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1. The nurse notes unexpectedly during a routine screening examination that the client
has a thready pulse. In what other way could this finding be documented?
a. A 2+ pulse
b. Pulse rate irregular and forceful
c. Pulse difficult to palpate and easy to obliterate
d. Pressure with the index finger causes pulsation
Source: Prentice Hall Nursing Comprehensive Review for the NCLEX – RN Review and Rationales 2008;
p238 Mary Ann Hogan.
2. The nurse is most concerned with providing further teaching for the client with
diabetes who does which of the following?
a. Drinks orange juice each morning
b. Eats an apple and cheese before going to bed
c. Buys canned fruit instead of fresh because it is cheaper
d. Eat six meals per day
Source: Prentice Hall Nursing Comprehensive Review for the NCLEX – RN Review and Rationales 2008;
p251Mary Ann Hogan.
3. When a client comes into the emergency room with complaints of constipation and
abdominal pain, which of the following would be the most common risk factors to assess
for?
a. History of diverticulitis and diverticulosis
b. Dietary and exercise pattern
c. Nutritional intake of proteins and fatty acids
d. Level of nutrition understanding and laxative abuse
Source: Prentice Hall Nursing Comprehensive Review for the NCLEX – RN Review and Rationales 2008;
p252 Mary Ann Hogan.
4. A nurse evaluates that the care plan related to normal physiologic changes has been
effective for a 70 – year – old client if he says,
a. “I have more sebaceous gland activity.”
b. “I have lost some of my social support systems.”
c. “I have an increased need for sleep.”
d. “I have less joint cartilage than I used to.”
Source: Prentice Hall Nursing Comprehensive Review for the NCLEX – RN Review and Rationales 2008;
p267 Mary Ann Hogan.
5. Which nursing intervention would be most appropriate to meet safety needs when
caring for an older adult with sensory changes?
a. Assist in preparing a bath because the client may not be able to determine the
intensity if heat.
b. Use care when administering an injection because older adults experience more
pain.
c. Massage with additional pressure because tactile perception of older adults is
diminished.
d. Use minimal touch with an older adult because touch will feel uncomfortable.
Answer: A – Assist in preparing a bath because the client may not be able to
determine the intensity if heat.
Because of loss of skin receptors, the older adult has an increase threshold to pain,
touch, and temperature. When feeding or bathing, remember that the older adult may
be unable to distinguish hot or cold or to determine the intensity if heat. The older adult
may feel less pain than younger adults and complain of only pressure or a minor
sensation. The older adult, however, is the only one who can identify if they have pain
or not. An older client’s sensory perception is less acute than that of younger adults, so
when giving massage, less pressure is needed. Everyone , and especially the older
adult, needs touch.
Source: Prentice Hall Nursing Comprehensive Review for the NCLEX – RN Review and Rationales 2008;
p267 Mary Ann Hogan.
6. A nurse is assessing an older adult client who is at risk for shock. The nurse will be
effectively assess for cyanosis on the:
a. Sclera of the eyes
b. Oral mucous membrane
c. Skin of the forehead
d. Nail beds of the finger or toes
Source: Prentice Hall Nursing Comprehensive Review for the NCLEX – RN Review and Rationales 2008;
p268 Mary Ann Hogan.
7. A client with chronic obstructive pulmonary disease (COPD) has given up smoking
and spaces out activities over the course of the day. The nurse should respond by
doing?
a. Say nothing about the behavior to avoid refocusing the client on the disease process
b. Ignore the maladaptive behavior
c. Reward the adaptive coping behaviors
d. Tell the client that adjustment was bound to occur overtime
Source: Prentice Hall Nursing Comprehensive Review for the NCLEX – RN Review and Rationales 2008;
p307 Mary Ann Hogan.
8. Which of the following indicates to the nurse that a non – communicative client’s pain is not
well managed?
a. Crackles in the lungs
b. Hyperactive bowel sounds
c. Unwillingness to eat without assistance
d. Constant restlessness and leg movement
Source: Prentice Hall Nursing Comprehensive Review for the NCLEX – RN Review and Rationales 2008;
p392 Mary Ann Hogan.
9. The nurse is planning discharge teaching for the client with gastroesophageal reflux
diseases (GERD). What dietary modification should be included?
a. Eat three meals and a bedtime snack
b. Avoid intake of caffeine and alcoholic beverages
c. Drink 12 to 16 ounces of water with each meal
d. Lie down for 15 to 20 minutes after eating
Source: Prentice Hall Nursing Comprehensive Review for the NCLEX – RN Review and Rationales 2008;
p417 Mary Ann Hogan.
10. A client is placed on enteral feeding via nasogastric tube to meet nutritional goals.
Which of the following assessments should be included in a plan of care in order to
maintain fluid balance?
a. Assess the skin area around the tube site
b. Weigh the client every other day
c. Maintain strict I&O and flush the tube once a day to ensure patency
d. Irrigate the tube with water as ordered and include this is fluid in total I&O
Answer: D – Irrigate the tube with water as ordered and include this is fluid in
total I&O.
A client who is receiving enteral feedings via nasogastric tube can be at risk for
dehydration caused by inadequate fluid intake. It is therefore important to irrigate the
tube with water as ordered (before and after feeding or medication administration) and
include these irrigations in the client’s total I&O measurements. Option A is incorrect ,
although inspection of the skin surrounding the tube is necessary; it does not relate to
fluid balance. Option B is incorrect because clients are often weighed daily. Option C is
incorrect because feeding tubes are not flushed only once a day.
Source: Prentice Hall Nursing Comprehensive Review for the NCLEX – RN Review and Rationales 2008;
p419 Mary Ann Hogan.
11. A client arrives in the emergency room and is assessed by the nurse. The client is
staggering, confuse, and verbally abusive, complains of headache from drinking
alcohol, and is asking for medication. The nurse explains to the client that the physician
will need to perform an assessment before the administration of medication. When the
client becomes verbally abusive, the nurse obtains leather restraints and threatens to
place the client in the restraint. With which of the following can the client legally charge
the nurse as a result of the nursing action?
a. Assault
b. Battery
c. Negligence
d. Invasion of privacy.
Answer: A – Assault
An assault occurs when a person puts another person in fear of a harmful or offensive
contact. For this intentional tort to be actionable, the victim must be aware of the threat
of harmful or offensive contact. Battery is the actual contact with one’s body. Negligence
involves actions below the standards of care. Invasion of privacy occurs with
unreasonable intrusion into the individual’s private affairs.
Source: Saunder’s Comprehensive Review for the NCLEX – RN Examination 4th Edition 2008 p64 Linda
Anne Silvestri.
12. The client is to undergo an invasive procedure. While providing information about
the procedure, the nurse provides legal protection of a client’s right to autonomy with
which of the following?
a. Informed consent
b. Beneficence
c. Good Samaritan Law
d. Advance directives
Source: Prentice Hall Nursing Fundamentals Reviews and Rationales 2nd Edition 2008 p100 Mary Ann
Hogan.
13. A nurse accidentally administers a drug to the wrong client and the client reacts
adversely to that drug. The nurse anticipates that this event could lead to which of the
following charges?
a. A tort
b. Malpractice
c. Fraud
d. Assault
Answer: B – Malpractice
Malpractice occurs when any form of negligence causes injury to the client. It is the
failure to act as a reasonably prudent person with the same knowledge and experience
would act in the same or similar situation. A tort is a wrong or injury that a person has
suffered from another’s action. Fraud is deliberate deception, and assault is an injury
inflicted on one person by another.
Source: Prentice Hall Nursing Fundamentals Reviews and Rationales 2nd Edition 2008 p102 Mary Ann
Hogan
Source: Thomson Asian Edition Nursing Leadership and Management A Practical Guide 2007 p54 by
Patricia Carrol.
15. Which of the following types of medications can be administered via gastrostomy
tube?
a. Any oral medications
b. Capsules whole contents are dissolve in water
c. Enteric-coated tablets that are thoroughly dissolved in water
d. Most tablets designed for oral use, except for extended-duration compounds
Answer: D – Most tablets designed for oral use, except for extended-duration
compounds.
Capsules, enteric-coated tablets, and most extended duration or sustained release
products should not be dissolved for use in a gastrostomy tube. They are
pharmaceutically manufactured in these forms for valid reasons, and altering them
destroys their purpose. The nurse should seek an alternate physician’s order when an
ordered medication is inappropriate for delivery by tube.
19. When transferring a patient from a bed to a chair, the nurse should use which
muscles to avoid back injury?
a. Abdominal muscles
b. Back muscles
c. Leg muscles
d. Upper arm muscles
20. In a recumbent, immobilized patient, lung ventilation can become altered, leading to
such respiratory complications as:
a. Respiratory acidosis, ateclectasis, and hypostatic pneumonia
b. Appneustic breathing, atypical pneumonia and respiratory alkalosis
c. Cheyne-Strokes respirations and spontaneous pneumothorax
d. Kussmail’s respirations and hypoventilation
22. Which of the following patients is at greater risk for contracting an infection?
a. A patient with leukopenia
b. A patient receiving broad-spectrum antibiotics
c. A postoperative patient who has undergone orthopedic surgery
d. A newly diagnosed diabetic patient
23. Which of the following constitutes a break in sterile technique while preparing a
sterile field for a dressing change?
a. Using sterile forceps, rather than sterile gloves, to handle a sterile item
b. Touching the outside wrapper of sterilized material without sterile gloves
c. Placing a sterile object on the edge of the sterile field
d. Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a
sterile container.
24. Which of the following nursing interventions is considered the most effective form or
universal precautions?
a. Cap all used needles before removing them from their syringes
b. Discard all used uncapped needles and syringes in an impenetrable protective
container
c. Wear gloves when administering IM injections
d. Follow enteric precautions
25. After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient
begins to exhibit fatigue, muscle cramping and muscle weakness. These symptoms
probably indicate that the patient is experiencing:
a. Hypokalemia
b. Hyperkalemia
c. Hypocalcemia
d. Hypercalcemia
Answer: A – Hypokalemia
Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an
inadequate potassium level), which is a potential side effect of diuretic therapy. The
physician usually orders supplemental potassium to prevent hypokalemia in patients
receiving diuretics.
26. When a nurse a nurse presents the nursing procedures to be followed, she refers to
what type of standards?
a. Process
b. Outcome
c. Structure
d. Criteria
Answer: A – Process
Process standards include care plans, nursing procedure to be done to address the
needs of the patients.
Source: Prentice Hall Nursing Fundamentals Reviews and Rationales 2nd Edition 2008 p103 Mary Ann
Hogan.
29. Which of the following is the best guarantee that the patient’s priority needs are
met?
a. Checking with the relative of the patient
b. Preparing a nursing care plan in collaboration with the patient
c. Consulting with the physician
d. Coordinating with other members of the team
30. A visual – decision making tool that graphically illustrates a project from start to
finish is called?
a. Decision tree
b. PERT flowchart
c. Gantt chart
d. Electronic organizer
Source: Thomson Asian Edition Nursing Leadership and Management A Practical Guide 2007 p97 by
Patricia Carrol.
31. All of the following nursing interventions are correct when using the Z-track method
of drug injection except:
a. Prepare the injection site with alcohol
b. Use a needle that’s a least 1” long
c. Aspirate for blood before injection
d. Rub the site vigorously after the injection to promote absorption
Answer: D – Rub the site vigorously after the injection to promote absorption.
The Z-track method is an I.M. injection technique in which the patient’s skin is pulled in
such a way that the needle track is sealed off after the injection. This procedure seals
medication deep into the muscle, thereby minimizing skin staining and irritation.
Rubbing the injection site is contraindicated because it may cause the medication to
extravasate into the skin.
32. The correct method for determining the vastus lateralis site for I.M. injection is to:
a. Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm
below the iliac crest
b. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the
arm
c. Palpate a 1” circular area anterior to the umbilicus
d. Divide the area between the greater femoral trochanter and the lateral femoral
condyle into thirds, and select the middle third on the anterior of the thigh
Answer: D – Divide the area between the greater femoral trochanter and the
lateral femoral condyle into thirds, and select the middle third on the anterior of
the thigh.
The vastus lateralis, a long, thick muscle that extends the full length of the thigh, is
viewed by many clinicians as the site of choice for I.M. injections because it has
relatively few major nerves and blood vessels. The middle third of the muscle is
recommended as the injection site. The patient can be in a supine or sitting position for
an injection into this site.
33. The nurse is providing tracheostomy care to a client who had a tracheostomy
performed 2 weeks ago. The client coughs the tube out of the trachea. Which of the
following actions should the nurse take first?
a. Call aloud for help
b. Suction the stoma to remove residual secretions
c. Grasp and spread the retention sutures to open the stoma
d. Attempt to reinsert a new tracheostomy tube
Answer: C – Grasp and spread the retention sutures to open the stoma.
The priority action of the nurse is to establish a patent airway. With this in mind, the
nurse spreads the retention sutures to reopen the stomal area. The nurse then quickly
calls aloud for help so assistance will arrive to aid in tube reinsertion. The nurse is not
likely to suction the area at this time, and the nurse would reinsert a new tracheostomy
tube if allowed by agency policy, since tube has been in place for more than 72 hours.
Source: Prentice Hall Nursing Comprehensive Review for the NCLEX – RN Review and Rationales 2008;
p467 Mary Ann Hogan.
34. The nurse should take the following actions when caring for a client with
nephrostomy tube?
a. Irrigate the tube every hour regardless of drainage
b. Keep a clamp at the bedside
c. Ensure the tubing is free of kinks
d. Tape the drainage bag to the bedrail
Source: Prentice Hall Nursing Comprehensive Review for the NCLEX – RN Review and Rationales 2008;
p468 Mary Ann Hogan.
35. The nurse is about to receive an intershift report on a client who has a Sengstaken –
Blakemore tube in place. The nurse expects that the client has which of the following
health problems as the primary reason for tube placement?
a. Cirrhosis
b. Esophageal varices
c. Portal hypertension
d. Abdominal ascites
Source: Prentice Hall Nursing Comprehensive Review for the NCLEX – RN Review and Rationales 2008;
p469 Mary Ann Hogan
36. A client with hypertension has been given a prescription to treat the disorder. The
nurse would explain that cough and loss of taste are side effects if which of the following
antihypertensive agents is prescribed?
a. Lisinopril (Prinivil)
b. Propranolol (Inderal)
c. Diltiazem (Cardizem)
d. Furosemide (Lasix)
Source: Prentice Hall Nursing Comprehensive Review for the NCLEX – RN Review and Rationales 2008;
p631 Mary Ann Hogan.
37. A client is diagnosed with deep vein thrombophlebitis. A nurse develops a plan of
care for the client and includes which position and activity in the plan?
a. Out – of bed activities as desired
b. Bed rest with affected extremity kept flat
c. Bed rest with elevation of the affected extremity
d. Bed rest with affected extremity being massaged
38. A nurse is inserting a nasogastric tube in an adult client. During the procedure, the
client begins to cough and has difficulty breathing. Which of the following is the
appropriate action of the nurse?
a. Quickly insert the tube
b. Notify the physician immediately
c. Remove the tube and reinsert when the respiratory distress subsides
d. Pull back on the tube and wait until the respiratory distress subsides
Answer: D – Pull back on the tube and wait until the respiratory distress
subsides.
During the insertion of a nasogastric tube, if the client experiences difficulty breathing or
any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait
until the distress subsides. Options B and C are unnecessary. Quickly inserting the tube
is not an appropriate action, it his situation, it may be likely that the tube has entered the
bronchus.
Source: Saunders Comprehensive Review for the NCLEX – RN Examination 2008; p264 Linda Anne
Silvestri.
39. A nurse is preparing to care for a client with potassium – deficit. The nurse reviews
the client’s record and determines that the client was at risk for developing the
potassium deficit because the client:
a. Has a renal failure
b. Requires nasogastric suction
c. Has a history of Addison’s disease
d. Is taking potassium – sparing diuretic
Source: Saunders Comprehensive Review for the NCLEX – RN Examination 2008; p104 Linda Anne
Silvestri.
40. A client has just undergone insertion of a central venous catheter at the bedside.
The nurse would be sure to check the results of which of the following before initiating
the flow rate of the client’s IV solution at 100mL/hr.
a. Serum osmolality
b. Serum electrolyte levels
c. Portable chest x – ray film
d. Intake and output record
Source: Saunders Comprehensive Review for the NCLEX – RN Examination 2008; p171 Linda Anne
Silvestri.
Answer: A – Moral
Morality is behavior in accordance with custom or tradition and usually personal or
religious beliefs; for example, in some cultures, a woman appearing in public without her
head covered is immoral (and perhaps illegal),while in other countries, it is morally
acceptable for a woman’s head to be uncovered.
Source: Thomson Asian Edition Nursing Leadership and Management A Practical Guide 2007 p298 by
Patricia Carrol.
42. In this ethical theory, decisions are based on what will provide the greatest good for
the greatest number of people:
a. Nonmaleficence
b. Teleology
c. Formalism
d. Utilitarianism
Answer: B – Utilitarianism
Decisions based on what will provide the greatest good for the greatest number of
people; for example, the decision to force people with pulmonary tuberculosis into
treatment is ethical, according to this theory, because it protects the greater population
from infection.
A – Is the principle of doing no harm.
B – Teleology or consequentialist theory; value of situation is determined by its
consequences.
C – Formalism/Deontology; an act is good only if it spring from goodwill, this ethical
theory does not allow for actions based on the concept of “the end justifies the means.”
Source: Thomson Asian Edition Nursing Leadership and Management A Practical Guide 2007 p297 –
298 by Patricia Carrol.
43. Which of the following qualities are relevant in documenting patient care?
a. Accuracy and conciseness
b. Thorough and currentness
c. Organization
d. All of the above
Source: Fundamentals of Nursing (Nurse Test a Review Series) p74 by June Looby Olsen et al.
44. A client ask why a diagnostic test has been ordered and the nurse replies ,”I am
unsure but I will find out for you.” When the nurse later returns and provides an
explanation, the nurse is acting under the principle of?
a. Nonmaleficence
b. Veracity
c. Paternalism
d. Fidelity
Answer: D – Fidelity
Fidelity means to be faithful to agreements and promises. This nurse acting on the
client’s behalf to obtain needed information and report it back to the client.
Nonmaleficence is duty to do no harm. Veracity refers to telling the truth – for example,
not lying to a client about a serious prognosis. Beneficence means doing good, such as
by implementing actions that benefit a client.
Source: Prentice Hall Nursing Comprehensive Review for the NCLEX – RN Review and Rationales 2008;
p35 - 36 Mary Ann Hogan.
45. The care delivery model in which one nurse is responsible for all aspects of patient
care for that shift is called?
a. Functional nursing
b. Team nursing
c. Total patient care
d. Patient – focused care
46. The nurse determines that a client is having a transfusion reaction. After the nurse
stops the transfusion, which action should immediately be taken?
a. Remove the IV line
b. Run normal saline at a keep vein open rate
c. Run a solution of 5% dextrose in water
d. Obtain a culture of the tip of the catheter device removed from the client
Source: Saunders Comprehensive Review for the NCLEX – RN Examination 2008; p181 Linda Anne
Silvestri.
47. A client has received transfusion of platelets. The nurse evaluates that the client is
benefiting most from this therapy if the client exhibits which of the following?
a. Increased hematocrit level
b. Increased hemoglobin level
c. Decline of elevated temperature to normal
d. Decreased oozing of blood from puncture sites and gums
Source: Saunders Comprehensive Review for the NCLEX – RN Examination 2008; p183 Linda Anne
Silvestri.
48. A nurse is inserting an indwelling urinary catheter into a male client. As the catheter
is inserted into the urethra, urine begins to flow into the tubing. At this point, the nurse:
a. Immediately inflates the balloon.
b. Inserts the catheter 2.5 – 5 cm and inflates the balloon.
c. Withdraws the catheter about 1 inch and inflates the balloon.
d. Inserts the catheter until resistance is met and inflates the balloon.
Source: Saunders Comprehensive Review for the NCLEX – RN Examination 2008; p265 Linda Anne
Silvestri.
49. A nurse is caring for a client with a severe burn who is scheduled for an autograft to
be placed on the lower extremity. The nurse develops a postoperative plan of care for
the client and includes which of the following?
a. Maintain the client in prone position
b. Elevate and immobilize the grafted extremity
c. Maintain the surgical extremity in a flat position
d. Keep the surgical extremity covered with blanket
Source: Saunders Comprehensive Review for the NCLEX – RN Examination 2008; p249 Linda Anne
Silvestri.
50. A prescribed amount of oxygen s needed for a patient with COPD to prevent:
a. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood
(PaCO2)
b. Circulatory overload due to hypervolemia
c. Respiratory excitement
d. Inhibition of the respiratory hypoxic stimulus
Source: http://nursingcrib.com/nursing-board-exam-review-questionnaires/foundation-of-nursing-
comprehensive-test-part-2-answers-and-rationale;retrieved February 18, 2010, 10:30am.
51. The nurse is caring for a client diagnosed with meningitis and implements which
transmission – based precautions for this client?
a. Private room or cohort client
b. Personal respiratory protection device
c. Private room with negative airflow pressure
d. Mask worn by staff when the client needs to leave the room
Source: Saunders Comprehensive Review for the NCLEX – RN Examination 2008; p195 Linda Anne
Silvestri.
52. The nurse is told by a physician that a client in hypovolemic shock will require
plasma expansion. The nurse anticipates receiving an order to transfuse which product?
a. Albumin
b. Platelets
c. Cryoprecipitate
d. Packed red blood cells
Answer: A – Albumin
Albumin may be used as a plasma expander. Platelets are used when the client’s
platelet count is low. Cryoprecipitate is useful in treating bleeding from hemophilia or
disseminated intravascular coagulopathy because it is rich in clotting factors. Packed
red blood cells replace erythrocytes and are not a plasma expander.
Source: Saunders Comprehensive Review for the NCLEX – RN Examination 2008; p180 Linda Anne
Silvestri.
53. A nurse is preparing to care for a client with esophageal varices who has just had s
Sengstaken – Blakemore tube inserted. The nurse gathers supplies, knowing that which
of the following items must be kept at the bedside at all times?
a. An obturator
b. A Kelly clamp
c. An irrigation set
d. A pair of scissors
Source: Saunders Comprehensive Review for the NCLEX – RN Examination 2008; p265 Linda Anne
Silvestri.
54. A client receiving parenteral nutrition (PN) in the home setting has a weight gain of
5lb in 1 week. The nurse next assesses the client to detect the presence of which of the
following?
a. Thirst
b. Polyuria
c. Decreased blood pressure
d. Crackles on auscultation of the lungs
Source: Saunders Comprehensive Review for the NCLEX – RN Examination 2008; p155 Linda Anne
Silvestri.
55. A client is scheduled for blood to be drawn from the radial artery for an arterial blood
gas determination. Before the blood is drawn, an Allen’s test is performed to determine
the adequacy of the:
a. Ulnar circulation
b. Carotid circulation
c. Femoral circulation
d. Popliteal circulation
Source: Saunders Comprehensive Review for the NCLEX – RN Examination 2008; p116 Linda Anne
Silvestri
56. Which nursing intervention would be most appropriate for promoting the
environmental safety of a client with a cognitive disorder?
a. Applying an identification bracelet on the client
b. Maintaining daily routine care for the client
c. Placing a clock and a daily schedule in the client’s room
d. Using short sentences with simple words when speaking with the client
Answer: A – Applying an identification bracelet on the client.
Applying an identification bracelet on the client would be most effective in helping to
ensure environmental and client safety should the client wander. Other measures
include installing alarms; instituting injury, fire, and poisoning precautions; providing
adequate lighting; and keeping the bed in a low position. Maintaining a daily routine
would be helpful for ensuring consistency and promoting optimal functioning. Clocks
and daily schedules would be helpful for reorienting the client and promoting optimal
cognitive function. Using short sentences with simple words would be appropriate for
maximizing effective communication.
58. The nurse assessing a client notes yellow plaques on the lid margins. The nurse
documents the finding as:
a. Exopthalmos
b. Xanthelasma
c. Corneal arcus
d. Ptosis
Answer: B – Xanthelasma
Yellow plaques noted most often on the lid margins are referred to as xanthelasma and
may indicate high lipid levels. Exophthalmos describes protrusion of the eyeball.
Corneal arcus is a thin grayish white arc seen toward the edge of the cornea. Ptosis
describes a drooping eyelid
Answer: D – Rigid, hard, boardlike abdomen and a white blood cell (WBC) count
of 20,000 mm.
One day after abdominal surgery, the client’s abdomen should be soft, not rigid or hard.
Also, the WBC count may be slightly elevated in response to the surgery, but an
elevation of 20,000 mmis highly suggestive of an infectious process. A rigid, boardlike
abdomen in conjunction with a seriously elevated WBC count suggests peritonitis and
requires immediate intervention. The client’s blood pressure and hematocrit are within
normal limits. One day after surgery, abdominal incisional pain would be expected and
often is rated as high when using a scale from 1 to 10. The client’s hemoglobin level is
within normal limits. Hypoactive bowel sounds would be expected 1 day after abdominal
surgery. The client’s potassium level is within normal limits.
60. An elderly client with a history of heart disease is receiving intravenous fluids for
dehydration. The client complains of shortness of breath. Physical assessment reveals
tachycardia, tachypnea, and jugular vein distention. The nurse recognizes that these
signs and symptoms indicate which of the following fluid volume imbalances?
a. Fluid overload
b. Hypovolemia
c. Hypernatremia
d. Hyponatremia
61. The nurse notes that a client appears very worried and upset about an upcoming
procedure. After acknowledging the client's discomfort and providing information and
support, the nurse evaluates that comfort care provided has been successful by:
a. Taking the client's blood pressure
b. Asking the client to relate the information back to the nurse to confirm understanding
c. Asking if the client understands the information
d. Asking if the client is now more comfortable about having the procedure performed
than previously
Answer: D – Asking if the client is now more comfortable about having the
procedure performed than previously.
The goal of comfort care is enhanced comfort; therefore, the nurse should compare
comfort levels before and after the intervention. Enhanced client comfort entails more
than simply understanding the procedure. While blood pressure may indicate tension or
stress, asking if the client is less stressed is a more reliable indicator of psychological
comfort.
62. What evidence most likely told the nurse a client had a negative Romberg test?
a. Maintains an upright posture and foot stance
b. Unable to maintain foot stance
c. Moves feet apart
d. Increased swaying
63. Which of the following descriptions best fits the eudaemonistic model of health?
a. Health is defined in terms of the individual's ability to fulfill societal roles.
b. Health is a process of adaptation.
c. Health is identified by the absence of disease or injury.
d. Health is the realization of a person's potential.
Source: Fundamentals of Nursing (Nurse Test a Review Series) p53 by June Looby Olsen et al.
65. Which of the following nursing theorists is credited with developing a conceptual
model specific to nursing, with man as the central focus?
a. Martha Rogers
b. Dorothea Orem
c. Dorothy Johnson
d. Sister Callista Roy
Source: Fundamentals of Nursing (Nurse Test a Review Series) p51by June Looby Olsen et al.
66. The nurse is changing the ties of the client with a tracheostomy. The safest method
of changing the tracheostomy ties is to:
a. Apply the new tie before removing the old one.
b. Have a helper present.
c. Hold the tracheotomy with the nondominant hand while removing the old tie.
d. Ask the doctor to suture the tracheostomy in place.
Answer: A – Apply the new tie before removing the old one.
The best method and safest way to change the ties of a tracheotomy is to apply the new
ones before removing the old ones. Having a helper is good, but the helper might not
prevent the client from coughing out the tracheotomy. Answer C is not the best way to
prevent the client from coughing out the tracheotomy. Asking the doctor to suture the
tracheotomy in place is not appropriate.
68. When administering atropine sulfate preoperatively to a client scheduled for lung
surgery, the nurse should tell the client which of the following?
a. “This medicine will make you drowsy.”
b. “This medicine will help you relax.”
c. “This medicine will make your mouth feel dry.”
d. “This medicine will reduce the risk of postoperative infection.”
Source: Lippincott’s review for NCLEX – RN 7th Edition 2002 p525 Diane M. Billings.
70. Which of the following techniques is correct for the nurse to use when inserting a
rectal suppository for an adult client?
a. Insert the suppository while the client bears down
b. Place the client in supine position
c. Position the suppository along the rectal wall.
d. Insert the suppository 2 inches into the rectum
Source: Lippincott’s review for NCLEX – RN 7th Edition 2002 p525 Diane M. Billings.
71. The nurse is administering the albumin solution to a client. During administration of
this solution, the nurse should evaluate the client closely for which of the following
complications?
a. Excessive diuresis
b. Fluid overload
c. Abnormal weight loss
d. Dehydration
Source: Lippincott’s review for NCLEX – RN 7th Edition 2002 p526 Diane M. Billings.
72. The sudden onset of which of the following signs and symptoms indicates a
potentially serious complication for the client receiving an intravenous solution?
a. Noisy respiration
b. Pupillary constriction
c. Halitosis
d. Moist skin
Source: Lippincott’s review for NCLEX – RN 7th Edition 2002 p526 Diane M. Billings.
73. Which of the following actions by the nurse will most likely ensure that the correct
client receives a medication?
a. Have the client state his or her name
b. Call the client by name
c. Learn to recognize the client
d. Check the client’s identification armband
Source: Lippincott’s review for NCLEX – RN 7th Edition 2002 p527 Diane M. Billings.
Source: Lippincott’s review for NCLEX – RN 7th Edition 2002 p527 Diane M. Billings.
75. A client with a history of congestive heart failure is prescribed ketorolac (Toradol) for
arthritis. The nurse should include which of the following instructions when teaching the
client about the drug?
a. Weigh yourself every morning
b. Take the medication on an empty stomach
c. Have your blood pressure checked weekly
d. Increase your fluid intake to 200ml/day
Source: Lippincott’s review for NCLEX – RN 7th Edition 2002 p528 Diane M. Billings.
76. Which of the following clients is most likely to exhibit deficient fluid volume?
a. A 21 – year – old man with profuse diaphoresis after a game of football
b. A 75 - year – old woman who has been placed on NPO hours before surgery
c. An 8 – month – old infant with persistent diarrhea for 24 hours
d. A 60 – year – old man with pneumonia and has a high fever
Source: Lippincott’s review for NCLEX – RN 7th Edition 2002 p529 Diane M. Billings.
77. Intravenous replacement therapy for a client with a nasogastric tube attached to low
suction will be needed primarily to meet which of the following objectives?
a. Maintain bladder function
b. Facilitate osmotic diuresis
c. Equalize intake and output
d. Maintain fluid and electrolyte balance
Source: Lippincott’s review for NCLEX – RN 7th Edition 2002 p532 Diane M. Billings.
78. A client is being prepared for a bronchoscopy. Which of the following preoperative
activities would be appropriate for the nurse to delegate to the unlicensed assistant?
a. Obtaining the signed consent
b. Placing the client on NPO status
c. Instructing the client about the procedure
d. Evaluating the client’s level of anxiety
Source: Lippincott’s review for NCLEX – RN 7th Edition 2002 p532 Diane M. Billings.
79. A client has a Swan-Ganz catheter in place. The nurse understands that this is
intended to measure
a. Right heart function
b. Left heart function
c. Renal tubule function
d. Carotid artery function
80. In which position should the nurse place the client to best inspect the Bartholin’s
gland?
a. Semi – Fowler’s
b. Sim’s
c. Lithotomy
d. Prone
Answer: C – Lithotomy
The Bartholin glands are part of the female anatomy located on the posterior aspect of
the vaginal orifice. Therefore, if the medical condition allows, having the client in a
lithotomy position (on her back, knees flexed, legs apart, with feet supported on a
surface or in stirrups) will provide the best opportunity for examination. The other
responses do not allow for assessment of the female genitalia.
Source: Prentice Hall Nursing Fundamentals Reviews and Rationales 2nd Edition 2008 p60 Mary Ann
Hogan.
81. The nursing care unit is considering changing the mode of nursing care delivery to
one that holds a nurse responsible and accountable over a 24 – hour period for the care
and treatment of a caseload. The nursing staff practicing this delivery system is using?
a. Primary nursing
b. Functional nursing
c. Total client care nursing practice
d. Team nursing
Source: Prentice Hall Nursing Fundamentals Reviews and Rationales 2nd Edition 2008 p102 Mary Ann
Hogan
83. Unfreezing,m moving to a new level and refreezing are steps that make up which of
the following theories/models of change?
a. Lewin’s Force – Field Model
b. Lippitt’s Phase of Change
c. Havelock ’s Six – Step Change Model
d. Roger’s Diffusion of Innovations
Source: Thomson Asian Edition Nursing Leadership and Management A Practical Guide 2007 p114 - 115
by Patricia Carrol.
84. What type of fever would the nurse document if the client had a wide range of
temperature fluctuations over normal for a period of 24 hours?
a. Intermittent
b. Remittent
c. Relapsing
d. Constant
Answer: B – Remittent
A remittent fever widely fluctuates above normal over a 24-hour period. An intermittent
fever rises above normal between periods of normal or subnormal temperatures. A
relapsing fever is short febrile periods of a few days interspersed with 1-2 days of
normal temperature. A constant fever remains above normal.
85. The four concept common to nursing that appear in each of the current conceptual
models are?
a. Person, nursing, environment, medicine
b. Person, health, nursing support system
c. Person, health, psychology, nursing
d. Person, environment, health, nursing
Source: Fundamentals of Nursing (Nurse Test a Review Series) p51 by June Looby Olsen et al.
86. A client had an oral surgery following a motor vehicle accident, and the nurse
assigned observed that the client is warm, flushing, and diaphoretic. Which of the
following would be the best method to assess the client’s body temperature?
a. Oral
b. Axillary
c. Forehead temperature strip
d. Rectal
Answer: D – Rectal
A client who has undergone oral surgery should not have the temperature taken by the
oral method. The client is exhibiting signs and symptoms of elevated body temperature
and the rectal method is the best choice. A forehead temperature strip and the axillary
method does not give the precise measurements as the rectal route in a client at risk for
infection ot other causes of hyperthermia.
Source: Prentice Hall Nursing Fundamentals Reviews and Rationales 2nd Edition 2008 159 Mary Ann
Hogan.
87. A nurse is preparing to apply a fentanyl (Duragesic) transdermal patch for pain
management. The nurse would not apply the patch to the client’s upper arm if the client:
a. Had bilateral mastectomies
b. Has minimal hair distribution to this area
c. Has intravenous catheters placed in the hands
d. Uses an overhead trapeze bar for bed mobility
Source: Prentice Hall Nursing Fundamentals Reviews and Rationales 2nd Edition 2008 231 Mary Ann
Hogan.
88. The nurse is assessing several clients with different types of injuries. The nurse
would conclude that the client who is least likely to develop a wound infection would be
the client with which of the following?
a. A contusion
b. A wound healing by second intension
c. Septic wound
d. A wound with purulent discharge
Answer: A – A contusion
A contusion is crushing of the tissues; there is no break in the skin. Therefore, this
wound is less likely to become infected. A septic wound is one that has been invaded by
pathogenic microorganisms. Purulent exudate also is an indicator of infection. A wound
healing by second intention is a wound in which there is extensive injury and the edges
of the wound are not well approximated. Because of this factor, this type of wound has a
risk of infection.
Source: Prentice Hall Nursing Fundamentals Reviews and Rationales 2nd Edition 2008 281 Mary Ann
Hogan.
89. Which assessment of the immobilized client would prompt the nurse to take further
action?
a. Client reports fatigue
b. Urinary output of 50 ml/hour
c. White blood cells 9500/mm3
d. Hypoactive bowel sounds
Source: Prentice Hall Nursing Fundamentals Reviews and Rationales 2nd Edition 2008 283 Mary Ann
Hogan.
90. Using the principles of standard precautions, the nurse decides to apply gloves
when performing which of the following nursing interventions?
a. Providing a back massage
b. Feeding the client
c. Providing hair care
d. Providing oral hygiene
91. Kristi is a young Unit Manager of the Pediatric Ward. Most of her staff nurses are
senior to her, very articulate, confident and sometimes aggressive. Katherine feels
uncomfortable believing that she is the scapegoat of everything that goes wrong in her
department. Which of the following is the best action that she must take?
a. Identify the source of the conflict and understand the points of friction
b. Disregard what she feels and continue to work independently
c. Seek help from the Director of Nursing
d. Quit her job and look for another employment.
Answer: A – Identify the source of the conflict and understand the points of
friction.
This involves a problem solving approach, which addresses the root cause of the
problem.
92. As a young manager, she knows that conflict occurs in any organization. Which of
the following statements regarding conflict is NOT true?
a. Can be destructive if the level is too high
b. Is not beneficial; hence it should be prevented at all times
c. May result in poor performance
d. May create leaders
93. Kristi tells one of the staff, “I don’t have time to discuss the matter with you now. See
me in my office later” when the latter asks if they can talk about an issue. Which of the
following conflict resolution strategies did she use?
a. Smoothing
b. Compromise
c. Avoidance
d. Restriction
Answer: C – Avoidance
This strategy shuns discussing the issue head-on and prefers to postpone it to a later
time. In effect the problem remains unsolved and both parties are in a lose-lose
situation.
Source: http://nclexreviewers.com/nclex-practice-tests; retrieved March 2, 2010, 2:00pm
94. Kristi knows that one of her staff is experiencing burnout. Which of the following is
the best thing for her to do?
a. Advise her staff to go on vacation.
b. Ignore her observations; it will be resolved even without intervention
c. Remind her to show loyalty to the institution.
d. Let the staff ventilate her feelings and ask how she can be of help.
Answer: D – Let the staff ventilate her feelings and ask how she can be of help.
Reaching out and helping the staff is the most effective strategy in dealing with burn out.
Knowing that someone is ready to help makes the staff feel important; hence her self-
worth is enhanced.
95. She knows that performance appraisal consists of all the following activities
EXCEPT:
a. Setting specific standards and activities for individual performance.
b. Using agency standards as a guide.
c. Determine areas of strength and weaknesses
d. Focusing activity on the correction of identified behavior.
96. The nurse has just assisted a client back to bed after a fall. The nurse and the
physician have assessed the client, and have determined that the client is not injured.
After completing the incident report, the nurse should take which action next?
a. Reassess the client
b. Conduct a staff meeting to discuss the fall]
c. Document in the nurse’s notes that an incident report was completed
d. Contact the nursing supervisor to update information regarding the fall.
97. A nurse who works on the night shift enters the medication room and finds a co –
worker with a tourniquet wrapped around the upper arm. The co – worker is about to
enter a needle, attached to a syringe containing a clear liquid, into the anticubital area.
The initial action of the nurse is which of the following?
a. Call the security
b. Call the police
c. Call the nursing supervisor
d. Lock the co – worker in the medication room until help is obtained
Source: Saunders Comprehensive Review for the NCLEX – RN Examination 4th Edition 2008 p64 Linda
Anne Silvestri.
99. A patient has just received 30 mg of codeine by mouth for pain. Five minutes later
he vomits. What should the nurse do first?
a. Call the physician
b. Remedicate the patient
c. Observe the emesis
d. Explain to the patient that she can do nothing to help him
100. To institute appropriate isolation precautions, the nurse must first know the:
a. Organism’s mode of transmission
b. Organism’s Gram-staining characteristics
c. Organism’s susceptibility to antibiotics
d. Patient’s susceptibility to the organism