He can substitute 1 oz of poultry for:

A.            One frankfurter

B.            One ounce of ham

C.            Two slices of bacon

D.            One-fourth cup dry cottage cheese

NO.193 The client tells the nurse, “I have pain in my left shoulder.” This is considered:

A.            Evaluation process

B.            Objective information

C.            Subjective information

D.            Complaining

NO.194 Endotracheal tube cuff pressure should never exceed:

A.            10 mm Hg

B.         &n