NCLEX QUESTIONS #4 FALL 2009

(Answers follow all questions)

Fundamentals of Nursing 1. When is it appropriate for a nurse to release information without the patients consent? A. When a TV station is doing a story on the patient B. When the patient has a sexually transmitted disease C. When a family member requests information D. When another physician (not presently treating the patient) orders information

Maternity 2. A nurse should instruct a woman on medroxyprogesterone (Depo-provera) contraception to increase which of the following in her diet? A. Calcium B. Potassium C. Folic acid D. Vitamin C

Pediatrics 3. An adolescent with conjunctivitis requires more teaching if he states which of the following? A. I should throw my contaminated contact lenses out. B. I should buy new contact lenses. C. I can wear my contact lenses if I clean them well. D. I should not wear contact lenses until the conjuctivitis is resolved.

Neurological Disorders (Adult) 4. While assessing a patient recovering from hip surgery the nurse notes that she is disoriented. What intervention should the nurse initiate? A. Apply restraints per protocol. B. Ask the family to stay with the patient at all times. C. Reorient the patient frequently and place a clock and calendar in her room. D. Post a falls precaution sign on her door.

Musculoskeletal/Integumentary Disorders (Adult) 5. A client arrives in the ER after an assault. She is very emotional, hyperventilating, trembling and very anxious. What is an appropriate nursing intervention? A. Ask her politely to be quiet because there is a baby in the next room. B. Remain with her until she calms down and the anxiety decreases. C. Place her in a quiet room by herself until she is calm. D. Begin to teach relaxation techniques.

Oncological/ Immune Disorders (Adult) 6. A nurse is reviewing a plan of care for a 37-year-old pregnant sickle cell patient. Which nursing diagnosis is most appropriate? A. Risk for Fluid volume, deficient B. Risk for Fluid volume, excess C. Risk for Pain, acute D. Risk for Body image, disturbed

Cardiovascular Disorders (Adult) 7. A nurse is giving discharge instructions to a patient who is receiving nitroglycerin for angina. The nurse knows the patient understands the information when she states: A. I will keep my medicine in a plastic bag in my purse. B. I will keep my medicine in the refrigerator. C. I will keep my medicine in a dark container to shield it from light. D. I will keep my medicine next to my bed.

Respiratory Disorders (Adult) 8. A nurse is caring for a patient with emphysema. The patient has a dyspneic spell during her assessment. Which of the following positions will maximize chest expansion? Choose all that apply. A. Sitting up with elbows on knees B. Laying flat on the back in a semi-fowlers position C. Standing and leaning against a wall D. Sitting up and leaning on a table

Endocrine Disorders (Adult) 9. A patient has just been diagnosed with diabetes mellitus. His doctor has requested glucagon for emergency use at home. The nurse instructs the patient that the purpose of this drug is to treat: A. Hyperglycemia from insufficient insulin injection. B. Hyperglycemia from eating a large meal. C. Hypoglycemia from insulin overdose. D. Lipohypertrophy from inadequate insulin absorption.

GI/GU Disorders (Adult) 10. A patient admitted with a gastric ulcer has started to vomit bright red blood. His Hgb level is 4.10 g/dl and his Bp is 105/45mm Hg. You are preparing to transfuse him with PRBC. The nurse must use a blood administration set that includes: A. Microdrip administration set B. Micron mesh filter C. Nonfiltered blood administration kit D. Syringe pump tubing

Sensory Disorders (Adults) 11. A nurse is educating a patient about Menieres disease and instructs the patient to play background music to help cope with which side effect? A. Dry mouth B. Insomnia C. Anxiety D. Chronic tinnitus

Psychiatric and Mental Health (Adults) 12. A nurse is speaking with a patient who is admitted in an acute psychotic state. The patient states, I am hearing terrible voices in my head and my sister is out to get me. What is the most appropriate response from the nurse? A. Dont be silly, your sister loves you. B. What exactly are the voices saying to you? C. How long have you been hearing voices? D. I will sit with you until the voices go away.

References Billings, D.M. (2008). Lippincotts Q&A Review for NCLEX-RN (9th edition). Ambler, PA: Lippincott Williams & Wilkins. Silvestri, L.A. (2008). Comprehensive Review for the NCLEX-RN Examination (4th edition). St Louis, MO: Saunders.

NCLEX #4 ANSWERS 1. B: STDs are communicable diseases that must be reported to the appropriate health agency. The other answers are a violation of the patients rights without a written consent by the patient. 2. A: This particular medication has a slight risk of osteoporosis. It may also affect glucose tolerance in women who are at risk for diabetes. 3. C: The patient can re-infect his eyes if he wears contaminated lenses and risk corneal ulceration as well. He should throw out the contaminated lenses, purchase new ones and wear glasses until the infection is resolved. 4. C: Disorientation may occur due to lack of sensory stimulation. Reorienting the patient frequently is most appropriate. Restraints may cause more disorientation and fear in the patient. It is not appropriate to ask the family to stay at the bedside at all times. 5. B: During a severe state of anxiety it is important for the nurse to remain with the patient. The patient will not be able to be taught relaxation techniques during a heightened state of anxiety. A patient should not be left alone at this time. Telling her to be quiet is inappropriate at this time. 6. A: Dehydration will cause sickling of the red blood cells. The sickle cells can have life-threatening consequences for the mother and fetus. Therefore, A is the highest priority. 7. C: All forms of nitroglycerine should be kept in a dark container that the pharmacist provides. The light deteriorates the medicine. 8. A, C, D: These are all positions that will maximize the patients chest expansion. Sitting is better than standing because it allows for the accessory muscles to be used for breathing rather than posture control, but if no chair is available leaning against a wall is effective as well. 9. C: Glucagon is for emergency use for insulin overdose. The patient will usually arouse within 20 minutes if unconscious. The family should also be instructed how to use the glucagon injection as well. 10. B: Blood products always need to be administered through a mesh filter. 11. D: The low-pitch roaring sound of tinnitus can be minimized by playing low background music. A quiet environment can make the tinnitus worse.

12. The nurse should gather more information about the content of the voices. B: This is the patients chief complaint. The nurse needs to determine if the voices are command hallucinations and if she may act on them. C: The onset and duration is important too but the PRIORITY is to determine type of hallucinations then determine the duration.

References Billings, D.M. (2008). Lippincotts Q&A Review for NCLEX-RN (9th edition). Ambler, PA: Lippincott Williams & Wilkins. Silvestri, L.A. (2008). Comprehensive Review for the NCLEX-RN Examination (4th edition). St Louis, MO: Saunders.