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Quote for the month

Constant attention by a good nurse may be just as important as a major operation by a surgeon.-Dag Hammarskjold

Saturday, September 25, 2010

NCLEX practice question 6

1. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first?
A) Gastric lavage PRN
B) Acetylcysteine (mucomyst) for age per pharmacy
C) Start an IV Dextrose 5% with 0.33% normal saline to keep vein open
D) Activated charcoal per pharmacy
The correct answer is A: Gastric lavage PRN
Removing as much of the drug as possible is the first step in treatment for this drug overdose. This is best done by gastric lavage. The next drug to give would be activated charcoal, then mucomyst and lastly the IV fluids

2.      Which of these statements best describes the characteristic of an effective reward-feedback system?

A)               Specific feedback is given as close to the event as possible

B)                 Staff are given feedback in equal amounts over time

C)               Positive statements are to precede a negative statement

D)               Performance goals should be higher than what is attainable

The correct answer is A: Specific feedback is given as close to the event as possible
Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if the standards are clearly understood.

3.      A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?

A)               A 2 month old infant with a history of rolling off the bed and has buldging fontanels with crying

B)                 A teenager who got a singed beard while camping

C)               An elderly client with complaints of frequent liquid brown colored stools

D)               A middle aged client with intermittent pain behind the right scapula

The correct answer is B: A teenager who got singed a singed beard while camping
This client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling.

4.      What would the nurse expect to see while assessing the growth of children during their school age years?

A)               Decreasing amounts of body fat and muscle mass

B)                 Little change in body appearance from year to year

C)               Progressive height increase of 4 inches each year

D)               Yearly weight gain of about 5.5 pounds per year

The correct answer is D: Yearly weight gain of about 5.5 pounds per year
School age children gain about 5.5 pounds each year and increase about 2 inches in height.

5.      Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test?

A)               Client must be NPO before the examination

B)                 Enema to be administered prior to the examination

C)               Medicate client with Lasix 20 mg IV 30 minutes prior to the examination

D)               No special orders are necessary for this examination

The correct answer is D: No special orders are necessary for this examination
No special preparation is necessary for this examination

6.      A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethizine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first?

A)               Raise the side rails on the bed

B)                 Place the call bell within reach

C)               Instruct the client to remain in bed

D)               Have the client empty bladder

The correct answer is D: Have the client empty bladder
The first step in the process is to have the client void prior to administering the pre-operative medication. The other actions follow this initial step in this sequence: 4 3 1 2

7.      A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is

A)               Maintain fluid and electrolyte balance

B)                 Control nausea

C)               Manage pain

D)               Prevent urinary tract infection

The correct answer is C: Manage pain The immediate goal of therapy is to alleviate the client’s pain

8.      A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?

A)               The muscles

B)                 The cerebellum

C)               The kidneys

D)               The leg bones

The correct answer is A: All striated muscles
Rhabdomyosarcoma is the most common children''s soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word and is “myo” which typically means muscle.

9.      A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information?

A)               Gravida 4 para 2

B)                 Gravida 2 para 1

C)               Gravida 3 para 1

D)               Gravida 3 para 2

The correct answer is C: Gravida 3 para 1
Gravida is the number of pregnancies and Parity is the number of pregnancies that reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).

10. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?

A)               Blood pressure 94/60

B)                 Heart rate 76

C)               Urine output 50 ml/hour

D)               Respiratory rate 16

The correct answer is A: Blood pressure 94/60
Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100; systolic B/P over 100) in order to safely administer both medications.

source: NCSBN

NCLEX practice question 5

1. The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to:
A) Excessive fetal weight
B) Low blood sugar levels
C) Depletion of subcutaneous fat
D) Progressive placental insufficiency

The correct answer is D: Progressive placental insufficiency
The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long term effects may be related to hypoxia

2.      Which individual is at greatest risk for developing hypertension?

A)               45 year-old African American attorney

B)                 60 year-old Asian American shop owner

C)               40 year-old Caucasian nurse

D)               55 year-old Hispanic teacher

The correct answer is A: 45 year-old African American attorney
The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising.

3.      At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states “My blood pressure is usually much lower.” The nurse should tell the client to

A)               go get a blood pressure check within the next 48 to 72 hours

B)                 check blood pressure again in 2 months

C)               see the health care provider immediately

D)               visit the health care provider within 1 week for a BP check

The correct answer is A: go get a blood pressure check within the next 48 to 72 hours
The blood pressure reading is moderately high with the need to have it rechecked in a few days. The client states it is ‘usually much lower.’ Thus a concern exists for complications such as stroke. However immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.

4.      During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to

A)               Increase fluids that are high in protein

B)                 Restrict fluids

C)               Force fluids and reassess blood pressure

D)               Limit fluids to non-caffeine beverages

The correct answer is C: Force fluids and reassess blood pressure
Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency.

5.      A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?

A)               Weight gain of 5 pounds

B)                 Edema of the ankles

C)               Gastric irritability

D)               Decreased appetite

The correct answer is D: Decreased appetite
Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias.

6.      The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to

A)               Achieve harmony

B)                 Maintain a balance of energy

C)               Respect life

D)               Restore yin and yang

The correct answer is D: Restore yin and yang
For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang

7.      A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time?

A)               Positive sweat test

B)                 Bulky greasy stools

C)               Moist, productive cough

D)               Meconium ileus

The correct answer is C: Moist Productive cough
Option c is a later sign. Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.

8.      During the evaluation of the quality of home care for a client with Alzheimer's disease, the priority for the nurse is to reinforce which statement by a family member?

A)               At least 2 full meals a day is eaten.

B)                 We go to a group discussion every week at our community center.

C)               We have safety bars installed in the bathroom and have 24 hour alarms on the doors.

D)               The medication is not a problem to have it taken 3 times a day.

The correct answer is C: We have safety bars installed in the bathroom and have 24 hour alarms on the doors.
Ensuring safety of the client with increasing memory loss is a priority of home care. Note all options are correct statements. However, safety is most important to reinforce.

9.      The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response?

A)               Electrical energy fields

B)                 Spinal column manipulation

C)               Mind-body balance

D)               Exercise of joints

The correct answer is B: Spinal column manipulation
The theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation.

10. The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention?

A)               Decrease in level of consciousness

B)                 Loss of bladder control

C)               Altered sensation to stimuli

D)               Emotional lability

The correct answer is A: Decrease in level of consciousness
A further decrease in the level of consciousness would be indicative of a further progression of the CVA.

11. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should

A)               Place a call to the client's health care provider for instructions

B)                 Send him to the emergency room for evaluation

C)               Reassure the client's wife that the symptoms are transient

D)               Instruct the client's wife to call the doctor if his symptoms become worse

The correct answer is B: Send him to the emergency room for evaluation
This client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care nurses must prioritize interventions based on assessment findings that are in the client''s best interest.

12. A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first?

A)               Prepare the child for x-ray of upper airways

B)                 Examine the child's throat

C)               Collect a sputum specimen

D)               Notify the healthcare provider of the child's status

The correct answer is D: Notify the health care provider of the child''s status
These findings suggest a medical emergency and may be due to epiglottises. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction.

13. A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which

A)               Increase the heart rate

B)                 Lead to dehydration

C)               Are considered aerobic

D)               May be competitive

The correct answer is B: Lead to dehydration
The client must take in adequate fluids before and during exercise periods.

14. A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is

A)               Start a peripheral IV

B)                 Initiate closed-chest massage

C)               Establish an airway

D)               Obtain the crash cart

The correct answer is C: Establish an airway
Establishing an airway is always the primary objective in a cardiopulmonary arrest.

15. When teaching a client with coronary artery disease about nutrition, the nurse should emphasize

A)               Eating 3 balanced meals a day

B)                 Adding complex carbohydrates

C)               Avoiding very heavy meals

D)               Limiting sodium to 7 gms per day

The correct answer is C: Avoiding very heavy meals
Eating large, heavy meals can pull blood away from the heart for digestion and is dangerous for the client with coronary artery disease.

16. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs?

A)               "I want to protect my child from any falls."

B)                 "I will set limits on exploring the house."

C)               "I understand the need to use those new skills."

D)               "I intend to keep control over our child."

The correct answer is C: "I understand the need to use those new skills."
Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment.

17. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?

A)               angina at rest

B)                 thrombus formation

C)               dizziness

D)               falling blood pressure

The correct answer is B: thrombus formation
Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure.

18. The nurse is caring for a client who had a total hip replacement 4 days ago. Which assessment requires the nurse’s immediate attention?

A)               I have bad muscle spasms in my lower leg of the affected extremity.

B)                 "I just can't 'catch my breath' over the past few minutes and I think I am in grave danger."

C)               "I have to use the bedpan to pass my water at least every 1 to 2 hours."

D)               "It seems that the pain medication is not working as well today."

The correct answer is B: "I just can''t ''catch my breath'' over the past few minutes and I think I am in grave danger."
The nurse would be concerned about all of these comments. However the most life threatening is option B. Clients who have had hip or knee surgery are at greatest risk for development of post operative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Option C may indicate a urinary tract infection. And option D requires further investigation and is not life threatening.

19. In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation?

A)               Polyphagia

B)                 Dehydration

C)               Bed wetting

D)               Weight loss

The correct answer is C: Bed wetting
In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bed wetting in a school age child is readily detected by the parents.

20. The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question?

A)               "You need to regain your strength before attempting such exertion."

B)                 "When you can climb 2 flights of stairs without problems, it is generally safe."

C)               "Have a glass of wine to relax you, then you can try to have sex."

D)               "If you can maintain an active walking program, you will have less risk."

The correct answer is B: "When you can climb 2 flights of stairs without problems, it is generally safe."
There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.

source: NCSBN