NCLEX-RN Quiz Part 2 (51-100)
NO.51 A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, "The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart." The nurse's best response is:
A. "I know you're feeling frightened right now, but I want you to know that I don't see anyone in the corner."
B. "You'll probably see strange things for a while until the PCP wears off."
C. "Try to sleep. When you wake up, the devil will be gone."
D. "You're probably feeling guilty because you used illegal drugs tonight."
NO.52 To facilitate maximum air exchange, the nurse should position the client in:
A. High Fowler
B. Orthopneic
C. Prone
D. Flat-supine
NO.53 A 48-year-old client is in the surgical intensive care unit after having had three-vessel coronary artery bypass surgery yesterday. She is extubated, awake, alert and talking. She is receiving digitalis for atrial arrhythmias. This morning serum electrolytes were drawn. Which abnormality would require immediate intervention by the nurse after contacting the physician?
A. Serum osmolality is elevated indicating hemoconcentration. The nurse should increase IV fluid rate.
B. Serum sodium is low. The nurse should change IV fluids to normal saline.
C. Blood urea nitrogen is subnormal. The nurse should increase the protein in the client's diet as soon as possible.
D. Serum potassium is low. The nurse should administer KCl as ordered.
NO.54 A male client is scheduled to have angiography of his left leg. The nurse needs to include which of the following when preparing the client for this procedure?
A. Validate that he is not allergic to iodine or shellfish.
B. Instruct him to start active range of motion of his left leg immediately following the procedure.
C. Inform him that he will not be able to eat or drink anything for 4 hours after the procedure.
D. Inform him that vital signs will be taken every hour for 4 hours after the procedure.
NO.55 A client had a transurethral resection of the prostate yesterday. He is concerned about the small amount of blood that is still in his urine. The nurse explains that the blood in his urine:
A. Should not be there on the second day
B. Will stop when the Foley catheter is removed
C. Is normal and he need not be concerned about it
D. Can be removed by irrigating the bladder
NO.56 The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on a fullstrength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the following?
A. The client aspirated tube feeding.
B. The nurse has placed the suction catheter in the esophagus.
C. This is a normal finding.
D. The feeding is infusing into the trachea.
NO.57 A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea, vomiting, and sore throat for the past several days. In caring for a young child with symptoms of influenza, the mother must be cautioned about:
A. Giving aspirin and bismuth subsalicylate (Pepto-Bismol) to treat the symptoms
B. Giving clear liquids too soon
C. Allowing the child to come in contact with other children for 3 days
D. The possibility of pneumonia as a complication
NO.58 A male client is considering having laser abdominal surgery and asks the nurse if there is any advantage in having this type of surgery? The nurse will respond based on the knowledge that laser surgery:
A. Has a smaller postoperative infection rate than routine surgery
B. Will eliminate the need for preoperative sedation
C. Will result in less operating time
D. Generally eliminates problems with complications
NO.59 Based on your knowledge of genetic inheritance, which of these statements is true for autosomal recessive genetic disorders?
A. Heterozygotes are affected.
B. The disorder is always carried on the X chromosome.
C. Only females are affected.
D. Two affected parents always have affected children.
NO.60 The pediatric nurse charts that the parents of a 4-yearold child are very anxious. Which observation would indicate to the nurse unhealthy coping by these parents:
A. Discussing their needs with the nursing staff
B. Discussing their needs with other family members
C. Seeking support from their minister
D. Refusing to participate in the child's care
NO.61 The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury. Normal fluid intake for a child of 2 years is:
A. 900 mL/24 hr
B. 1300 mL/24 hr
C. 1600 mL/24 hr
D. 2000 mL/24 hr Answer: C Explanation:
(A, B, D) These values are incorrect. Normal intake for a child of 2 years is about 1600 mL in 24 hours.
(C) This value is correct. Normal intake for a child of 2 years is about 1600 mL in 24 hours.
NO.62 A couple is planning the conception of their first child.The wife, whose normal menstrual cycle is 34 days in length, correctly identifies the time that she is most likely to ovulate if she states that ovulation should occur on day:
A. 14+2 days
B. 20+2 days
C. 16+2 days
D. 22+2 days
NO.63 The nurse is collecting a nutritional history on a 28- year-old female client with iron-deficiency anemia and learns that the client likes to eat white chalk. When implementing a teaching plan, the nurse should explain that this practice:
A. Will bind calcium and therefore interfere with its metabolism
B. Will cause more premenstrual cramping
C. Interferes with iron absorption because the iron precipitates as an insoluble substance
D. Causes competition at iron-receptor sites between iron and vitamin B1
NO.64 A child becomes neutropenic and is placed on protective isolation. The purpose of protective isolation is to:
A. Protect the child from infection
B. Provide the child with privacy
C. Protect the family from curious visitors
D. Isolate the child from other clients and the nursing staff
NO.65 A schizophrenic client who is experiencing thoughts of having special powers states that "I am a messenger from another planet and can rule the earth." The nurse assesses this behavior as:
A. Ideas of reference
B. Delusions of persecution
C. Thought broadcasting
D. Delusions of grandeur
NO.66 Following a gastric resection, which of the following actions would the nurse reinforce with the client in order to alleviate the distress from dumping syndrome?
A. Eating three large meals a day
B. Drinking small amounts of liquids with meals
C. Taking a long walk after meals
D. Eating a low-carbohydrate diet
NO.67 A 6-year-old child is attending a pediatric clinic for a routine examination. What should the nurse assess for while conducting a vision screening?
A. Hearing test
B. Gait
C. Strabismus
D. Papilledema
NO.68 Which of the following ECG changes would be seen as a positive myocardial stress test response?
A. Hyperacute T wave
B. Prolongation of the PR interval
C. ST-segment depression
D. Pathological Q wave
NO.69 A client with cystic fibrosis exhibits activity intolerance related to the pulmonary problems associated with his disease. However, he needs to be encouraged to participate in daily physical exercise. The ultimate aim of exercise is to:
A. Create a sense of well-being and self-worth
B. Help him overcome respiratory infections
C. Establish an effective, habitual breathing pattern
D. Promote normal growth and development
NO.70 A common complication of cirrhosis of the liver is prolonged bleeding. The nurse should be prepared to administer?
A. Vitamin C
B. Vitamin K
C. Vitamin E
D. Vitamin A
NO.71 The nurse in the mental health center is instructing a depressed client about the dietary restrictions necessary in taking her medication, which is a monoamine oxidase (MAO) inhibitor. Which of the following is she restricting from the client's diet?
A. Cream cheese
B. Fresh fruits
C. Aged cheese
D. Yeast bread
NO.72 A 67-year-old client will be undergoing a coronary arteriography in the morning. Client teaching about postprocedure nursing care should include that:
A. Bed rest with bathroom privileges will be ordered
B. He will be kept NPO for 8-12 hours
C. Some oozing of blood at the arterial puncture site is normal
D. The leg used for arterial puncture should be kept straight for 8-12 hours
NO.73 The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:
A. Inspiration is longer than expiration
B. Breath sounds are high pitched
C. Breath sounds are slightly muffled
D. Inspiration and expiration are equal
NO.74 Parents should be taught not to prop the bottle when feeding their infants. In addition to the risk of choking, it puts the infant at risk for:
A. Otitis media
B. Asthma
C. Conjunctivitis
D. Tonsillitis
NO.75 A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent:
A. Bladder spasms
B. Clot formation
C. Scrotal edema
D. Prostatic infection
NO.76 Priapism may be a sign of:
A. Altered neurological function
B. Imminent death
C. Urinary incontinence
D. Reproductive dysfunction
NO.77 The healthcare team determines that an elderly client has had progressive changes in memory over the last 2 years that have interfered with her personal, social, or occupational functioning. Her memory, learning, attention, and judgment have all been affected in some way. These symptoms describe which of the following conditions?
A. Dementia
B. Parkinsonism
C. Delirium
D. Mania
NO.78 After instructing a female client on circumcision care, the nursery nurse asks her to restate some of the key points covered. Which statement shows that the client will properly care for her son's circumcision?
A. "I'll make sure I soak the gauze with warm water first, before I take it off each time."
B. "I'll make sure that I report any drainage around where they operated."
C. "I'll apply alcohol to the area daily to clean it and prevent any infection."
D. "I'll keep a close watch on it for a day or two."
NO.79 The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have:
A. A low birth weight
B. A birth defect
C. Anemia
D. Nicotine withdrawal
NO.80 Respiratory function is altered in a 16-year-old asthmatic. Which of the following is the cause of this alteration?
A. Altered surfactant production
B. Paradoxical movements of the chest wall
C. Increased airway resistance
D. Continuous changes in respiratory rate and depth
NO.81 The FHR pattern in a laboring client begins to show early decelerations. The nurse would best respond by:
A. Notifying the physician
B. Changing the client to the left lateral position
C. Continuing to monitor the FHR closely
D. Administering O2 at 8 L/min via face mask
NO.82 A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must:
A. Assess the site for leakage of blood or fluids
B. Auscultate the site for a bruit
C. Assess the site for bruising or hematoma
D. Inspect the site for color, warmth, and sensation
NO.83 A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:
A. Prevent air from entering the pleural space
B. Prevent fluid from entering the pleural space
C. Provide a means to measure chest drainage
D. Provide an indicator of respiratory effort
NO.84 A 42-year-old male client has been treated at an alcoholic rehabilitation center for physiological alcohol dependence. The nurse will be able to determine that he is preparing for discharge and is effectively coping with his problem when he shares with her the following information:
A. "I know that I will not ever be able to socially drink alcohol again and will need the support of the AA group."
B. "I know that I can only drink one or two drinks at social gatherings in the future, but at least I don't have to continue AA."
C. "I really wasn't addicted to alcohol when I came here, I just needed some help dealing with my
divorce."
D. "It really wasn't my fault that I had to come here. If my wife hadn't left, I wouldn't have needed those drinks."
NO.85 Which of the following should be included in discharge teaching for a client with hepatitis C?
A. He should take aspirin as needed for muscle and joint pain.
B. He may become a blood donor when his liver enzymes return to normal.
C. He should avoid alcoholic beverages during his recovery period.
D. He should use disposable dishes for eating and drinking.
NO.86 A physician's order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a microdrip tubing set. How many drops per minute should the nurse administer?
A. 1 gtt/min
B. 5 gtt/min
C. 50 gtt/min
D. 100 gtt/min
NO.87 A 48-year-old male client is hospitalized with mild ascites, bruising, and jaundice. He has a 20- year history of alcohol abuse. The client is diagnosed with cirrhosis. His serum ammonia level is high, indicating hepatic encephalopathy. He has esophageal varices. Which of the following may cause the varices to rupture?
A. Lifting heavy objects
B. Walking briskly
C. Ingestion of barbiturates
D. Ingestion of antacids
NO.88 The nurse is admitting an infant with bacterial meningitis and is prepared to manage the following possible effects of meningitis:
A. Constipation
B. Hypothermia
C. Seizure
D. Sunken fontanelles
NO.89 A male client received a heart-lung transplant 1 month ago at a local transplant center. While visiting the nursing center to have his blood pressure taken, he complains of recent weakness and fatigue. He also tells the nurse that he is considering stopping his cyclosporine because it is expensive and is causing his face to become round. He fears he will catch viruses and be more susceptible to infections. The nurse responds to this last statement by explaining that cyclosporine:
A. Is given to prevent rejection and makes him less susceptible to infection than other oral corticosteroids
B. Is available at discount pharmacies for a reduced price
C. Is usually not necessary after the first year following transplantation
D. May initially cause weakness, dizziness, and fatigue, but these side effects will gradually resolve themselves
NO.90 After the RN is finished the initial assessment of a newborn baby and after the initial bonding between the newborn and the mother has taken place in the delivery room, the RN will bring the newborn to the well-baby nursery. Before the newborn is taken from the delivery room and brought to the well-baby nursery, the RN makes sure that which of the following interventions was completed?
A. The physician verifies the exact time of birth.
B. The nurse counts the instruments and sponges with the scrub nurse.
C. The nurse instills prophylactic ointment in the conjunctival sacs of the newborn's eyes.
D. The nurse makes sure the mother and her newborn have been tagged with identical bands.
NO.91 A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction. One comfort measure the nurse can employ is to:
A. Place her in knee-chest position during the contraction
B. Use effleurage during the contraction
C. Apply strong sacral pressure during the contraction
D. Have her push with each contraction
NO.92 A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first:
A. Reinforce the dressing.
B. Continue to monitor the dressing.
C. Notify the physician.
D. Note the time and amount of blood.
NO.93 A 48-year-old female client is going to have a cholecystectomy in the morning. In planning for her postoperative care, the nurse is aware that a priority nursing diagnosis for her will be high risk for:
A. Knowledge deficit
B. Urinary retention
C. Impaired physical mobility
D. Ineffective breathing pattern
NO.94 To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and O2 demand will occur with which of the following?
A. Positive inotropic therapy
B. Negative chronotropic therapy
C. Increase in balance of myocardial O2 supply and demand
D. Afterload reduction therapy
NO.95 A gravida 2 para 1 client is hospitalized with severe preeclampsia. While she receives magnesium sulfate
(MgSO4) therapy, the nurse knows it is safe to repeat the dosage if:
A. Deep tendon reflexes are absent
B. Urine output is 20 mL/hr
C. MgSO4serum levels are>15 mg/dL
D. Respirations are>16 breaths/min
NO.96 The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 1-2 hours if needed. The most likely rationale for this order is:
A. The client will settle down more quickly if he thinks the staff is medicating him
B. The medication will sedate the client until the physician arrives
C. Haloperidol is a minor tranquilizer and will not oversedate the client
D. Rapid neuroleptization is the most effective approach to care for the violent or potentially violent client
NO.97 A 27-year-old primigravida stated that she got up from the chair to fix dinner and bright red blood was running down her legs. She denies any pain previously or currently. The client is very concerned about whether her baby will be all right. Her vital signs include P 120 bpm, respirations 26 breaths/min, BP 104/58 mm Hg, temperature 98.2_F, and fetal heart rate 146 bpm. Laboratory findings revealed hemoglobin 9.0 g/dL, hematocrit 26%, and coagulation studies within normal range. On admission, the peripad she wore was noted to be half saturated with bright red blood. A medical diagnosis of placenta previa is made. The priority nursing diagnosis for this client would be:
A. Decreased cardiac output related to excessive bleeding
B. Potential for fluid volume excess related to fluid resuscitation
C. Anxiety related to threat to self
D. Alteration in parenting related to potential fetal injury
NO.98 A client has chronic obstructive pulmonary disease. She is slowly losing weight, and her daughter is very concerned about increasing her nutrition. The nurse helps the daughter devise a plan of care for her mother. The plan of care should include which of the following interventions to promote nutrition?
A. Offer her oral hygiene before and after meals.
B. Encourage her to consume milk products.
C. Encourage her to engage in an activity before a meal to stimulate her appetite.
D. Restrict her fluid intake to three glasses of water a day.
NO.99 In admitting a client to the psychiatric unit, the nurse must explain the rules and regulations of the unit. A client with antisocial personality disorder makes the following remark, "Forget all those rules. I always get along well with the nurses." Which nursing response to him would be most effective?
A. "OK, don't listen to the rules. See where you end up."
B. "I'm pleased that you get along so well with the staff. You must still know and abide by the rules."
C. "It is irrelevant whether you get along with the nurses."
D. "I'm not the other nurses. You better read the rules yourself."
NO.100 A 14-year-old teenager is demonstrating behavior indicative of an obsessive-compulsive disorder. She is obsessed with her appearance. She will not leave her room until her hair, clothes, and makeup are perfect. She always dresses immaculately. Recently, she expressed disgust over her appearance after she gained 5 lb. After observing a marked weight loss over a 2-week period, her mother suspects that she is experiencing bulimia. She eats everything on her plate, then runs to the bathroom. In interviewing the teenager, she discusses in great detail all of the events leading to her bulimia, but not her feelings. What defense mechanism is she using?
A. Dissociation
B. Intellectualization
C. Rationalization
D. Displacement
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Rating:
/5
Solution: NCLEX-RN Quiz Part 2 (51-100)