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Quiz Session - Attempts With Random Questions

NCLEX-PN Exam Questions

Page 10 of 50

181.

How often and why should you reposition an incontinent comatose client in the bed?

  • You should reposition the client at least every two hours to minimize the risk for skin breakdown secondary to maceration

  • You should reposition the client every hour to minimize the risk for skin breakdown secondary to shearing

  • You should reposition the client every hour to minimize the risk for skin breakdown secondary to friction

  • You should reposition the client every two hours to minimize the risk for skin breakdown secondary to friction

Correct answer: You should reposition the client at least every two hours to minimize the risk for skin breakdown secondary to maceration

Skin breaks down for a number of reasons, including moisture, which macerates the skin. Incontinence is a major risk factor associated with skin breakdown, so incontinent patients, and other clients at risk, should be repositioned at least every two hours. Friction and shearing are also factors that lead to skin breakdown; however, incontinence does not lead to these forces. Instead, improperly pulling patients up in bed produces these high risk forces.

182.

You are preparing the bathtub for your patient. The tub has a lift chair. How should you check the temperature of the water to prevent scalding?

  • Use a tub thermometer as per your facility's policy

  • Use your inner wrist to check the water to make sure it isn't too hot

  • Lower the patient very gradually into the tub and ask them to tell you right away if the water is too hot

  • There is no need to check water temperature prior to bathing patients

Correct answer: Use a tub thermometer as per your facility's policy

To prevent scald injuries, which can be fatal, use a tub thermometer to record the tub temperature prior to putting the patient into the tub. Using your wrist is not accurate, and asking the patient to tell you if the water is too hot won't be helpful if part of the patient's body (i.e., feet and legs) are already immersed.

183.

What are the six elements of malpractice?

  • Foreseeability, causation, patient harm, a duty owed to the patient, the duty being breached, and the breach causing an injury and/or damages

  • Omission, commission, neglect, abuse, intention and non-intentionality

  • Breaches of ethics, law, professional conduct, omission, commission and confidentiality

  • Foreseeability, causation, patient harm, a duty owed to the patient, the duty being breached, and the breach being intentional

Correct answer: Foreseeability, causation, patient harm, a duty owed to the patient, the duty being breached, and the breach causing an injury and/or damages

The breach can be intentional or not intentional.

184.

Which of the following is a clinical assessment finding consistent with fluid volume overload?

  • Crackles in the lungs

  • Hypotension

  • Thready pulses

  • Weight loss

Correct answer: Crackles in the lungs

Hypervolemia, also known as fluid volume overload, is a condition characterized by excessive fluid volume. It is an upsurge of too much blood plasma, causing an elevated volume of blood. There are several clinical assessment findings consistent with fluid volume overload. These include crackles in the lungs, peripheral edema, jugular venous distension, and shortness of breath. Bounding pulses, hypertension, and weight gain may also be present.

185.

A patient who is admitted to the emergency room has overdosed on diazepam (Valium). The patient is awake. You anticipate administering which of the following as a priority? 

  • Activated charcoal 

  • Flumazenil (Romazicon)

  • Calcium chloride

  • Naloxone (Narcan)

Correct answer: Activated charcoal 

Diazepam, a CNS depressant, is a benzodiazepine. Overdose can produce cardiovascular or respiratory depression, coma, shock, seizures, and death. If the patient is awake, vomiting is induced and activated charcoal is administered. If the patient is comatose, an airway is established and maintained, and gastric lavage with activated charcoal is the priority. Seizure precautions are also indicated. In addition, intravenous (IV) flumazenil may be used during a benzodiazepine overdose to reverse the effects. 

Naloxone (Narcan) is given for opioid overdose. Calcium chloride is used for the treatment of hypocalcemia and hyperkalemia, and as an antidote to magnesium intoxication due to an overdose of magnesium sulfate.

186.

The licensed practical nurse is conducting a developmental assessment of a 10-month-old male. She expects the baby will be able to do which of the following?

  • Say "mama"

  • Hold a cup with both hands

  • Say "moo" when shown a picture of a cow and asked what a cow says

  • Have a closed anterior fontanelle

Correct answer: Say "mama"

For the 10-month-old child, it would be appropriate to expect the patient to be able to speak one or two words, such as "mama" or "dada." The 6- to 12-month-old infant should also be able to sit independently without support, and may stand and walk while holding on to objects for support. The 12- to 18-month-old infant should have a closed anterior fontanelle, be able to hold a cup with both hands, and make animal noises in response to animal pictures. At this age the baby should also stand and walk freely.

187.

You are caring for a dying patient who has requested that no measures be used to prolong her life. The patient is comatose and has gurgling respirations. Your coworker wants to suction the patient and administer oxygen. 

How should you respond?

  • Explain that the patient and family have already discussed these measures and have decided to allow the patient to die without intervention

  • Allow your coworker to suction and administer oxygen because it will make the patient more comfortable 

  • Tell your coworker that you will do it, because it is your responsibility, not hers

  • Explain that the patient and family have already discussed these measures and tell your coworker to mind her own patients

Correct answer: Explain that the patient and family have already discussed these measures and have decided to allow the patient to die without intervention

End-of-life measures should be clarified with the patient and family as much as possible. As the nurse caring for this patient, your duty is to ensure that the patient's and family's wishes are respected and to support and advocate for them. 

188.

The nurse should encourage a newly-pregnant woman to take folic acid daily for the duration of her pregnancy for prevention of which of the following fetal conditions? 

Select all that apply.

  • Neural tube defects

  • Orofacial clefts

  • Rubella

  • Sickle cell anemia

  • Down syndrome

Folic acid is a B vitamin that helps to prevent birth defects and pregnancy complications like neural tube defects, cleft palates, premature births, intrauterine growth restrictions (IUGR), and miscarriage. Once a woman becomes pregnant, the recommended dose of folic acid to 600-800 micrograms per day.

The other answer choices are not caused by folic acid deficiencies in the pregnant woman.

189.

Which medication is correctly and accurately paired with its side effect?

  • Lasix: Hypokalemia

  • Lasix: Hyperkalemia

  • Aldactone: Hypokalemia

  • Aldactone: Hyperkalemia

Correct answer: Lasix: Hypokalemia

Lasix is a loop diuretic that depletes potassium. When clients take Lasix, they often take a potassium supplement, and their potassium levels are monitored in an ongoing manner. Aldactone is a potassium-sparing diuretic that does not impact potassium levels.

190.

The informed consent process is necessary for all of the following patient care situations except:

  • Cardiopulmonary resuscitation (CPR)

  • Placement of a peripherally inserted central catheter (PICC) line

  • Excision of a non-cancerous lesion

  • Transfusion of blood products

Correct answer: Cardiopulmonary resuscitation (CPR)

Informed consent is the process by which a health care provider discloses appropriate information to a patient, so that the patient may make a voluntary choice to accept or refuse treatment. The goal of informed consent is to allow the patient the opportunity to be an informed participant in his or her health care decisions.

In general, any medical intervention requires informed consent by the patient. This includes placement of a PICC line, minor surgical procedures, and transfusion of blood products. A life-threatening emergency in which the patient is not conscious, such as performing cardiopulmonary resuscitation (CPR), is an example of a situation in which informed consent would not be required.

191.

You are providing care for a child with hemolytic uremic syndrome (HUS). The child has been anuric and will be receiving peritoneal dialysis treatment. You will include all the following interventions in the plan of care except: 

  • Monitoring the arteriovenous (AV) fistula

  • Limiting fluids, as prescribed

  • Administering blood products to treat severe anemia

  • Instituting measures to prevent infection

Correct answer: Monitoring the arteriovenous (AV) fistula

HUS is thought to be associated with bacterial toxins, chemicals, and viruses that cause acute kidney injury in children, occurring primarily among infants and small children between the ages of 6 months and 5 years. Symptoms often include a triad of anemia, thrombocytopenia, and renal failure. 

The child undergoing peritoneal dialysis for treating anuria will be placed on fluid restrictions and will also need adequate nutrition and measures taken to prevent infection. Blood products may be prescribed to treat severe anemia, but administered with caution to prevent fluid overload. 

Peritoneal dialysis does not require an AV fistula (only hemodialysis does). 

192.

Your patient's abdominal wound dehisces, and bowel can be seen protruding through the opened incision. Nursing interventions include:

  • Positioning the patient in bed with the knees bent and the head of the bed no higher than 20 degrees to prevent an increase in intraabdominal pressure

  • Covering the wound with gauze soaked in betadine

  • Gently reducing the exposed viscera

  • Assessment of the patient's vital signs q hourly

Correct answer: Positioning the patient in bed with the knees bent and the head of the bed no higher than 20 degrees to prevent an increase in intraabdominal pressure

Positioning the patient appropriately will decrease abdominal pressure. Cover the wound with gauze or towels soaked in sterile saline. Do not attempt to replace any exposed organs. Assess vitals q 15 minutes to watch for signs of shock.

193.

A patient seen in the clinic is suspected of having Ménière’s syndrome. Which of the following manifestations is/are commonly associated with this condition?

Select all that apply.

  • Feelings of fullness in the ear

  • Vertigo and loss of balance

  • Tinnitus

  • Unilateral hearing loss

  • Ear drainage

  • Severe ear pain

Ménière’s syndrome is a condition of the inner ear, characterized by dilation of the endolymphatic system by overproduction or decreased reabsorption of endolymphatic fluid. 

This syndrome is characterized by tinnitus, ear fullness, unilateral sensorineural hearing loss, vertigo, balance disturbance, and nausea and vomiting (from vertigo). Symptoms occur in attacks that last for several days, causing the patient to become totally incapacitated during the attack. This is a chronic condition that generally only affects one ear. While initial hearing loss is reversible, as the frequency of attacks continues, hearing loss becomes permanent. 

A priority nursing intervention in the care of a patient with this condition is instituting safety measures.

Ear drainage and ear pain are not typically associated with Ménière’s.

194.

A nine-month-old infant has been diagnosed with acute otitis media and prescribed antibiotic therapy. When educating the child's parents on home care, the nurse should include which of the following interventions in the home treatment plan?

Select all that apply.

  • Encourage increased fluid intake

  • Administer acetaminophen or ibuprofen as prescribed

  • Provide foods that are soft, pureed, and overall easy to chew

  • When administering ear drops, pull the pinna up and back

  • When breast or bottle-feeding, position the child supine to prevent pain

The child with an acute ear infection should be encouraged to drink plenty of fluids (though this could be difficult, as the child may be in pain). Chewing also can be painful, so encourage soft, pureed foods as much as possible. Tylenol and/or ibuprofen will help to alleviate pain and fever; encourage parents to administer as prescribed. 

To administer ear medication in the child younger than three years of age, pull the earlobe down and back. In the older child (three years and up), pull the pinna up and back. Keep the child as upright as possible when feeding to accommodate drainage of fluid and prevent reflux.

195.

Which agent or piece of equipment is correctly and accurately paired with its type of asepsis?

  • Surgical asepsis: Autoclave

  • Surgical asepsis: Alcohol prep of the skin

  • Medical asepsis: Healthcare asepsis

  • Medical asepsis: Autoclave

Correct answer: Surgical asepsis: Autoclave

Surgical asepsis destroys all microorganisms and spores. An autoclave sterilizes items using extreme temperature and pressure. This renders the items sterile; therefore, an autoclave is a piece of equipment used for surgical asepsis.

196.

Of the following, which is considered a definitive positive pregnancy sign?

  • Positive fetal heart tones

  • Positive pregnancy test

  • Positive fetal movement

  • Absence of menstrual period

Correct answer: Positive fetal heart tones

Definitive positive signs of pregnancy are those that are clear in identifying the presence of a fetus. Signs cannot be attributed to other conditions, such as an ectopic pregnancy or hydatidiform mole. These positive signs include presence of a fetal heart tone, visualization of the pregnancy with an ultrasound, and palpation of the outline of a fetus.

197.

All of the following are examples of protected health information (PHI) except:

  • Employment records of an individual

  • A medical record held by a physician

  • An x-ray held by a radiologist

  • A record of prescriptions held by a pharmacist

Correct answer: Employment records of an individual 

Protected health information (PHI) is any identifiable health information. This information may be maintained or transmitted in any form by a covered entity or their business associate. Identifiable health information includes any health information, including demographic information, which identifies the individual. 

Medical records, x-ray results, and prescription records are all examples of protected health information. Employment records are not considered protected health information.

198.

Which of the following individuals are at risk for latex allergy?

Select all that apply.

  • Health care workers

  • Individuals undergoing multiple surgeries

  • Individuals with spina bifida

  • Individuals with a history of malignancy

  • An individual working in an environment where exposure to asbestos exists

Latex allergy is a hypersensitivity to latex. Symptoms can range from mild contact dermatitis to moderately severe symptoms of rhinitis, conjunctivitis, urticaria, and bronchospasm to severe life-threatening anaphylaxis. Those at-risk for latex allergy include health care workers; those who work in the rubber industry; those having multiple surgeries; spina bifida patients; individuals wearing gloves frequently such as food handlers, hairdressers, and auto mechanics.

Individuals with a history of malignancy and people who are exposed often to asbestos are not at high-risk for the development of latex allergy.

199.

A nurse in a neonatal care nursery receives a call from the delivery room and is told that a newborn with spina bifida will be transported to the nursery. The maternity nurse prepares which of the following priority items at the newborn's bedside?

  • A bottle of sterile normal saline

  • A rectal thermometer

  • A blood pressure cuff

  • A specific gravity urinometer

Correct answer: A bottle of sterile normal saline

The newborn with spina bifida is at risk for infection before the closure of the sac. A sterile saline dressing is placed over the sac to maintain moisture of the sac and its contents. This prevents tearing or breakdown of the skin integrity at the site.

200.

How many milligrams (mg) are in 1 gram (g)?

  • 1,000 mg

  • 30 mg

  • 60 mg

  • 100 mg

  • 100,000 mg

Correct answer: 1,000 mg

1 g = 1,000 mg

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