NCLEX-RN Quiz Part 3 (101-150)
NO.101 A 27-year-old healthy primigravida is brought to the labor and birthing room by her husband at 32 weeks' gestation. She experienced a sudden onset of painless vaginal bleeding. Following an ultrasound examination, the diagnosis of bleeding secondary to complete placenta previa is made.
Expected assessment findings concerning the abdomen would include:
A. A rigid, boardlike abdomen
B. Uterine atony
C. A soft relaxed abdomen
D. Hypertonicity of the uterus
NO.102 The nurse assesses a client on the second postpartum day and finds a dark red discharge on the peripad. The stain appears to be about 5 inches long. Which of the following correctly describes the character and amount of lochia?
A. Lochia alba, light
B. Lochia serosa, heavy
C. Lochia granulosa, heavy
D. Lochia rubra, moderate
NO.103 Which of the following blood values would require further nursing action in a newborn who is 4 hours old?
A. Hemoglobin 17.2 g/dL
B. Platelets 250,000/mm3
C. Serum glucose 30 mg/dL
D. White blood cells 18,000/mm3
NO.104 A client was not using his seat belt when involved in a car accident. He fractured ribs 5, 6, and 7 on the left and developed a left pneumothorax. Assessment findings include:
A. Crackles and paradoxical chest wall movement
B. Decreased breath sounds on the left and chest pain with movement
C. Rhonchi and frothy sputum
D. Wheezing and dry cough
NO.105 MgSO4 is ordered IV following the established protocol for a client with severe PIH. The anticipated effects of this therapy are anticonvulsant and:
A. Vasoconstrictive
B. Vasodilative
C. Hypertensive
D. Antiemetic
.
NO.106 The nurse is caring for a 6-week-old girl with meningitis. To help her develop a sense of trust, the nurse should:
A. Give her a small soft blanket to hold
B. Give her good perineal care after each diaper change
C. Leave the door open to her room
D. Pick her up when she cries
NO.107 The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:
A. Immediate treatment of mild PIH includes the administration of a variety of medications
B. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation
C. Self-discipline is required to control caloric intake throughout the pregnancy
D. The client may not recognize the early symptoms of PIH
NO.108 A client at 9 weeks' gestation comes for an initial prenatal visit. On assessment, the nurse discovers this is her second pregnancy. Her first pregnancy resulted in a spontaneous abortion. She is 28 years old, in good health, and works full-time as an elementary school teacher. This information alerts the nurse to which of the following:
A. An increased risk in maternal adaptation to pregnancy
B. The need for anticipatory guidance regarding the pregnancy
C. The need for teaching regarding family planning
D. An increased risk for subsequent abortions
NO.109 A mother is unsure about the type of toys for her 17-month-old child. Based on knowledge of growth and development, what toy would the nurse suggest?
A. A pull toy to encourage locomotion
B. A mobile to improve hand-eye coordination
C. A large toy with movable parts to improve pincer grasp
D. Various large colored blocks to teach visual discrimination
NO.110 During an examination, the nurse notes that an infant has diaper rash on the convex surfaces of his buttocks, inner thighs, and scrotum. Which of the following nursing interventions will be most effective in resolving the condition?
A. Coating the inflamed areas with zinc oxide
B. Using talcum powder on the inflamed areas to promote drying
C. Removing the diaper entirely for extended periods of time
D. Cleaning the inflamed area thoroughly with disposable wet "wipes" at each diaper change
NO.111 The nurse is admitting a client with folic acid deficiency anemia. Which of the following questions is most important for the nurse to ask the client?
A. "Do you take aspirin on a regular basis?"
B. "Do you drink alcohol on a regular basis?"
C. "Do you eat red meat?"
D. "Have your stools been normal?"
NO.112 A client is receiving IV morphine 2 days after colorectal surgery. Which of the following observations indicate that he may be becoming drug dependent?
A. The client requests pain medicine every 4 hours.
B. He is asleep 30 minutes after receiving the IV morphine.
C. He asks for pain medication although his blood pressure and pulse rate are normal.
D. He is euphoric for about an hour after each injection.
NO.113 When preparing insulin for IV administration, the nurse identifies which kind of insulin to use?
A. NPH
B. Human or pork
C. Regular
D. Long acting
NO.114 A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, "Oh dear, I feel like I have to urinate again!" Which of the following is the most appropriate initial nursing response?
A. Assure her that this is most likely the result of bladder spasms.
B. Check the collection bag and tubing to verify that the catheter is draining properly.
C. Instruct her to do Kegel exercises to diminish the urge to void.
D. Ask her if she has felt this way before.
NO.115 Following TURP, which of the following instructions would be appropriate to prevent or alleviate anxiety concerning the client's sexual functioning?
A. "You may resume sexual intercourse in 2 weeks."
B. "Many men experience impotence following TURP."
C. "A transurethral resection does not usually cause impotence."
D. "Check with your doctor about resuming sexual activity."
NO.116 The most frequent cause of early postpartum hemorrhage is:
A. Hematoma
B. Coagulation disorders
C. Uterine atony
D. Retained placental fragments
NO.117 A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse's best response is:
A. "You'll have to get permission from the physician to visit. Clients are pretty sick after the first treatment."
B. "Visitors are not allowed. We will telephone you to inform you of her progress."
C. "There's really no need to stay with her. She's going to sleep for several hours after the treatment."
D. "Yes, you may visit. She may experience temporary drowsiness, confusion, or memory loss after each treatment."
NO.118 A client at 6 months' gestation complains of tiredness and dizziness. Her hemoglobin level is 10 g/dL, and her hematocrit value is 32%. Her nutritional intake is assessed as sufficient. The most likely diagnosis is:
A. Iron-deficiency anemia
B. Physiological anemia
C. Fatigue due to stress
D. No problem indicated
NO.119 At 32 weeks' gestation, a client is scheduled for a fetal activity test (nonstress test). She calls the clinic and asks the RN, "How do I prepare for the test I am scheduled for?" The RN will most likely inform her of the following instructions to help prepare her for the test:
A. "You need to know that an IV is always started before the test."
B. "You will need to drink 6 to 8 glasses of water to fill your bladder."
C. "Do not eat any food or drink any liquids before the test is started."
D. "You will have to remain as still as you possibly can."
NO.120 An infant with a congenital heart defect is being discharged with an order for the administration of digoxin elixir every 12 hours. The parents need to be taught when administering digoxin to the infant that:
A. If the infant vomits within 30 minutes of the digoxin administration, repeat the dose
B. They need to mix it with formula so the infant swallows it easily
C. If the infant vomits two or more consecutive doses or becomes listless or anorexic, notify the physician
D. If a dose of digoxin is skipped for more than 6 hours, a new timetable for administration must be developed
NO.121 A 26-year-old client has no children. She has had an abdominal hysterectomy. In the first 24 hours postoperatively, the nurse would be concerned if the client:
A. Cries easily and says she is having abdominal pain
B. Develops a temperature of 102_F
C. Has no bowel sounds
D. Has a urine output of 200 mL for 4 hours
NO.122 A 9-year-old child was in the garage with his father, who was repairing a lawnmower. Some gasoline ignited and caused an explosion. His father was killed, and the child has split-thickness and full-thickness burns over 40% of his upper body, face, neck, and arms. All of the following nursing diagnoses are included on his care plan. Which of these nursing diagnoses should have top priority during the first 24-48 hours postburn?
A. Pain related to tissue damage from burns
B. Potential for infection related to contamination of wounds
C. Fluid volume deficit related to increased capillary permeability
D. Potential for impaired gas exchange related to edema of respiratory tract
NO.123 A 35-year-old client is admitted to the hospital with diabetic ketoacidosis. Results of arterial blood gases are pH 7.2, PaO2 90, PaCO2 45, and HCO3 16. The nursing assessment of arterial blood gases indicate the presence of:
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis
NO.124 A client is dilated 8 cm and entering the transition phase of labor. Common behaviors of the laboring woman during transition are:
A. Frustration, vague in communication
B. Seriousness, some difficulty following directions
C. Calmness, follows directions easily
D. Excitement, openness to instructions
NO.125 A 30-year-old client has a history of several recent traumatic experiences. She presents at the physician's office with a complaint of blindness. Physical exam and diagnostic testing reveal no organic cause. The nurse recognizes this as:
A. Delusion
B. Illusion
C. Hallucination
D. Conversion
NO.126 One afternoon 3 weeks into his alcohol treatment program, a client says to the nurse, "It's really not all my fault that I have a drinking problem. Alcoholism runs in my family. Both my grandfather and father were heavy drinkers." The nurse's best response would be:
A. "That might be a problem. Tell me more about them."
B. "Risk factors can often be controlled by self-responsibility."
C. "It sounds like you're intellectualizing your drinking problem."
D. "Your grandfather and father were both alcoholics?"
NO.127 A female client at 36 weeks' gestation has been treated successfully for premature labor for 4 weeks. She has begun having uterine contractions today and has been admitted to the labor and delivery suite. Her amniocentesis results reveal a lecithin/sphingomyelin (L/S) ratio of 2 and positive phosphatidylglycerol (PG). These lab values indicate:
A. Placental maturity
B. Suspected chronic asphyxia
C. Cord compression
D. Fetal lung maturity
NO.128 Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients?
A. Vitamin C and zinc
B. Folic acid and niacin
C. Vitamin A and biotin
D. Thiamine and pyroxidine
NO.129 A complication for which the nurse should be alert following a liver biopsy is:
A. Hepatic coma
B. Jaundice
C. Ascites
D. Shock
NO.130 Proper positioning for the child who is in Bryant's traction is:
A. Both hips flexed at a 90-degree angle with the knees extended and the buttocks elevated off the bed
B. Both legs extended, and the hips are not flexed
C. The affected leg extended with slight hip flexion
D. Both hips and knees maintained at a 90-degree flexion angle, and the back flat on the bed
NO.131 A female baby was born with talipes equinovarus. Her mother has requested that the nurse assigned to the baby come to her room to discuss the baby's condition. The nurse knows that the pediatrician has discussed the baby's condition with her mother and that an orthopedist has been consulted but has not yet seen the baby. What should the nurse do first?
A. Call the orthopedist and request that he come to see the baby now.
B. Question the mother and find out what the pediatrician has told her about the baby's condition.
C. Tell the mother that this is not a serious condition.
D. Tell the mother that this condition has been successfully treated with exercises, casts, and/or braces.
NO.132 What specific hormone must be present in serum or urine laboratory tests used to diagnose pregnancy?
A. Human chorionic gonadotropin
B. Estrogen
C. -fetoprotein
D. Sphingomyelin
NO.133 In assisting preconceptual clients, the nurse should teach that the corpus luteum secretes progesterone, which thickens the endometrial lining in which of the phases of the menstrual cycle?
A. Menstrual phase
B. Proliferative phase
C. Secretory phase
D. Ischemic phase
NO.134 The nurse is caring for a client with pancreatitis. Which of the following IV medications would the nurse expect the physician to prescribe for control of pain in this client?
A. Morphine sulfate
B. Kerolac tromethamine (Toradol)
C. Promethazine (Phenergan)
D. Meperidine (Demerol)
NO.135 The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this finding?
A. Palpate these pulses again in 15 minutes.
B. Use a Doppler to determine presence and strength of these pulses.
C. Document the finding that the pulses are not palpable.
D. Call the physician and notify the physician of this finding.
NO.136 A 33-year-old client is diagnosed with bipolar disorder, acute phase. This is her first psychiatric hospitalization, and she is being evaluated for treatment with lithium. Which of the following diagnostic tests are essential prior to the initiation of lithium therapy with this client?
A. Hematocrit, hemoglobin, and white blood cell (WBC) count
B. Blood urea nitrogen, electrolytes, and creatinine
C. Glucose, glucose tolerance test, and random blood sugar
D. X-rays, electroencephalogram, and electrocardiogram (ECG)
NO.137 A 60-year-old woman exhibits forgetfulness, emotional lability, confusion, and decreased
concentration. She has been unable to perform activities of daily living without assistance. After a thorough medical evaluation, a diagnosis of Alzheimer's disease was made. An appropriate nursing intervention to decrease the anxiety of this client would include:
A. Allowing the client to perform activities of daily living as much as possible unassisted
B. Confronting confabulations
C. Reality testing
D. Providing a highly stimulating environment
NO.138 On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle feeding. The nurse should initially recommend to her to:
A. Take 2 ibuprofen (Motrin) tablets by mouth now because the baby will be returning for feeding in 20 minutes
B. Allow the infant to breast-feed at the next feeding time to empty the breasts
C. Apply ice packs to the breasts and wear a supportive, well-fitting bra
D. Take a warm shower and express milk from both breasts until empty
NO.139 While changing the dressing on a client's central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be appropriate to implement based on this finding?
A. Discontinue the central line.
B. Begin a peripheral IV.
C. Document in the nurse's notes and notify the physician after redressing the site.
D. Clean the site well and redress.
NO.140 A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL system to record her obstetrical history, the nurse should record:
A. 3-2-0-0-2
B. 2-2-0-2-2
C. 3-1-1-0-2
D. 2-1-1-0-2
NO.141 A 60-year-old male client was hospitalized 3 days ago with the diagnosis of acute anterior wall myocardial infarction. Today he has been complaining of increasing weakness and shortness of breath. Crackles in both lung bases are audible on auscultation. He is developing:
A. An extension of his myocardial infarction
B. Pneumonia
C. Pulmonary edema
D. Pulmonary emboli
NO.142 After a liver biopsy, the best position for the client is:
A. High Fowler
B. Prone
C. Supine
D. Right lateral
NO.143 A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:
A. Blood pressure increase from 100/80 to 115/85 after lunch
B. Headache that is unresponsive to acetaminophen (Tylenol)
C. Pulse rate ranges between 68 bpm and 76 bpm
D. Temperature rise to 102_F rectally
NO.144 A 67-year-old man had a physical examination prior to beginning volunteer work at the hospital. A routine chest x-ray demonstrated left ventricular hypertrophy. His blood pressure was 180/110. He is 45 lb overweight. His diet is high in sodium and fat. He has a strong family history of hypertension. The client is placed on antihypertensive medication; a low-sodium, low-fat diet; and an exercise regimen. On his next visit, compliance would best be determined by:
A. A blood pressure reading of 130/70 with a 5-lb weight loss
B. No side effects from antihypertensive medication and an accurate pill count
C. No evidence of increased left ventricular hypertrophy on chest x-ray
D. Serum blood levels of the antihypertensive medication within therapeutic range
NO.145 The physician has ordered that a daily exercise program be instituted by a client with type I diabetes following his discharge from the hospital. Discharge instructions about exercise should include which of the following?
A. Exercise should be performed 30 minutes before meals.
B. A snack may be needed before and/or during exercise.
C. Hyperglycemia may occur 2-4 hours after exercise.
D. The blood glucose level should be 100 mg or below before exercise is begun.
NO.146 Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. The physician is immediately notified and orders 50 mL of dextrose and 10 U of regular insulin IV push. The nurse administering these drugs knows the Rationale for this therapy is to:
A. Remove the potassium from the body by renin exchange
B. Protect the myocardium from the effects of hypokalemia
C. Promote rapid protein catabolism
D. Drive potassium from the serum back into the cells
NO.147 A 26-year-old female client presents at 10 weeks' gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her grandmother also has insulin-dependent diabetes. The client's previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches tall and her current weight is 130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following factors places her at risk for gestational diabetes?
A. Age>25 years
B. Maternal weight
C. Previous birth of an infant weighing>9 lb
D. Family history of heart disease
NO.148 When assessing residual volume in tube feeding, the feeding should be delayed if the amount of gastric contents (residual) exceeds:
A. 20 mL
B. 25 mL
C. 30 mL
D. 50 mL
NO.149 A 5-year-old child was recently diagnosed as having acute lymphoid leukemia. She is hospitalized for additional tests and to begin a course of chemotherapy designed to induce a remission. She is scheduled to have a bone marrow aspiration tomorrow. She has had a bone marrow test previously and is apprehensive about having another. Which of the following interventions will be most effective in relieving her anxiety?
A. Explain what will take place and what she will see, feel, and hear.
B. Remind her that she has had this procedure before and that it is nothing to be afraid of.
C. Tell her not to worry about it, that it will be over soon and she can join her friends in the playroom.
D. Give her a big hug and tell her that she is a big girl now and that she will do just fine.
NO.150 A female client was employed as a client care technician in a hemodialysis unit. She recently began to experience extreme fatigue, being able to sleep for 16-20 hours at a time. She also noted that her urine was tea colored, which she rationalized was a result of the vitamins she began taking to alleviate fatigue. She was diagnosed with hepatitis B.
After a brief hospital stay, she is discharged to her parent's home. Her mother asks the nurse if any precautions are necessary to prevent transmission to the client's family. The nurse explains necessary precautions, which include:
A. Isolation of the client from the remainder of the family
B. Separate bathroom facilities if possible; if not, then cleansing daily of the facilities with a chloride solution
C. No necessary precautions because she is beyond the contagious phase
D. Laundering clothes separately in cold water with a chloride solution
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Solution: NCLEX-RN Quiz Part 3 (101-150)