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NCLEX RN Practice Questions 16

1. The primary reason for rapid continuous rewarming of the area affected by frostbite is to:

a. Lessen the amount of cellular damage
b. Prevent the formation of blisters
c. Promote movement
d. Prevent pain and discomfort

2. A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse’s response is based on the knowledge that hemodialysis works by:

a. Passing water through a dialyzing membrane
b. Eliminating plasma proteins from the blood
c. Lowering the pH by removing nonvolatile acids
d. Filtering waste through a dialyzing membrane

3. During a home visit, a client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is most appropriate?

a. Administer an antibiotic
b. Contact the physician for an order for immune globulin
c. Administer an antiviral
d. Tell the client that he should remain in isolation for 2 weeks

4. A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact?

a. The client should be placed in a room with negative pressure.
b. Infection requires close contact; therefore, the door may remain open.
c. Transmission is highly likely, so the client should wear a mask at all times.
d. Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown.

5. A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain?

a. "The pain will go away in a few days."
b. "The pain is due to peripheral nervous system interruptions. I will get you some pain medication."
c. "The pain is psychological because your foot is no longer there."
d. "The pain and itching are due to the infection you had before the surgery."

6. A client with cancer of the pancreas has undergone a Whipple procedure. The nurse is aware that during the Whipple procedure, the doctor will remove the:

a. Head of the pancreas
b. Proximal third section of the small intestines
c. Stomach and duodenum
d. Esophagus and jejunum

7. The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to avoid eating:

a. Fruits
b. Salt
c. Pepper
d. Ketchup

8. A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to:

a. Have a Protime done monthly
b. Eat more fruits and vegetables
c. Drink more liquids
d. Avoid crowds

9. The nurse is assisting the physician with removal of a central venous catheter. To facilitate removal, the nurse should instruct the client to:

a. Perform the Valsalva maneuver as the catheter is advanced
b. Turn his head to the left side and hyperextend the neck
c. Take slow, deep breaths as the catheter is removed
d. Turn his head to the right while maintaining a sniffing position

10. A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for:

a. Allergies to pineapples and bananas
b. A history of streptococcal infections
c. Prior therapy with phenytoin
d. A history of alcohol abuse

11. The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:

a. Using oil- or cream-based soaps
b. Flossing between the teeth
c. The intake of salt
d. Using an electric razor

12. The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to:

a. Apply the new tie before removing the old one.
b. Have a helper present.
c. Hold the tracheotomy with the nondominant hand while removing the old tie.
d. Ask the doctor to suture the tracheostomy in place.

13. The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to:

a. Turning the client to the left side
b. Milking the tube to ensure patency
c. Slowing the intravenous infusion
d. Notifying the physician

14. The infant is admitted to the unit with tetrology of falot. The nurse would anticipate an order for which medication?

a. Digoxin
b. Epinephrine
c. Aminophyline
d. Atropine

15. The nurse is educating the lady’s club in self-breast exam. The nurse is aware that most malignant breast masses occur in the Tail of Spence. On the diagram, place an X on the Tail of Spence.

16. The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:

a. Tire easily
b. Grow normally
c. Need more calories
d. Be more susceptible to viral infections

17. The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:

a. Determine lung maturity
b. Measure the fetal activity
c. Show the effect of contractions on fetal heart rate
d. Measure the well-being of the fetus

18. The nurse is evaluating the client who was admitted 8 hours ago for induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse?

a. Instruct the client to push
b. Perform a vaginal exam
c. Turn off the Pitocin infusion
d. Place the client in a semi-Fowler’s position

19. The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as:

a. Atrial flutter
b. A sinus rhythm
c. Ventricular tachycardia
d. Atrial fibrillation

20. A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should:

a. Be injected into the deltoid muscle
b. Be injected into the abdomen
c. Aspirate after the injection
d. Clear the air from the syringe before injections

21. The nurse has a preop order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The correct method of administering these medications is to:

a. Administer the medications together in one syringe
b. Administer the medication separately
c. Administer the Valium, wait 5 minutes, and then inject the Phenergan
d. Question the order because they cannot be given at the same time

22. A client with frequent urinary tract infections asks the nurse how she can prevent the reoccurrence. The nurse should teach the client to:

a. Douche after intercourse
b. Void every 3 hours
c. Obtain a urinalysis monthly
d. Wipe from back to front after voiding

23. Which task should be assigned to the nursing assistant?

a. Placing the client in seclusion
b. Emptying the Foley catheter of the preeclamptic client
c. Feeding the client with dementia
d. Ambulating the client with a fractured hip

24. The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside?

a. A tracheotomy set
b. A padded tongue blade
c. An endotracheal tube
d. An airway

25. The physician has ordered a histoplasmosis test for the elderly client. The nurse is aware that histoplasmosis is transmitted to humans by:

a. Cats
b. Dogs
c. Turtles
d. Birds

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