How to pass NCLEX NCLEX-PN exam with the help of dumps?

Question # 1

If your patient is acutely psychotic, which of the following independent nursing interventions would not be appropriate?

A. Conveying calmness with one on one interaction
B. Recognizing and dealing with your own feelings to prevent escalation of thepatient’s anxiety level
C. Encourage client participation in group therapy
D. Listen and identify causes of their behavior

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Question # 2

Which of the following syndromes associated with incomplete lesions of the spinal cord is a result of damage to one-half of the spinal cord? 

A. Brown-Séquard syndrome
B. posterior cord syndrome
C. central cord syndrome
D. cauda equina syndrome

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Question # 3

A client receiving preoperative instructions asks questions repeatedly about when to stop eating the night before the procedure. The nurse tries torefocus the client. The nurse notes that the client is frequently startled by noises in the hall. Assessment reveals rapid speech, trembling hands, tachypnea, tachycardia, and elevated blood pressure. The client admits to feeling nervous and having trouble sleeping. Based on the assessment, the nurse documents that the client has: 

A. mild anxiety.
B. moderate anxiety.
C. severe anxiety.
D. a panic attack.

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Question # 4

A 64 year-old Alzheimer’s patient has exhibited excessive cognitive decline resulting in harmful behaviors. The physician orders restraints to be placed on the patient. Which of the following is the appropriate procedure?

A. Secure the restraints to the bed rails on all extremities.
B. Notify the physician that restraints have been placed properly.
C. Communicate with the patient and family the need for restraints.
D. Position the head of the bed at a 45 degree angle.

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Question # 5

A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most?

A. temperature of 102° F and a productive cough
B. arterial blood gases (ABGs) with a PaO2 of 92 and PaCO2 of 40 mmHg
C. trachea deviating to the right
D. barrel-chested appearance

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Question # 6

Metformin (Glucophage) is administered to clients with type II diabetes mellitus. Metformin is an example of:

A. an antihyperglycemic agent.
B. a hypoglycemic agent.
C. an insulin analogue.
D. a pancreatic alpha cell stimulant.

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Question # 7

An nurse is instructing a patient on the order of sensations with the application of an ice water bath for a swollen right ankle. Which of the following is the correct order of sensations experienced with an ice water bath?

A. cold, burning, aching, and numbness
B. burning, aching, cold, and numbness
C. aching, cold, burning and numbness
D. cold, aching, burning and numbness

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Question # 8

A 20-year-old male client had a diving accident with subsequent paraplegia. He says to thenurse, “No woman will ever want to marry me now.” Which of the following responses bythe nurse is most therapeutic?

A. “Don’t worry. Maybe you’ll meet a paraplegic woman.”
B. “There is someone for everyone in this world.”
C. “You are still an attractive man, even though you can’t walk.”
D. “Tell me more about your feelings on this issue.”

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Question # 9

A patient has recently been prescribed Zidovudine (Retrovir). The patient has AIDS. Whichof the following side effects should the patient specifically watch out for?

A. Weakness and SOB
B. Fever and anemia
C. Hypertension and SOB
D. Fever and hypertension

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Question # 10

A client reports that someone is in the room and trying to kill him. The nurse’s best response is:

A. “No one is in your room. Let’s get you more medicine.”
B. “I do not see anyone, but you seem to be very frightened.”
C. “No one can hurt you here.”
D. “Just tell the person to go away.”

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Question # 11

A twenty-one year old man suffered a concussion and the MD ordered a MRI. The patientasks, “Will they allow me to sit up during the MRI?” The correct response by the nurseshould be.

A. “I will have to talk to the doctor about letting you sit upright during the test.”
B. “You will be positioned in the reverse Trendelenburg position to maximizethe view of thebrain.”
C. “The radiologist will let you know.”
D. “You will have to lie down on your back during the test.”

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Question # 12

A thirty-seven year-old female in room 307 has a diagnosis of acquired immune deficiency syndrome (AIDS). Which of the following situations requires nurse intervention? 

A. A certified nursing assistant states, “The patient in 307 is not wearing glovesshaving her legs.” 
B. A nursing assistant at the nursing station states, “The patient in 307 has arespiratory rate of 16.”
C. A nursing student in the cafeteria states, “Dr.Jones told the patient in room307 that she was going to die.” 
D. A certified nursing assistant states, “Dr. Jones hasn’t made rounds thismorning.”

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Question # 13

A nurse is reviewing a patient’s current Lithium levels. Which of the following values isoutside the therapeutic range?

A. 1.0 mEq/L
B. 1.1 mEq/L
C. 1.2 mEq/L
D. 1.3 mEq/L

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Question # 14

A primigravida begins labor when her family is unavailable and she is alone. She is very upset that her family is not with her. Which approach can the nurse take to meet the client’s needs at this time?

A. asking whether another individual wants to be her support person
B. assuring her that the nursing triage group will be with her at all times
C. telling her you will try to locate her family
D. reinforcing the woman’s confidence in her own abilities to cope and maintain a sense of control

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Question # 15

A nurse is caring for a patient in the step down unit. The patient has signs of increasedintracranial pressure. Which of the following is not a sign of increased intracranialpressure?

A. Bradycardia
B. Increased pupil size bilaterally
C. Change in LOC
D. Vomiting

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Question # 16

A nurse has been assigned a patient who has recently been diagnosed with Guillain-Barre’Syndrome. Which of the following statements is the most applicable when discussing theimpairments with Guillain-Barre’ Syndrome with the patient?

A. Guillain-Barre’ Syndrome gets better after 5 years in almost all cases.
B. Guillain-Barre’ Syndrome causes limited sensation in the abdominal region.
C. Guillain-Barre’ Syndrome causes muscle weakness in the legs.
D. Guillain-Barre’ Syndrome does not effect breathing in severe cases.

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Question # 17

In hanging a parenteral IV fluid that is to be infused by gravity, rather than with an infusion pump, the nurse notes that the IV tubing is available in different drop factors. Which tubing is a microdrop set?

A. 15 drops per milliliter
B. 60 drops per milliliter
C. 20 drops per milliliter
D. 10 drops per milliliter

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Question # 18

Medical records indicate a patient has developed a condition of respiratory alkalosis. Which of the following clinical signs would not apply to a condition of respiratory alkalosis? 

A. Muscle tetany
B. Syncope
C. Numbness
D. Anxiety

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Question # 19

The nurse sustains a needle puncture that requires HIV prophylaxis. Which of the followingmedication regimens should be used?

A. an antibiotic such as Metronidazole and a protease inhibitor (Saquinivir)
B. two non-nucleoside reverse transcriptase inhibitors
C. one protease inhibitor such as Nelfinavir
D. two protease inhibitors

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Question # 20

How does the ANA define the psychiatric nursing role?

A. a specialized area of nursing practice that employs theories of human behavior as its science and the powerful use of self as its art
B. assisting the therapist to relieve the symptoms of clients
C. to solve clients’ problems and give them the answers
D. having a client committed to long-term therapy with the nurse

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Question # 21

Signs of internal bleeding include all of the following except: 

A. painful or swollen extremities.s  
B. a tender, rigid abdomen.  
C. vomiting bile.  
D. bruising.  

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Question # 22

A patient asks a nurse the following question. Exposure to TB can be identified best with which of the following procedures? Which of the following tests is the most definitive of TB?

A. Chest x-ray
B. Mantoux test
C. Breath sounds examination 
D. Sputum culture for gram-negative bacteria

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Question # 23

A 64 year-old male who has been diagnosed with COPD, and CHF exhibits an increase intotal body weight of 10 lbs. over the last few days. The nurse should:

A. Contact the patient’s physician immediately.
B. Check the intake and output on the patient’s flow sheet.
C. Encourage the patient to ambulate to reduce lower extremity edema.
D. Check the patient’s vitals every 2 hours.

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Question # 24

Which type of dressing is recommended to place over a site when a chest tube is removed by the physician?

A. transparent dressing
B. colloidal dressing
C. petrolatum gauze
D. nonadherent dressing

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Question # 25

The physician wants to know if a client is tolerating his total parenteral nutrition. Which of the following laboratory tests is likely to be ordered?

A. triglyceride level
B. liver function tests
C. a glucose tolerance test
D. a complete blood count

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Question # 26

A gastroenterologist should be consulted for clients suffering from:

A. digestive system diseases.
B. urinary system diseases.
C. female reproductive system diseases.
D. nervous system diseases.

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Question # 27

A 24 year-old man has been admitted to the hospital due to work-related back injury. Thepatient’s wife would like to see the patient’s chart. The nurse should:

A. Provide the chart to the patient’s wife following verbal approval by the patient.
B. Provide the chart to the patient’s wife after consulting with the patient’s physician.
C. Get written approval from the patient prior to providing the wife with chart informationand call the MD about the patient’s request.
D. Tell the patient’ wife, a copy of the patient’s medical record is on-file with medicalrecords.

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Question # 28

A 62 year-old female is being seen on a home visit by a nurse. The patient reports she has been taking Premarin for years. Which of the following would indicate an over-dosage?

A. Lower extremity edema  
B. Sensory changes in the upper extremities  
C. Increased occurrence of fractures  
D. Decreased peripheral blood flow  

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Question # 29

A patient has been diagnosed with diabetes mellitus. Which of the following is not a clinical sign of diabetes mellitus?

A. Polyphagia
B. Polyuria
C. Metabolic acidosis
D. Lower extremity edema

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Question # 30

A woman seeks assistance because she recently remembered childhood sexual abuse.The nurse should include which of the following goals for this client?

A. prosecuting the perpetrator
B. managing symptoms of anxiety and fear
C. determining if the memories are real
D. collaborating the client’s story

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Question # 31

A paraplegic client is in the hospital to be treated for an electrolyte imbalance. Which level of care is the client currently receiving?

A. primary prevention
B. secondary prevention
C. tertiary prevention 
D. health promotion

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Question # 32

After the client discusses her relationship with her father, the nurse says, “Tell me whether I am understanding your relationship with your father. You feel dominated and controlled by him?” This is an example of:

A. verbalizing the implied.  
B. seeking consensual validation.  
C. encouraging evaluation.  
D. suggesting collaboration.  

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Question # 33

A 14 year-old boy has been admitted to a mental health unit for observation and treatment. The boy becomes agitated and starts yelling at nursing staff members. What should the nurse first response be? 

A. Create an atmosphere of seclusion for the boy according to procedures.
B. Remove other patients from the area via wheelchairs for added speed.
C. Ask the patient, “What is making you mad?”
D. Ask the patient, “Why are you doing this, have you thought about what yourparents might say?”

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Question # 34

The nurse working with elderly clients should keep in mind that falls are most likely tohappen to elderly who are:

A. in their 80s.
B. living at home.
C. hospitalized.
D. living on only Social Security income.

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Question # 35

A 32-year-old female frequently comes to her primary care provider with vague complaints of headache, abdominal pain, and trouble sleeping. In the past, the physician has dutifully prescribed medication, but little else. Which of the following comments by the nurse to the physician is appropriate?

A. “Often women who are victims of domestic violence suffer vague symptoms such as abdominal pain.”
B. “Often women become offended if asked about their safety in relationships.”  
C. “It is mandatory that all women be questioned about domestic violence.”  
D. “How would you feel to know that her partner is beating her and you didn’t ask?”  

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Question # 36

A nurse working a surgical unit, notices a patient is experiencing SOB, calf pain, and warmth over the posterior calf. All of these may indicate which of the following medical conditions?

A. Patient may have a DVT. 
B. Patient may be exhibiting signs of dermatitis.
C. Patient may be in the late phases of CHF.
D. Patient may be experiencing anxiety after surgery.

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Question # 37

A nurse is caring for a patient who has recently been diagnosed with fibromyalgia andCOPD. Which of the following tasks should the nurse delegate to a nursing assistant?

A. Transferring the patient to the shower.
B. Ambulating the patient for the first time.
C. Taking the patient’s breath sounds
D. Educating the patient on monitoring fatigue

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Question # 38

A nurse is caring for a retired MD. The MD asks the question, “What type of cells secrete insulin?” The correct answer is: 

A. alpha cells
B. beta cells
C. CD4 cells
D. helper cells

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Question # 39

Issues addressed in ethics committees include all of the following except: 

A. nonpayment of bills.  
B. euthanasia.  
C. starting or stopping treatment.  
D. use of feeding tubes.  

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Question # 40

Which of the following symptoms is not indicative of autonomic dysreflexia in the client with a spinal cord injury? 

A. sudden onset of headache
B. flushed face
C. hypotension
D. nasal congestion

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Question # 41

While admitting a client to an acute-care psychiatric unit, the nurse asks about substanceabuse based on knowledge that:

A. psychiatric illness is more prevalent in addicted populations.
B. people with psychiatric disorders are more prone to substance abuse.
C. substance disorders are easily detected and diagnosed in acute-care psychiatricsettings.
D. undetected substance problems have no real effect on treatment of psychiatricdisorders.

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Question # 42

A client is 36 hours post-op a TKR surgery. 270 cc’s of sero-sanguinous accumulates in thesurgical drains. What action should the nurse take?

A. Notify the doctor
B. Empty the drain
C. Do nothing
D. Remove the drain

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Question # 43

The home health nurse has made a visit to an 85-year-old female client’s home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan?

A. The client should remove all scatter rugs from the floor and minimize clutter.  
B. The client should not get up and move around the house.  
C. The client does not need to install a raised toilet and grab bar because she is able to walk on her own.
D. The client should wear a robe and socks while walking in the house.  

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Question # 44

A nurse is working in a pediatric clinic and a 25 year-old mother comes in with a 4 week-old baby. The mother is stress out about loss of sleep and the baby exhibits signs of colic. Which of the following techniques should the nurse teach the mother?

A. Distraction of the infant with a red object
B. Prone positioning techniques
C. Tapping reflex techniques
D. Neural warmth techniques

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Question # 45

A nurse working in a pediatric clinic observes bruises on the body of a four year-old boy. The parents report the boy fell riding his bike. The bruises are located on his posterior chest wall and gluteal region. The nurse should:

A. Suggest a script for counseling for the family to the doctor on duty.  
B. Recommend a warm bath for the boy to decrease healing time.  
B. Recommend a warm bath for the boy to decrease healing time.  
D. Recommend ROM to the patient’s spine to decrease healing time.  

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Question # 46

The nurse is teaching a client about communicable diseases and explains that a portal of entry is:

A. a vector.
B. a source, like contaminated water.
C. food.
D. the respiratory system.

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Question # 47

A nurse is caring for a retired MD. The MD asks the question, “What type of cells createexocrine secretions?” The correct answer is:

A. alpha cells
B. beta cells
C. acinar cells
D. plasma cells

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Question # 48

A 26-year-old single woman is knocked down and robbed while walking her dog one evening. Three months later, she presents at the crisis clinic, stating that she cannot put this experience out of her mind. She complains of nightmares, extreme fear of being outside or alone, and difficulty eating and sleeping. What is the best response by the nurse?

A. “I will ask the physician to prescribe medication for you.”  
B. “That must have been a very difficult and frightening experience. It might be helpful to talk about it.
C. “In the future, you might walk your dog in a more populated area or hire someone else to take over this task.”  
D. “Have you thought of moving to a safer neighborhood?”  

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Question # 49

A nurse suspects a patient is developing Bell’s Palsy. The nurse wants to test the function of cranial nerve VII. Which of the following would be the most appropriate testing procedures?

A. Test the taste sensation over the back of the tongue and activation of the facial muscles.
B. Test the taste sensation over the front of the tongue and activation of the facial muscles.
C. Test the sensation of the facial muscles and sensation of the back of the tongue.
D. Test the sensation of the facial muscles and sensation of the front of the tongue.

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Question # 50

Following an automobile accident that caused a head injury to an adult client, the nurse observes that the client sleeps for long periods of time. The nurse determines that the client has experienced injury to the:

A. hypothalamus.
B. thalamus.
C. cortex.
D. medulla.

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Question # 51

A small amount of bubbling is seen in the water seal of a pleural drainage system when aclient coughs. What should the nurse do?

A. Consider it a normal finding.
B. Check the system for leaks.
C. Clamp the chest tube.
D. Change the drainage system.

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Question # 52

A 32 year-old male with a complaint of dizziness has an order for Morphine via. IV. The nurse should do which of the following first? 

A. Check the patient’s chest x-ray results.  
B. Retake vitals including blood pressure.  
C. Perform a neurological screen on the patient.  
D. Request the physician on-call assess the patient.  

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Question # 53

A mother of a newborn notices a nurse placing liquid in her baby’s eyes. Which of the following is an inaccurate statement about the need for eyedrops following birth?

A. Eyedrops following birth help reduce the risk of eye infection.
B. Eyedrops are required by the law.
C. Eyedrops will keep the eye moist.
D. Eyedrops are required by law every 6 hours following birth.

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Question # 54

Which of the following lab values would indicate symptomatic AIDS in the medical chart?(T4 cell count per deciliter)

A. Greater than 1000 cells per deciliter
B. Less than 500 cells per deciliter
C. Greater than 2000 cells per deciliter
D. Less than 200 cells per deciliter

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Question # 55

The nurse who was not promoted tells another friend, “I knew I’d never get the job. The hospital administrator hates me.” If she actually believes this of the administrator, who, in reality, knows little of her, she is demonstrating: 

A. compensation.
B. reaction formation.
C. projection.
D. denial.

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Question # 56

A nurse assesses a 83 year-old female’s venous ulcer for the second time that is locatednear the right medial malleolus. The wound is exhibiting purulent drainage and the patienthas limited mobility in her home. Which of the options is the best course of action?

A. Encourage warm water soaks to the right foot.
B. Notify the case manager of the purulent drainage.
C. Determine the patient’s pulse in the right ankle.
D. Recommend increased activity to reduce the purulent drainage.

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Question # 57

Which of the following is responsible for laws mandating the reporting of certain infections and diseases?

A. Centers for Disease Control and Prevention (CDC)
B. individual state laws
C. National Institute of Health Research (NIH)
D. Health and Human Services (HHS)

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Question # 58

A patient has recently been prescribed (Norvasc). Which of the following side effect/sshould the patient specifically watch out for?

A. Hypotension and Angina
B. Hypertension
C. Lower extremity edema
D. Peripheral sensory loss and SOB

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Question # 59

A nurse is screening patients for various vaccines. Which of the following vaccines is contraindicated during pregnancy?

A. Diphtheria
B. Hepatitis B
C. Mumps
D. Tetanus

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Question # 60

A nurse doing a home health visit consults with a male patient that has a diagnosis of CAD and COPD. The patient is currently taking Ventolin, Azmacort, Aspirin, and Theophylline. The patient complains of upset stomach, nausea and feeling uncomfortable. The nurse should:

A. Contact the patient’s physician immediately
B. Recommend the patient position himself in right sidelying.
C. Recommend the patient schedule a doctor’s visit the next day.
D. Recommend a hold on the drug-Azmacort

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Question # 61

A nurse is implementing a community awareness campaign about accidental poisoning. Which of the following should she teach in the class?  

A. The child should be given milk.
B. The child should be given syrup of Ipecac
C. The poison control center should be contacted
D. The child should be taken to the ER

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Question # 62

A nurse gave medications to the wrong client. She stated the client responded to the name called. What is the nurse’s appropriate documentation?

A. Note in medication records the drug given
B. The client was not hurt, no need for documentation
C. Note the client’s orientation
D. Completely fill out an incident report

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Question # 63

A nurse reviewed the arterial blood gas reading of a 25 year-old male. The nurse should be able to conclude the patient is experiencing which of the following conditions?Bicarbonate ion-25 mEq/lPH-7.41PaCO2-29 mmHgPaO2-54 mmHg(FiO2)-.22 

A. metabolic acidosis
B. respiratory acidosis
C. metabolic alkalosis
D. respiratory alkalosis 

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Question # 64

A newborn has been delivered. An Apgar score is given. What does this scoring system indicate?

A. heart rate, respiratory effort, color, muscle tone, reflex irritability  
B. heart rate, bleeding, cyanosis, edema  
C. bleeding, reflex, edema  
D. respiratory effort, heart rate, seizures  

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Question # 65

Why is it often necessary to draw a complete blood count and differential (CBC/differential) when a client is being treated with an antiepileptic drug (AED)?

A. The hematocrit is adversely affected because of an increased vascular volume.
B. AEDs affect immune modulators increasing the risk of infection.
C. AEDs induce white blood cell reduction.
D. A side effect of some AEDs is blood dyscrasia.

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Question # 66

The best nursing diagnosis for a client with newly diagnosed Diabetes Mellitus is: 

A. Impaired Skin Integrity.
B. Knowledge Deficit: New Diabetes Diagnosis.
C. Alteration in Nutrition: More than Body Requirements.
D. Fluid Volume Deficit.

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Question # 67

To manage time most effectively, the nurse responds to which of the following stimuli first:

A. the physician’s loud verbal direction.
B. the nursing supervisor who is going to a meeting.
C. unit staff leaving on a break.
D. the care needs of the returning postoperative client just exiting the elevator.

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Question # 68

Mr. Lee comes to the clinic with thick green drainage around his eyelids. The nurse examiner takes his history and performs a physical examination, beginning with an eye history. General information the nurse should seek is: 

A. type of employment.  
B. burning or itchy sensation in the eyes.  
C. position of the eyelids.  
D. existence of floaters.  

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Question # 69

A nursing care plan for a client with sleep problems has been implemented. All of thefollowing should be expected outcomes except:

A. the client reports no episodes of awakening during the night.
B. the client falls asleep within 1 hour of going to bed.
C. the client reports satisfaction with his amount of sleep.
D. the client rates sleep as an 8 or more on the visual analog scale.

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Question # 70

A client taking isotretinoin (Accutane) tells the nurse that she is pregnant. What should the nurse teach this client?

A. Her pregnancy is threatened, and the fetus is at risk for teratogenesis.
B. She has a reportable condition, and the pregnancy must be terminated.
C. Accutane is a Category D drug, which means it is unsafe in pregnancy.
D. Her pregnancy must be followed carefully by a genetic specialist.

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Question # 71

A nurse is administering an antibiotic to a 4 year old girl, who does not have an identification bracelet. What action should the nurse take?

A. Ask another staff member who the child is.
B. Ask the child’s mother to state the child’s name.
C. Ask the child for her name.
D. Withhold the medication until an ID bracelet can be set-up.

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Question # 72

A nurse is assessing a 18 year-old female who has recently suffered a TBI. The nurse notes a slower pulse and impaired respiration. The nurse should report these findings immediately to the physician, due to the possibility the patient is experiencing which of the following conditions?

A. Increased intracranial pressure
B. Increased function of cranial nerve X
C. Sympathetic response to activity
D. Meningitis

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Question # 73

The only time that an individual may receive medical care without giving informed consent is:

A. when the durable power of attorney for health care is not available.
B. in an emergency, life-or-death situation. 
C. when the physician is not available for discussion with the client.
D. when they (clients) are not able to speak for themselves.

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Question # 74

A 93 year-old female with a history of Alzheimer’s Disease gets admitted to an Alzheimer’s unit. The patient has exhibited signs of increased confusion and limited stability with gait. Moreover, the patient is refusing to use a w/c. Which of the following is the most appropriate course of action for the nurse?

A. Recommend the patient remain in her room at all times.  
B. Recommend family members bring pictures to the patient’s room.  
C. Recommend a speech therapy consult to the doctor.  
D. Recommend the patient attempt to walk pushing the w/c for safety.  

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Question # 75

A month after receiving a blood transfusion, an immunocompromised client develops fever, liver abnormalities, a rash, and diarrhea. The nurse should suspect this client has:

A. nothing related to the blood transfusion.
B. graft-versus-host disease (GVHD).
C. myelosuppression.
D. an allergic response to a recent medication.

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Question # 76

The nurse is assessing an elder who the nurse suspects is being physically abused. The most important question for nurse to ask is:

A. “How much money do you keep around the house?”
B. “Who provides your physical care?”
C. “How close does your nearest relative live?”
D. “What form of transportation do you use?”

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Question # 77

A client who has a known history of cardiac problems and is still smoking enters the clinic complaining of sudden onset of sharp, stabbing pain that intensifies with a deep breath. The pain is occurring on only one side and can be isolated upon general assessment. The nurse concludes that this description is most likely caused by: 

A. pleurisy.
B. pleural effusion.
C. atelectasis.
D. tuberculosis.

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Question # 78

Which direction given to the nursing assistant is most likely to accomplish the task of getting a urine specimen delivered to the lab immediately after collection?

A. “Make it a stat delivery.”
B. “Please do it as soon as you can after break.”
C. “This client is delirious, and we’re worried about a urinary sepsis.”
D. “Take this client to the bathroom now and collect a urine specimen from this voiding.Take the specimen to the lab immediately.”

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Question # 79

What is the primary goal of family education?

A. symptom reduction
B. improved quality of life
C. increased knowledge about mental illness
D. improved caregiving skills

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Question # 80

A patient that has delivered a 8.2 lb. baby boy 3 days ago via c-section, reports whitepatches on her breast that aren’t going away. Which of the following medications may benecessary?

A. Nystatin
B. Atropine
C. Amoxil
D. Loritab

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Question # 81

If a client has chronic renal failure, which of the following sexual complications is the client at risk of developing?

A. retrograde ejaculation
B. decreased plasma testosterone
C. hypertrophy of testicles
D. state of euphoria

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Question # 82

A 55 year-old female asks a nurse the following, “Which mineral/vitamin is the most important to prevent progression of osteoporosis. The nurse should state:

A. Potassium
B. Magnesium
C. Calcium
D. Vitamin B12

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Question # 83

Chemotherapeutic agents often produce a degree of myelosuppression includingleukopenia. Leukopenia does not present immediately but is delayed several days orweeks because:

A. the client’s hemoglobin and hematocrit are normal.
B. red blood cells are affected first.
C. folic acid levels are normal.
D. the current white cell count is not affected by chemotherapy.

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Question # 84

A client has been taking a drug (Drug A) that is highly metabolized by the cytochrome p450 system. He has been on this medication for 6 months. At this time, he is started on a second medication (Drug B) that is an inducer of the cytochrome p-450 system. You should monitor this client for:

A. increased therapeutic effects of Drug A.
B. increased adverse effects of Drug B.
C. decreased therapeutic effects of Drug A.
D. decreased therapeutic effects of Drug B.

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Question # 85

A nurse is instructing a patient about the warning signs of (Digitalis) side effects. Which ofthe following side effects should the nurse tell the patient are sometimes associated withexcessive levels of Digitalis?

A. Seizures
B. Muscle weakness
C. Depression
D. Anxiety

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Question # 86

The PN is caring for a client with diabetes insipidus. The nurse can expect the lab work toshow:

A. elevated urine osmolarity and elevated serum osmolarity.
B. decreased urine osmolarity and decreased serum osmolarity.
C. elevated urine osmolarity and decreased serum osmolarity.
D. decreased urine osmolarity and elevated serum osmolarity.

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Question # 87

A nurse is caring for a patient who has experienced burns to the right lower extremity. According to the Rule of Nines which of the following percents most accurately describes the severity of the injury? 

A. 36%
B. 27%
C. 18%
D. 9%

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Question # 88

A client is going to have an endoscopy performed. Which of the following is not a probable reason for an endoscopy procedure? 

A. Aspiration noted on honey thick diet.
B. Pain with a bowel movement
C. Pain felt in the left upper quadrant
D. Right shoulder pain

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Question # 89

After group therapy, the female victim of intimatepartner violence confides to the nurse that she does not feel in any immediate danger. Which of the following statements about victims of domestic violence is true?

A. Victims of domestic violence are often the best predictors of their risk of harm.
B. Victims of domestic violence often overestimate their safety risk.
C. Victims of domestic violence are typically in a state of denial.
D. Victims of domestic violence know that keeping peace with their partner is the best method of preventing another attack.

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Question # 90

A patient that has TB can be taken off restrictions after which of the following parameters have been met?

A. Negative culture results.  
B. After 30 days of isolation.  
C. Normal body temperature for 48 hours.  
D. Non-productive cough for 72 hours.  

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Question # 91

When choosing a needle gauge for an intramuscular injection in a 12 year old boy. Which of the following gauges would you choose?

A. 27 gauge
B. 25 gauge
C. 22 gauge
D. 20 gauge

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Question # 92

A client diagnosed with Borderline Personality Disorder frequently attempts to burn herself. The best intervention to facilitate behavior change is:

A. constantly observing the client to prevent self-harm.  
B. enlisting the client in defining and describing harmful behaviors.  
C. checking on the client every 15 minutes to ensure she is not engaging in harmful behavior.
D. removing all items from the environment that the client could use to harm herself.  

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Question # 93

A legal right to confidentiality of client information is waived when: 

A. a court system subpoenas information.
B. a family member requests health care information of a client.
C. a living will takes effect.
D. the client is declared incompetent by the legal system.

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Question # 94

A mother brings her 1-year-old child to the clinic. The child has no record of previous immunizations, and the mother confirms the child has not been immunized. Teaching by the nurse should include which of the following?

A. Immunizations may be started at any age.
B. The recommended immunization schedule must be followed exactly.
C. If a primary series of immunizations is interrupted, the series must be restarted.
D. This child is at increased risk for reaction to the vaccines, when they are started.

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Question # 95

After securing the client’s safety from a faulty electric bed, the nurse should take which action? 

A. Discuss the matter with the client’s significant others.  
B. Document the incident in the client’s record in detail.  
C. Notify the physician.  
D. Prepare an incident report.  

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Question # 96

People-related supervisory tasks include all of the following except:

A. coaching.
B. encouraging.
C. target setting.
D. rewarding.

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Question # 97

The Token Economy is a type of therapy that focuses on: 

A. play therapy.  
B. behavior modification.  
C. milieu therapy.  
D. associative.  

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Question # 98

A family member of a client with a diagnosis of Schizophrenia asks about the prognosis. The nurse’s response is based on the knowledge that schizophrenia: 

A. affects women more often than men.  
B. is usually diagnosed between the ages of 15 and 45.  
C. is a chronic, deteriorating disease with periods of remission.  
D. is diagnosed later in women due to a protective hormone effect.  

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Question # 99

A nurse is assessing a patient’s right lower extremity. The extremity is warm to touch, red and swollen. The patient is also running a low fever. Which of the following conditions would be the most likely cause of the patient’s condition?

A. Herpes
B. Scleroderma
C. Dermatitis
D. Cellulitis

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Question # 100

A nurse is returning phone calls in a pediatric clinic. Which of the following reports most requires the nurse’s immediate attention and phone call?

A. A 8 year-old boy has been vomiting and appears to have slower movements and has a history of an atrio-ventricular shunt placement.
B. A 10 year-old girl feels a dull pain in her abdomen after doing sit-ups in gym class.  
C. A 7 year-old boy has been having a low fever and headache for the past 3 days that has history of an anterior knee wound.  
D. A 7 year-old girl that had a cast on her right ankle is complaining of itching.  

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Question # 101

When a drug is listed as Category X and prescribed to women of child-bearing age/capacity, the nurse and the interdisciplinary team should counsel the client that: 

A. Pregnancy tests might be unreliable while taking the drug.
B. She must use a reliable form of birth control.
C. She should not take the Category X drug on days she has intercourse.
D. She must follow up with an endocrinologist.

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Question # 102

The client on Floxin must be alerted to which of the following adverse effects? 

A. stunting of height in teens and young adults  
B. propensity of anovulatory uterine bleeding  
C. intractable diarrhea  
D. tendon rupture  

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Question # 103

The ICU nurse caring for a client who has just been declared brain dead can expect to find evidence of the client’s wishes regarding organ donation: 

A. on the driver’s license of the client.
B. in the client’s safety deposit box.
C. in the client’s last will and testament.
D. on the client’s insurance card.

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Question # 104

A nurse is assigned to do pre-operative teaching on a blind patient who is scheduled for surgery the following morning. What teaching strategy would best fit the situation?

A. Verbal teaching in short sessions throughout the day  
B. Pre-operative booklet on the surgery in Braille  
C. Provide a tape for the client  
D. Have the blind patient’s family member instruct the patient.  

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Question # 105

How many feet should separate the nurse and the source when extinguishing a small, wastebasket fire with an appropriate extinguisher?

A. 1 foot
B. 2 feet 
C. 4 feet
D. 6 feet

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Question # 106

Which of the following is one of the main goals for Healthy People 2010? 

A. reduction of health care costs  
B. elimination of health disparities  
C. investigation of substance abuse  
D. determination of an acceptable morbidity rate  

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Question # 107

When a client describes their family as having multiple wives, all of whom are sisters, married to one man, the nurse documents the family structure as?

A. polyandry  
B. soronal  
C. nonsororal  
D. sororate  

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Question # 108

The nurse provides a postoperative client with an analgesic medication and darkens the room before the client goes to sleep for the night. The nurse’s actions: 

A. help the client’s circadian rhythm.
B. stimulate hormonal changes in the brain.
C. decrease stimuli from the cerebral cortex.
D. alert the hypothalamus in the brain.

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Question # 109

A patient has experienced a severe third degree burn to the trunk in the last 36 hours.Which phase of burn management is the patient in?

A. Shock phase
B. Emergent phase
C. Healing phase
D. Wound proliferation phase

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Question # 110

A nurse who is assessing the health-related physical fitness of a client as part of a health assessment should focus on which of the following aspects of the assessment?

A. agility
B. speed
C. body composition
D. risk factors

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Question # 111

Which of the following statements by a client with spinal cord injury indicates a need for further teaching by the nurse regarding bowel management?

A. “I should avoid eating foods that produce gas.”  
B. “I should drink more fluids like coffee and cola.”  
C. “I should set a regular schedule for bowel movements.”  
D. “I should sit in an upright position for bowel movements.”  

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Question # 112

The nurse observes a staff member not following the plan of care for a client with an antisocial personality disorder. The nurse should: 

A. confront the staff member immediately and say, “You know that is not the treatment plan.”
B. write an incident report to create a paper trail of the staff member’s failure to follow the planned program. 
C. ask the staff member to talk in private, and reinforce how antisocial clients try to divide staff. 
D. bring up the incident during the weekly conference so that this staff member is not assigned to work with antisocial persons again. 

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Question # 113

A patient has recently been diagnosed with symptomatic bradycardia. Which of the following medications is the most recognized for treatment of symptomatic bradycardia?

A. Questran  
B. Digitalis  
C. Nitroglycerin  
D. Atropine  

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Question # 114

A nurse at outpatient clinic is returning phone calls that have been made to the clinic. Which of the following calls should have the highest priority for medical intervention?

A. A home health patient reports, “I am starting to have breakdown of my heels.”  
B. A patient that received an upper extremity cast yesterday reports, “I can’t feel my fingers in my right hand today.”
C. A young female reports, ”I think I sprained my ankle about 2 weeks ago.”  
D. A middle-aged patient reports, ”My knee is still hurting from the TKR.”  

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Question # 115

A nurse is reviewing a patient’s medical record. The record indicates the patient has limited shoulder flexion on the left. Which plane of movement is limited?

A. Horizontal
B. Sagittal
C. Frontal
D. Vertical

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Question # 116

The nurse is developing a care plan for a client with severe anxiety. An appropriateoutcome for the client is that within 4 days the client should:

A. Have decreased anxiety.
B. Talk to the nurse for 10 minutes.
C. Sit quietly for 30 minutes.
D. Develop an adaptive coping mechanism.

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Question # 117

A patient has been ordered to get Klonapin for the first time. Which of the following side effects is not associated with Klonapin?

A. Drowsiness
B. Ataxia
C. Salivation elevated
D. Diplopia

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Question # 118

The nurse notices that a family is waiting at the nursing station desk for its loved one to bebrought to the unit for admission during a change-of-shift report. The nurse should:

A. request that the family wait for its loved one in the client’s room and wait to resume thereport until the family has left the desk area.B. request that a nursing assistant bring coffee for the family while it waits at the desk andcontinue with the report.C. request that the family have a seat in the station rather than stand while awaiting itsloved one.D. request that the family wait for its loved one in the Emergency Department waiting room.Answer: AExplanation:To protect the privacy of clients and the confidentiality of the information shared in achange-of-shift report, the family should be asked to wait in the client’s room, and thereport should be resumed only after it can no longer hear what is said.Coordinated Care 
B. request that a nursing assistant bring coffee for the family while it waits at the desk andcontinue with the report.
C. request that the family have a seat in the station rather than stand while awaiting itsloved one.
D. request that the family wait for its loved one in the Emergency Department waiting room.

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Question # 119

An infection in a central venous access device is not eliminated by giving antibiotics through the catheter. How might bacterial glycocalyx contribute to this?

A. It protects the bacteria from antibiotic and immunologic destruction.
B. Glycocalyx neutralizes the antibiotic, rendering it ineffective.
C. It competes with the antibiotic for binding sites on the microbe.
D. Glycocalyx provides nutrients for microbial growth.

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Question # 120

When giving an intramuscular injection to an infant. Which of the following sites ispreferred? 

A. Ventrogluteal region
B. Deltoid
C. Vastus lateralis
D. Dorsogluteal region

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Question # 121

A two-year old has been in the hospital for 3 weeks and seldom seen family members due to isolation precautions. Which of the following hospitalization changes is most like to be occurring?

A. Guilt
B. Trust
C. Separation anxiety
D. Shame

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Question # 122

One drug can alter the absorption of another drug. One drug increases intestinal motility. Which effect does this have on the second drug?

A. None; absorption of the second drug is not affected.
B. The increased gut motility increases the absorption of the second drug.
C. The absorption of the second drug cannot be predicted.
D. Less of the second drug is absorbed.

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Question # 123

Which of the following is not considered one of the five rights of medication administration?

A. client
B. drug
C. dose
D. routine

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Question # 124

A patient has just been prescribed Minipress to control hypertension. The nurse should instruct the patient to be observant of the following:

A. Dizziness and light headed sensations
B. Weight gain
C. Sensory changes in the lower extremities
D. Fatigue

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Question # 125

A nurse is working in a pediatric clinic and a mother brings in her 13 month old child who has Down Syndrome. The mother reports, “My child’s muscles feel weak and he isn’t moving well. My RN friend check his reflexes and she said they are diminished.” Which of the following actions should the nurse take first? 

A. Contact the physician immediately
B. Have the patient go to X-ray for a c-spine work-up.
C. Start an IV on the patient 
D. Position the child’s neck in a neutral position

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Question # 126

A physician orders a serum creatinine for a hospitalized client. The nurse should explain to the client and his family that this test:

A. is normal if the level is 4.0 to 5.5 mg/dl.  
B. can be elevated with increased protein intake.  
C. is a better indicator of renal function than the BUN.  
D. reflects the fluid volume status of a person.  

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Question # 127

When a couple experiencing infertility presents for a fertility workup, which of the followingprocedures should the nurse prepare the couple to have first? 

A. hysterosalpingography
B. semen analysis
C. endometrial biopsy
D. transvaginal ultrasound

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Question # 128

The chemotherapeutic agent 5-fluorourcacil (5-FU) is ordered for a client as an adjunctmeasure to surgery. Which statement about chemotherapy is true?

A. It is a local treatment affecting only tumor cells.
B. It is a systemic treatment affecting both tumor and normal cells.
C. It has not yet been proved an effective treatment for cancer.
D. It is often the drug of choice because it causes few, if any, side effects.

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Question # 129

The teaching plan for a postpartum client who is about to be discharged should includewhich of the following instructions?

A. “It is normal for your breasts to be tender. You should call the physician if you also haveredness and fatigue.”
B. “Because your baby was delivered vaginally, you might have to urinate more frequently.”
C. “It is normal to run a low-grade temperature for a few days. If it is higher than 100° F,call your physician.”
D. “Be sure to call your physician if your vaginal discharge becomes bright red.”

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Question # 130

Which of the following microorganisms is easily transmitted from client to client on thehands of health care workers?

A. mycobacterium tuberculosis
B. clostridium tetani
C. staphylococcus aureus
D. human immunodeficiency virus

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Question # 131

When a woman is receiving postpartum epidural morphine, the nurse should plan toobserve for which of the following side effects to occur within the first 3 hours?

A. nausea and vomiting
B. itching
C. urinary retention
D. somnolence

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Question # 132

Client room environments should include:

A. a made bed, fresh water, thermostat regulation, and clean floors in all occupied clientareas.
B. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
C. accident prevention, comfort, a room (including furniture) that has been cleaned withchloroseptic wash, a bed that is made every other day.
D. odor control (by spraying the room with deodorizers), closet storage of all client objects,a clean room. (Gloves should be worn when cleaning.)

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Question # 133

During the work phase of the nurse-client relationship, the client says to her primary nurse,“ You think that I could walk if I wanted to, don’t you?” What is the best response by the nurse? 

A. “Yes, if you really wanted to, you could.”
B. “Tell me why you’re concerned about what I think.”
C. “Do you think you could walk if you wanted to?”
D. “I think you’re unable to walk now, whatever the cause.”

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Question # 134

An 80-year-old aphasic CVA client had abdominal surgery 2 days ago. Which of thefollowing puts this client at the highest risk for inadequate pain management?

A. inability to turn, cough, and breathe deeply
B. inability to communicate pain
C. inability to ambulate freely
D. inability to use a bedside commode

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Question # 135

When teaching a woman about possible side effects of hormone replacement therapy, thenurse should include information about all of the following except:

A. Hypoglycemia in diabetic women.
B. The possible return of monthly menses when taking combination hormones.
C. Increased risk of gallbladder disease.
D. Increased risk of breast, cervical, and ovarian cancer with long-term use.

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Question # 136

For which condition might a client’s antidiuretic hormone (ADH) level be increased?

A. diabetes mellitus
B. diabetes insipidus
C. hypothyroidism
D. hyperthyroidism

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Question # 137

As part of the teaching plan for a client with type I diabetes mellitus, the nurse shouldinclude that carbohydrate needs might increase when:

A. an infection is present.
B. there is an emotional upset.
C. a large meal is eaten.
D. active exercise is performed.

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Question # 138

In alcoholics with anemia:

A. pernicious anemia is more common than folic acid deficiency.
B. iron deficiency and folic acid deficiency can coexist. 
C. the alcohol interferes with iron absorption.
D. oral vitamin replacement is contraindicated.

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Question # 139

Which of the following is not a function of parathyroid hormone?

A. moving calcium from bones to the bloodstream
B. promoting renal tubular reabsorption of phosphorus
C. promoting renal tubular reabsorption of calcium
D. enhancing renal production of vitamin D metabolites

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Question # 140

Which cultural group has the highest incidence of inflammatory bowel disease (IBD)? 

A. Asians  
B. Caucasians  
C. Hispanics  
D. African Americans  

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Question # 141

Mrs. Owens is the 81-year-old mother of Jonathan, who is 54 years old. Jonathan has hadschizophrenia since he was 16 years old. Which of Mrs. Owens’s concerns is likely topredominate?

A. “Will my retirement funds outlast me?”
B. “Who will handle my funeral arrangements?”
C. “What will become of Jonathan when I am gone?”
D. “How can I get Jonathan’s physician to talk to me?”

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Question # 142

Which of the following foods can cause diarrhea when eaten by a client with an ileostomy? 

A. eggs
B. coffee
C. fish
D. garlic

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Question # 143

Increased cortisol levels might be found in a client with which condition?

A. Cushing’s syndrome
B. Addison’s disease
C. renal failure
D. congestive heart failure

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Question # 144

Which of the following blood pressure parameters indicates PIH? Elevation over a baselineof:

A. 30 mmHg systolic and/or 15 mmHg diastolic.
B. 40 mmHg systolic and/or 20 mmHg diastolic.
C. 10 mmHg systolic and/or 5 mmHg diastolic.
D. 20 mmHg systolic and/or 20 mmHg diastolic.

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Question # 145

Pain tolerance in an elderly client with cancer should:

A. Stay the same.
B. Decrease.
C. Increase.
D. Cancer should have no effect on pain tolerance for an elderly client.

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