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NCLEX Practice Exam for Fundamentals of Nursing 2 (PM)
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Question 1
A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
A
Deficient fluid volume related to blood and fluid loss from surgery
B
Risk for aspiration related to anesthesia
C
Acute pain related to surgery
D
Impaired physical mobility related to surgery
Question 1 Explanation:
Risk for aspiration related to anesthesia takes priority for thins client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The other options, although important, are secondary.
Question 2
The nurse in charge identifies a patient’s responses to actual or potential health problems during which step of the nursing process?
A
Assessment
B
Nursing diagnosis
C
Planning
D
Evaluation
Question 2 Explanation:
The nurse identifies human responses to actual or potential health problems during the nursing diagnosis step of the nursing process. During the assessment step, the nurse systematically collects data about the patient or family. During the planning step, the nurse develops strategies to resolve or decrease the patient’s problem. During the evaluation step, the nurse determines the effectiveness of the plan of care.
Question 3
A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client?
A
Prevent infection
B
Prevent injury
C
Promote rest
D
Promote fluid balance
Question 3 Explanation:
The client is at risk for infection because WBC count is dangerously low. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.
Question 4
A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and nonproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is:
A
Fatigue from overwork and understaffing
B
Failure to incorporate staff in decision making
C
Unhappiness about the charge in leadership
D
Unexpected feeling and emotions among the staff
Question 4 Explanation:
The usual or most prevalent reason for lack of productivity in a group of competent nurses is inadequate communication or a situation in which the nurses have unexpected feeling and emotions. Although the other options could be contributing to the problematic situation, they’re less likely to be the cause.
Question 5
A 65-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, “How long will it take for my scars to disappear?” which statement would be the nurse’s best response?
A
“Wound healing is very individual but within 4 months the scar should fade.”
B
"If you don’t develop an infection, the wound should heal any time between 1 and 3 years from now.”
C
“The contraction phase of wound healing can take 2 to 3 years.”
D
“With your history and the type of location of the injury, it’s hard to say.”
Question 5 Explanation:
Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information.
Question 6
Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client?
A
High-Fowler’s
B
Supine
C
Side-lying
D
Semi-Fowler’s
Question 6 Explanation:
Because of lethargy, the post tonsillectomy client is at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side-lying position until he awake is best. The semi-Fowler’s, supine, and high-Fowler’s position don’t allow for adequate oral drainage in a lethargic post tonsillectomy client, and increase the risk of blood aspiration.
Question 7
A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor would the nurse recognize as most important?
A
A history of diabetes
B
Recent pelvic surgery
C
An active daily walking program
D
A history of increased aspirin use
Question 7 Explanation:
The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and thrombophlebitis of the deep vein is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client’s risk of DVT. In general, diabetes is a contributing factor associated with peripheral vascular disease.
Question 8
Using Abraham Maslow’s hierarchy of human needs, a nurse assigns highest priority to which client need?
A
Belonging
B
Safety
C
Elimination
D
Security
Question 8 Explanation:
According to Maslow, elimination is a first-level or physiological need, and therefore takes priority over all other needs. Security and safety are second-level needs; belonging is a third-level need. Second- and third-level needs can be met only after a client’s first-level needs have been satisfied.
Question 9
A female client is admitted to the emergency department with complaints of chest pain shortness of breath. The nurse’s assessment reveals jugular vein
distention. The nurse knows that when a client has jugular vein distension, it’s typically due to:
A
An electrolyte imbalance
B
Fluid overload
C
Dehydration
D
A neck tumor
Question 9 Explanation:
Fluid overload causes the volume of blood within the vascular system to increase. This increase causes the vein to distend, which can be seen most obviously in the neck veins. A neck tumor doesn’t typically cause jugular vein distention. An electrolyte imbalance may result in fluid overload, but it doesn’t directly contribute to jugular vein distention.
Question 10
One aspect of implementation related to drug therapy is:
A
Documenting drugs given
B
Setting realistic client goals
C
Establishing outcome criteria
D
Developing a content outline
Question 10 Explanation:
Although documentation isn’t a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client’s reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are part of planning rather than implementation.
Question 11
While examining a client’s leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse in charge to apply?
A
Moist, sterile saline gauze
B
Povidone-iodine-soaked gauze
C
Dry sterile dressing
D
Sterile petroleum gauze
Question 11 Explanation:
Moist, sterile saline dressings support would heal and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine can irritate epithelial cells, so it shouldn’t be left on an open wound.
Question 12
If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff may do which of the following?
A
Cause sciatic nerve damage
B
Produce a false-low measurement
C
Produce a false-high measurement
D
Fail to show changes in blood pressure
Question 12 Explanation:
Using an undersized blood pressure cuff produces a falsely elevated blood pressure because the cuff can’t record brachial artery measurements unless it’s excessively inflated. The sciatic nerve wouldn’t be damaged by hyperinflation of the blood pressure cuff because the sciatic nerve is located in the lower extremity.
Question 13
Nurse Margareth is revising a client’s care plan. During which step of the nursing process does such revision take place?
A
Evaluation
B
Assessment
C
Planning
D
Implementation
Question 13 Explanation:
During the evaluation step of the nursing process the nurse determines whether the goals established in the care plan have been achieved, and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. Assessment involves data collection. Planning involves setting priorities, establishing goals, and selecting appropriate interventions.
Question 14
A nurse assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he’s impotent and says that he’s concerned about its effect on his marriage. In planning this client’s care, the most appropriate intervention would be to:
A
Encourage the client to ask questions about personal sexuality
B
Provide time for privacy
C
Provide support for the spouse or significant other
D
Suggest referral to a sex counselor or other appropriate professional
Question 14 Explanation:
The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client’s care. The nurse doesn’t normally provide sex counseling. Therefore, providing time for privacy and providing support for the spouse or significant other are important, but not as important as referring the client to a sex counselor.
Question 15
Nurse Berri inspects a client’s pupil size and determines that it’s 2 mm in the left eye and 3 mm in the right eye. Unequal pupils are known as:
A
Anisocoria
B
Ataxia
C
Diplopia
D
Cataract
Question 15 Explanation:
Unequal pupils are called anisocoria. Ataxia is uncoordinated actions of involuntary muscle use. A cataract is an opacity of the eye’s lens. Diplopia is double vision.
Question 16
The nurse in charge is assessing a patient’s abdomen. Which examination technique should the nurse use first?
A
Percussion
B
Palpation
C
Auscultation
D
Inspection
Question 16 Explanation:
Inspection always comes first when performing a physical examination. Percussion and palpation of the abdomen may affect bowel motility and therefore should follow auscultation.
Question 17
Which statement regarding heart sounds is correct?
A
S1 is loudest at the apex, and S2 is loudest at the base
B
S1 and S2 sound equally loud over the entire cardiac area.
C
S1 and S2 sound fainter at the base
D
S1 and S2 sound fainter at the apex
Question 17 Explanation:
The S1 sound—the “lub” sound—is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 sounds. The S2—the “dub” sound—is loudest at the base. It sounds shorter, sharper, higher, and louder there than S1
Question 18
The nurse in charge must monitor a patient receiving chloramphenicol for adverse drug reaction. What is the most toxic reaction to chloramphenicol?
A
Status epilepticus
B
Lethal arrhythmias
C
Malignant hypertension
D
Bone marrow suppression
Question 18 Explanation:
The most toxic reaction to chloramphenicol is bone marrow suppression. Chloramphenicol is not known to cause lethal arrhythmias, malignant hypertension, or status epilepticus.
Question 19
Which document addresses the client’s right to information, informed consent, and treatment refusal?
A
Nurse Practice Act
B
Code for Nurses
C
Patient’s Bill of Rights
D
Standard of Nursing Practice
Question 19 Explanation:
The Patient’s Bill of Rights addresses the client’s right to information, informed consent, timely responses to requests for services, and treatment refusal. A legal document, it serves as a guideline for the nurse’s decision making. Standards of Nursing Practice, the Nurse Practice Act, and the Code for Nurses contain nursing practice parameters and primarily describe the use of the nursing process in providing care.
Question 20
Which intervention is an example of primary prevention?
A
Administering a measles, mumps, and rubella immunization to an infant
B
Obtaining a Papanicolaou smear to screen for cervical cancer
C
Administering digoxin (Lanoxicaps) to a patient with heart failure
D
Using occupational therapy to help a patient cope with arthritis
Question 20 Explanation:
Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a smear for a screening test are examples for secondary prevention, which promotes early detection and treatment of disease. Using occupational therapy to help a patient cope with arthritis is an example of tertiary prevention, which aims to help a patient deal with the residual consequences of a problem or to prevent the problem from recurring.
Question 21
A male client in a behavioral-health facility receives a 30-minute psychotherapy session, and provider uses a current procedure terminology (CPT) code that bills for a 50-minute session. Under the False Claims Act, such illegal behavior is known as:
A
Overbilling
B
Upcoding
C
Misrepresentation
D
Unbundling
Question 21 Explanation:
Upcoding is the practice of using a CPT code that’s reimbursed at a higher rate than the code for the service actually provided. Unbundling, overbilling, and misrepresentation aren’t the terms used for this illegal practice.
Question 22
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time?
A
Impaired gas exchanges related to increased blood flow
B
Fluid volume excess related to peripheral vascular disease
C
Altered peripheral tissue perfusion related to venous congestion
D
Risk for injury related to edema
Question 22 Explanation:
Altered peripheral tissue perfusion related to venous congestion” takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis. Impaired gas exchange is related to decreased, not increased, blood flow. No evidence suggest that this patient has a fluid volume excess. Risk for injury related to edema may be warranted but is secondary to altered tissue perfusion.
Question 23
When positioned properly, the tip of a central venous catheter should lie in the:
A
Subclavian vein
B
Superior vena cava
C
Jugular vein
D
Basilica vein
Question 23 Explanation:
When the central venous catheter is positioned correctly, its tip lies in the superior vena cava, inferior vena cava, or the right atrium—that is, in central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilica, jugular, and subclavian veins are common insertion sites for central venous catheters.
Question 24
A male client is on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?
A
Inadequate protein intake
B
Inadequate massaging of the affected area
C
Low calcium level
D
Inadequate vitamin D intake
Question 24 Explanation:
A client on bed rest suffers from a lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Inadequate vitamin D intake and low calcium levels aren’t factors in poor healing for this client. A pressure ulcer should never be massaged.
Question 25
A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.d. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming:
A
Bananas and oranges
B
Fresh, green vegetables
C
Lean red meat
D
Creamed corn
Question 25 Explanation:
Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach the patient to increase intake of potassium-rich foods, such as bananas and oranges. Fresh, green vegetables; lean red meat; and creamed corn are not good sources of potassium.
Question 26
A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to:
A
Provide pain relief
B
Assess the client’s airway
C
Splint the chest wall with a pillow
D
Encourage deep breathing and coughing
Question 26 Explanation:
The first priority is to evaluate airway patency before assessing for signs of obstruction, sternal retraction, stridor, or wheezing. Airway management is always the nurse’s first priority. Pain management and splinting are important for the client’s comfort, but would come after airway assessment. Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries.
Question 27
The nurse in charge is caring for an Italian client. He’s complaining of pain, but he falls asleep right after his complaint and before the nurse can assess his pain. The nurse concludes that:
A
He was faking pain
B
The pain went away
C
Someone else gave him medication
D
He may have a low threshold for pain
Question 27 Explanation:
People of Italian heritage tend to verbalize discomfort and pain. The pain was real to the client, and he may need medication when he wakes up.
Question 28
Nurse Cay inspects a client’s back and notices small hemorrhagic spots. The nurse documents that the client has:
A
Uremia
B
Extravasation
C
Petechiae
D
Osteomalacia
Question 28 Explanation:
Petechiae are small hemorrhagic spots. Extravasation is the leakage of fluid in the interstitial space. Osteomalacia is the softening of bone tissue. Uremia is an excess of urea and other nitrogen products in the blood.
Question 29
Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance?
A
Ask the client each morning to describe the quantity of sleep during the previous night
B
Provide the client with normal sleep aids, such as pillows, back rubs, and snacks
C
Administer sleeping medication before bedtime
D
Teach the client relaxation techniques, such as guided imagery, medication, and progressive muscle relaxation
Question 29 Explanation:
The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill such as relaxation techniques. Sleep medication should be avoided whenever possible. At some point, the nurse should do a thorough sleep assessment, especially if common sense interventions fail
Question 30
Nurse Danny has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?
A
Spaghetti with cream sauce, broccoli, and tea
B
Baked beans, hamburger, and milk
C
Chicken cutlet, spinach, and soda
D
Bouillon, spinach, and soda
Question 30 Explanation:
Baked beans, hamburger, and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination provides less protein than the baked beans-hamburger-milk selection.
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NCLEX Practice Exam for Fundamentals of Nursing 2 (EM)
Choose the letter of the correct answer. You got 30 minutes to finish the exam .Good luck!
Start
Congratulations - you have completed NCLEX Practice Exam for Fundamentals of Nursing 2 (EM).
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%%
Your answers are highlighted below.
Question 1
A male client in a behavioral-health facility receives a 30-minute psychotherapy session, and provider uses a current procedure terminology (CPT) code that bills for a 50-minute session. Under the False Claims Act, such illegal behavior is known as:
A
Overbilling
B
Upcoding
C
Unbundling
D
Misrepresentation
Question 1 Explanation:
Upcoding is the practice of using a CPT code that’s reimbursed at a higher rate than the code for the service actually provided. Unbundling, overbilling, and misrepresentation aren’t the terms used for this illegal practice.
Question 2
Which statement regarding heart sounds is correct?
A
S1 and S2 sound fainter at the base
B
S1 is loudest at the apex, and S2 is loudest at the base
C
S1 and S2 sound fainter at the apex
D
S1 and S2 sound equally loud over the entire cardiac area.
Question 2 Explanation:
The S1 sound—the “lub” sound—is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 sounds. The S2—the “dub” sound—is loudest at the base. It sounds shorter, sharper, higher, and louder there than S1
Question 3
Nurse Danny has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?
A
Spaghetti with cream sauce, broccoli, and tea
B
Baked beans, hamburger, and milk
C
Bouillon, spinach, and soda
D
Chicken cutlet, spinach, and soda
Question 3 Explanation:
Baked beans, hamburger, and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination provides less protein than the baked beans-hamburger-milk selection.
Question 4
Nurse Margareth is revising a client’s care plan. During which step of the nursing process does such revision take place?
A
Implementation
B
Evaluation
C
Assessment
D
Planning
Question 4 Explanation:
During the evaluation step of the nursing process the nurse determines whether the goals established in the care plan have been achieved, and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. Assessment involves data collection. Planning involves setting priorities, establishing goals, and selecting appropriate interventions.
Question 5
The nurse in charge is assessing a patient’s abdomen. Which examination technique should the nurse use first?
A
Inspection
B
Percussion
C
Palpation
D
Auscultation
Question 5 Explanation:
Inspection always comes first when performing a physical examination. Percussion and palpation of the abdomen may affect bowel motility and therefore should follow auscultation.
Question 6
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time?
A
Risk for injury related to edema
B
Altered peripheral tissue perfusion related to venous congestion
C
Impaired gas exchanges related to increased blood flow
D
Fluid volume excess related to peripheral vascular disease
Question 6 Explanation:
Altered peripheral tissue perfusion related to venous congestion” takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis. Impaired gas exchange is related to decreased, not increased, blood flow. No evidence suggest that this patient has a fluid volume excess. Risk for injury related to edema may be warranted but is secondary to altered tissue perfusion.
Question 7
Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance?
A
Provide the client with normal sleep aids, such as pillows, back rubs, and snacks
B
Teach the client relaxation techniques, such as guided imagery, medication, and progressive muscle relaxation
C
Ask the client each morning to describe the quantity of sleep during the previous night
D
Administer sleeping medication before bedtime
Question 7 Explanation:
The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill such as relaxation techniques. Sleep medication should be avoided whenever possible. At some point, the nurse should do a thorough sleep assessment, especially if common sense interventions fail
Question 8
A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
A
Risk for aspiration related to anesthesia
B
Deficient fluid volume related to blood and fluid loss from surgery
C
Acute pain related to surgery
D
Impaired physical mobility related to surgery
Question 8 Explanation:
Risk for aspiration related to anesthesia takes priority for thins client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The other options, although important, are secondary.
Question 9
A nurse assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he’s impotent and says that he’s concerned about its effect on his marriage. In planning this client’s care, the most appropriate intervention would be to:
A
Provide time for privacy
B
Provide support for the spouse or significant other
C
Encourage the client to ask questions about personal sexuality
D
Suggest referral to a sex counselor or other appropriate professional
Question 9 Explanation:
The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client’s care. The nurse doesn’t normally provide sex counseling. Therefore, providing time for privacy and providing support for the spouse or significant other are important, but not as important as referring the client to a sex counselor.
Question 10
When positioned properly, the tip of a central venous catheter should lie in the:
A
Subclavian vein
B
Jugular vein
C
Superior vena cava
D
Basilica vein
Question 10 Explanation:
When the central venous catheter is positioned correctly, its tip lies in the superior vena cava, inferior vena cava, or the right atrium—that is, in central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilica, jugular, and subclavian veins are common insertion sites for central venous catheters.
Question 11
A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor would the nurse recognize as most important?
A
A history of increased aspirin use
B
An active daily walking program
C
A history of diabetes
D
Recent pelvic surgery
Question 11 Explanation:
The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and thrombophlebitis of the deep vein is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client’s risk of DVT. In general, diabetes is a contributing factor associated with peripheral vascular disease.
Question 12
If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff may do which of the following?
A
Cause sciatic nerve damage
B
Fail to show changes in blood pressure
C
Produce a false-high measurement
D
Produce a false-low measurement
Question 12 Explanation:
Using an undersized blood pressure cuff produces a falsely elevated blood pressure because the cuff can’t record brachial artery measurements unless it’s excessively inflated. The sciatic nerve wouldn’t be damaged by hyperinflation of the blood pressure cuff because the sciatic nerve is located in the lower extremity.
Question 13
A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to:
A
Splint the chest wall with a pillow
B
Assess the client’s airway
C
Provide pain relief
D
Encourage deep breathing and coughing
Question 13 Explanation:
The first priority is to evaluate airway patency before assessing for signs of obstruction, sternal retraction, stridor, or wheezing. Airway management is always the nurse’s first priority. Pain management and splinting are important for the client’s comfort, but would come after airway assessment. Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries.
Question 14
A female client is admitted to the emergency department with complaints of chest pain shortness of breath. The nurse’s assessment reveals jugular vein
distention. The nurse knows that when a client has jugular vein distension, it’s typically due to:
A
A neck tumor
B
An electrolyte imbalance
C
Dehydration
D
Fluid overload
Question 14 Explanation:
Fluid overload causes the volume of blood within the vascular system to increase. This increase causes the vein to distend, which can be seen most obviously in the neck veins. A neck tumor doesn’t typically cause jugular vein distention. An electrolyte imbalance may result in fluid overload, but it doesn’t directly contribute to jugular vein distention.
Question 15
The nurse in charge is caring for an Italian client. He’s complaining of pain, but he falls asleep right after his complaint and before the nurse can assess his pain. The nurse concludes that:
A
Someone else gave him medication
B
He may have a low threshold for pain
C
He was faking pain
D
The pain went away
Question 15 Explanation:
People of Italian heritage tend to verbalize discomfort and pain. The pain was real to the client, and he may need medication when he wakes up.
Question 16
The nurse in charge must monitor a patient receiving chloramphenicol for adverse drug reaction. What is the most toxic reaction to chloramphenicol?
A
Lethal arrhythmias
B
Status epilepticus
C
Malignant hypertension
D
Bone marrow suppression
Question 16 Explanation:
The most toxic reaction to chloramphenicol is bone marrow suppression. Chloramphenicol is not known to cause lethal arrhythmias, malignant hypertension, or status epilepticus.
Question 17
Using Abraham Maslow’s hierarchy of human needs, a nurse assigns highest priority to which client need?
A
Security
B
Belonging
C
Elimination
D
Safety
Question 17 Explanation:
According to Maslow, elimination is a first-level or physiological need, and therefore takes priority over all other needs. Security and safety are second-level needs; belonging is a third-level need. Second- and third-level needs can be met only after a client’s first-level needs have been satisfied.
Question 18
A male client is on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?
A
Inadequate protein intake
B
Low calcium level
C
Inadequate vitamin D intake
D
Inadequate massaging of the affected area
Question 18 Explanation:
A client on bed rest suffers from a lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Inadequate vitamin D intake and low calcium levels aren’t factors in poor healing for this client. A pressure ulcer should never be massaged.
Question 19
Which intervention is an example of primary prevention?
A
Administering digoxin (Lanoxicaps) to a patient with heart failure
B
Obtaining a Papanicolaou smear to screen for cervical cancer
C
Administering a measles, mumps, and rubella immunization to an infant
D
Using occupational therapy to help a patient cope with arthritis
Question 19 Explanation:
Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a smear for a screening test are examples for secondary prevention, which promotes early detection and treatment of disease. Using occupational therapy to help a patient cope with arthritis is an example of tertiary prevention, which aims to help a patient deal with the residual consequences of a problem or to prevent the problem from recurring.
Question 20
A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client?
A
Prevent injury
B
Promote rest
C
Promote fluid balance
D
Prevent infection
Question 20 Explanation:
The client is at risk for infection because WBC count is dangerously low. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.
Question 21
A 65-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, “How long will it take for my scars to disappear?” which statement would be the nurse’s best response?
A
“With your history and the type of location of the injury, it’s hard to say.”
B
“The contraction phase of wound healing can take 2 to 3 years.”
C
“Wound healing is very individual but within 4 months the scar should fade.”
D
"If you don’t develop an infection, the wound should heal any time between 1 and 3 years from now.”
Question 21 Explanation:
Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information.
Question 22
Nurse Cay inspects a client’s back and notices small hemorrhagic spots. The nurse documents that the client has:
A
Uremia
B
Petechiae
C
Osteomalacia
D
Extravasation
Question 22 Explanation:
Petechiae are small hemorrhagic spots. Extravasation is the leakage of fluid in the interstitial space. Osteomalacia is the softening of bone tissue. Uremia is an excess of urea and other nitrogen products in the blood.
Question 23
Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client?
A
Semi-Fowler’s
B
Side-lying
C
High-Fowler’s
D
Supine
Question 23 Explanation:
Because of lethargy, the post tonsillectomy client is at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side-lying position until he awake is best. The semi-Fowler’s, supine, and high-Fowler’s position don’t allow for adequate oral drainage in a lethargic post tonsillectomy client, and increase the risk of blood aspiration.
Question 24
A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.d. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming:
A
Lean red meat
B
Fresh, green vegetables
C
Bananas and oranges
D
Creamed corn
Question 24 Explanation:
Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach the patient to increase intake of potassium-rich foods, such as bananas and oranges. Fresh, green vegetables; lean red meat; and creamed corn are not good sources of potassium.
Question 25
A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and nonproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is:
A
Unhappiness about the charge in leadership
B
Failure to incorporate staff in decision making
C
Fatigue from overwork and understaffing
D
Unexpected feeling and emotions among the staff
Question 25 Explanation:
The usual or most prevalent reason for lack of productivity in a group of competent nurses is inadequate communication or a situation in which the nurses have unexpected feeling and emotions. Although the other options could be contributing to the problematic situation, they’re less likely to be the cause.
Question 26
The nurse in charge identifies a patient’s responses to actual or potential health problems during which step of the nursing process?
A
Evaluation
B
Assessment
C
Nursing diagnosis
D
Planning
Question 26 Explanation:
The nurse identifies human responses to actual or potential health problems during the nursing diagnosis step of the nursing process. During the assessment step, the nurse systematically collects data about the patient or family. During the planning step, the nurse develops strategies to resolve or decrease the patient’s problem. During the evaluation step, the nurse determines the effectiveness of the plan of care.
Question 27
One aspect of implementation related to drug therapy is:
A
Documenting drugs given
B
Establishing outcome criteria
C
Developing a content outline
D
Setting realistic client goals
Question 27 Explanation:
Although documentation isn’t a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client’s reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are part of planning rather than implementation.
Question 28
While examining a client’s leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse in charge to apply?
A
Dry sterile dressing
B
Povidone-iodine-soaked gauze
C
Moist, sterile saline gauze
D
Sterile petroleum gauze
Question 28 Explanation:
Moist, sterile saline dressings support would heal and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine can irritate epithelial cells, so it shouldn’t be left on an open wound.
Question 29
Which document addresses the client’s right to information, informed consent, and treatment refusal?
A
Code for Nurses
B
Standard of Nursing Practice
C
Patient’s Bill of Rights
D
Nurse Practice Act
Question 29 Explanation:
The Patient’s Bill of Rights addresses the client’s right to information, informed consent, timely responses to requests for services, and treatment refusal. A legal document, it serves as a guideline for the nurse’s decision making. Standards of Nursing Practice, the Nurse Practice Act, and the Code for Nurses contain nursing practice parameters and primarily describe the use of the nursing process in providing care.
Question 30
Nurse Berri inspects a client’s pupil size and determines that it’s 2 mm in the left eye and 3 mm in the right eye. Unequal pupils are known as:
A
Ataxia
B
Cataract
C
Diplopia
D
Anisocoria
Question 30 Explanation:
Unequal pupils are called anisocoria. Ataxia is uncoordinated actions of involuntary muscle use. A cataract is an opacity of the eye’s lens. Diplopia is double vision.
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1. Which intervention is an example of primary prevention?
Administering digoxin (Lanoxicaps) to a patient with heart failure
Administering a measles, mumps, and rubella immunization to an infant
Obtaining a Papanicolaou smear to screen for cervical cancer
Using occupational therapy to help a patient cope with arthritis
2. The nurse in charge is assessing a patient’s abdomen. Which examination technique should the nurse use first?
Auscultation
Inspection
Percussion
Palpation
3. Which statement regarding heart sounds is correct?
S1 and S2 sound equally loud over the entire cardiac area.
S1 and S2 sound fainter at the apex
S1 and S2 sound fainter at the base
S1 is loudest at the apex, and S2 is loudest at the base
4. The nurse in charge identifies a patient’s responses to actual or potential health problems during which step of the nursing process?
Assessment
Nursing diagnosis
Planning
Evaluation
5. A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.d. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming:
Fresh, green vegetables
Bananas and oranges
Lean red meat
Creamed corn
6. The nurse in charge must monitor a patient receiving chloramphenicol for adverse drug reaction. What is the most toxic reaction to chloramphenicol?
Lethal arrhythmias
Malignant hypertension
Status epilepticus
Bone marrow suppression
7. A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time?
Impaired gas exchanges related to increased blood flow
Fluid volume excess related to peripheral vascular disease
Risk for injury related to edema
Altered peripheral tissue perfusion related to venous congestion
8. When positioned properly, the tip of a central venous catheter should lie in the:
Superior vena cava
Basilica vein
Jugular vein
Subclavian vein
9. Nurse Margareth is revising a client’s care plan. During which step of the nursing process does such revision take place?
Assessment
Planning
Implementation
Evaluation
10. A 65-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, “How long will it take for my scars to disappear?” which statement would be the nurse’s best response?
“The contraction phase of wound healing can take 2 to 3 years.”
“Wound healing is very individual but within 4 months the scar should fade.”
“With your history and the type of location of the injury, it’s hard to say.”
“If you don’t develop an infection, the wound should heal any time between 1 and 3 years from now.”
11. One aspect of implementation related to drug therapy is:
Developing a content outline
Documenting drugs given
Establishing outcome criteria
Setting realistic client goals
12. A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor would the nurse recognize as most important?
A history of increased aspirin use
Recent pelvic surgery
An active daily walking program
A history of diabetes
13. Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance?
Administer sleeping medication before bedtime
Ask the client each morning to describe the quantity of sleep during the previous night
Teach the client relaxation techniques, such as guided imagery, medication, and progressive muscle relaxation
Provide the client with normal sleep aids, such as pillows, back rubs, and snacks
14. While examining a client’s leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse in charge to apply?
Dry sterile dressing
Sterile petroleum gauze
Moist, sterile saline gauze
Povidone-iodine-soaked gauze
15. A male client in a behavioral-health facility receives a 30-minute psychotherapy session, and provider uses a current procedure terminology (CPT) code that bills for a 50-minute session. Under the False Claims Act, such illegal behavior is known as:
Unbundling
Overbilling
Upcoding
Misrepresentation
16. A nurse assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he’s impotent and says that he’s concerned about its effect on his marriage. In planning this client’s care, the most appropriate intervention would be to:
Encourage the client to ask questions about personal sexuality
Provide time for privacy
Provide support for the spouse or significant other
Suggest referral to a sex counselor or other appropriate professional
17. Using Abraham Maslow’s hierarchy of human needs, a nurse assigns highest priority to which client need?
Security
Elimination
Safety
Belonging
18. A male client is on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?
Inadequate vitamin D intake
Inadequate protein intake
Inadequate massaging of the affected area
Low calcium level
19. A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
Acute pain related to surgery
Deficient fluid volume related to blood and fluid loss from surgery
Impaired physical mobility related to surgery
Risk for aspiration related to anesthesia
20. Nurse Cay inspects a client’s back and notices small hemorrhagic spots. The nurse documents that the client has:
Extravasation
Osteomalacia
Petechiae
Uremia
21. Which document addresses the client’s right to information, informed consent, and treatment refusal?
Standard of Nursing Practice
Patient’s Bill of Rights
Nurse Practice Act
Code for Nurses
22. If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff may do which of the following?
Fail to show changes in blood pressure
Produce a false-high measurement
Cause sciatic nerve damage
Produce a false-low measurement
23. Nurse Danny has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?
Baked beans, hamburger, and milk
Spaghetti with cream sauce, broccoli, and tea
Bouillon, spinach, and soda
Chicken cutlet, spinach, and soda
24. A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to:
Assess the client’s airway
Provide pain relief
Encourage deep breathing and coughing
Splint the chest wall with a pillow
25. A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and nonproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is:
Unhappiness about the charge in leadership
Unexpected feeling and emotions among the staff
Fatigue from overwork and understaffing
Failure to incorporate staff in decision making
26. A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client?
Promote fluid balance
Prevent infection
Promote rest
Prevent injury
27. Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client?
Semi-Fowler’s
Supine
High-Fowler’s
Side-lying
28. Nurse Berri inspects a client’s pupil size and determines that it’s 2 mm in the left eye and 3 mm in the right eye. Unequal pupils are known as:
Anisocoria
Ataxia
Cataract
Diplopia
29. The nurse in charge is caring for an Italian client. He’s complaining of pain, but he falls asleep right after his complaint and before the nurse can assess his pain. The nurse concludes that:
He may have a low threshold for pain
He was faking pain
Someone else gave him medication
The pain went away
30. A female client is admitted to the emergency department with complaints of chest pain shortness of breath. The nurse’s assessment reveals jugular vein
distention. The nurse knows that when a client has jugular vein distension, it’s typically due to:
A neck tumor
An electrolyte imbalance
Dehydration
Fluid overload
Answers and Rationales
Answer B. Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a smear for a screening test are examples for secondary prevention, which promotes early detection and treatment of disease. Using occupational therapy to help a patient cope with arthritis is an example of tertiary prevention, which aims to help a patient deal with the residual consequences of a problem or to prevent the problem from recurring.
Answer B. Inspection always comes first when performing a physical examination. Percussion and palpation of the abdomen may affect bowel motility and therefore should follow auscultation.
Answer D. The S1 sound—the “lub” sound—is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 sounds. The S2—the “dub” sound—is loudest at the base. It sounds shorter, sharper, higher, and louder there than S1.
Answer B. The nurse identifies human responses to actual or potential health problems during the nursing diagnosis step of the nursing process. During the assessment step, the nurse systematically collects data about the patient or family. During the planning step, the nurse develops strategies to resolve or decrease the patient’s problem. During the evaluation step, the nurse determines the effectiveness of the plan of care.
Answer B. Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach the patient to increase intake of potassium-rich foods, such as bananas and oranges. Fresh, green vegetables; lean red meat; and creamed corn are not good sources of potassium.
Answer D. The most toxic reaction to chloramphenicol is bone marrow suppression. Chloramphenicol is not known to cause lethal arrhythmias, malignant hypertension, or status epilepticus.
Answer D. Altered peripheral tissue perfusion related to venous congestion” takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis. Option A is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Option B is inappropriate because no evidence suggest that this patient has a fluid volume excess. Option C may be warranted but is secondary to altered tissue perfusion.
Answer A. When the central venous catheter is positioned correctly, its tip lies in the superior vena cava, inferior vena cava, or the right atrium—that is, in central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilica, jugular, and subclavian veins are common insertion sites for central venous catheters.
Answer D. During the evaluation step of the nursing process the nurse determines whether the goals established in the care plan have been achieved, and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. Assessment involves data collection. Planning involves setting priorities, establishing goals, and selecting appropriate interventions.
Answer C. Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information.
Answer B. Although documentation isn’t a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client’s reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are part of planning rather than implementation.
Answer B. The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and thrombophlebitis of the deep vein is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client’s risk of DVT. In general, diabetes is a contributing factor associated with peripheral vascular disease.
Answer D. The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill such as relaxation techniques. Sleep medication should be avoided whenever possible. At some point, the nurse should do a thorough sleep assessment, especially if common sense interventions fail.
Answer C. Moist, sterile saline dressings support would heal and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine can irritate epithelial cells, so it shouldn’t be left on an open wound.
Answer C. Upcoding is the practice of using a CPT code that’s reimbursed at a higher rate than the code for the service actually provided. Unbundling, overbilling, and misrepresentation aren’t the terms used for this illegal practice.
Answer D. The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client’s care. The nurse doesn’t normally provide sex counseling. Therefore, providing time for privacy and providing support for the spouse or significant other are important, but not as important as referring the client to a sex counselor.
Answer B. According to Maslow, elimination is a first-level or physiological need, and therefore takes priority over all other needs. Security and safety are second-level needs; belonging is a third-level need. Second- and third-level needs can be met only after a client’s first-level needs have been satisfied.
Answer B. A client on bed rest suffers from a lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Inadequate vitamin D intake and low calcium levels aren’t factors in poor healing for this client. A pressure ulcer should never be massaged.
Answer D. Risk for aspiration related to anesthesia takes priority for thins client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The other options, although important, are secondary.
Answer C. Petechiae are small hemorrhagic spots. Extravasation is the leakage of fluid in the interstitial space. Osteomalacia is the softening of bone tissue. Uremia is an excess of urea and other nitrogen products in the blood.
Answer B. The Patient’s Bill of Rights addresses the client’s right to information, informed consent, timely responses to requests for services, and treatment refusal. A legal document, it serves as a guideline for the nurse’s decision making. Standards of Nursing Practice, the Nurse Practice Act, and the Code for Nurses contain nursing practice parameters and primarily describe the use of the nursing process in providing care.
Answer B. Using an undersized blood pressure cuff produces a falsely elevated blood pressure because the cuff can’t record brachial artery measurements unless it’s excessively inflated. The sciatic nerve wouldn’t be damaged by hyperinflation of the blood pressure cuff because the sciatic nerve is located in the lower extremity.
Answer A. Baked beans, hamburger, and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination provides less protein than the baked beans-hamburger-milk selection.
Answer A. The first priority is to evaluate airway patency before assessing for signs of obstruction, sternal retraction, stridor, or wheezing. Airway management is always the nurse’s first priority. Pain management and splinting are important for the client’s comfort, but would come after airway assessment. Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries.
Answer B. The usual or most prevalent reason for lack of productivity in a group of competent nurses is inadequate communication or a situation in which the nurses have unexpected feeling and emotions. Although the other options could be contributing to the problematic situation, they’re less likely to be the cause.
Answer B. The client is at risk for infection because WBC count is dangerously low. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.
Answer D. Because of lethargy, the post tonsillectomy client is at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side-lying position until he awake is best. The semi-Fowler’s, supine, and high-Fowler’s position don’t allow for adequate oral drainage in a lethargic post tonsillectomy client, and increase the risk of blood aspiration.
Answer A. Unequal pupils are called anisocoria. Ataxia is uncoordinated actions of involuntary muscle use. A cataract is an opacity of the eye’s lens. Diplopia is double vision.
Answer A. People of Italian heritage tend to verbalize discomfort and pain. The pain was real to the client, and he may need medication when he wakes up.
Answer D. Fluid overload causes the volume of blood within the vascular system to increase. This increase causes the vein to distend, which can be seen most obviously in the neck veins. A neck tumor doesn’t typically cause jugular vein distention. An electrolyte imbalance may result in fluid overload, but it doesn’t directly contribute to jugular vein distention.