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Quiz Session - Attempts With Random Questions

NCLEX-PN Exam Questions

Page 6 of 50

101.

Your patient, who is recovering from heart surgery, suddenly becomes unresponsive. You determine that the patient is apneic and pulseless and begin CPR, calling for help as you do so. The cardiac monitor shows a wide, regular and rapid rhythm. You know that this rhythm is probably:

  • Ventricular tachycardia

  • Paroxysmal supraventricular tachycardia

  • Ventricular fibrillation

  • 3rd-degree AV block

Correct answer: Ventricular tachycardia

Ventricular tachycardia appears as a wide, rapid and regular rhythm on the cardiac monitor or ECG. A recent history of angina, CHF or MI makes it more likely that the rhythm is ventricular tachycardia, rather than a more benign rhythm with aberrancy.

102.

A new mother is breastfeeding her 2-month-old infant. She is concerned that the infant is "not getting enough to eat". The infant's weight is appropriate for its age and the infant appears well-nourished. The mother reports 4 to 5 wet diapers per day and 3 to 4 yellow loose stools. Which of the following responses will best provide the new mother with reassurance that her infant is getting enough nourishment?

  • "If your baby is urinating and stooling several times a day and is gaining weight, you can feel confident that he is getting enough nourishment."

  • "All new mothers worry about whether their baby is getting enough to eat."

  • "Are you sure the baby is feeding often enough?"

  • "I will send you to a lactation consultant if you are concerned."

Correct answer: "If your baby is urinating and stooling several times a day and is gaining weight, you can feel confident that he is getting enough nourishment."

Providing the mother with concrete feedback (number of wet and soiled diapers are adequate and weight is increasing) gives the mother positive feedback to focus on and teaches her what to watch for. Telling her that all new mothers worry does little to ease her anxiety. Asking her whether she is certain the baby is feeding often enough sounds critical and will not reassure an anxious mother. There is no need to consult a lactation consultant if the baby is doing well, unless the mother requires further reassurance.

103.

Concepts formed as a result of culture, family, friends, education, and work are known as:

  • Values

  • Religion

  • Ideas

  • Principles

Correct answer: Values

Values are defined as the concepts formed as a result of one's exposure to family, friends, work, education, and culture. Values hold a positive connotation and provide the framework through which one carries out their daily business.

As a nurse, it is important to be aware of an individual's value system in order to work toward a therapeutic nurse-patient relationship. Additionally, one's values will ultimately guide important treatment decisions; therefore, it is important for the nurse to understand the values of the patient.

104.

Which statement about bone healing is accurate?

  • Callus formation is a phase of bone healing

  • Hip fractures usually completely heal in about seven weeks

  • Complete bone healing for minor fractures occurs in about three weeks

  • Hemolysis is the second stage of bone healing

Correct answer: Callus formation is a phase of bone healing

The other phases of bone healing are hematoma formation, not hemolysis; fibrin mesh formation; osteoblast invasion; and remodeling. Fractures, other than a major fracture of the hip, are usually completely healed in six to eight weeks, and this healing process typically begins approximately 48 hours after the trauma or injury. Hip fractures take about 16 weeks to heal.

105.

A nurse is teaching a postpartum client about breastfeeding. Which of the following instructions should the nurse include?

  • The diet should include additional fluids

  • Prenatal vitamins should be discontinued

  • Soap should be used to cleanse the breasts

  • Birth control measures are not necessary while breastfeeding

Correct answer: The diet should include additional fluids

The diet for a breastfeeding client should include additional fluids. Prenatal vitamins should be taken as prescribed, and soap should not be used on the breast because it tends to remove natural oils, which increases the chance of cracked nipples. Birth control measures need to be resumed.

106.

A Chinese couple has just given birth to a baby boy and are on the postpartum unit. They refuse to allow the nurse to give their son a bath. The most appropriate response by the nurse is:

  • Acknowledge the couple's refusal of the bath

  • Explain to the couple that the baby should be bathed for infection-prevention purposes

  • Notify the social worker of the couple's refusal to participate in adequate hygiene practices

  • Continue to ask the couple if the baby may be bathed

Correct answer: Acknowledge the couple's refusal of the bath

Cultural competency is awareness regarding another individual's cultural needs and beliefs. In nursing, it allows the nurse to see each patient as a unique individual and respect their wishes regarding usual care. In Chinese culture, there is a belief that water is harmful to the mother and baby and therefore it is avoided in the early postpartum period. The appropriate response by the culturally competent nurse is to acknowledge the couple's refusal of the bath due to their cultural beliefs.

107.

When instructing a patient on how to find their radial pulse, the nurse explains:

  • Place two fingers over the inner wrist at the base of the thumb

  • Place two fingers on the inner elbow

  • Place two fingers along the side of the neck

  • Place two fingers on the inner aspect of the thigh near the groin

Correct answer: Place two fingers over the inner wrist at the base of the thumb

The radial pulse can be found by placing two fingers on the radial artery, which is located at the inner wrist near the base of the thumb. The patient may need to move their fingers around in order to feel the pulse sensation. The thumb should never be used to palpate a pulse, as this can interfere with accurately identifying the pulse.

108.

You are caring for a patient who is receiving a continuous heparin infusion to treat deep vein thrombosis (DVT). The patient's activated partial thromboplastin time (aPTT) is 75 seconds. You review the laboratory results with the registered nurse, anticipating which action is needed?  

  • Leaving the rate of the heparin infusion as is

  • Discontinuing the heparin infusion 

  • Increasing the rate of the heparin infusion

  • Decreasing the rate of the heparin infusion 

Correct answer: Leaving the rate of the heparin infusion as is

A normal aPTT varies between 30 and 40 seconds, depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of DVT is to keep the aPTT between 1.5 and 2.5 times normal. 

This means that the patient's value would not be less than 45 seconds (1.5*30)  or greater than 100 seconds (2.5*40). Therefore, the patient's aPTT is within the therapeutic range at 75 seconds, and the dose would remain unchanged. 

109.

All of the following routes are considered parenteral methods of administration except:

  • Rectal

  • Intravenous

  • Intraosseous

  • Intradermal

Correct answer: Rectal

Enteral administration involves the esophagus, stomach, and small and large intestines (e.g., the gastrointestinal tract). Methods of administration include oral, sublingual, and rectal. Parenteral routes do not involve the gastrointestinal tract. Parenteral routes include intraosseous, intravenous, intradermal, and intramuscular, to name a few.

110.

Medicare does not reimburse for certain conditions that can be prevented within a hospital. Examples of such conditions include all of the following except:

  • Pneumothorax

  • Air embolism

  • Blood incompatibility

  • Pressure ulcers

Correct answer: Pneumothorax

In 2008 Medicare issued a new policy that certain preventable conditions that occur within a hospital would not be reimbursed. There are many conditions currently not reimbursed and the list continues to grow each year. Examples of conditions not currently reimbursed include air embolism, blood incompatibility, pressure ulcers, mediastinitis following CABG, catheter-associated infections, objects inadvertently left in place following surgery, and more. At this time, pneumothorax is not an example of a preventable condition that is not reimbursed.

111.

The licensed practical nurse (LPN) is caring for a patient who is receiving intravenous (IV) antibiotic therapy. The LPN notes a bolus of air in the IV tubing and immediately stops the infusion due to the risk of air embolism. Which of the following manifestations would the patient exhibit if an air embolism is present?

Select all that apply.

  • Tachycardia

  • Cyanosis

  • Dyspnea

  • Increased blood pressure

  • Distended jugular veins

An air embolism occurs during IV therapy when a bolus of air enters the vein through an inadequately primed IV line, from a loose connection, during a tubing change, or the removal of an IV. Signs include tachycardia, chest pain and dyspnea, hypotension (not hypertension), cyanosis, and a decreased level of consciousness. The tubing should be completely primed with fluid prior to initiation of therapy to prevent air boluses in the line, and the nurse should monitor the tubing closely for any air bubbles. All connections should be secure, and IV fluid bags or bottles should be replaced prior to becoming completely empty.

If an air bolus is suspected, the LPN should immediately notify the RN, the tubing should be clamped, and the patient turned onto the left side with the head of the bed lowered (Trendelenburg position) to trap the air in the right atrium. Notify the primary health care provider (PHCP). 

Distended jugular veins may be observed in the case of circulatory overload from IV therapy, not an air embolism.

112.

Your patient is going for an MRI. It is important to ask if the patient:

  • Has a pacemaker

  • Has a fear of the dark

  • Has an allergy to contrast dye

  • Has a prosthetic limb

Correct answer: Has a pacemaker

Patients who have pacemakers cannot have an MRI, as the MRI may cause malfunctioning of the pacemaker. No contrast dye is used for MRIs. A prosthetic limb could be removed prior to the MRI.

113.

You have verified the patient's consent for a blood transfusion. Vital signs have been obtained and the client has an appropriate-sized IV in place. What should you check prior to obtaining the cross-matched blood from the blood bank?

  • Ensure that there is a physician's order present on the chart

  • Ensure that the patient has not changed his/her mind

  • Ensure that the physician has left orders for Benadryl and Tylenol in case of reaction

  • Ensure that the patient has no allergies

Correct answer: Ensure that there is a physician's order present on the chart

Check for a valid physician's order prior to checking blood out of the blood bank. The order should state how many units are to be infused, as well as how long each unit is to be infused over. Blood must be infused within 4 hours.

114.

The correct ratio of compressions to ventilations in child CPR with 2 rescuers is:

  • 15 to 2

  • 30 to 2

  • 15 to 1

  • 30 to 1

Correct answer: 15 to 2

When 2 rescuers are present, the ratio of compressions to ventilations is 15:2. When a single rescuer is present, the ratio is 30:2

115.

Your patient has just had carpal tunnel surgery to his left wrist. What should you check frequently following any surgery on a limb?

  • Color, sensation and movement

  • Color, edema and hand grip

  • Pain, movement and length of the cast

  • Edema, pain and hardness of the cast

  • All of these

Correct answer: Color, sensation and movement

Color, sensation and movement (CSM) should be checked frequently to assess adequacy of circulation following any surgery or procedure affecting the extremities.

116.

Which of the following incidences need to be reported to hospital risk management?

Select all that apply.

  • Any patient fall

  • Needle-stick injuries

  • A visitor who exhibits symptoms of a communicable disease

  • An inappropriate prescription that the nurse clarifies before administering to the patient

  • A patient who is going for surgery and signs informed consent one hour prior to the procedure

Risk management is a strategic method to identify, analyze, and evaluate risks, followed by a plan for reducing the frequency of accidents and injuries. Incident reports are utilized as a means of identifying risk situations and improving patient care. 

Incidents that needs to be reported include:

  • Accidental omission of prescribed therapies
  • Circumstances that led to injury or a risk for patient injury
  • Patient falls
  • Medication administration errors
  • Needle-stick injuries
  • Procedure- or equipment-related accidents
  • A visitor injury that occurred on the health care agency's premises
  • A visitor who exhibits symptoms of a communicable disease

As long as informed consent is signed prior to a procedure, and the nurse clarifies an inappropriate prescription before administering it to the patient, there is no need to complete an incident report.

117.

Your patient has an area on his coccyx measuring 2 cm by 2 cm. Yellow slough is present, as well as some granulation tissue. You can visualize subcutaneous fatty tissue but no bone or muscle is visible. The wound is 4 cm in depth and tunneling is present at 2:00. This wound most likely represents what stage of pressure ulcer?

  • Stage III

  • Stage II

  • Stage I

  • Stage IV

Correct answer: Stage III

Stage III pressure ulcers involve full thickness tissue loss. Bone, tendons, muscle or other structures are not visible. Slough may be present. Undermining/tunneling may be present. Depth will vary by anatomic location.

118.

Your patient is in third degree AV block. His heart rate is 36 bpm and BP is 74/48. He is confused and is experiencing chest discomfort. The physician has made the decision to pace the patient with the transcutaneous pacemaker. What should you do to prepare the patient prior to pacing?

  • Remove excess hair from the patient's chest in the areas where the pacing pads will go

  • Keep the patient awake and alert so that he can convey how he is feeling

  • Place the anterior lead on the patient's back and the posterior lead on the patient's chest

  • Select a lead that maximizes amplitude of the T wave

Correct answer: Remove excess hair from the patient's chest in the areas where the pacing pads will go

Removing excess hair ensures that there will be good contact between the pacing pads and the skin. If the patient is awake and able to feel pain, consider sedation if there is time. Pads may be placed in the anterior-posterior position or the anterior-anterior position (most common). Select a lead that maximizes the amplitude of the R wave, not the T wave.

119.

The nurse is assessing the casted extremity of a patient. The nurse should check for signs and symptoms that would indicate impaired circulation, including: 

Select all that apply.

  • Tingling and numbness

  • Dependent edema

  • Discoloration and reports of pain

  • Diminished pulse

  • Presence of a "hot spot" on the cast

  • Odor or purulent drainage from the cast

The nurse should monitor a casted extremity for circulatory impairment such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse. If any of these signs are present, the RN and PHCP should be notified immediately. 

Signs and symptoms of infection under a casted extremity include "hot spots" on the cast, foul odor, purulent drainage, changes in pain, and fever. These should also be reported to RN and PHCP immediately.

120.

Which of the following laboratory value changes are reflected in the patient with respiratory acidosis?

Select all that apply.

  • Decreased pH

  • Decreased PaO2

  • Increased PaCO2

  • Hypokalemia

  • Decreased HCO3

In the acid-base imbalance respiratory acidosis, laboratory values are as follows:

  • pH is decreased (less than 7.35)
  • Bicarbonate (HCO3) is normal or increased (21-28 mEq/L or higher)
  • Partial pressure of oxygen in arterial blood (PaO2) is decreased (less than 80 mm Hg)
  • Partial pressure of carbon dioxide in arterial blood (PaCO2) is increased (45 mm Hg or greater)
  • Potassium levels are elevated (hyperkalemia)

Common causes of respiratory acidosis include conditions that obstruct the airway or depress the respiratory system.

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