Sample Nclex Questions with Rationale ii

The RN is very short staffed because two people did not show up for work. Of the following four clients, which one would the RN care for first?

A) A client just admitted with acute abdominal pain and possible cholecystitis.
B) A client with nephrotic syndrome with increasing edema; hourly urine checks and vital signs.
C) A head injury client just admitted to the unit.
D) A confused client yelling because he is in soft restraints and can't get out of bed.

Answer: C
C) Head injury takes first priority because the danger of increasing intracranial pressure must be assessed and reported immediately. Second priority for assessment would be client (A) because of the unstable and possible serious condition. The client with nephrotic syndrome should be evaluated and diet and drug protocols started, but he is not as critical. The confused client needs to be calmed down but until there are more team members available, his care can wait.
NP:P; CN:PH; CA:M

Topic: Physiological Integrity
A 30-year-old woman staggers into the emergency room saying that she has been assaulted and raped. The priority assessment the nurse will perform is to

A) Observe the degree of emotional trauma the client has suffered.
B) Assess the assault injuries and degree of trauma.
C) Determine the client's level of knowledge concerning legal implications.
D) Identify the client's crisis response.

Answer: B
B) The most important first assessment is to focus on immediate medical care in terms of the injuries sustained and the degree of physical trauma experienced. The emotional component, crisis response and legal implications will follow.
NP:A; CN:PS; CA:PS

Topic: Psychosocial Integrity
The nurse understands that the purpose of instilling a broad spectrum antibiotic or silver nitrate in the newborn infant's eyes is to prevent

A) Ophthalmia neonatorum.
B) Retrolental fibroplasia.
C) Erythroblastosis fetalis.
D) Icterus neonatorum.

Answer: A
A) Ophthalmia neonatorum is caused by the gonococcus organism in the birth canal. Erythromycin is often the preferred choice because it also kills Chlamydia, the most common sexually transmitted disease.
NP:AN; CN:PH; CA:MA

Topic: Physiological Integrity
When charting the procedure for applying restraints to a client, the nurse would include

A) Condition of the extremity following application.
B) What the client says about the restraint.
C) Physician's orders regarding the restraint.
D) Procedure for applying the restraint.

Answer: A
A) Evaluation of the effects of the restraint is important to chart. Procedure is not relevant and what the client says may or may not be appropriate. Physician orders are already charted so you would not chart them again.
NP:P; CN:S; CA:M

Topic: Safe, Effective Care Environment
The surgeon orders a Foley catheter to be inserted. Of the following interventions, the one to carry out first would be to

A) Check the catheter for patency.
B) Clean the perineum from front to back.
C) Explain the procedure to the client and tell her that she will feel slight, temporary discomfort.
D) Arrange the sterile items on the sterile field.

Answer: C
C) Giving the client an adequate explanation for the procedure will result in less anxiety and more cooperation.
NP:P; CN:PH; CA:M

Topic: Physiological Integrity
The nurse is assigned to dry and wrap a new baby. The nurse will don gloves to complete this task because

A) Wearing gloves is standard procedure for normal newborns.
B) It is important to observe universal precautions before the infant's first bath.
C) It is the nurse's choice whether or not to wear gloves.
D) The infant requires protection from infection.

Answer: B
B) With the high increase in numbers of HIV positive newborns, the Centers for Disease Control (CDC) guidelines include wearing gloves when handling newborns before their first bath.
NP:P; CN:S; CA:MA

Topic: Safe, Effective Care Environment
When assessing a child's neurological functioning, the nurse should become alarmed when

A) The child is babbling incoherently.
B) An irritable child becomes lethargic.
C) The child appears sleepy in mid-afternoon.
D) A 3-month-old infant has a positive Babinski reflex.

Answer: B
B) A change from irritability to lethargy signals serious central nervous system deterioration and demands immediate action. Babinski signs often persist until the child begins to walk. The time of day should be considered when evaluating neurological function because children can appear lethargic at usual sleep times. The age of the child should be considered when assessing language.
NP:E; CN:PH; CA:P

Topic: Physiological Integrity
A client with acute lymphocytic leukemia is scheduled to receive Cytoxan. The most important nursing intervention when caring for a client receiving Cytoxan is to

A) Observe for ulceration of the oral mucosa.
B) Observe for changes in mental alertness.
C) Give large quantities of fluids prior to and following drug administration.
D) Observe for signs of gastrointestinal disturbance.

Answer: C
C) A serious side effect of Cytoxan is hemorrhagic cystitis, and fluids would help prevent this from occurring.
NP:I; CN:PH; CA:S

Topic: Physiological Integrity
A client's IV orders for a 24 hour period are to administer 2500 ml. The IV administration set delivers 15 gtts/ml. At what speed will the nurse adjust the IV rate?

A) 31 gtts/min.
B) 26 gtts/min.
C) 21 gtts/min.
D) 16 gtts/min.

Answer: B
B) To calculate the IV rate: (a) Determine number of ml/hour: Divide 2500 ml by 24 hours = 104 ml/hr. (b) Multiply 104 ml X 15 gtts = 1560 gtts/hr. (c) Divide 1560 gtts/hr by 60 min = 26 gtts/min.
NP:P; CN:PH; CA:M

Topic: Physiological Integrity
A 32-year-old man was admitted to the locked unit of the psychiatric hospital because he was caught slashing his neighbors' tires. He states that he "knew they were out to get him." The most appropriate first intervention for a client who has a potential for violence is to

A) Stay close to the client so that he does not feel people are afraid of him.
B) Remove stimuli that appear to frighten the client.
C) Arrange for distraction by exposure to constant stimuli.
D) Place the client in four-point restraints.

Answer: B
B) The first goal for the nurse is to prevent loss of control. Removing stimuli that may be frightening to the client would be the first intervention.
NP:P; CN:PS; CA:PS

Topic: Psychosocial Integrity
Following surgery for a gastric resection, a male client arrives in the recovery room in stable condition. His vital signs are BP 132/80, P 80, R 20. One hour postoperatively, his urine is 40 mL/hr and he has a CVP reading of 4-5. His BP is 100/40, P 88, and R 24. Based on this data, the initial intervention is to

A) Administer vasodilator drugs as ordered.
B) Administer intravenous fluids as ordered to maintain a CVP reading of 5 to 9 cm of water pressure.
C) Place several blankets over the client to increase his body temperature.
D) Place the client in Trendelenburg's position.

Answer: B
B) The first intervention is to increase IV fluids to maintain a CVP reading of 5 to 9 cm water pressure. Vasodilators will be administered to reduce peripheral resistance to blood flow and to increase capillary perfusion after the intravascular space has been expanded.
NP:I; CN:PH; CA:S

Topic: Physiological Integrity
Client education is an important component of the total nursing care plan. The primary purpose of client education is to

A) Collect client data.
B) Determine readiness to learn.
C) Increase client's knowledge that will affect health status.
D) Assess degree of compliance.

Answer: C
C) The primary purposes of client education include increasing knowledge, increasing self-esteem, improving client's ability to make decisions, and facilitating behavioral changes.
NP:AN; CN:H; CA:M

Topic: Health Promotion and Maintenance
Of the following skin eruptions, the one with the best prognosis because it is not as dangerous as the other lesions is

A) Malignant melanoma.
B) Basal cell epithelioma.
C) Sebaceous cyst.
D) Squamous cell epithelioma.

Answer: C
C) A sebaceous cyst is a benign (nonmalignant) growth. Basal cell epithelioma and squamous cell epithelioma are both superficial, easily excised, slow-growing tumors. Melanoma is the most dangerous.
NP:AN; CN:PH; CA:M


Topic: Physiological Integrity
A nurse is assigned to a client as her induction of labor is begun. After 20 minutes of the Pitocin infusion, the client has a contraction that does not relax after 90 seconds. The first action is to

A) Turn the client on her left side.
B) Discontinue the Pitocin infusion.
C) Notify the physician.
D) Start oxygen by mask.

Answer: B
B) If a contraction lasts longer than 90 seconds, the safe and correct first action is to turn off the Pitocin. Prolonged contractions can result in a ruptured uterus. The nurse may also administer oxygen and call the physician.
NP:I; CN:H; CA:MA


Topic: Health Promotion and Maintenance
One day a client with terminal cancer says to the nurse, "Well, I've given up all hope. I know I'm going to die soon." The most therapeutic response for the nurse to say is

A) "You've given up all hope?"
B) "We should talk about dying."
C) "You know, your doctor will be here soon. Why don't you talk to him about your feelings."
D) "Now, one should never give up all hope. We are finding new cures every day."

Answer: A
A) This reflective response will open up communication and enable the client to express whatever concerns or feelings she has without confining her to a discussion of dying (answer B).
NP:I; CN:PS; CA:M


Topic: Psychosocial Integrity
The nurse has just participated in the safe delivery of a dead fetus. The parents are very upset and angry at the staff. The most appropriate nursing response in this situation is to

A) Explain what happened to the parents.
B) Allow the parents to express their anger.
C) Guide the parents in planning future pregnancies.
D) Do nothing as the parents need to go through grieving.

Answer: B
B) As part of the mourning process, the parents may need to express anger at the staff. It is most therapeutic to allow or even encourage expression of this anger. It is too soon to go into an explanation of what happened or to discuss future pregnancies.
NP:I; CN:PS; CA:MA


Topic: Psychosocial Integrity
An elderly client has just been admitted to the nursing unit with the diagnosis of congestive heart failure. The client is experiencing dyspnea and becomes very agitated. The priority intervention is to

A) Administer oxygen at 3 L/minute using nasal prongs per standing orders.
B) Evaluate breath sounds.
C) Place the client in Fowler's position.
D) Tell the client the nurse will stay there so she won't be alone.

Answer: C
C) All four of the interventions will be carried out; however, placing the client in Fowler's position is the most important intervention at this time. This position will provide better mechanics for breathing because it increases lung expansion.
NP:I; CN:PH; CA:M


Topic: Physiological Integrity
A client just received a diagnosis of carcinoma. While making morning rounds the day before surgery, the nurse observes the client crying. An appropriate response would be to

A) Ignore the crying, as the nurse realizes the client may not want to talk.
B) Go in the room, sit down, and stay quietly with her.
C) Acknowledge the client by saying, "Good morning," as the nurse passes the door and observe if she seems to wish to talk.
D) Go in the room and ask her why she is crying.

Answer: B
B) The most effective communication technique in this case would be silence; support the client nonverbally, accept her, and open up the opportunity for an expression of feelings.
NP:I; CN:PS; CA:M


Topic: Psychosocial Integrity
An RN observes an LVN giving a client an injection and the LVN is not wearing gloves. When the RN asks why the LVN did not put on gloves, she replies, "Oh, I know this client well and he is no risk." The RN should reply

A) "We will clarify this situation with the charge nurse."
B) "Well, if you know this client--but I don't think it is safe nursing practice."
C) "Universal precautions for all clients is an important concept. Tell me what it means."
D) "Regulations state that we all must wear gloves. I will place you on report."

Answer: C
C) The best way to determine what the LVN knows, understands or believes is to ask this basic question. Once the RN has baseline data, teaching about the importance of always using universal precautions can be done. When a nurse is inconsistent with the use of these standard precautions, clients and other team members are in jeopardy. Universal precautions are to be used for all clients when there is a danger of coming into contact with body fluids.
NP:I; CN:S; CA:M


Topic: Safe, Effective Care Environment
Urecholine (bethanechol chloride) is ordered prn for a client following a transurethral resection (TUR). Which of the following conditions would need to be present for the nurse to administer this drug?

A) Inability to void.
B) Complaints of bladder spasms.
C) Complaints of severe pain.
D) Frequent episodes of painful urination.

Answer: A
A) Urecholine stimulates the parasympathetic nervous system. It increases the tone and motility of the smooth muscles of the urinary tract. It is used frequently following a TUR when the client has a lack of muscle tone and is unable to void. Bladder spasms can be relieved with Belladonna or opium suppositories.
NP:E; CN:PH; CA:S


Topic: Physiological Integrity
One year ago, a client lost her husband to whom she had been married for 10 years. They had a stormy marriage, punctuated by frequent disagreements and several separations. The client is experiencing intense grief, which she seems unable to work through. To understand this behavior, the nurse should know that when a partner dies,

A) The more dependent the relationship, the more difficult the grief process.
B) The longer the marriage, the more intense the grief.
C) A year is too soon to expect the client to have worked through the grief process.
D) The more ambivalent the relationship, the more intense the grief.

Answer: D
D) When both positive and negative feelings are felt toward the deceased, the grief process is more difficult to resolve because of guilt arising from the negative feelings. The length of the marriage or the extent of dependency in the relationship does not influence the grief process as much as the ambivalent feelings.
NP:AN; CN:PS; CA:PS


Topic: Psychosocial Integrity
During visiting hours, a client the nurse is caring for becomes very agitated and angry with his visitor. The most effective nursing approach to this client is to

A) Restrict his visitor from coming to the hospital for a few days.
B) Approach your client in a warm, supportive manner and assist him to explore his feelings.
C) Confront your client and tell him that talking about his feelings is therapeutic.
D) Ask your client if he would like his prn sedative in order to rest.

Answer: B
B) This approach would help decrease the client's anxiety and assist him in gaining insights. Answers (A) and (D) deny the problem and (C) is not as conducive to open communication.
NP:P; CN:PS; CA:PS


Topic: Psychosocial Integrity
Electroshock therapy (ECT) is a possible method of treating severe depression, especially if other methods have failed. The purpose of giving Atropine and a muscle relaxant to clients before ECT is to reduce

A) Secretions and the possibility of fractures.
B) Convulsions and fractures.
C) Anxiety and loss of memory.
D) The possibility of cardiac arrest.

Answer: A
A) The muscle relaxant drug lessens strong muscular contractions which could cause fractures, and Atropine is given to reduce secretions by blocking vagal stimulation.
NP:AN; CN:PS; CA:PS


Topic: Psychosocial Integrity
A 30-year-old male client with a suspected brain tumor is admitted to the hospital. His symptoms have progressed rapidly. The physician is concerned about the immediate possibility of increased intracranial pressure. The assessment finding that is the most reliable index of cerebral status is a/an

A) Altered level of consciousness.
B) Increased systolic blood pressure.
C) Unilateral pupillary dilatation.
D) Decreased pulse pressure.

Answer: A
A) Level of consciousness is the most sensitive indicator of the client's neurological status. The earliest changes may be a decrease in attention or alteration in orientation. These signs indicate impaired blood flow to the cerebral cortex and reticular activating system.
NP:A; CN:PH; CA:M


Topic: Physiological Integrity
The most therapeutic position for the nurse to place a client in following a stapedectomy is

A) Low-Fowler's.
B) Prone.
C) Side-lying, nonsurgical.
D) High-Fowler's.

Answer: A
A) Low-Fowler's position immediately postoperatively is usually the position of choice. Clients can experience vertigo, thus high-Fowler's position is avoided. If the physician allows a side-lying position, it is usually on the surgical side to facilitate drainage.
NP:I; CN:PH; CA:S

Topic: Physiological Integrity
The client insists on being discharged from the hospital against medical advice. From a legal standpoint, the most important nursing action is to

A) Request that the client sign the against medical advice (AMA) form.
B) Determine exactly why the client wants to leave.
C) Notify the supervisor and hospital administration.
D) Put all appropriate forms in the client's chart before he leaves the hospital.

Answer: A
A) All of the above actions would be appropriate to carry out. Legally, signing the against medical advice (AMA) form is most important.
NP:E; CN:S; CA:M


Topic: Safe, Effective Care Environment
A 7 year old has been diagnosed with scoliosis during a school screening. It is important for the parents and child to have the information that

A) Surgery is rarely indicated.
B) She should avoid physical activity until after her surgery.
C) It will get better with improved posture.
D) She may wear a brace for 1 to 2 years if the scoliosis is not severe.

Answer: D
D) Bracing can effectively stop the progression of mild scoliosis, while posture will not change structural scoliosis. Surgery is indicated for severe scoliosis and when the curve increases as the child grows. Physical activity does not need to be restricted before surgery.
NP:P; CN:PH; CA:P


Topic: Physiological Integrity
A client with a fractured right leg has been in Buck's extension traction for a week. The nurse assessing the client finds that he is now unable to dorsiflex his right foot. Interpreting this finding, the nurse concludes that the

A) Peroneal nerve function is impaired.
B) Traction has been on too long.
C) Foot is undergoing some ischemic changes.
D) Fracture is healing with a malunion.

Answer: A
A) Dorsiflexion of the foot requires an intact peroneal nerve. Compression, from any part of the traction apparatus, along the lateral surface of the leg just below the knee can exert pressure on the peroneal nerve and impede its function.
NP:AN; CN:PH; CA:S


Topic: Physiological Integrity
The nurse observes that signs of hypoxia occur during a tracheostomy suctioning procedure. The step in the procedure that will prevent hypoxia is to

A) Limit suction time to 20 seconds.
B) Hyperinflate the lungs with 100% oxygen prior to suctioning.
C) Ensure that the catheter is no more than three-quarters the diameter of the tube.
D) Suction no more than three consecutive times before administering oxygen.

Answer: B
B) Hyperinflation of lungs with oxygen prevents hypoxia during the suctioning procedure in clients requiring frequent treatments. The catheter should be no more than one-half the diameter of the trach tube; suctioning time is 10 seconds; and the client should be oxygenated between each suctioning.


Topic: Physiological Integrity
An elderly client with the diagnosis of COPD has been admitted to the hospital. In talking with the client about the diet that he was eating at home, which diet would be best for this client?

A) Moderate CHO, low protein, low fat.
B) High CHO, moderate protein, low fat.
C) High CHO, high protein, low fat.
D) Low CHO, high protein, high fat.

Answer: D
D) Carbohydrate metabolism produces carbon dioxide which increases the blood levels of carbon dioxide. High protein prevents muscle wasting and helps preserve the strength of muscles, including the muscles of respiration. Calorie and energy needs are met by increasing the fat intake.
NP:AN; CN:PH; CA:M


Topic: Physiological Integrity
Assessing reflexes of a 6-week-old infant, the nurse would expect to find which of the following reflexes present?

A) Sucking reflex, walking reflex.
B) Kernig's reflex, Moro's reflex.
C) Babinski's sign, neck righting reflex.
D) Moro's reflex, rooting reflex.

Answer: D
D) Moro's and rooting reflexes are present at birth and disappear at about 4 months. Neck righting reflex evolves at 4 months and disappears at 9 to 12 months. Kernig's sign is present with meningeal irritation.
NP:E; CN:H; CA:P


Topic: Health Promotion and Maintenance
Following a normal delivery, the physician orders the drug Methergine to decrease uterine bleeding. The nurse will assess for

A) Ejection of milk from the breast.
B) A change in blood pressure.
C) A generalized vasoconstrictive effect.
D) Light uterine contractions.

Answer: B
B) Side effects of this drug could include hypertension, so blood pressure and pulse should be monitored. Uterine contractions should be firm if the drug is having the desired effect. A vasoconstrictive effect is the expected drug action. Breast milk is more likely to appear with oxytocin.
NP:A; CN:H; CA:MA


Topic: Health Promotion and Maintenance
Instructing a client who has just received orders for nitroglycerin, the nurse informs the client that it should be taken

A) Only when chest pain is not relieved by rest.
B) Every 2 to 3 hours during the day.
C) At the first indication of chest pain.
D) Before every meal and at bedtime.

Answer: C
C) Nitroglycerin should be taken whenever the client feels a full, pressure feeling or tightness in his or her chest, and not wait until chest pain is severe. It can also be taken prophylactically to prevent an anginal attack before engaging in an activity known to cause angina.
NP:I; CN:PH; CA:M


Topic: Physiological Integrity
The nurse knows that biliary pain will best be controlled by administering the medication

A) Demerol.
B) Codeine.
C) Morphine.
D) Thorazine.

Answer: A
A) If narcotics are used, such as morphine, they can cause biliary colic; therefore, Demerol would be the drug of choice for pain. Thorazine is used to control anxiety or nausea.
NP:P; CN:PH; CA:M


Topic: Physiological Integrity
An obese 14 year old is admitted to the adolescent unit with a tentative diagnosis of type 1 diabetes mellitus. Adolescent diabetics frequently have more difficulty than diabetics in other age groups because

A) The disease is usually more severe in adolescents than in younger children.
B) Adolescents have difficulty regulating their insulin.
C) Adolescents have a difficult time with long-acting insulin.
D) Adolescents as a group have poor eating habits.

Answer: D
D) As young adults start spending more time with their peer groups, they frequently adopt eating habits of this group which are often not appropriate for diabetics.
NP:AN; CN:PH; CA:P


Topic: Physiological Integrity
The nurse is assigned to care for a client just completing the last cycle of peritoneal dialysis. Two liters of fluid were infused and there was 1 liter of fluid returned. The appropriate nursing intervention is to

A) Do nothing as no other intervention is necessary.
B) Chart the discrepancy and report to the head nurse.
C) Insert a needle into the drainage system air vent.
D) Flush the catheter with normal saline.

Answer: C
C) If drainage is stalled, inserting a needle into the air vent will provide an airway in the bag. This will assist drainage by allowing the escape of air from the system, facilitating drainage of dialysate. Another intervention would be to move the client from side to side to stimulate drainage.
NP:I; CN:PH; CA:M


Topic: Physiological Integrity
A postdelivery maternity client returns to the clinic on postpartum day four. On the physical exam, the nurse finds that her fundus is 5 fingerbreadths below the umbilicus, her lochia is scant and serosa, her breasts are full and dripping milk. An analysis of the findings leads the nurse to

A) Alert the physician.
B) Do nothing. The findings are normal.
C) Place her under constant observation.
D) Observe her again in about 30 minutes for changes.

Answer: B
B) These are normal physical findings for postpartum day four. If the client is breast feeding, it may be time for the baby to nurse. If she is not breast feeding, she should have on a tight, well-fitted bra. Ice packs may be applied to the breasts.
NP:I; CN:H; CA:MA


Topic: Health Promotion and Maintenance
A client, age 18, fell off a ladder while painting his parents' home. He has been brought to the hospital by ambulance. The nurse is assigned to complete an initial assessment. An indication of increased intracranial pressure (ICP) would be a

A) Pulse rate of 96.
B) Blood pressure of 160/80.
C) Respiratory rate of 18 and irregular.
D) Temperature of 100 degrees F orally.

Answer: B
B) Blood pressure is increased with a wide pulse pressure (the difference between the systolic pressure and the diastolic pressure). The cerebrospinal fluid pressure may cause elevated blood pressure by reducing oxygen supply to the hypothalamic vasomotor center. The excess of carbon dioxide which then forms will stimulate the center and cause an increase in the blood pressure.
NP:A; CN:PH; CA:M


Topic: Physiological Integrity
A client came into the emergency room in respiratory distress. The physician gave her theophylline to relax the smooth muscle of the bronchi. The nurse will evaluate the effects of this medication by checking

A) Heart rate and rhythm.
B) Respiratory rate.
C) Blood pressure.
D) Pulse rate.

Answer: A
A) Because this drug can cause tachycardia and arrhythmias, it is important to assess the heart rate and rhythm. It may also cause hypotension and GI distress.
NP:E; CN:PH; CA:M


Topic: Physiological Integrity
An elderly client is scheduled for electro-convulsive therapy (ECT). The nurse will do the client teaching. One important principle is to tell the client that

A) He will receive three types of medication.
B) He will recover rapidly from the effects of the procedure.
C) This procedure will help his depression.
D) When he wakes up, he may have some short-term memory loss for recent events.

Answer: D
D) The client needs to be prepared for short-term memory loss and told that it will resolve in 6 to 9 months. While it is true that he will receive three medications, he needs more specific information about their action. NP:I; CN:PS; CA:PS


Topic: Psychosocial Integrity
A client was admitted to the psychiatric unit of the hospital with a diagnosis of obsessive-compulsive disorder. The admission history describes the client as having difficulty adjusting to situations, having a low tolerance for anxiety, and exhibiting compulsive personality traits. The nurse's understanding of this disorder is that the primary purpose for compulsive behavior is an attempt to

A) Gain control of the environment.
B) Influence others.
C) Avoid anxiety.
D) Reduce anxiety.

Answer: D
D) The primary purpose for the compulsive activity is an attempt to reduce the anxiety level. If anxiety is increased, the client may extend the compulsive behavior or develop a new compulsion-all in an attempt to reduce anxiety.
NP:AN; CN:PS; CA:PS


Topic: Psychosocial Integrity
When a new baby's condition of hyperbilirubinemia continues to worsen, he is given an exchange transfusion. Priority nursing care of the infant following the transfusion is to monitor

A) Fluid balance.
B) Hyperglycemia.
C) Respiratory status.
D) For hemorrhage.

Answer: D
D) Because the transfusion is given via the umbilical catheter, the cord should be observed for bleeding. All vital signs should be monitored frequently. Oxygen may be given, but possible hemorrhage is the higher priority.
NP:I; CN:PH; CA:MA


Topic: Physiological Integrity
A 50-year-old woman was admitted to the medical unit for a breast biopsy. Following the results, the client is scheduled for a modified mastectomy. The client says to the nurse, "I don't know why you are all so concerned; I'm not that sick." The nurse understands that the defense mechanism the client is using is

A) Rationalization.
B) Denial.
C) Projection.
D) Regression.

Answer: B
B) The client is refusing to accept the implications of the diagnosis to protect herself from the unpleasant reality. Denial is a stage of the grief process.
NP:AN; CN:PS; CA:M


Topic: Psychosocial Integrity
A client had a thoracotomy and lobectomy. There are two chest tubes in place connected to a water-seal drainage system which is connected to wall suction. Which assessment finding validates that the system is working correctly?

A) Constant bubbling in the suction control chamber.
B) Intermittent bubbling in the drainage collection chamber.
C) Intermittent bubbling in the suction control chamber.
D) Constant bubbling in the water-seal chamber.

Answer: A
A) When a water-seal drainage system is connected to a suction source, there should be continuous bubbling in the suction control chamber. All of the other assessment findings indicate some form of malfunction in the system.
NP:E; CN:PH; CA:S


Topic: Physiological Integrity
In teaching a client to irrigate his colostomy, the nurse knows that he should irrigate

A) By gravity flow from a container placed at a height of three feet above the ostomy opening.
B) By gravity from a container placed at shoulder height.
C) At any height as long as the flow is regulated by gravity.
D) By gravity flow several inches above the ostomy opening.

Answer: B
B) It is important to use a Laird tip on the catheter and position the irrigant no higher than shoulder height to reduce the risk of perforation.
NP:AN; CN:PH; CA:S


Topic: Physiological Integrity
With increasing intracranial pressure (ICP), the pulse rate would also be altered. The nurse will expect to chart the pulse as

A) Rapid and thready.
B) Slow progressing to rapid.
C) Slow and irregular.
D) Rapid and bounding.

Answer: B
B) A slow pulse occurs in conjunction with an increased systolic blood pressure due to venous stasis and vasomotor changes. As the intracranial pressure increases, the pulse becomes tachycardic.
NP:I; CN:PH; CA:M


Topic: Physiological Integrity
The nurse is assigned a client whose orders include heparin therapy. When administering heparin, the substance the nurse will keep at the bedside as the antidote is

A) Magnesium sulfate.
B) Vitamin K.
C) Protamine sulfate.
D) Calcium gluconate.

Answer: C
C) Protamine sulfate is the antagonist for Heparin. Answer (B), vitamin K, is the antagonist for Coumadin. Answer (D) is the antagonist for magnesium sulfate.
NP:P; CN:PH; CA:M


Topic: Physiological Integrity
A client who is 38 weeks pregnant with premature rupture of the membranes comes to the hospital. After a quick assessment, the nurse detects an abnormal fetal heart pattern. The first intervention is to

A) Administer oxygen.
B) Palpate for the umbilical cord.
C) Place the client in knee-chest position.
D) Notify the physician.

Answer: C
C) The first intervention is to position the client so that the presenting part is off the umbilical cord. When rupture of the membranes occurs prematurely, the infant is usually small and the cord may slip through the birth canal. The nurse would notify the physician and administer oxygen as ordered.
NP:I; CN:H: CA:MA


Topic: Health Promotion and Maintenance
The most important nursing action in maintaining medical asepsis is

A) Noncontamination of the equipment.
B) Thorough handwashing.
C) Running water over the hands for 1 minute.
D) Rinsing hands thoroughly and then drying.

Answer: B
B) The most important action to promote medical asepsis is handwashing.
NP:I; CN:S; CA:M


Topic: Safe, Effective Care Environment
Discussing a diabetic's diet plan with the client, the nurse would emphasize that the snack should

A) Be taken at the time the insulin exerts its maximum effect.
B) Consist of at least 500 calories.
C) Consist of complex carbohydrates.
D) Be taken 30 minutes before the insulin exerts its maximum effect.

Answer: D
D) To prevent hypoglycemia, the snack must be taken 30 minutes before the peak action of the insulin. This ensures that the blood glucose level is up when the insulin peaks. The snack should be at least 200 calories and consist of fruit juice, a meat exchange, and a bread exchange.
NP:I; CN:PH; CA:M


Topic: Physiological Integrity
A client is just learning how to use crutches. The initial instruction on the use of crutches to move upstairs should be to

A) Place crutches on the stair and then move the affected leg to the stair.
B) Start with crutches and the unaffected leg on the same level.
C) Place crutches on the step after the affected leg is moved up the stair.
D) Start with crutches and the affected leg on same level.

Answer: B
B) The crutches and unaffected leg start on the same level; then, the unaffected leg is moved to the step, followed by the crutches and affected leg.
NP:I; CN:PH; CA:S


Topic: Physiological Integrity
The physician orders Meperidine hydrochloride IM q4h prn for a client in labor. Which phase of labor is the safest for the nurse to administer this medication?

A) Active phase.
B) Early active phase.
C) Expulsion phase.
D) Transition phase.

Answer: A
A) The safest phase is at 4 to 5 cm dilatation or the active phase. Given too early, this medication will decrease or stop labor; given later in labor, it will depress the infant's respirations.
NP:P; CN:H; CA:MA


Topic: Health Promotion and Maintenance
The set of formal guidelines for governing an RN's professional action is called

A) Accountability.
B) Professional responsibility.
C) Patient's Bill of Rights.
D) Nurses' Code of Ethics.

Answer: D
D) The Code of Ethics assists the nurse to problem solve where judgment is required. It encompasses professional responsibility and accountability.
NP:AN; CN:S; CA:M


Topic: Safe, Effective Care Environment
A client has been ordered to have blood work drawn for serum electrolytes. She is on bedrest and has an IV in the vein of the right forearm. The most appropriate site for blood withdrawal is

A) Left upper arm (brachial vein).
B) Foot (greater saphenous vein).
C) Left forearm (median cubital vein).
D) Right forearm (radial vein).

Answer: C
C) Blood should be drawn from the most peripheral vein to preserve the integrity of the vein for future lab work. With an IV in the right forearm, this site would be unacceptable for blood withdrawal.
NP:P; CN:PH; CA:M

Topic: Physiological Integrity
A two-year-old has orders for bedrest. He continually asks the nurse why he has to be in bed. The best nursing strategy is to

A) Continue to explain the reason when he asks.
B) Change the subject to get his mind on something else.
C) Tell him that he just asked that question and the answer is the same.
D) Distract him so he will stop asking the question.

Answer: A
A) At age two, children center their attention on one aspect of a situation. It is important that the nurse answer the child's questions honestly and each time they are asked.
NP:P; CN:PH; CA:P


Topic: Physiological Integrity
A client on lithium carbonate is instructed to return to the clinic to have her blood checked in a week. The rationale for emphasizing this teaching is that the

A) Serum level of lithium must be kept below 1.6 mEq/liter.
B) Toxic range appears only at levels exceeding 2.0 mEq/liter.
C) Serum level of lithium is important to test to determine if symptoms are controlled but not toxic.
D) Central nervous system is the chief target, so the serum level must be kept stable, not fluctuating.

Answer: C
C) Lithium levels should be monitored to determine if symptoms are controlled but not in the toxic range. Blood level fluctuates so it must be consistently monitored. Side effects may occur at levels above 1.6 mEq/liter but toxicity usually does not occur below 2.0 mEq/liter. Toxicity may occur even with an acceptable level of lithium in the blood.
NP:E; CN:PS; CA:PS


Topic: Psychosocial Integrity
A client needs to have a sterile urine specimen sent to the laboratory for a culture and sensitivity. After inserting the catheter, the nurse finds that urine is not flowing. The next action is to

A) Reassess if the catheter is in the vagina; if so, remove it and reinsert into meatus.
B) Insert the catheter a little farther, wait a few seconds, and if urine does not flow, reassess placement.
C) Remove the catheter, check the meatus, and reinsert the catheter.
D) Obtain a new, larger sized catheter and insert it.

Answer: B
B) Check if catheter is inserted far enough into urethra or if it is in vagina. If in vagina, leave in place as a landmark, obtain new sterile set-up, and insert new catheter.
NP:I; CN:PH; CA:M


Topic: Physiological Integrity
The acid-base abnormality demonstrated with ABG 1 in the values listed above is

A) Respiratory alkalosis.
B) Respiratory acidosis.
C) Metabolic alkalosis.
D) Metabolic acidosis.

Answer: B
B) Respiratory acidosis (hypercarbia or increased CO2) exhibits the following manifestations: headache, dizziness, confusion, tremor, somnolence. Respiratory alkalosis (hyperventilation or decreased CO2) exhibits the following manifestations: paresthesias, tetany, anxiety, tachycardia.
NP:AN; CN:PH; CA:M


Topic: Physiological Integrity
An elderly client has just completed chelation therapy for lead poisoning. The nurse assesses his condition and observes that he is experiencing tetany. The nurse knows the client is low in

A) Magnesium (Mg++).
B) Calcium (Ca++).
C) Potassium (K+).
D) Sodium (NA+).

Answer: B
B) Tetany is caused by low calcium or hypocalcemia caused by the chelation process which carried the calcium, as well as the lead, out of the body.
NP:AN; CN:PH; CA:M


Topic: Physiological Integrity
The main purpose for obtaining vital signs on a client who has just been admitted to the hospital is to

A) Determine the client's regulatory mechanisms.
B) Determine variation in temperature, pulse and respiration.
C) Provide information to determine the client's homeostatic balance.
D) Obtain a total picture of the client's health status.

Answer: D
D) The major objective is to obtain a total picture of a client's health status. It will also yield important baseline information for future assessments.
NP:A; CN:PH; CA:M


Topic: Physiological Integrity
The nurse will carefully monitor an infant's oxygen level because too high a level could result in

A) Retrolental fibroplasia.
B) Peripheral circulatory collapse.
C) Kernicterus.
D) Cardiac damage.

Answer: A
A) High blood levels of oxygen cause spasms of the retinal vessels, and the destruction of these vessels can cause retrolental fibroplasia and blindness.
NP:AN; CN:PH; CA:P


Topic: Physiological Integrity
A client with hypertension is taking the medication chlorothiazide (Diuril). The nurse would instruct her to regularly include in her diet

A) Liver and organ meats.
B) Dairy products.
C) Dried fruits and bananas.
D) Apples.

Answer: C
C) Thiazide diuretics excrete potassium and sodium during diuresis, so the diet should be supplemented regularly with foods high in potassium. Dried fruits and bananas are the only foods included that are high in potassium.
NP:I; CN:PH; CA:M


Topic: Physiological Integrity
A 24-year-old female client who was recently married is told by her physician to come back to the clinic when she is having her menstrual period to have a vaccination of rubella. The nurse explains that the purpose of the timing of the vaccination is that the

A) Vaccine is live and must not be given when a woman is pregnant.
B) Vaccine is live and a negative titer is present during menses.
C) Vaccine is dead and will interfere with hormone production.
D) Blood titer must be positive and this occurs during menses.

Answer: A
A) The rubella vaccine is live and will cause severe damage to a fetus. This vaccine must be given when it is certain the woman is not pregnant, thus immediately following pregnancy or the menstrual period is a safe time. The woman must have a negative titer to receive the vaccine.
NP:I; CN:PH; CA:M


Topic: Physiological Integrity
While assessing a client who has orders for a hot-water bottle, heating pad, or hot compress, the first sign of possible thermal injury is

A) Pain.
B) Redness in the area.
C) Edema.
D) Tingling sensation in the extremities.

Answer: B
B) Redness, or erythema, is the first sign of possible injury. This is an important observation to prevent a burn injury.
NP:A; CN:PH; CA:M

Topic: Physiological Integrity
The nurse is preparing the discharge plan for a client with gout. The nurse will know the client understands dietary requirements if he chooses a meal of

A) Salmon, rice, broccoli, and milk.
B) Liver, fried onions, potatoes, and cauliflower.
C) Broiled chicken, potato, gravy, and green beans.
D) Cheese omelet, wheat toast, and broiled tomato.

Answer: D
D) The client should be on a low-purine diet and should recognize the restricted foods: gravy, fish, fowl, and organ meats. Eggs, cheese, breads, fat, and most vegetables are allowed.
NP:E; CN:PH; CA:M


Topic: Physiological Integrity
Using Leopold's maneuvers, the nurse assesses the presence of a firm round prominence over the pubic symphysis, a smooth convex structure on the client's right side, irregular structures on the left side, and a soft roundness in the fundus. The nurse would conclude that the fetal position is

A) Left occiput posterior-LOP.
B) Left occiput anterior-LOA.
C) Right occiput anterior-ROA.
D) Right occiput posterior-ROP.

Answer: C
C) The head is down, the back is on the right side, legs on left, and fetus' buttocks in the fundus indicate the position of ROA.
NP:AN; CN:H; CA:MA


Topic: Health Promotion and Maintenance
A client with Alzheimer's disease frequently makes up stories or confabulates. The nurse can best handle this behavior by

A) Telling the client he is making up stories.
B) Orienting the client to reality.
C) Allowing the client to confabulate.
D) Ignoring the client's stories.

Answer: C
C) The client confabulates as a part of his condition. It is important to allow this behavior to protect his self-esteem. Telling the client he should not make up stories will not change the behavior.
NP:I; CN:PS; CA:PS


Topic: Psychosocial Integrity
When assessing a child suspected of having epiglottitis, the nursing action is to

A) Keep the child calm while administering 100% oxygen and awaiting an expert at intubation.
B) Send the child to x-ray immediately for a chest x-ray.
C) Lay the child down flat to calm him/her down.
D) Give IM antibiotics as standard orders while attempting to start an IV.

Answer: A
A) Keeping the child calm is important because any added trauma to the airway, even from crying, could cause airway obstruction. Children should be positioned upright in "sniffing position" to help maintain airway patency. Oxygen is delivered in the method best tolerated by the child and only the most experienced nurse should attempt intubation--difficult because of swollen tissues. Children suspected of having epiglottitis should never be left alone.
NP:I; CN:PH; CA:P


Topic: Physiological Integrity
If the nurse is concerned that child abuse has occurred, it is the professional responsibility of the nurse to

A) Notify the physician.
B) Chart the concern and bring it to the staff's attention.
C) Notify the charge nurse.
D) Notify the designated child welfare agency.

Answer: D
D) When child abuse is suspected, it is the nurse's professional responsibility to report it to the designated agency according to hospital policyÑusually child welfare. The nurse does not legally have to notify the charge nurse or physician, but it is good staff communication.
NP:P; CN:PS:CA:PS

Topic: Psychosocial Integrity
A client with obsessive-compulsive disorder who performs a ritual of pacing is scheduled for group therapy. The nurse would plan that the therapy occur

A) After the client has just completed the pacing ritual.
B) In the middle of the ritual, as this is the optimal time for a low anxiety level.
C) In the evening, when the anxiety is low after practicing her ritual all day.
D) Before the client starts her ritual in the morning and gets too anxious.

Answer: A
A) It is important not to plan any treatment or therapy before or during the ritual. Immediately after completing the ritual act, anxiety will be the lowest.
NP:P; CN:PS; CA:PS

Topic: Psychosocial Integrity
When assessing pain in an infant, the nurse knows that infants typically display pain by

A) Increased sleeping time, refusal to eat, and irritability.
B) Inconsolable crying, facial grimacing, and vigorous body movements.
C) Withdrawing quietly and refusing to eat.
D) Crying, increased appetite, and sleeping more.

Answer: B
B) Facial grimacing, inconsolable crying, and flailing body movements have been described as diagnostic signs of pain in infants (data from CHEOPS Scale). Changes in appetite and sleep can be attributed to other causes.
NP:A; CN:PH; CA:P


Topic: Physiological Integrity
Considering a client's condition of acute rheumatic fever, which one of the following nursing measures should be included in the plan of care?

A) Isolation for prevention of infection.
B) Sufficient vitamins for tissue repair.
C) Warm soaks for joint pain.
D) Adherence to bedrest regimen.

Answer: D
D) The most important nursing care would be bedrest so that the heart is not overtaxed and the body has sufficient rest time to repair the damage caused by the systemic inflammatory disease. Warm soaks given to reduce joint pain and a good diet are necessary for repair of any organ, but in this instance they are not the most important aspects of nursing care. Normally, isolation is not required.
NP:P; CN:PH; CA:M


Topic: Physiological Integrity
A client in renal failure has orders for Amphojel to be taken with his meals. The nurse will explain that the rationale for this medication is to

A) Bind phosphate for elimination.
B) Counteract the diarrhea caused by hyperkalemia.
C) Protect against gastric ulceration.
D) Replace aluminum lost during dialysis.

Answer: A
A) Aluminum hydroxide gel is given to bind phosphate for elimination to help counteract the stimulus (high phosphate) for hypocalcemia.
NP:AN; CN:PH; CA:M


Topic: Physiological Integrity
A diabetic client gave birth to a healthy 8 lb baby. For the second feeding, the baby was given glucose water. The next most important nursing action is to

A) Observe for hyperbilirubinemia.
B) Monitor infant glucose levels with Dextrostix.
C) Administer formula, preferably breast milk.
D) Monitor the infant's respiratory status.

Answer: B
B) Dextrostix results yield data about blood glucose level; this is essential data for monitoring hypoglycemia in the infant of a diabetic mother. The respiratory status would be automatically monitored, as would the bilirubin level, but the glucose level for an infant of a diabetic mother is the first priority after the glucose feeding.
NP:I; CN:H; CA:MA


Thanks to Ma'm Rose!