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Quiz Session - Attempts With Random Questions

NCLEX-PN Exam Questions

Page 4 of 50

61.

The physician ordered 1 gram of acetaminophen to be administered orally as needed for a temperature greater than 101.5 degrees Fahrenheit. The unit has 500 milligram tablets of acetaminophen stocked in the medication dispenser. How many tablets should the nurse administer?

  • 2 tablets

  • 1 tablet

  • 4 tablets

  • 0.5 tablet

Correct answer: 2 tablets

To calculate the number of tablets needed, one should first convert grams to milligrams. 1 gram equals 1,000 milligrams. To administer 1,000 milligrams using 500 milligram tablets, you divide 1,000 by 500, which is 2. The nurse should administer 2 tablets to achieve the prescribed dose.

62.

T- and B- lymphocytes are essential for a normal and healthy immune system. Which of the following are the types of T-lymphocytes? 

Select all that apply.

  • Helper/inducer

  • Suppressor

  • Cytotoxic/cytolytic

  • Natural killer (NK) 

  • Humoral 

T-lymphocytes are cells (one of the most important white blood cells in the immune system) that originate in the bone marrow and migrate to lymphoid tissue, lying dormant until they are needed to form sensitized lymphocytes for cellular immunity or antibodies for humoral immunity. Types of T lymphocytes are helper T cells, cytotoxic T cells, and suppressor (T regulatory) cells. 

NK cells are a type of cytotoxic lymphocyte that play a critical role in the innate immune system, providing quick responses to virus-infected cells and responding to tumor formation. Humoral immunity is a type of immediate response that provides protection against acute, rapidly evolving bacterial and viral infections.

63.

The most common complication of hemodialysis is:

  • Hypotension

  • Abdominal pain

  • Disequilibrium syndrome

  • Chest pain

Correct answer: Hypotension

Hypotension occurs most frequently, affecting 20 to 30% of patients at some point. It may be caused by removing too much weight (i.e. due to inaccurate pre-dialysis weight), heart disease, septicemia or taking blood pressure medications prior to dialysis.

64.

A patient is admitted to the medical/surgical unit with a platelet count of 20,000. The licensed practical nurse instructs the patient:

  • Do not walk in bare feet

  • Remain in bed at all times

  • Floss teeth daily

  • Drink alcohol sparingly

Correct answer: Do not walk in bare feet

A normal platelet count is between 150,000 and 300,000. For a patient with a platelet count of 20,000 there is significant risk of bleeding. Nursing measures must promote safety and prevent injury associated with the lowered ability for blood to clot. It is important to instruct patients with low platelet counts not to walk in bare feet, to eliminate alcohol from their diet, to use a soft-bristled toothbrush, to refrain from flossing, and to prevent constipation. 

65.

Which of the following signs and symptoms is/are present with placenta previa?

Select all that apply.

  • Painless vaginal bleeding

  • Bleeding is bright red

  • The uterus is soft, relaxed, and nontender

  • Bleeding is dark red 

  • Abdominal pain is severe

  • Uterine rigidity is present

In placenta previa, the placenta is improperly implanted in the lower uterine segment near or over the internal cervical os. This condition often presents suddenly as painless, bright red vaginal bleeding. Previa often occurs in the last half of pregnancy. The uterus remains soft, relaxed, and nontender. 

Placenta previa should not be confused with a placental abruption, in which the placenta prematurely and suddenly separates from the uterine wall (also in the second half of pregnancy), and presents with uterine rigidity, severe abdominal pain, signs of fetal distress, and dark red vaginal bleeding. Signs of maternal shock may be present if bleeding is excessive.

66.

Precautions that should be followed for a patient diagnosed with C. difficile infection include:

  • Contact precautions

  • Airborne precautions

  • Standard precautions

  • Droplet precautions

Correct answer: Contact precautions

C. difficile is one of the most important causes of infectious diarrhea in the United States. As normal bacteria found in the gut overgrow, including C. difficile, they have the potential for causing infectious colitis.

C. difficile is transmitted through contact with infectious spores and therefore, contact precautions (disposable gown and gloves) should be implemented for patients with this type of infection.

67.

A mother with a diagnosis of preeclampsia is on intravenous (IV) magnesium therapy for 24 hours post delivery. The nurse suspects the mother may be experiencing toxicity from this medication. Which of the following signs and symptoms would she likely be exhibiting?

Select all that apply.

  • Respirations of 10 breaths/minute

  • Lethargy

  • Hypotension

  • Urinary output of 50 mL/hr

  • Hyperreflexive deep tendon reflexes 

Magnesium sulfate is a central nervous system depressant and anticonvulsant. It works by causing smooth muscle relaxation and is used to both stop preterm labor and to prevent and control seizures in preeclamptic and eclamptic patients. The nurse should monitor closely for signs of toxicity, including respiratory depression (less than 12 breaths/minute), depressed (not hyperreflexive) reflexes, flushing, hypotension, extreme lethargy or muscle weakness, decreased urine output (less than 30 mL/hr), pulmonary edema, and elevated serum magnesium levels. Maternal vital signs should be monitored every 30 to 60 minutes while on IV magnesium and, if toxicity is suspected, a serum magnesium level should be drawn (target range is 4 mEq/L to 7.5 mEq/L).

68.

A 16-year-old patient is seen in the outpatient pediatric clinic with symptoms suspicious for strep throat. The licensed practical nurse is instructed to obtain a throat culture. When performing the procedure, the nurse knows to avoid which structure in order to prevent stimulation of the gag reflex?

  • Uvula

  • Tongue

  • Tonsil

  • Larynx

Correct answer: Uvula

When obtaining a throat swab or throat culture, the nurse should avoid the uvula to prevent stimulating the gag reflex. The larynx, tonsils, and tongue do not have a direct impact on gag reflex stimulation.

69.

The licensed practical nurse is providing care for a patient who has just undergone a thoracentesis at the bedside. Which of the following actions is most appropriate immediately following a thoracentesis?

  • Apply pressure to the puncture site

  • Have the patient turn on their side

  • Administer a bolus of IV fluids

  • Encourage the patient to cough

Correct answer: Apply pressure to the puncture site

Post-procedural care for the patient who has undergone a bedside thoracentesis would first involve the nurse applying pressure to the puncture site. Then, a sterile dressing would be applied over the puncture site. The purpose of these interventions are to prevent air entry into the pleural space, causing a pneumothorax. A post-procedural chest x-ray should be obtained, along with frequent vital signs. Deep breathing should also be encouraged.

70.

You are preparing to administer medication through your patient's gastrostomy tube. You have delivered a small bolus of air via a 60 ml syringe and auscultated for the sound of air over the stomach, and have attempted to aspirate stomach contents to confirm placement of the tube. You were unable to auscultate any sound over the stomach during the air bolus and could not aspirate any stomach contents. What could the potential problem be?

  • All of these

  • The tube is resting against the wall of the stomach

  • The tube is blocked

  • The tube has migrated and is no longer in the stomach

Correct answer: All of these

All of these are potential problems with a gastrostomy tube. Should you be unable to verify placement of the tube, hold any feedings or medications and notify the physician. An x-ray to check for placement may be necessary.

71.

Women are at a higher risk of cystitis (urinary tract infections) than men, due to a shorter urethra and a closer proximity of the urethra to the rectum. Which of the following women are most vulnerable to cystitis? 

Select all that apply.

  • A sexually active woman

  • A pregnant woman

  • A postmenopausal woman

  • A woman with severe asthma

  • A woman with a broken arm

A urinary tract infection (UTI), also referred to as cystitis, refers to an inflammation of the bladder from an infection, obstruction of the urethra, or other irritants. The most common causative agents are E. coli, Enterobacter, Pseudomonas, and Serratia species. Sexually active and pregnant women are at high risk of getting a UTI. Postmenopausal women are also vulnerable to cystitis (due to reduced estrogen levels, which lead to reduced levels of vaginal Lactobacilli bacteria, which protect against infection). 

Recommendations include using good perineal care (wiping from front to back), avoiding bubble baths, tub baths, and vaginal deodorants or sprays, voiding every 2 to 3 hours, wearing cotton pants and avoiding tight clothing, using estrogen vaginal creams to restore pH (if menopausal), and voiding and drinking a glass of water after intercourse. 

Asthma and fractures do not increase the risk or make a woman more susceptible to getting a UTI.

72.

All of the following are considered types of tube feeding except:

  • Intermittent

  • Bolus

  • Continuous

  • Cyclical

Correct answer: Intermittent

Tube feedings are administered through a gastrointestinal tube, for the patient who cannot take food by mouth. Tube feedings can be administered continuously (around the clock), cyclically (over 8 hours during the day or at night), or as a bolus feed (all at once over 30 or 60 minutes). The different types of feeds depend on the patient and their individual needs.

73.

The nurse is providing medication education to a patient newly diagnosed with hypothyroidism. The patient has been prescribed levothyroxine sodium. The nurse would instruct the patient to report which of the following symptoms, which are indicative of toxicity?

Select all that apply.

  • Excessive sweating

  • Palpitations

  • Lethargy

  • Intolerance to cold

  • Hypoglycemia

The patient taking a thyroid hormone is instructed to report symptoms of hyperthyroidism such as tachycardia, chest pain, palpitations, and excessive sweating. These signs are indicative of medication toxicity. 

Lethargy, hypothermia, and hypoglycemia are signs of hypothyroidism.

74.

The nurse is assessing a 52-year-old woman at a routine clinic appointment who has a history of depression. She reports her libido has been significantly decreased, and she worries her husband will leave her or have an affair. Which of the following factors would the nurse identify as significant in contributing to the patient's sexual difficulty?

Select all that apply.

  • Current list of medications

  • Physical health status

  • Quality of marital relationship

  • Education

  • Work history

Education and work history would have the least significance in relation to this patient's lack of libido and sexual desire. Depression, performance anxiety, and other sexual disorders can be strong contributing factors, even when organic causes also exist. While experiencing sexual problems can feel isolating, it’s actually fairly common. Certain antidepressants can cause a decreased libido and, while any woman can experience sexual dysfunction, older women tend to experience it more often. Quality of the relationship and physical health also play an important role in sexual performance.

75.

You are working in the endoscopy unit. You are preparing a patient for a colonoscopy. Why is it important to ensure that patients have refrained from taking any blood thinners (aspirin, NSAIDS, warfarin) for a week to 10 days prior to the procedure?

  • The examining doctor may have to perform a polypectomy during the procedure

  • Irritation of hemorrhoids from the bowel prep required may result in significant bleeding

  • The colonoscope often causes bleeding as it is advanced through the colon

  • Patients may form a hematoma at the IV site when the IV is removed

Correct answer: The examining doctor may have to perform a polypectomy during the procedure

Should the physician find a polyp during the procedure, it may be removed. Removal of polyps can cause brisk bleeding in patients taking blood thinners. For this reason, patients are counseled to discontinue taking blood thinners for a period of time prior to the procedure.

76.

The nurse is caring for a patient that has been prescribed a liquid medication. When preparing to administer this elixir, which of the following actions by the nurse are correct?

Select all that apply.

  • Place medication cup on a flat surface and at eye-level to measure

  • Place thumbnail at medicine cup line indicating amount to be given

  • Do not mix with other liquid medication in the same cup

  • Return excess medication to its container if too much was poured out of original container

  • Pour liquid from same side as bottle's label to ensure appropriate medication is being administered

To pour liquid medication accurately, the medication cup should be placed on a level surface at eye level and then poured while the nurse is reading the measuring markings (placing thumbnail at line indicating desired dose). Medicine cups have a capacity of 30 mL or 1 oz; if the dose is less than 5 mL, use a syringe specially designed for oral administration. Liquids should never be mixed with tablets or other liquids in the same medicine cup. Do not return poured medication to its original container; instead, properly discard poured medication if not used. Pour liquids from opposite side of bottle's label (not same side) to avoid spilling medicine onto the label. Offer ice chips before giving unpleasant-tasting medications in order to numb the patient's taste buds.

77.

Prior to delegating a task, the nurse should first:

  • Be certain the task can be delegated

  • Attempt to complete the task on his or her own

  • Be certain the delegatee can legally carry out the task

  • Call the physician for an order to permit delegation

Correct answer: Be certain the task can be delegated

Delegation of tasks is a multi-step process. First, the nurse should be certain the task is one which can be delegated to another health care worker. Then, the nurse should ensure the delegatee is legally able to carry out the task. Next, the task can be delegated by providing thorough and clear directions. Finally, the task should be evaluated to ensure completion, with the understanding that the nurse holds accountability for the care provided.

78.

Your 8-year-old patient has tonsillitis. The physician prescribes Amoxicillin 20 mg/kg po daily in 3 divided doses. Your patient weighs 71 pounds. How much medication will a single dose contain (in mg)? Round to the nearest whole number.

  • 213 mg

  • 757 mg

  • 640 mg

  • 160 mg

Correct answer: 213 mg

71 pounds is equivalent to 32 kg. 20 mg x 32 kg = 640 mg. 640 mg/3 = 213 mg. Each dose of Amoxicillin will equal 213 mg.

79.

What should you do in order to protect yourself from a back injury?

  • Push rather than pull

  • Pull rather than push

  • Use the back muscles for lifting

  • Use the short muscles instead of the long muscles

Correct answer: Push rather than pull

Pushing is safer than pulling in many ways, including maintaining good back health. It leads to less back stress and strain than pulling. Back muscles and short muscles should not be used; instead, the long muscles of the body are used to prevent back injuries.

80.

The licensed practical nurse (LPN) is obtaining vital signs on an adult patient who has come into clinic for an annual checkup. Which of the following values should the LPN report to the registered nurse (RN)? 

Select all that apply.

  • A blood pressure reading of 160/101

  • A respiratory rate of 24

  • An oxygen saturation reading of 89%

  • An oral temperature of 99 degrees Fahrenheit

  • A pulse rate of 83

The following ranges are normal for an adult:

  • Blood pressure (BP): Systolic pressure below 120 mm Hg and diastolic pressure below 80 mm Hg (120/80); a reading of greater than or equal to 160/100 mm Hg indicates stage 2 hypertension and needs to be addressed.
  • Respiratory rate: Normal is between 12 to 20 breaths/min; a respiratory rate of 24 indicates tachypnea and needs to be further assessed.
  • Oxygen saturation: A usual pulse oximetry reading is between 95% and 100%. A pulse oximetry reading of lower than 90% necessitates PHCP notification; values below 90% are acceptable only in certain chronic conditions.
  • Temperature: Normal body temperature ranges from 97.5F to 99.5F (36.4C to 37.5C). An oral temperature of 99F is considered within normal limits and does not necessitate further action.
  • Pulse: The average adult pulse (heart) rate is 60 to 100 beats/min. A pulse of 83 is within normal limits and does not necessitate further action by the LPN.
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