NCLEX-RN Quiz Part 6 (251-300)

NO.251 A client's transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing, anxious, and very restless. The nurse knows these assessment findings are congruent with:

A.            Hemolytic transfusion reaction

B.            Febrile transfusion reaction

C.            Circulatory overload

D.            Allergic transfusion reaction

NO.252 A hyperactive client is experiencing flight of ideas. The most therapeutic activity for him would be:

A.            Doing crafts in occupational therapy

B.            Working a 1000-piece puzzle

C.            Playing bridge with three other clients

D.            Playing basketball in the gym

NO.253 A client is 6 weeks pregnant. During her first prenatal visit, she asks, "How much alcohol is safe to drink during pregnancy?" The nurse's response is:

A.            Up to 1 oz daily

B.            Up to 2 oz daily

C.            Up to 4 oz weekly

D.            No alcohol

NO.254 MgSO4 blood levels are monitored and the nurse would be prepared to administer the following antidote for MgSO4 side effects or toxicity:

A.            Magnesium oxide

B.            Calcium hydroxide

C.            Calcium gluconate

D.            Naloxone (Narcan)

NO.255 A client is being discharged on warfarin (Coumadin), an oral anticoagulant. The nurse instructs him about using this drug. Which following response by the client indicates the need for further teaching?

A.            "I should shave with my electric razor while on Coumadin."

B.            "I will inform my dentist that I am on anticoagulant therapy before receiving dental work."

C.            "I will continue with my usual dosage of aspirin for my arthritis when I return home."

D.            "I will wear an ID bracelet stating that I am on anticoagulants."

NO.256 The physician is preparing to induce labor on a 40-week multigravida. The nurse should anticipate the administration of:

A.            Oxytocin (Pitocin)

B.            Progesterone

C.            Vasopressin (Pitressin)

D.            Ergonovine maleate

NO.257 The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to:

A.            Wear gloves for the procedure

B.            Place and adjust the pad from back to front

C.            Cleanse and wipe the perineum from front to back

D.            Protect the outer surface of the pad from contamination

NO.258 A 42-year-old client presents with a diagnosis of paranoid schizophrenia. She has become increasingly restless and verbally argumentative, and her speech has become pressured. She is exhibiting signs of:

A.            Depression

B.            Agitation

C.            Psychotic ideation

D.            Anhedonia

NO.259 A 52-year-old client's abdominal aortic aneurysm ruptured. She received rapid massive blood transfusions for bleeding. One potential complication of blood administration

for which she is especially at risk is:

A.            Air embolus

B.            Circulatory overload

C.            Hypocalcemia

D.            Hypokalemia

NO.260 In evaluating the laboratory results of a client with severe pressure ulcers, the nurse finds that her albumin level is low. A decrease in serum albumin would contribute to the formation of pressure ulcers because:

A.            The proteins needed for tissue repair are diminished.

B.            The iron stores needed for tissue repair are inadequate.

C.            A decreased serum albumin level indicates kidney disease.

D.            A decreased serum albumin causes fluid movement into the blood vessels, causing dehydration.

NO.261 A measurable outcome criterion in the nursing care of an adolescent with anorexia nervosa would be:

A.            Accepting her present body image

B.            Verbalizing realistic feelings about her body

C.            Having an improved perception of her body image

D.            Exhibiting increased self-esteem

NO.262 A client was admitted to the hospital for a TURP. Within 48 hours of admission and 12 hours postoperatively, both the blood pressure and pulse increased. He became agitated, thought snakes were crawling on his arms and legs, and generally became unmanageable. He pulled out his IV and urinary catheter in attempt to rid himself of the snakes. He was sweating profusely. The admission nurse's notes indicated that the client admitted to "having a few drinks now and then." He is probably experiencing which of the following?

A.            Major psychotic depression

B.            Delirium tremens

C.            Generalized anxiety disorder

D.            Adjustment disorder with mixed features

NO.263 Except for initial explosiveness on admission, a client diagnosed with schizophrenia stays in her room. She continues to believe other people are out to get her. A nursing intervention basic to

improving withdrawn behavior is:

A.            Assigning her to occupational therapy

B.            Having her sit with the nurses while they chart

C.            Helping her to make friends

D.            Facilitating  communication

NO.264 An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to:

A.            A tension pneumothorax

B.            An asthma attack

C.            Pneumonia

D.            Pulmonary embolus

NO.265 A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and kill her. The best verbal response to the client by the nurse at this time is:

A.            "I understand that the voices are real to you, but I want you to know I don't hear them. They are a symptom of your illness."

B.            "Just don't pay attention to the voices. They'll go away after some medication."

C.            "You can't leave here. This unit is locked and the doctor has not ordered your discharge."

D.            "We will have to put you in seclusion and restraints for a while. You could hurt someone with thoughts like that."

NO.266 A 20-year-old male client is being treated for protein deficiency. If he likes all of the following foods, which one would the nurse recommend to increase in the diet?

A.            Cantaloupe

B.            Rice

C.            Chicken

D.            Green beans

NO.267 To prevent fungal infections of the mouth and throat, the nurse should teach clients on inhaled steroids to:

A.            Rinse the plastic holder that aerosolizes the drug with hydrogen peroxide every other day

B.            Rinse the mouth and gargle with warm water after each use of the inhaler

C.            Take antacids immediately before inhalation to neutralize mucous membranes and prevent infection

D.            Rinse the mouth before each use to eliminate colonization of bacteria

NO.268 Which of the following physician's orders would the nurse question on a client with chronic arterial insufficiency?

A.            Neurovascular checks every 2 hours

B.            Elevate legs on pillows

C.            Arteriogram in the morning

D.            No smoking

NO.269 The nurse instructs a client on the difference between true labor and false labor. The nurse explains, "In true labor:

A.            Uterine contractions will weaken with walking."

B.            Uterine contractions will strengthen with walking."

C.            The cervix does not dilate."

D.            The fetus does not descend."

NO.270 A 55-year-old client is unconscious, and his physician has decided to begin tube feeding him using a smallbore silicone feeding tube (Keofeed, Duo-Tube). After the tube is inserted, the nurse identifies the most reliable way to confirm appropriate placement is to:

A.            Aspirate gastric contents

B.            Auscultate air insufflated through the tube

C.            Obtain a chest x-ray

D.            Place the tip of the tube under water and observe for air bubbles

NO.271 A client is being treated for congestive heart failure. His medical regimen consists of digoxin (Lanoxin) 0.25 mg po daily and furosemide 20 mg po bid. Which laboratory test should the nurse monitor?

A.            Intake and output

B.            Calcium

C.            Potassium

D.            Magnesium

NO.272 A 45-year-old client has a permanent colostomy. Which of the following foods should he avoid?

A.            Peanut butter and jelly sandwich and milk

B.            Corn beef and cabbage and boiled potatoes

C.            Oatmeal, whole-wheat toast, and milk

D.            Tuna on whole-wheat bread and iced tea

NO.273 A nasogastric (NG) tube inserted preoperatively is attached to low, intermittent suctions. A client with an NG tube exhibits these symptoms: He is restless; serum electrolytes are Na 138, K 4.0, blood pH 7.53. This client is most likely experiencing:

A.            Hyperkalemia

B.            Hyponatremia

C.            Metabolic acidosis

D.            Metabolic alkalosis

NO.274 A 25-year-old client is admitted for a tonsillectomy. She tells the nurse that she has had eisodes of muscle cramps, weakness, and unexplained temperature elevation. Many years ago her

father died shortly after surgery after developing a high fever. She further tells the nurse that her surgeon is having her take dantrolene sodium (Dantrium) prophylactically prior to her tonsillectomy. Dantrolene sodium is ordered preoperatively to reduce the risk or prevent:

A.            Infection postoperatively

B.            Malignant hyperthermia

C.            Neuroleptic malignant syndrome

D.            Fever postoperatively

NO.275 A 70-year-old homeless woman is admitted with pneumonia. She is weak, emaciated, and febrile. The physician orders enteral feedings intermittently by nasogastric tube. When inserting the nasogastric tube, once the tube passes through the oropharynx, the nurse will instruct the client to:

A.            Tilt her head backwards

B.            Swallow as tube passes

C.            Hold breath as tube passes

D.            Cough as tube passes

NO.276 A client has been instructed in how to take her nitroglycerin tablets. The nurse giving her instructions knows the client understands the information when she tells her:

A.            "I should contact my physician if I have headaches after I take this medicine."

B.            "I should keep the tablets in the refrigerator."

C.            "I should call the doctor if three doses of the medicine do not relieve my pain."

D.            "I should take these with water but not with milk."

NO.277 A 1-year-old child is to receive an IM injection ordered by his pediatrician. He has fallen asleep in his mother's arms when the nurse approaches. Which approach is most appropriate at thistime?

A.            Give the injection in the vastus lateralis site before the child awakens.

B.            Awaken the child first and give the injection in the ventrogluteal site.

C.            Awaken the child first and give the injection in the dorsogluteal site.

D.            Ask the mother to place the child on the examination table and leave the room, and then give the injection in an appropriate site.

NO.278 A male client had a right below-the-knee amputation 4 days ago. His incision is healing well. He has gotten out of bed several times and sat at the side of the bed. Each time after returning to bed, he has experienced pain as if it were located in his right foot. Which nursing measure indicates the nurse has a thorough understanding of phantom pain and its management?

A.            Phantom pain is entirely in the client's mind. The client should be instructed that the pain is psychological and should not be treated.

B.            The basis for phantom pain may occur because the nerves still carry pain sensation to the brain even though the limb has been amputated. The pain is real, intense, and should be treated.

C.            The cause of phantom pain is unknown. The nurse should provide the client with support, promote sleep, and handle the injured limb smoothly and gently.

D.            Phantom pain is caused by trauma, spasms, and edema at the incisional site. It will decrease when postoperative edema decreases. It should be treated with nonnarcotic medication whenever possible.

NO.279 A 23-year-old male client is admitted to the chemical dependency unit with a medical diagnosis of alcoholism. He reports that the last time he drank was 3 days ago, and that now he is starting to "feel kind of shaky." Based on the information given above, nursing care goals for this client will initially focus on:

A.            Self-concept problems

B.            Interpersonal issues

C.            Ineffective coping skills

 D.           Physiological stabilization

NO.280 A female client has a chest tube placed. It is accidentally pulled out of the intrapleural space when she is ambulating. The first action the nurse should take is to:

A.            Instruct the client to cough deeply to re-expand her lung

B.            Put on sterile gloves and replace the tube

C.            Apply a petrolatum dressing over the site

D.            Auscultate the lung to determine if she needs the tube replaced

NO.281 A male client has heart failure. He has been instructed to gradually increase his activities. Which signs and symptoms of worsening heart failure should the nurse tell him to watch for that would indicate a need for him to lower his activity level?

A.            Pain in his legs when he walks

B.            Thirst, weight loss, and polyuria

C.            Drowsiness and lethargy after his activities

D.            Weight gain, edema in his lower extremities, and shortness of breath

NO.282 A 52-year-old client who underwent an exploratory laparotomy for a bowel obstruction begins to complain of hunger on the third postoperative day. His nasogastric (NG) tube was removed this morning, and he has an IV of D5W with 0.45% normal saline running at 125 mL/hr. He asks when he can get rid of his IV and start eating. The nurse recognizes that he will be able to begin taking oral fluids and nourishment when:

A.            It is determined that he has no signs of wound infection

B.            He is able to eat a full meal without evidence of nausea or vomiting

C.            The nurse can detect bowel sounds in all four quadrants

D.            His blood pressure returns to its preoperative baseline level or greater

NO.283 A client has received preoperative teaching for the vertical partial laryngectomy that he is scheduled to have in the morning. The nurse determines that the teaching has been effective when the client states:

A.            "I know I will need special swallowing training after my surgery."

B.            "The quality of my voice will be excellent after surgery."

C.            "I will have very little difficulty swallowing after surgery."

D.            "I may also have to have a radical neck dissection done."

NO.284 A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching?

A.            "If he develops diarrhea lasting for more than 2-3 days, I will contact the doctor or nurse."

B.            "I should anticipate that he will gain about 1 lb/day now that he is on continuous feedings."

C.            "It is important to keep the head of his bed elevated or sit him in the chair during feedings."

D.            "I should use prepared or open formula within 24 hours and store unused portions in the refrigerator."

NO.285 A 70-year-old client has pneumonia and has just had a respiratory arrest. He has just been intubated with an 8- mm endotracheal tube. During auscultation of his chest, breath sounds were found to be absent on the left side. The nurse identifies the most likely cause of this as:

A.            Inappropriate endotracheal tube size

B.            Left-sided pneumothorax

C.            Right mainstem bronchus intubation

D.            Pneumonia

NO.286 The nurse has been caring for a 16-year-old female who recently experienced date rape. After having had crisis intervention and been hospitalized for 2 weeks, the nurse knows that the client is effectively coping with the rape when she tells the nurse:

A.            "I know it was my fault that it happened, because I shouldn't have been out so late."

B.            "If I had not worn that sexy dress that night, he wouldn't have raped me."

C.            "I know my date just had so much passion he couldn't handle me saying 'no.' "

D.            "I know now that it was not my fault, but I want to continue counseling after my discharge."

 

NO.287 Seven days ago, a 45-year-old female client had an ileostomy. She is self-sufficient and well otherwise. Which of the following long-term objectives would be unrealistic?

A.            She should be able to control evacuation of her bowels.

B.            She should be able to return to a regular diet.

C.            She should be able to resume sexual activity.

D.            She should be able to manage her own care.

NO.288 A client was exhibiting signs of mania and was recently started on lithium carbonate. She has no known physical problems. A teaching plan for this client would include which of the following?

A.            Regular foods should be eaten, including those that contain salt, such as bacon, ham, V-8 juice, and tomato juice.

B.            Restrict fluids to 1000 mL/day.

C.            Restrict foods that contain salt or sodium.

D.            Discontinue the medication if nausea occurs.

NO.289 An 8-year-old child is admitted to the hospital for surgery. She has had no previous hospitalizations, and both she and her family appear anxious and fearful. It will be most helpful for the nurse to:

A.            Take the child to her room and calmly and matter-offactly begin to get her ready to go to the operating room

B.            Take time to orient the child and her family to the hospital and the forthcoming events

C.            Explain that as soon as the child goes to the operating room she will have time to answer any questions the family has

D.            Tell the child and her family that there is nothing to worry about, that the operation will not take long, and she will soon be as "good as new"

NO.290 A family by court order undergoes treatment by a family therapist for child abuse. The nurse, who is the child's case manager knows that treatment has been effective when:

A.            The child is removed from the home and placed in foster care

B.            The child's parents identify the ways in which he is different from the rest of the family

C.            The child's father is arrested for child abuse

D.            The child's parents can identify appropriate behaviors for children in his age group

NO.291 When a client questions the nurse as to the purpose of exercise electrocardiography (ECG) in the diagnosis of cardiovascular disorders, the nurse's response should be based on the fact that:

A.            The test provides a baseline for further tests

B.            The procedure simulates usual daily activity and myocardial performance

C.            The client can be monitored while cardiac conditioning and heart toning are done

D.            Ischemia can be diagnosed because exercise increases O2 consumption and demand

NO.292 A premature infant needs supplemental O2 therapy. A nursing intervention that reduces the risk of retrolental fibroplasia is to:

A.            Maintain O2at <40%

B.            Maintain O2at>40%

 C.           Give moist O2at>40%

D.            Maintain on 100% O2

NO.293 A 6-year-old girl has been diagnosed with a urinary tract infection secondary to vesicoureteral reflux. Which statement by her mother indicates a need for further teaching?

A.            "I have taught her to wipe from front to back after urinating."

B.            "I make sure she drinks plenty of fluids every day."

C.            "She enjoys wearing nylon panties, but I make her change them everyday."

D.            "She tries to empty her bladder completely after she urinates, like I told her."

NO.294 A neonate was admitted to the hospital with projectile vomiting. According to the parents, the baby had experienced vomiting episodes after feeding for the last 2 days. A medical diagnosis of hypertrophic pyloric stenosis was made. On assessment, the infant had poor skin turgor, sunken eyeballs, dry skin, and weight loss. Identify the number-one priority nursing diagnosis.

A.            Fluid volume deficit

B.            Altered nutrition

C.            Altered bowel elimination

D.            Anxiety

NO.295 The nurse is teaching a 10-year-old insulin-dependent diabetic how to administer insulin. Which one of the following steps must be taught for insulin administration?

A.            Never use abdominal site for a rotation site.

B.            Pinch the skin up to form a subcutaneous pocket.

 C.           Avoid applying pressure after injection.

D.            Change needles after injection.

NO.296 The health team needs to realize that the compulsive concern with cleanliness that a client with severe anxiety exhibits is most likely an attempt to:

A.            Reduce his anxiety

B.            Avoid going to psychotherapy

C.            Manipulate the health team members

D.            Increase his self-image by showing higher standards than the fellow clients

NO.297 A physician's order reads: Administer furosemide oral solution 0.5 mL stat. The furosemide bottle dosage is 10 mg/mL. What dosage of furosemide should the nurse give to this infant?

A.            5 mg

B.            0.5 mg

C.            0.05 mg

D.            20 mg

NO.298 A client is being discharged with albuterol (Proventil) and beclomethasone dipropionate (Vanceril) to be administered via inhalation three times a day and at bedtime. Client teaching regarding the sequential order in which the drugs should be administered includes:

A.            Glucocorticoid followed by the bronchodilator

B.            Bronchodilator followed by the glucocorticoid

C.            Alternate successive administrations

D.            According to the client's preference

NO.299 The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should:

A.            Increase his nasal O2 to 6 L/min

B.            Place him in a lateral Sims' position

C.            Encourage pursed-lip breathing

D.            Have him breathe into a paper bag

NO.300 A 27-year-old man was diagnosed with type I diabetes 3 months ago. Two weeks ago he complained of pain, redness, and tenderness in his right lower leg. He is admitted to the hospital with a slight elevation of temperature and vague complaints of "not feeling well." At

4:30

PM on the day of his admission, his blood glucose level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to:

A.Give him 3 tbsp of sugar dissolved in 4 oz of grape juice to drink B.Ask him to dissolve three pieces of hard candy in his mouth

C.Have him drink 4 oz of orange juice

D.Monitor him closely until dinner arrives