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NCLEX RN Practice Questions 17

1. Whats the first intervention for a patient experiencing chest pain and an 5p02 of 89%? A. Administer morphine. B. Administer oxygen. C. Administer sublingual nitroglycerin. D. Obtain an electrocardiogram (ECC)

2. Which of the following signs and symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm? A. Abdominal pain. B. Absent pedal pulses. C. Chest pain. D. Lower back pain.

3. In which of the following types of cardiomyopathy does cardiac output remain normal? A. Dilated. B. Hypertrophic. C. Obliterative. D. Restrictive.

4. Which of the following interventions should be your first priority when treating a patient experiencing chest pain while walking? A. Have the patient sit down. B. Get the patient back to bed. C. Obtain an ECG. D. Administer sublingual nitroglycerin.

5. Which of the following positions would best aid breathing for a patient with acute pulmonary edema? A. Lying flat in bed. B. Left side-lying position. C. High Fowlers position. D. Semi-Fowlers position.

6. A pregnant woman arrives at the emergency department (ED) with abruptio placentae at 34 weeks gestation. Shes at risk for which of the following blood dyscrasias? A. Thrombocytopenia. B. Idiopathic thrombocytopenic purpura (ITP). C. Disseminated intravascular coagulation (DIC). D. Heparin-associated thrombosis and thrombocytopenia (HATT).

7. A 16-year-old patient involved in a motor vehicle accident arrives in the ED unconscious and severely hypotensive. Hes suspected to have several fracture of his pelvis and legs. Which of the following parenteral fluids is the best choice for his current condition? A. Fresh frozen plasma. B. 0.9% sodium chloride solution. C. Lactated Ringers solution. D. Packed red blood cells. 8. Corticosteroids are potent suppressors of the bodys inflammatory response. Which of the following conditions or actions do they suppress? A. Cushing syndrome. B. Pain receptors. C. Immune response. D. Neural transmission. 9. A patient infected with human immunodeficiency virus (HIV) begins zidovudine therapy. Which of the following statements best describes this drugs action? A. It destroys the outer wall of the virus and kills it. B. It interferes with viral replication. C. It stimulates the immune system. D. It promotes excretion of viral antibodies.

10. A 20-year-old patient is being treated for pneumonia. He has a persistent cough and complains of severe pain on coughing. What could you tell him to hel him reduce his discomfort? A. "Hold your cough as much as possible."

B. "Place the head of your bed flat to help with coughing." C. "Restrict fluids to help decrease the amount of sputum." D. "Splint your chest wall with a pillow for comfort."

11. A 19-year-old patient comes to the ED with acute asthma. His respiratory rate is 44 breaths/minute, and he appears to be in acute respiratory distress. Which of the following actions should you take first? A. Take a full medical history. B. Give a bronchodilator by nebulizer. C. Apply a cardiac monitor to the patient. D. Provide emotional support for the patient.

12. A firefighter who was involved in extinguishing a house fire is being treated for smoke inhalation. He develops severe hypoxia 48 hours after the incident requiring intubation and mechanical ventilation. Which of the following conditions has he most likely developed? A. Acute respiratory distress syndrome (ARDS). B. Atelectasis. C. Bronchitis. D. Pneumonia.

13. Which of the following measures best determines that a patient who had a pneumothorax no longer needs a chest tube? A. You see a lot of drainage from the chest tube. B. Arterial blood gas (ABG) levels are normal. C. The chest X-ray continues to show the lung is 35% deflated. D. The water-seal chamber doesnt fluctuate when no suction is applied.

14. Which of the following nursing interventions should you use to prevent footdrop and contractures in a patient recovering from a subdural hematoma? A. High-top sneakers. B. Low-dose heparin therapy. C. Physical therapy consultation. D. Sequential compressive device.

15. Which of the following signs of increased intracranial pressure (ICP) would appear first after head trauma? A. Bradycardia. B. Large amounts of very dilute urine. C. Restlessness and confusion. D. Widened pulse pressure.

16. When giving intravenous (I.V.) phenytoin, which of the following methods should you use? A. Use an in-line filter. B. Withhold other anticonvulsants. C. Mix the drug with saline solution only. D. Flush the I.V. catheter with dextrose solution. 17. After surgical repair of a hip, which of the following positions is best for the patients legs and hips? A. Abduction. B. Adduction. C. Prone. D. Subluxated.

18. Which of the following factors should be the primary focus of nursing management in a patient with acute pancreatitis? A. Nutrition management. B. Fluid and electrolyte balance. C. Management of hypoglycemia. D. Pain control.

19. After a liver biopsy, place the patient in which of the following positions? A. Left side-lying, with the bed flat. B. Right side-lying, with the bed flat. C. Left side-lying, with the bed in semi-Fowlers position. D. Right side-lying, with the bed in semi-Fowlers position.

20. Which of the following potentially serious complications could occur with therapy for hypothyroidism? A. Acute hemolytic reaction. B. Angina or cardiac arrhythmia.

C. Retinopathy. D. Thrombocytopenia.

21. Adequate fluid replacement and vasopressin replacement are objectives of therapy for which of the following disease processes? A. Diabetes mellitus. B. Diabetes insipidus. C. Diabetic ketoacidosis. D. Syndrome of inappropriate antidiuretic hormone secretion (SIADH).

22. Patients with Type 1 diabetes mellitus may require which of the following changes to their daily routine during periods of infection? A. No changes. B. Less insulin. C. More insulin. D. Oral diabetic agents.

23. On a follow-up visit after having a vaginal hysterectomy, a 32-year-old patient has a decreased hematocrit level. Which of the following complications does this suggest? A. Hematoma. B. Hypovolemia. C. Infection. D. Pulmonary embolus (PE).

24. A patient has partial-thickness burns to both legs and portions of his trunk. Which of the following I.V. fluids is given first? A. Albumin. B. D5W. C. Lactated Ringers solution. D. 0.9% sodium chloride solution with 2 mEq of potassium per 100 ml.

25. Which of the following techniques is correct for obtaining a wound culture specimen from a surgical site? A. Thoroughly irrigate the wound before collecting the specimen. B. Use a sterile swab and wipe the crusty area around the outside of the wound. C. Gently roll a sterile swab from the center of the wound outward to collect drainage. D. Use a sterile swab to collect drainage from the dressing.

1. B Administering supplemental oxygen to the patient is the first priority. Administer oxygen to increase SpO2 to greater than 90% to help prevent further cardiac damage. Sublingual nitroglycerin and morphine are commonly administered after oxygen. 2. D Lower back pain results from expansion of the aneurysm. The expansion applies pressure in the abdomen, and the pain is referred to the lower back. Abdominal pain is the most common symptom resulting from impaired circulation. Absent pedal pulses are a sign of no circulation and would occur after a ruptured aneurysm or in peripheral vascular disease. Chest pain usually is associated with coronary artery or pulmonary disease. 3. B Cardiac output isnt affected by hypertrophic cardiomyopathy because the size of the ventricle remains relatively unchanged. Dilated cardiomyopathy, obliterative cardiomyopathy, and restrictive cardiomyopathy all decrease cardiac output. 4. A The initial priority is to decrease oxygen consumption by sitting the patient down. Administer sublingual nitroglycerin as you simultaneously do the ECG. When the patients condition is stabilized, he can be returned to bed. 5. C High Fowlers position facilitates breathing by reducing venous return. Lying flat and side-lying positions worsen breathing and increase the hearts workload. 6. C Abruptio placentae is a cause of DIC because it activates the clotting cascade after hemorrhage. Thrombocytopenia results from decreased production of platelets. ITP doesnt have a definitive cause. A patient with abruptio placentae wouldnt get heparin and, as a result, wouldnt be at risk for HATT. 7. D In a trauma situation, the first blood product given is unmatched (0 negative) packed red blood cells. Fresh frozen plasma often is used to replace clotting factors. Lactated Ringers solution or 0.9% sodium chloride is used to increase volume and blood pressure, but too much of these crystalloids will dilute the blood and wont improve oxygen-carrying capacity. 8. C Corticosteroids suppress eosinophils, lymphocytes, and natural-killer cells, inhibiting the natural inflammatory process in an infected or injured part of the body. This helps resolve inflammation, stabilizes lysosomal membranes, decreases capillary permeability, and depresses phagocytosis of tissues by white blood cells, thus blocking the release of more inflammatory materials. Excessive corticosteroid therapy can lead to Cushing syndrome. 9. B Zidovudine inhibits DNA synthesis in HIV, thus interfering with viral replication. The drug doesnt destroy the viral wall, stimulate the immune system, or promote HIV antibody excretion. 10. D Showing this patient how to splint his chest wall will help decrease discomfort when coughing. Holding in his coughs will only increase his pain. Placing the head of the bed flat may increase the frequency of his cough and his work of breathing. Increasing fluid intake will help thin his secretions, making it easier for him to clear them. 11. B The patient having an acute asthma attack needs more oxygen delivered to his lungs and body. Nebulized bronchodilators open airways and increase the amount of oxygen delivered. The patient may not need cardiac monitoring because hes only 19 years old, unless he has a medical history of cardiac problems. 12. A Severe hypoxia after smoke inhalation typically is related to ARDS. The other choices arent typically associated with smoke inhalation. 13. D The chest tube isnt removed until the patients lung has adequately reexpanded and is expected to stay that way. One indication of reexpansion is the cessation of fluctuation in the water-seal chamber when suction isnt applied. The chest X-ray should show that the lung is reexpanded. Drainage should be minimal before the chest tube is removed. An ABG test isnt necessary if clinical assessment criteria are met.

14. A High-top sneakers are used to prevent footdrop and contractures in patients with neurologic conditions. A consult with physical therapy is important to prevent footdrop, but you can use high-top sneakers independently. 15. C The earliest sign of increased ICP is a change in mental status. Bradycardia and widened pulse pressure occur later. The patient may void a lot of very dilute urine if his posterior pituitary is damaged. 16. C Phenytoin is compatible only with saline solutions; dextrose causes an insoluble precipitate to form. You neednt withhold additional anticonvulsants or use an in-line filter. 17. A After surgical repair of the hip, keep the legs and hips abducted to stabilize the prosthesis in the acetabulum. 18. B Acute pancreatitis is commonly associated with fluid isolation and accumulation in the bowel secondary to ileus or peripancreatic edema. Fluid and electrolyte loss from vomiting is a major concern. Therefore, your priority is to manage hypovolemia and restore electrolyte balance. Pain control and nutrition also are important. Patients are at risk for hyperglycemia, not hypoglycemia. 19. B Positioning the patient on his right side with the bed flat will splint the biopsy site and minimize bleeding. The other positions wont do this and may cause more bleeding at the site or internally. 20. B Precipitation of angina or cardiac arrhythmia is a potentially serious complication of hypothyroidism treatment. Acute hemolytic reaction is a complication of blood transfusions. Retinopathy typically is a complication of diabetes mellitus. Thrombocytopenia doesnt result from treating hypothyroidism. 21. B Maintaining adequate fluid and replacing vasopressin are the main objectives in treating diabetes insipidus. An excess of antidiuretic hormone leads to SIADH, causing the patient to retain fluid. Diabetic ketoacidosis is a result of severe insulin insufficiency. 22. C During periods of infection or illness, patients with Type 1 diabetes may need even more insulin to compensate for increased blood glucose levels. 23. A A decreased hematocrit level is a sign of hematoma, a delayed complication of abdominal and vaginal hysterectomy. Symptoms of hypovolemia include increased hematocrit and hemoglobin values. Symptoms of a PE include dyspnea, chest pain, cough, hemoptysis, restlessness, and signs of shock. 24. C Lactated Ringers solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a bur n. Albumin is used as adjunct therapy, not primary fluid replacement. Dextrose isnt given to burn patients during the first 24 hours because it can cause pseudodiabetes. The patient is hyperkalemic from the potassium shift from the intracellular space to the plasma, so potassium would be detrimental. 25. C Rolling a swab from the center outward is the right way to obtain a culture specimen from a wound. Irrigating the wound washes away drainage, debris, and many of the colonizing or infecting microorganisms. The outside of the wound and the dressing may be colonized with microorganisms that havent affected the wound, so specimens from these sites could give inaccurate results.

You are doing some teaching with a client who is starting on a sulfonylurea antidiabetic agent. The client mentions that he usually has a couple of beers each night and takes an aspirin each day to prevent heart attack and/or strokes. Which of the following responses would be best on the part of the nurse?

a. As long as you only drink two beers and take one aspirin, this should not be a problem b. The aspirin is alright but you need to give up drinking any alcoholic beverages c. Aspirin and alcohol will cause the stomach to bleed more when on a sulfonylurea drug d. Taking alcohol and/or aspirin with a sulfonylurea drug can cause development of hypoglycemiaD. Taking alcohol and/or aspirin with a sulfonylurea drug can cause development of hypoglycemia Alcohol and/or aspirin taken with a sulfonylurea can cause development of hypoglycemia.

1. Nurse Jay is performing wound care. Which of the following practices violates surgical asepsis?
A.Holding sterile objects above the waist B.Considering a 1 edge around the sterile field as being contaminated C.Pouring solution onto a sterile field cloth D.Opening the outermost flap of a sterile package away from the body 2. During the acute phase of a burn, the nurse in-charge should assess which of the following? A.Clients lifestyle B.Alcohol use C.Tobacco use D.Circulatory status 3. Nurse Kate is changing a dressing and providing wound care. Which activity should she perform first? A.Assess the drainage in the dressing. B.Slowly remove the soiled dressing C.Wash hands thoroughly. D.Put on latex gloves. 4. Nurse May is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the plan of care? A.Turn and reposition the client at least once every 8 hours. B.Vigorously massage lotion into bony prominences. C.Post a turning schedule at the clients bedside. D.Slide the client, rather than lifting, when turning. 5. Nurse Jane formulates a nursing diagnosis of Impaired physical mobility for a client with third-degree burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which related-to phrase? A.Related to fat emboli B.Related to infection C.Related to femoral artery occlusion D.Related to circumferential eschar 6. The nurse is assessing for the presence of cyanosis in a male dark-skinned client. The nurse understands that which body area would provide the best assessment? A.Lips B.Sacrum C.Earlobes D.Back of the hands 7. Which of the following individuals is least likely to be at risk of developing psoriasis? A.A 32 year-old-African American B.A woman experiencing menopause C.A client with a family history of the disorder D.An individual who has experienced a significant amount of emotional distress 8. Which of the following clients would least likely be at risk of developing skin breakdown?

A.A client incontinent of urine feces B.A client with chronic nutritional deficiencies C.A client with decreased sensory perception D.A client who is unable to move about and is confined to bed 9. The nurse prepares to care for a male client with acute cellulites of the lower leg. The nurse anticipates that which of the following will be prescribed for the client? A.Cold compress to the affected area B.Warm compress to the affected area C.Intermittent heat lamp treatments four times daily D.Alternating hot and cold compresses continuously 10. The clinic nurse assesses the skin of a white characteristic is associated with this skin disorder? A.Clear, thin nail beds B.Red-purplish scaly lesions C.Oily skin and no episodes of pruritus D.Silvery-white scaly patches on the scalp, elbow, knees, and sacral regions 11. The clinic nurse notes that the physician has documented a diagnosis of herpes zoster (shingles) in the male clients chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made following which diagnostic test? A.Patch test B.Skin biopsy C.Culture of the lesion D.Woos light examination 12. The nurse is assigned to care for a female client with herpes zoster (Shingles). Which of the following characteristics would the nurse expect to note when assessing the lesions of this infection? A.Clustered skin vesicles B.A generalized body rash C.Small blue-white spots with a red base D.A fiery red, edematous rash on the cheeks 13. When assessing a lesion diagnosed as malignant melanoma, the nurse in-charge most likely expects to note which of the following? A.An irregular shaped lesion B.A small papule with a dry, rough scale C.A firm, nodular lesion topped with crust D.A pearly papule with a central crater and a waxy border 14. The nurse prepares discharge instructions for a male client following cryosurgery for the treatment of a malignant skin lesion. Which of the following should the nurse include in the instruction? A.Avoid showering for 7 to 10 days B.Apply ice to the site to prevent discomfort C.Apply alcohol-soaked dressing twice a day D.Clean the site with hydrogen peroxide to prevent infection 15. Nurse Carl reviews the clients chart and notes that the physician has documented a diagnosis of paronychia. Based on this diagnosis, which of the following would the nurse expect to note during the assessment? A.Red shiny skin around the nail bed B.White taut skin in the popliteal area C.White silvery patches on the elbows D.Swelling of the skin near the parotid gland 16. A male client arrives at the emergency room and has experienced frostbites to the right hand. Which of the following would the nurse note on assessment of the clients hand? A.A pink, edematous hand B.A fiery red skin with edema in the nail beds C.Black fingertips surrounded by an erythematous rash D.A white color to the skin, which is insensitive to touch 17. The evening nurse reviews the nursing documentation in the male clients chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client s sacral area? A.Intact skin B.Full-thickness skin loss C.Exposed bone, tendon, or muscle D.Partial-thickness skin loss of the dermis 18. Nurse Ivy is implementing a teaching plan to a group of adolescents regarding the causes of acne. Which of the following is an appropriate nursing statement regarding the cause of this disorder? A.Acne is caused by oily skin B.The actual cause is not known C.Acne is caused by eating chocolate D.Acne is caused as a result of exposure to heat and humidity 19. The nurse is reviewing the health care record of a male clients scheduled to be seen at the health care clinic. The nurse determines that which of the following individuals is at the greatest risk for development of an integumentary disorder? A.An adolescent B.An older female C.A physical education teacher D.An outdoor construction worker 20. A male client schedule for a skin biopsy is concerned and asks the nurse how painful the procedure is. The appropriate response by the nurse is: A.There is no pain associated with this procedure B.The local anesthetic may cause a burning or stinging sensation C."A preoperative medication will be given so you will be sleeping and will not feel any pain D.There is some pain, but the physician will prescribe an opioid analgesic following the procedure 21. The nurse is teaching a female client with a leg ulcer about tissue repair and wound healing. Which of the following statements by the client indicates effective teaching? A.Ill limit my intake of protein. B.Ill make sure that the bandage is wrapped tightly. C.My foot should feel cold. D.Ill eat plenty of fruits and vegetables. 22. Following a full-thickness (third-degree) burn of his left arm, a male client is treated with artificial skin. The client understands postoperative care of artificial skin when he states that during the first 7 days after the procedure, he will restrict: A.range of motion. B.protein intake C.going outdoors. D.fluid ingestion 23. Following a small-bowel resection, a male client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is: A.erythema B.leukocytosis C.pressurelike pain. D.swelling 24. While in a skilled nursing facility, a female client contracted scabies, which is diagnosed the day after discharge. The clie nt is living at her daughters home, where six other persons are living. During her visit to the clinic, she asks a staff nurse, What should my family do? The most accurate response from the nurse is: A.All family members will need to be treated. B.If someone develops symptoms, tell him to see a physician right away. C.Just be careful not to share linens and towels with family members. D.After youre treated, family members wont be at risk for contracting scabies. 25. The nurse is assessing a male client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem? A.Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg B.Urine output of 20 ml/hour C.White pulmonary secretions

D.Rectal temperature of 100.6 F (38 C) 26. A female client exhibits s purplish bruise to the skin after a fall. The nurse would document this finding most accurately using which of the following terms? A.Purpura B.Petechiae C.Ecchymosis D.Erythema 27. An older clients physical examination reveals the presence of a number of bright red-colored lesions scattered on the trunk and tights. The nurse interprets that this indicates which of the following lesions due to alterations in blood vessels of the skin? A.Cherry angioma B.Spider angioma C.Venous star D.Purpura 28. A nurse is reviewing the medical record of a male client to be admitted to the nursing unit and notes documentation of reticular skin lesions. The nurse expects that these lesions will appear to be: A.Ring-shaped B.Linear C.Shaped like an arc D.Net-like appearance 29. A male client seen in an ambulatory clinic has a butterfly rash across the nose. The nurse interprets that this finding is consistent with early manifestations of which of the following disorders? A.Hyperthyroidism B.Perncious anemia C.Cardiopulmonary disorders D.Systemic lupus erythematosus (SLE) 30. A female client with cellulites of the lower leg has had cultures done on the affected area. The nurse reading the culture report understands that which of the following organisms is not part of the normal flora of the skin? A.Staphylococcus epidermidis B.Staphylococcus aureus C.Escherichia coli (E. coli) D.Candida albicans