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Quiz Session - Attempts With Random Questions

NCLEX-PN Exam Questions

Page 7 of 50

121.

Your client has schizophrenia. What symptoms/signs would you expect to see?

  • Auditory hallucinations, delusions of grandeur, loose associations

  • Sadness, feelings of worthlessness, anorexia

  • Periods of hyperactivity alternating with periods of depression

  • Mistrust, paranoia, delusions of persecution and jealousy

Correct answer: Auditory hallucinations, delusions of grandeur, loose associations

Auditory hallucinations, delusions of grandeur and loose associations are all typical of schizophrenia. These clients may hear voices telling them to do something to themselves or to others. Their physical appearance is often unkempt. They often ramble from one subject to another (loose associations).

122.

Your patient has just had arterial blood gases drawn and you must interpret the results. Identify the normal value:

  • pH 7.35

  • PaCO2 32

  • PaO2 107 mmHg

  • HCO3 28 mEq/L

Correct answer: pH 7.35

Normal pH is 7.34 to 7.45. Normal PaCO2 is 33 to 45 mmHg. Normal PaO2 is 75 to 105 mmHg. Normal HCO3 is 22 to 26 mEq/L.

123.

The nurse is caring for a patient with kidney disease. The nurse understands this patient is at high risk for which of the following conditions related to renal insufficiency?

Select all that apply.

  • Fluid volume excess

  • Potassium imbalances

  • Sodium imbalances

  • Fluid volume deficit

  • Diabetes mellitus

A patient with kidney damage or failure is at high risk for fluid volume excess due to the inability of the kidney(s) to properly filter fluids out of the body. In addition, there will be electrolyte imbalances present (including potassium and sodium) as the kidneys are not functioning properly. Diuretics and/or dialysis is often indicated for kidney failure. 

Though untreated or poorly managed diabetes could cause kidney disease, the patient with kidney disease is not at high risk for the development of diabetes.

124.

You are caring for a patient who has suffered a traumatic brain injury (TBI). In what position should the patient be placed to optimize cerebral perfusion pressure and decrease intracranial pressure?

  • Head midline, with the head of the bed elevated 15 to 30 degrees

  • Head midline with the patient in high Fowler's position

  • Head deviated to the left with the patient lying supine

  • Head deviated to the right with the patient lying on their left side

Correct answer: Head midline, with the head of the bed elevated 15 to 30 degrees

The patient's head is positioned midline to encourage jugular venous drainage and the head of the bed is elevated to 15 to 30 degrees. These methods have been found to be effective in decreasing intracranial pressure and optimizing CPP in adult patients with TBI. Both increasing the head of the bed beyond 30 degrees and decreasing the head of the bed below 15 degrees have been associated with increased ICP and/or decreased CPP.

125.

You are the licensed practical nurse in the team that is caring for a group of 25 patients. The team also has a registered nurse (RN), another licensed practical nurse/licensed vocational nurse (LPN/LVN), and nursing assistants. The nurse who delegates and assigns tasks to other nursing staff, according to their scope of practice, is responsible to do what?

  • Supervise the delegee

  • Manage the delegee

  • Retain authority relating to the task and its completion

  • Retain the responsibility related to the task and its completion

Correct answer: Supervise the delegee

The nurse who delegates and assigns tasks to other nursing staff supervises and follows up on those delegated tasks. Delegation is the act of assigning the authority and responsibility for aspects of client care to another, according to their scope of practice and level of competency, including other considerations. The nurse who delegates to others retains accountability for the completion and quality of the care that has been delegated, so supervision is critically important.

126.

An emergency department nurse receives a call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the emergency department. What is the initial nursing action?

  • Activate the agency disaster plan

  • Prepare the triage room

  • Obtain additional supplies from central supply

  • Obtain additional nursing staff to assist in treating the casualties

Correct answer: Activate the agency disaster plan

In an external disaster, many victims may be brought to the emergency room for treatment. The other options may be components of preparing for the casualties. The initial nursing action is to activate the agency disaster plan.

127.

Which hormone of reproduction is correctly and accurately paired with its function and role during pregnancy?

  • Human chorionic gonadotropin: Prevents the shedding of the endometrium

  • Gonadotropin releasing hormone: Stimulates milk letdown during lactation

  • Progesterone: Increases uterine contractility during labor

  • Oxytocin: Stimulates the pituitary gland to release luteinizing hormone

Correct answer: Human chorionic gonadotropin: Prevents the shedding of the endometrium

Among the several hormones of pregnancy and reproduction is human chorionic gonadotropin, which prevents the shedding of the endometrium during pregnancy as it normally does during the nonpregnancy state. Other hormones include oxytocin, gonadotropin releasing hormone, and progesterone.

128.

The nurse manager is conducting a study to determine hand washing compliance, then plans to revise the unit policy according to the results. The purpose of this activity is:

  • Quality improvement

  • Research study

  • Identifying employees who are deficient

  • Saving money on hand washing cost

Correct answer: Quality improvement

Quality improvement activities are conducted within health care systems to identify areas of deficiency and revise or create policies that promote better care. By conducting a study on hand washing compliance, the unit manager is collecting the data necessary to revise the current policies. Hand washing is a critical measure in patient care, and can have an adverse effect on patients and health care workers if it is not utilized effectively.

129.

Your patient's physician has ordered an intravenous pyelogram. What should you include in your teaching regarding this procedure? Identify the correct information.

  • Patients who are diabetic, especially those taking Glucophage, are at risk for kidney failure due to the contrast dye used in the procedure

  • It is preferable that patients be slightly dehydrated prior to the procedure

  • Barium helps to outline the organs, making it easier to identify abnormalities such as stricture

  • This test is an alternative for patients who are allergic to iodine

Correct answer: Patients who are diabetic, especially those taking Glucophage, are at risk for kidney failure due to the contrast dye used in the procedure

The test may be contraindicated for patients who are severely dehydrated. Barium is not used in this procedure. Iodine allergy is a contraindication for this procedure.

130.

The purpose of an advance directive is to:

  • Establish one's end-of-life care preferences ahead of time

  • Direct one's next of kin to appropriate legal teams at the end of life 

  • Provide health care workers with advance notice regarding whether a patient should be admitted to the hospital or not

  • Provide health insurance to the elderly

Correct answer: Establish one's end-of-life care preferences ahead of time

An advance directive is a legal document put in place to establish, or define, one's end-of-life care preferences ahead of time. The document only goes into effect when one becomes incapacitated and is unable to speak for himself/herself. Within the advance directive are medical decisions, which impact the type and extent of care provided. These medical decisions are related to ventilator support, CPR, supplemental nutrition including tube feeding, and comfort care measures.

It is essential to inquire of a patient, upon admission, whether or not they have an advance directive in place. If they do, a copy should be placed in their file and appropriate notations made in the chart regarding CPR, code status, etc.

131.

The licensed practical nurse is caring for a baby in the outpatient clinic. The baby's father inquires when it would be appropriate to introduce solid foods. The LPN replies:

  • Around 5 months

  • Around 1 year

  • Around 3 months

  • Around 9 months

Correct answer: Around 5 months

Solid foods may be safely introduced around 5 months of age. It is best to recommend parents start with a food that is least likely to trigger allergies, such as rice cereal. The gastrointestinal tract of the infant is expected to be matured by 5 months of age and thus be able to digest solid foods. Infants also should have the coordination to move food from the front to the back of their mouths by this time.

132.

An infant is born with tetralogy of Fallot (TOF). The nurse caring for this infant understands that this condition is comprised of which of the following cardiac defects? 

Select all that apply.

  • Ventricular septal defect (VSD)

  • Pulmonary stenosis

  • Overriding aorta

  • Right ventricular hypertrophy

  • Atrial septal defect (ASD)

  • Aortic stenosis

TOF, a congenital, structural heart condition, is comprised of four defects: 

  1. VSD
  2. Pulmonary stenosis
  3. Overriding aorta
  4. Right ventricular hypertrophy

These structural defects cause oxygen-poor blood to flow out of the heart and to the rest of the body, resulting in cyanosis (from deoxygenated blood entering the systemic arterial circulation). With early diagnosis and appropriate surgical treatment, most individuals with TOF can lead relatively normal lives. 

133.

The nurse is preparing for the admission of a patient with a sealed radiation implant. When providing care, which of the following interventions should the nurse implement? 

Select all that apply.

  • The patient should be in a private room with a private bath

  • Nursing assignments to this patient should be rotated

  • Wear a lead shield when providing direct patient care

  • Limit exposure time to 1 hour per care provider per 8-hour shift 

  • Visitors should be limited to 2 hours per day and should be at least 3 feet from the source 

A sealed radiation source is a type of chemotherapy and is implanted within the tumor target tissues. The patient emits radiation while the implant is in place. When caring for a patient with a sealed radiation implant, place them in a private room with a caution sign on the door. Rotate nursing assignments to limit exposure and limit direct care to 30 minutes per care provider per 8-hour shift (always wearing a lead shield to reduce the transmission of radiation). Likewise, visitors should be limited to 30 minutes per day and should be at least 6 feet from the patient (radiation source).

134.

The nurse provides dietary education to a patient newly diagnosed with type 2 diabetes mellitus. Which of the following statements made by the patient indicate an understanding of the newly prescribed diabetic diet?

Select all that apply.

  • "I will eat a balanced meal plan."

  • "I will choose fruit instead of processed sugars when I am craving something sweet." 

  • "I will switch from drinking regular soda to diet soda."

  • "I will need to eat multiple small meals throughout the day."

  • "I will need to purchase special diabetic foods."

When educating a newly diagnosed diabetic patient on a diabetic diet, it is important to emphasize to the patient and family that this is a healthy-eating plan that is naturally rich in nutrients and low in both fats and calories. Whole grains, fruits, and vegetables are staples of this diet, and it is, in fact, the best eating plan for most of the population. It is not necessary for the patient to purchase special diabetic foods. 

The diet should be individualized to the patient's weight, medication, activity level, and other health complications. If the patient is not already eating several small meals each day, there is no need to start this with the newly prescribed diabetic diet. However, the patient should be instructed to recognize signs of hypoglycemia and eat extra food if needed (should not be deducted from regular meal plan). Though the goal would be to eliminate soda altogether, the patient could start by eliminating regular soda and replacing it with diet (sugar-free).

135.

Which sign or symptom would you most likely expect to observe when a client is experiencing panic?

  • Dilated pupils

  • Mild agitation 

  • Attention-seeking behavior

  • Fatigue

Correct answer: Dilated pupils

Dilated pupils are a sign of a panic attack. Other signs and symptoms associated with panic attacks include sheer terror, chest pain, tremors, and physical exhaustion.

136.

Which of the following is an example of a crystalloid solution?

  • All of these

  • Lactated Ringer's solution

  • Normal saline

  • Hypertonic saline

Correct answer: All of these

Crystalloid solutions are balanced electrolyte/salt solutions that can pass through semipermeable membranes and may be hypertonic, hypotonic or isotonic.

137.

A nurse is reinforcing nutrition instructions to an Asian American patient. When reviewing the plan of care, the nurse is aware that which of the following foods may be included in common dietary practices in the Asian American heritage? 

Select all that apply.

  • Raw fish

  • Rice

  • Vegetables

  • Fried foods

  • Cornmeal

Asian American food preferences usually include raw fish, rice, and vegetables. These foods should be included in the plan of care if possible. 

Fried foods are often a part of the African American diet. Cornmeal is a staple in various groups of the Native American diet.

138.

A binding agreement between two or more parties that defines specific terms of an agreement is known as a:

  • Contract

  • Declaration

  • Legal agreement

  • Consent form

Correct answer: Contract

A contract is a binding agreement between two or more parties that defines specific terms of an agreement. Within the nursing profession, a contract may be created between the employer and the nurse that specifies job and performance expectations. The contract should also discuss compensation as a result of the services provided by the nurse. Should one of the parties fail to uphold their obligation within the contract, a breach of contract is said to have occurred.

139.

You are explaining a procedure to a patient who is a Chinese American. During your explanation of the treatment, the patient continuously smiles and nods. You take this to mean:

  • The patient is displaying behavior typical of her culture

  • The patient understands your explanation

  • The patient agrees with your explanation

  • The patient does not speak English and a translator is required

Correct answer: The patient is displaying behavior typical of her culture

Interpersonal harmony is valued by persons of the Chinese culture, signified by nodding and smiling. Nodding and smiling should not be interpreted as the patient giving consent or showing approval or agreement with what you are saying.

140.

Patients who are visual learners will learn best from:

  • Diagrams

  • Audio lectures

  • Discussion

  • Examining a scale model

Correct answer: Diagrams

Visual learners learn by seeing; therefore, any tool or teaching method that allows them to visualize learning material will be of value.

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