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Quiz Session - Attempts With Random Questions

NCLEX-PN Exam Questions

Page 3 of 50

41.

When explaining a potentially painful procedure to a patient, it is important to uphold which of the following ethical principles?

  • Veracity

  • Justice

  • Beneficence

  • Autonomy

Correct answer: Veracity

Veracity is an ethical principle which refers to the right to communicate truthfully and accurately. When explaining a potentially painful procedure to a patient, it is important to maintain veracity and communicate the truth to respect the patient's rights. Providing a truthful explanation allows the patient to have realistic expectations and also helps to create a more trusting nurse-patient relationship.

42.

Assessment of clients with suicidal ideation should include:

  • Asking them whether they have a specific plan

  • Suggesting the client join a support group

  • Referring the client to a psychiatrist

  • Administering an antidepressant medication

Correct answer: Asking them whether they have a specific plan

Asking whether the patient has a specific plan is an assessment question. The other answers are interventions.

43.

A patient with bipolar disorder is exhibiting manic behaviors. The nurse formulates a diagnosis of, "Disturbed thought processes related to difficulty concentrating, secondary to flight of ideas." Which of the following are other hallmarks of mania?  

Select all that apply.

  • Elevated or euphoric mood

  • Impulsivity

  • Grandiosity

  • Increased appetite

  • Lack of sexual interest

Defining characteristics of mania include an elevated or euphoric mood, unlimited energy, rapid and increased speech (very talkative), racing thoughts, inability to sleep, increase in goal-directed activities (that may result in harmful consequences, such as spending excessive money, traveling, or sexual promiscuity), and psychomotor agitation. The manic patient is impulsive and has grandiose and persecutory delusions. S/he may often exhibit a significant decrease in appetite because of involvement in more important activities. 

Lack of sexual interest is often associated with the depressive phase of bipolar disorder.

44.

The nurse is caring for a child with a probable diagnosis of measles. Common manifestations of measles include the "three Cs," along with a rash that starts on the face and spreads downward. Which of the following are included in the "three Cs?" 

Select all that apply.

  • Cough

  • Coryza

  • Conjunctivitis 

  • Confusion 

  • Constant pain 

  • Constipation

Rubeola (measles) is a viral illness that has been widely eradicated with the use of the MMR vaccine (measles, mumps, rubella). It is characterized by fever, malaise, the "three Cs" (coryza, cough, and conjunctivitis), rash, and koplik spots (small, red spots with a bluish-white center and a red base, located on the buccal mucosa). Measles is contagious from roughly four days before to five days after the body rash appears, mainly during the prodromal stage (pertaining to early symptoms that mark the onset of disease). Airborne droplet precautions should be instituted if the child is hospitalized, and the child should be kept as comfortable as possible (antipyretics for fever, cool mist vaporizer for cough and coryza) throughout the duration of the illness.

45.

A female client requests information about using the calendar method of contraception. Which assessment is most important for the nurse to obtain?

  • An accurate menstrual cycle diary from the past 6 to 12 months

  • Amount of weight gain or weight loss during the previous year

  • Skin pigmentation and hair texture for evidence of hormonal changes

  • Previous birth control methods and beliefs about the calendar method

Correct answer: An accurate menstrual cycle diary from the past 6 to 12 months

An accurate menstrual cycle diary for the past 6 to 12 months is the most important assessment to obtain.

46.

You are teaching a client about contraception. Which of the following statements is true?

  • Oil-based lubricants should not be used with latex condoms

  • Patches must be changed every 3 days

  • You can insert an IUD yourself with practice

  • The main ingredient in Depo Provera is estrogen

Correct answer: Oil-based lubricants should not be used with latex condoms

Oil-based lubricants can break down the latex in latex condoms--water-soluble lubricants may be used. Birth control patches are changed weekly. An IUD must be inserted and replaced by your physician. Depo Provera contains progestin.

47.

The nurse is interviewing the parents of an injured child. The nurse suspects child abuse. Which of the following strongly indicates that child abuse may be a problem?

Select all that apply.

  • The injury is not consistent with the child's developmental stage

  • There is a fracture present with no history of trauma

  • The parents are fearful when approached and interviewed

  • The family lives in low-income housing

  • The mother and father tell different stories about what happened

When the child's injuries are inconsistent with age and developmental stage, if there are unexplained bruises, burns, or fractures without history of trauma, or if parents seem fearful when approached about what happened, the nurse should be suspicious about child abuse occurring. Nurses are legally required to report all cases of suspected child abuse to the appropriate local or state agency. 

Living in a low-income housing area, with no other indicators of child abuse, should not raise suspicion (as child abuse occurs in all socioeconomic groups). Parents may tell different stories because their perceptions may be different regarding what happened. If the story changes, however, when asked similar questions by different healthcare professionals, this is an indicator that child abuse may be a problem.

48.

A patient undergoes laboratory testing with a basic metabolic panel (BMP). The nurse in the outpatient clinic notes a potassium level of 2.8 mEq/L. The nurse proceeds with the following teaching:

  • Encourage intake of foods like avocados, spinach, and tomatoes

  • Encourage intake of foods like apples, cabbage, and corn

  • Encourage intake of foods like cauliflower, applesauce, and blackberries

  • Encourage intake of foods like grapes, eggplant, and peaches

Correct answer: Encourage intake of foods like avocados, spinach, and tomatoes

A normal potassium level is between 3.5 and 5 mEq/L. This patient is hypokalemic (potassium level is low). Therefore, the nurse should encourage the consumption of foods high in potassium. Such foods include avocados, bananas, cantaloupe, oranges, strawberries, tomatoes, carrots, mushrooms, spinach, fish, pork, beef, veal, potatoes, and raisins.

The other foods mentioned are all low in potassium and would be more beneficial for a person with chronic kidney disease who may have high potassium levels.

49.

Which of the following statements is true about nursing care plans?

  • They must be updated every 24-48 hours

  • They do not go into the permanent chart

  • They contain general information

  • They contain goals set by the nursing staff only

Correct answer: They must be updated every 24-48 hours

Nursing care plans are a part of the permanent chart and are designed to document mutually agreed-upon goals of the patient, family, and health care team. Care plans should be updated every 24-48 hours to ensure goals are being evaluated. The plans must be specific in the information they contain as well.

50.

You are the nurse on a pediatric unit, and you will be administering medications using different routes. You should be fully aware of which age-specific characteristic in relation to different routes of medication?

  • Dosages are based on kilograms of weight for toddlers

  • The gluteus maximus is the preferred intramuscular site for infants

  • The deltoid is the preferred intramuscular site for toddlers

  • Capsules should be opened and put into applesauce for toddlers

Correct answer: Dosages are based on kilograms of weight for toddlers

Dosages are based on kilograms of weight for toddlers, infants, preschool and school age children. The vastus lateralis is the preferred site for intramuscular injections until the toddler is walking, after which the gluteus maximus develops and can be used for intramuscular injections. The deltoid is not used for intramuscular injections until the child is a preschooler, and capsules should not be put into applesauce. If the child cannot tolerate capsules, another form of the medication should be used with a doctor's order.

51.

A patient has been recently diagnosed with osteoarthritis (OA). Which of the following signs and symptoms would the nurse anticipate this patient to exhibit? 

Select all that apply.

  • Heberden's or Bouchard's nodes

  • Joint pain and stiffness

  • Functional impairment

  • Severe bone deformity

  • Swan-neck fingers

OA, or degenerative joint disease (DJD) is marked by progressive deterioration of the articular cartilage and the formation of bony buildup in peripheral and axial joints. Joint pain occurs, intensifying after activity, and progresses as the disease does. Stiffness and functional impairment (difficulty getting up after prolonged periods of sitting, and inability to perform ADLs) are other primary clinical manifestations of OA. Heberden's or Bouchard's nodes in the hands develop (hard bony lumps in the joints) as well, over time. 

Severe bone deformity and swan-neck fingers are seen in patients with a diagnosis of rheumatoid arthritis (RA), which is a chronic systemic inflammatory disease.

52.

Your patient has chronic hepatitis C and has been started on interferon. You teach the patient that side effects of interferon might include:

  • All of these

  • Depression

  • Fatigue

  • Persistent flu-like symptoms

Correct answer: All of these

All of these side effects may occur with interferon. Anemia, bone marrow suppression, and dehydration are other, more serious, side effects of interferon therapy.

53.

A nurse is planning care for the newborn of a diabetic mother. What is a priority nursing diagnosis for this infant?

  • Risk for injury related to low blood glucose levels

  • Hyperthermia related to excess fat and glycogen

  • Risk for delayed development related to excessive size

  • Risk for aspiration related to impaired suck and swallow

Correct answer: Risk for injury related to low blood glucose levels

The neonate born to a diabetic mother is at risk for hypoglycemia. Risk for injury related to low blood glucose levels would be a priority nursing diagnosis. The other options are not expected problems.

54.

Signs/symptoms of anaphylaxis may include the following:

  • All of these

  • Urticaria

  • Hypotension

  • Cramping abdominal pain

Correct answer: All of these

All of these are symptoms of anaphylaxis. Other symptoms/signs may include wheezing, angioedema, dyspnea, syncope, dizziness, headache, rhinitis, nausea/vomiting and chest pain.

55.

Which of the following provides guidance regarding what nursing tasks can be delegated to another health care worker?

  • Nurse Practice Act

  • Regulated Health Professions Act

  • Nursing Assistant Act

  • Nurses Bill of Rights

Correct answer: Nurse Practice Act

The Nurse Practice Act is enacted by all states and territories by the state legislature. The Nurse Practice Act defines the standards and scope of nursing practice within each state, which is also verified by the respective Board of Nursing. The Act provides additional guidance with respect to licensure, authority and power of a Board of Nursing, education program standards, and disciplinary action procedures.

56.

Which statement about biliary disease is accurate?

  • Cholecystitis is an acute or chronic inflammation of the biliary tract

  • Cholelithiasis is the acute inflammation of the biliary tract

  • Acalculous cholecystitis usually results from calcium composite stones

  • Loring’s sign signals cholecystitis

Correct Answer: Cholecystitis is an acute or chronic inflammation of the biliary tract

Cholecystitis can be acute or chronic; it is the inflammation of the biliary tract. Cholelithiasis, on the other hand, is the abnormal production of gallstones and often leads to cholecystitis. Most gallstones are comprised of calcium; however, some cases of cholecystitis can occur in the absence of any gallstones. This form of cholecystitis is referred to as acalculous cholecystitis. It is Murphy’s sign, not Loring’s sign, that is a symptom of cholecystitis.

57.

A nurse is assessing a newborn infant born to a mother who is addicted to drugs. Which of the following assessment findings would the nurse expect to note during the assessment of this infant?

  • Incessant crying

  • Lethargy

  • Sleepiness

  • Cuddling when held

Correct answer: Incessant crying

A newborn infant who is born to a drug addicted mother is irritable. The infant is easily overloaded by sensory stimulation. The infant may be difficult to console. The infant would hyperextend and posture rather than cuddle when held.

58.

A phenomenon that occurs when two similar drugs taken together have an effect that is greater than if each is taken separately is known as:

  • Synergism

  • Interference

  • Additive effect

  • Antagonism

Correct answer: Synergism

Synergism is a phenomenon that occurs when two similar drugs are taken together and the result or effect is greater than if they were taken separately. Synergism is a type of drug-to-drug interaction, and it is important for nurses to review a patient's entire medication list to check for any potential drug-to-drug interactions. Other drug-to-drug interactions include antagonism, interference, additive effect, and displacement.

59.

Which of the following is true regarding the use of a gait belt?

  • Ensure you can place three or four fingers between the belt and the patient

  • Tie the end of the gait belt in a knot

  • Tighten the gait belt as tight as it will go

  • Place the gait belt below the patient's hips

Correct answer: Ensure you can place three or four fingers between the belt and the patient

A gait belt is used as an assistive device to help promote steadiness while transferring a patient from one position to another. While the belt should be tight, the nurse should still be able to place three or four fingers between the gait belt and the patient. The belt should not be too loose or it will not serve its purpose. It should be placed above the patient's hips, near the waistline.

60.

A nurse is giving a report to a nursing assistant who will be caring for a client who has hand restraints. The nurse instructs the nursing assistant to assess the skin integrity of the restrained hands how often?

  • Every 30 minutes

  • Every 2 hours

  • Every 3 hours

  • Every 4 hours

Correct answer: Every 30 minutes

The nurse should instruct the nursing assistant to assess restraints and skin integrity every 30 minutes. Agency guidelines regarding the use of restraints should always be followed.

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