NCLEX Q & A's Part 2

1.    A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?

A.   Place the client in a sitting position with the head hyperextended

B.    Pack the nares tightly with gauze to apply pressure to the source of bleeding

C.   Pinch the soft lower part of the nose for a minimum of 5 minutes

D.   Apply ice packs to the forehead and back of the neck

2.    A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate post-operative period for the nurse to take is:

A.   Blood pressure

B.    Temperature

C.   Output

D.   Specific gravity

3.    A client with Addison's disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?

A.   Glucometer readings as ordered

B.    Intake/output measurements

C.   Sodium and potassium levels monitored

D.   Daily weights

4.    A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses' next action be?

A.   Obtain a crash cart

B.    Check the calcium level

C.   Assess the dressing for drainage

D.   Assess the blood pressure for hypertension

5.    A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?

A.   Impaired physical mobility related to decreased endurance

B.    Hypothermia r/t decreased metabolic rate

C.   Disturbed thought processes r/t interstitial edema

D.   Decreased cardiac output r/t bradycardia

6.    The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client?

A.   Report muscle weakness to the physician.

B.    Allow six months for the drug to take effect.

C.   Take the medication with fruit juice.

D.   Ask the doctor to perform a complete blood count before starting the medication.

7.    The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:

A.   Utilize an infusion pump

B.    Check the blood glucose level

C.   Place the client in Trendelenburg position

D.   Cover the solution with foil

8.    The 6-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?

A.   Blood pressure of 126/80

B.    Blood glucose of 110mg/dL

C.   Heart rate of 60bpm

D.   Respiratory rate of 30 per minute

9.    The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:

A.   Replenish his supply every 3 months

B.    Take one every 15 minutes if pain occurs

C.   Leave the medication in the brown bottle

D.   Crush the medication and take with water

10. The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?

A.   Macaroni and cheese

B.    Shrimp with rice

C.   Turkey breast

D.   Spaghetti

11. The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:

A.   Feet

B.    Neck

C.   Hands

D.   Sacrum

12. The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the:

A.   Phlebostatic axis

B.    PMI

C.   Erb's point

D.   Tail of Spence

13. The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:

A.   Question the order

B.    Administer the medications

C.   Administer separately

D.   Contact the pharmacy

14. The best method of evaluating the amount of peripheral edema is:

A.   Weighing the client daily

B.    Measuring the extremity

C.   Measuring the intake and output

D.   Checking for pitting

15. A client with vaginal cancer is being treated with a radioactive vaginal implant. The client's husband asks the nurse if he can spend the night with his wife. The nurse should explain that:

A.   Overnight stays by family members is against hospital policy.

B.    There is no need for him to stay because staffing is adequate.

C.   His wife will rest much better knowing that he is at home.

D.   Visitation is limited to 30 minutes when the implant is in place.

16. The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?

A.   Roast beef sandwich, potato chips, pickle spear, iced tea

B.    Split pea soup, mashed potatoes, pudding, milk

C.   Tomato soup, cheese toast, Jello, coffee

D.   Hamburger, baked beans, fruit cup, iced tea

17. The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?

A.   "I will make sure I eat breakfast within 10 minutes of taking my insulin."

B.    "I will need to carry candy or some form of sugar with me all the time."

C.   "I will eat a snack around three o'clock each afternoon."

D.   "I can save my dessert from supper for a bedtime snack."

18. The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first 2 weeks of life because:

A.   New parents need time to learn how to hold the baby.

B.    The umbilical cord needs time to separate.

C.   Newborn skin is easily traumatized by washing.

D.   The chance of chilling the baby outweighs the benefits of bathing.

19. A client with leukemia is receiving Trimetrexate. After reviewing the client's chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:

A.   Treat iron-deficiency anemia caused by chemotherapeutic agents

B.    Create a synergistic effect that shortens treatment time

C.   Increase the number of circulating neutrophils

D.   Reverse drug toxicity and prevent tissue damage

20. A 4-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:

A.   Hib titer

B.    Mumps vaccine

C.   Hepatitis B vaccine

D.   MMR

21. The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication:

A.   30 minutes before meals

B.    With each meal

C.   In a single dose at bedtime

D.   30 minutes after meals

22. A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?

A.   Call security for assistance and prepare to sedate the client.

B.    Tell the client to calm down and ask him if he would like to play cards.

C.   Tell the client that if he continues his behavior he will be punished.

D.   Leave the client alone until he calms down.

23. When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:

A.   Check the client for bladder distention

B.    Assess the blood pressure for hypotension

C.   Determine whether an oxytocic drug was given

D.   Check for the expulsion of small clots

24. A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client's symptoms are consistent with a diagnosis of:

A.   Pneumonia

B.    Reaction to antiviral medication

C.   Tuberculosis

D.   Superinfection due to low CD4 count

25. The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client's history should be reported to the doctor?

A.   Diabetes

B.    Prinzmetal's angina

C.   Cancer

D.   Cluster headaches

26. The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig's sign is charted if the nurse notes:

A.   Pain on flexion of the hip and knee

B.    Nuchal rigidity on flexion of the neck

C.   Pain when the head is turned to the left side

D.   Dizziness when changing positions

27. The client with Alzheimer's disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:

A.   Agnosia

B.    Apraxia

C.   Anomia

D.   Aphasia

28. The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:

A.   Chronic fatigue syndrome

B.    Normal aging

C.   Sundowning

D.   Delusions

29. The client with confusion says to the nurse, "I haven't had anything to eat all day long. When are they going to bring breakfast?" The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?

A.   "You know you had breakfast 30 minutes ago."

B.    "I am so sorry that they didn't get you breakfast. I'll report it to the charge nurse."

C.   "I'll get you some juice and toast. Would you like something else?"

D.   "You will have to wait a while; lunch will be here in a little while."

30. The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer's disease. Which side effect is most often associated with this drug?

A.   Urinary incontinence

B.    Headaches

C.   Confusion

D.   Nausea

Answers and Rationales:

1.    Answer C is correct. The client should be positioned upright and leaning forward, to prevent aspiration of blood. Answers A, B, and D are incorrect because direct pressure to the nose stops the bleeding, and ice packs should be applied directly to the nose as well. If a pack is necessary, the nares are loosely packed.

2.    Answer A is correct. Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. The remaining gland might have been suppressed due to the tumor activity. Temperature would be an indicator of infection, decreased output would be a clinical manifestation but would take longer to occur than blood pressure changes, and specific gravity changes occur with other disorders; therefore, answers B, C, and D are incorrect.

3.    Answer A is correct. IV glucocorticoids raise the glucose levels and often require coverage with insulin. Answer B is not necessary at this time, sodium and potassium levels would be monitored when the client is receiving mineral corticoids, and daily weights is unnecessary; therefore, answers B, C, and D are incorrect.

4.    Answer B is correct. The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. The tingling is due to low calcium levels. The crash cart would be needed in respiratory distress but would not be the next action to take; thus, answer A is incorrect. Hypertension occurs in thyroid storm and the drainage would occur in hemorrhage, so answers C and D are incorrect.

5.    Answer D is correct. The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices; therefore, answers A, B, and C are incorrect.

6.    Answer A is correct. The client taking antilipidemics should be encouraged to report muscle weakness because this is a sign of rhabdomyositis. The medication takes effect within 1 month of beginning therapy, so answer B is incorrect. The medication should be taken with water because fruit juice, particularly grapefruit, can decrease the effectiveness, making answer C incorrect. Liver function studies should be checked before beginning the medication, not after the fact, making answer D incorrect.

7.    Answer B is correct. Hyperstat is given IV push for hypertensive crises, but it often causes hyperglycemia. The glucose level will drop rapidly when stopped. Answer A is incorrect because the hyperstat is given by IV push. The client should be placed in dorsal recumbent position, not a Trendelenburg position, as stated in answer C. Answer D is incorrect because the medication does not have to be covered with foil.

8.    Answer C is correct. A heart rate of 60 in the baby should be reported immediately. The dose should be held if the heart rate is below 100bpm. The blood glucose, blood pressure, and respirations are within normal limits; thus answers A, B, and D are incorrect.

9.    Answer C is correct. Nitroglycerine should be kept in a brown bottle (or even a special air- and water-tight, solid or plated silver or gold container) because of its instability and tendency to become less potent when exposed to air, light, or water. The supply should be replenished every 6 months, not 3 months, and one tablet should be taken every 5 minutes until pain subsides, so answers A and B are incorrect. If the pain does not subside, the client should report to the emergency room. The medication should be taken sublingually and should not be crushed, as stated in answer D.

10. Answer C is correct. Turkey contains the least amount of fats and cholesterol. Liver, eggs, beef, cream sauces, shrimp, cheese, and chocolate should be avoided by the client; thus, answers A, B, and D are incorrect. The client should bake meat rather than frying to avoid adding fat to the meat during cooking.

11. Answer B is correct. The jugular veins in the neck should be assessed for distension. The other parts of the body will be edematous in right-sided congestive heart failure, not left-sided; thus, answers A, C, and D are incorrect.

12. Answer A is correct. The phlebostatic axis is located at the fifth intercostals space midaxillary line and is the correct placement of the manometer. The PMI or point of maximal impulse is located at the fifth intercostals space midclavicular line, so answer B is incorrect. Erb’s point is the point at which you can hear the valves close simultaneously, making answer C incorrect. The Tail of Spence (the upper outer quadrant) is the area where most breast cancers are located and has nothing to do with placement of a manometer; thus, answer D is incorrect.

13. Answer B is correct. Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix for hypertension. Answers A, C, and D are incorrect because the order is accurate. There is no need to question the order, administer the medication separately, or contact the pharmacy.

14. Answer B is correct. The best indicator of peripheral edema is measuring the extremity. A paper tape measure should be used rather than one of plastic or cloth, and the area should be marked with a pen, providing the most objective assessment. Answer A is incorrect because weighing the client will not indicate peripheral edema. Answer C is incorrect because checking the intake and output will not indicate peripheral edema. Answer D is incorrect because checking for pitting edema is less reliable than measuring with a paper tape measure.

15. Answer D is correct. Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time spent exposed to radium, putting distance between people and the radium source, and using lead to shield against the radium. Teaching the family member these principles is extremely important. Answers A, B, and C are not empathetic and do not address the question; therefore, they are incorrect.

16. Answer B is correct. The client with a facial stroke will have difficulty swallowing and chewing, and the foods in answer B provide the least amount of chewing. The foods in answers A, C, and D would require more chewing and, thus, are incorrect.

17. Answer A is correct. Novalog insulin onsets very quickly, so food should be available within 10–15 minutes of taking the insulin. Answer B does not address a particular type of insulin, so it is incorrect. NPH insulin peaks in 8–12 hours, so a snack should be eaten at the expected peak time. It may not be 3 p.m. as stated in answer C. Answer D is incorrect because there is no need to save the dessert until bedtime.

18. Answer B is correct. The umbilical cord needs time to dry and fall off before putting the infant in the tub. Although answers A, C, and D might be important, they are not the primary answer to the question.

19. Answer D is correct. Leucovorin is the antidote for Methotrexate and Trimetrexate which are folic acid antagonists. Leucovorin is a folic acid derivative. Answers A, B, and C are incorrect because Leucovorin does not treat iron deficiency, increase neutrophils, or have a synergistic effect.

20. Answer A is correct. The Hemophilus influenza vaccine is given at 4 months with the polio vaccine. Answers B, C, and D are incorrect because these vaccines are given later in life.

21. Answer B is correct. Proton pump inhibitors such as Nexium and Protonix should be taken with meals, for optimal effect. Histamine-blocking agents such as Zantac should be taken 30 minutes before meals, so answer A is incorrect. Tagamet can be taken in a single dose at bedtime, making answer C incorrect. Answer D does not treat the problem adequately and, therefore, is incorrect.

22. Answer A is correct. If the client is a threat to the staff and to other clients the nurse should call for help and prepare to administer a medication such as Haldol to sedate him. Answer B is incorrect because simply telling the client to calm down will not work. Answer C is incorrect because telling the client that if he continues he will be punished is a threat and may further anger him. Answer D is incorrect because if the client is left alone he might harm himself.

23. Answer A is correct. If the fundus of the client is displaced to the side, this might indicate a full bladder. The next action by the nurse should be to check for bladder distention and catheterize, if necessary. The answers in B, C, and D are actions that relate to postpartal hemorrhage.

24. Answer C is correct. A low-grade temperature, blood-tinged sputum, fatigue, and night sweats are symptoms consistent with tuberculosis. If the answer in A had said pneumocystis pneumonia, answer A would have been consistent with the symptoms given in the stem, but just saying pneumonia isn’t specific enough to diagnose the problem. Answers B and D are not directly related to the stem.

25. Answer B is correct. If the client has a history of Prinzmetal’s angina, he should not be prescribed triptan preparations because they cause vasoconstriction and coronary spasms. There is no contraindication for taking triptan drugs in clients with diabetes, cancer, or cluster headaches making answers A, C, and D incorrect.

26. Answer A is correct. Kernig’s sign is positive if pain occurs on flexion of the hip and knee. The Brudzinski reflex is positive if pain occurs on flexion of the head and neck onto the chest so answer B is incorrect. Answers C and D might be present but are not related to Kernig’s sign.

27. Answer B is correct. Apraxia is the inability to use objects appropriately. Agnosia is loss of sensory comprehension, anomia is the inability to find words, and aphasia is the inability to speak or understand so answers A, C, and D are incorrect.

28. Answer C is correct. Increased confusion at night is known as "sundowning" syndrome. This increased confusion occurs when the sun begins to set and continues during the night. Answer A is incorrect because fatigue is not necessarily present. Increased confusion at night is not part of normal aging; therefore, answer B is incorrect. A delusion is a firm, fixed belief; therefore, answer D is incorrect.

29. Answer C is correct. The client who is confused might forget that he ate earlier. Don’t argue with the client. Simply get him something to eat that will satisfy him until lunch. Answers A and D are incorrect because the nurse is dismissing the client. Answer B is validating the delusion.

30. Answer D is correct. Nausea and gastrointestinal upset are very common in clients taking acetlcholinesterase inhibitors such as Exelon. Other side effects include liver toxicity, dizziness, unsteadiness, and clumsiness. The client might already be experiencing urinary incontinence or headaches, but they are not necessarily associated; and the client with Alzheimer’s disease is already confused. Therefore, answers A, B, and C are incorrect.