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Quiz Session - Attempts With Random Questions

NCLEX-PN Exam Questions

Page 9 of 50

161.

The purpose of inserting a chest tube is to:

  • Restore negative pressure in the intrapleural space

  • Provide positive pressure within the thoracic cavity

  • Provide positive expiratory pressure

  • Provide pain relief from increased intrathoracic pressure

Correct answer: Restore negative pressure in the intrapleural space

Insertion of a chest tube is an invasive procedure designed to restore negative pressure in the intrapleural space. When the normally negative pressure of the intrapleural space is disrupted, it causes the lung to collapse and a patient to develop respiratory symptoms. Therefore, the tube is placed to restore negative pressure until the underlying condition can heal. Conditions that commonly necessitate a chest tube include a pneumothorax, blunt chest trauma, empyema, or hemothorax.

162.

All of the following can help to prevent back injury of the health care worker except:

  • Ensuring housekeepers clean both sides of the hallway at one time

  • Ensuring both health care workers and patients wear good footwear while transferring or ambulating

  • Maintaining eye contact with the patient

  • Requesting additional help from co-workers for difficult transfers

Correct answer: Ensuring housekeepers clean both sides of the hallway at one time

In addition to using proper body mechanics, or ergonomics, additional measures may be taken to reduce the likelihood of a health care worker sustaining a back injury. Housekeepers should only clean one side of passageways at a time, to reduce the chances of fall or injury on wet surfaces. Additionally, good footwear should be used and eye contact made with patients at all times during transfers. Finally, it is appropriate to request additional assistance from co-workers for patients who may be more difficult transfers.

163.

The school nurse is performing lice checks on each child in the first grade class after one of the students came down with head lice (pediculosis capitis). Which of the following findings would indicate that a child has a "positive" head check? 

 Select all that apply.

  • Tiny white sacs are observed on the hair shaft that do not brush away

  • Small tan or greyish specks are observed moving throughout the scalp

  • Child scratches the scalp excessively

  • White flaky particles are observed throughout the entire scalp that flake away easily 

  • Lesions noted behind the ears 

Pediculosis capitis is an infestation of the hair and scalp with lice. The nits (white eggs) are seen on the hair shaft (dandruff is white flaky particles that flake away easily; nits do not brush away). Adult lice may be seen and appear as small tan or grayish specks, which can crawl quickly. 

Though head lice causes excessive itching and scratching, other conditions may cause this, too. It is important to observe actual nits or adult lice to diagnosis this condition. Lesions noted behind the ears would be more indicative of an infectious process than head lice.

164.

You are working in the emergency room when you are notified that the ambulance is bringing in a woman who has taken an overdose of Tylenol. You should anticipate administering which of the following drugs?

  • N-acetylcysteine

  • Calcium gluconate

  • Narcan

  • Sodium bicarbonate

Correct answer: N-acetylcysteine

The antidote to acetaminophen overdose is N-acetylcysteine (NAC). It is most effective when given within 8 hours of ingesting acetaminophen. NAC can prevent liver failure if given early enough.

165.

You are teaching a patient with newly diagnosed hypertension how to take an accurate blood pressure reading at home with an automatic blood pressure monitor. Which of the following statements is false?

  • Your arm should be positioned so that it is below the level of your heart

  • You should not smoke or drink coffee for 30 minutes prior to taking your blood pressure

  • You should not take your blood pressure around a long sleeve--a bare arm will provide the most accurate reading

  • You should sit for 5 minutes before taking your blood pressure

Correct answer: Your arm should be positioned so that it is below the level of your heart

When taking a blood pressure reading, the arm should be supported at the level of the heart. You should rest for 5 minutes before obtaining a blood pressure reading. Drinking coffee or smoking prior to taking your blood pressure may cause an elevation in blood pressure.

166.

What is the primary purpose of the continuity of care?

  • To ensure seamless, coordinated quality care

  • To ensure the least costly care possible

  • To facilitate communication among providers

  • To integrate the patient into the community

Correct answer: To ensure seamless, coordinated quality care

The primary purpose of the continuity of care is to ensure seamless, coordinated quality care along the continuum of care as the client condition changes. The continuum of care moves and transitions the client from one area of a facility to another (transfer). It also moves the client to a different level of care in the community (discharge).

167.

The nurse is working with older clients in a long-term care facility. Which of the following activities performed by the nurse fosters reminiscence among these clients?

  • Storytelling hours

  • Pet therapy sessions

  • Calendars and clocks

  • Pottery classes

Correct answer: Storytelling hours

Clients who like to retell stories or past events need to be provided the opportunity to do so. This phenomenon is called life review or reminiscence.

168.

You are caring for a 76-year-old client who has had recent surgery. When you arrive at work at 7a.m., you notice that this client is confused and you learn that the client is now affected with an electrolyte imbalance. With which disorder is this client most likely affected?

  • Delirium

  • Dementia

  • Hypernatremia

  • Hyperkalemia

Correct answer: Delirium

Delirium can be caused by a number of factors, including electrolyte and metabolic imbalances. Delirium, unlike dementia, appears suddenly and is often reversible once the underlying cause, like an electrolyte imbalance, is treated.

169.

You are caring for a patient who has been diagnosed with AIDS following treatment for PCP (pneumocystis pneumonia). The patient's CD4 count is 300. You know that the guidelines for antiretroviral therapy state that patients should be started on therapy when the CD4 count:

  • is less than 350 cells/mm3

  • is less than 500 cells/mm3

  • is between 400 and 500 cells/mm3

  • is greater than 500 cells/mm3

Correct answer: Is less than 350 cells/mm3

Antiretroviral therapy should be initiated in all patients with a history of an AIDS-defining illness or with a CD4 count <350 cells/mm3 . The presence of an AIDS-defining illness, such as PCP, also dictates that antiretroviral therapy should be started.

170.

Which of the following is a complete and well-written expected patient outcome or goal?

  • The client will ambulate at least 20 feet, three times a day, with a walker

  • The client will understand the need for ambulation

  • The nurse will assist the client to ambulate at least 20 feet, three times a day, with a walker

  • The nurse will help the client to understand the need for ambulation

Correct answer: The client will ambulate at least 20 feet, three times a day, with a walker

The SMARTTA framework can be used for setting goals:
• S= Specific
• M= Measurable
• A= Achievable
• R= Realistic
• T= Timeframe
• T= Trackable
• A= Agreed to by the client and significant other(s)

171.

Which of the following are indications of true labor?

Select all that apply.

  • Contractions occur regularly

  • Contractions become stronger, last longer, and occur closer together

  • The fetus becomes engaged in the pelvis and begins to descend

  • Contractions are present and irregular

  • Contractions are primarily felt in the upper abdomen and/or groin

With true labor, contractions are regular, increasing in intensity and duration with walking. They are often felt in the lower back and radiate to the lower portion of the abdomen. Bloody show is often present, and cervical dilation and effacement are progressive. The fetus often engages and descends down into the birth canal. 

False labor often includes contractions that are irregular and more annoying than painful. These contractions may be felt in the upper abdomen or groin area, and there is no cervical dilation with walking. The fetal head may not be engaged yet in the pelvis.

172.

Contraindications to paracentesis include:

  • All of these

  • Bowel distension

  • Cellulitis at the proposed puncture site

  • A confused and agitated patient

Correct answer: All of these

All of these are contraindications to paracentesis. Fluid replacement is considered strictly optional for paracentesis of more than 5 and is generally no longer recommended for paracentesis of a smaller volume.

173.

According to Elizabeth Kubler-Ross, all of the following are considered stages of grief except:

  • Resentment

  • Acceptance

  • Depression

  • Bargaining

Correct answer: Resentment

Elizabeth Kubler-Ross, a psychiatrist, proposed a model that describes five stages commonly seen in those experiencing grief. These stages, which can occur in any order, include: denial, anger, bargaining, depression and acceptance. The acronym "DABDA" can be used to help recall the five stages of grief.

174.

What type of immunity is acquired through the use of immunizations?

  • Active

  • Passive

  • Natural

  • Innate

Correct answer: Active

Active immunity is the type of immunity acquired through the use of immunizations. A vaccine or immunization stimulates a primary response against the antigen without causing symptoms of the disease. There are four different types of vaccines, which include live or attenuated, inactivated, toxoid, and subunit vaccines.

175.

The organization responsible for promoting safer, higher quality care among hospital organizations in addition to evaluating and providing accreditation is known as:

  • The Joint Commission (TJC)

  • The American Hospitals Association (AHA)

  • The American Nurses Association (ANA)

  • The Department of Health and Human Services (HHS)

Correct answer: The Joint Commission

The Joint Commission is a non-profit organization that works to promote safer, higher quality care in hospital organizations. The Joint Commission is also responsible for evaluating and designating organizations with accreditation. Finally, the Commission publishes annual patient safety goals in order to improve overall patient safety.

176.

A patient has been prescribed digoxin for heart failure, and the nurse is providing medication education regarding digoxin therapy. Which of the following signs and symptoms should the nurse instruct the patient to monitor for that are early manifestations indicative of digoxin toxicity? 

Select all that apply.

  • Nausea and vomiting

  • Diarrhea

  • Weight loss

  • Heart rate abnormalities

  • Visual disturbances

Early signs of digoxin toxicity present as gastrointestinal manifestations (think anorexia, nausea, vomiting, diarrhea); then heart rate abnormalities (bradycardia, heart block, premature ventricular contractions, tachydysrhythmias), and visual disturbances (diplopia, blurred vision, yellow-green halos, photophobia) appear as late signs of toxicity. While a patient is on digoxin therapy, serum digoxin levels should be monitored, as well as electrolyte levels and renal function tests.

177.

Which of the following are early signs of the presence of a cataract?

Select all that apply.

  • Blurred vision

  • Decreased color perception

  • Double vision

  • Absence of the red reflex

  • Reduced visual acuity

A cataract is an opacity (cloudiness) of the lens of the eye that distorts the image projected onto the retina and can progress to blindness if left untreated. Vision loss is gradual, and causes include aging (senile cataracts), hereditary (congenital cataracts), and injury (traumatic cataracts). If there is eye redness or pain, the cataract is likely age-related.

Early signs include blurred vision and decreased color perception. Late signs include diplopia (double vision), reduced visual acuity, absence of the red reflex, and the presence of a white pupil. 

178.

Of the following minors, which cannot provide their own informed consent?

  • Minors seeking elective surgery

  • Pregnant minors

  • Minors seeking psychiatric services

  • Married minors

Correct answer: Minors seeking elective surgery

There are select cases in which a minor does not need a legal guardian or parent to provide informed consent. Examples of these cases include: pregnant minors, married minors, minors that are seeking inpatient or outpatient psychiatric services, emancipated and mature minors, minors seeking birth control services, and minors over a specific age (usually 12) that are seeking STD, HIV, alcohol, or drug rehabilitation treatment.

A minor seeking elective surgery would require informed consent of a legal guardian.

179.

The nurse is caring for a patient hospitalized for an exacerbation of Crohn's disease and suspects the patient is suffering from hypocalcemia. Which of the following are clinical signs of hypocalcemia? 

Select all that apply.

  • Positive Chvostek's sign

  • Positive Trousseau's sign

  • Prolongation of QT interval

  • Bradycardia

  • Positive Brudzinski's sign

Tests for hypocalcemia are Chvostek's and Trousseau's signs. When lightly tapping the cheek (the facial nerve in front of the ear), there will be a contraction of facial muscles if the Chvostek's sign is positive. Trousseau's sign is a carpal spasm induced by inflating a blood pressure cuff above the patient's systolic pressure for a few minutes. When observing an EKG strip, the QT interval will be prolonged if hypocalcemia is present. The patient is tachycardic, not bradycardic; Brudzinski's sign tests for meningitis, not hypocalcemia.

180.

A therapy for depression that involves administering a small amount of electric current through electrodes placed on the skull, resulting in a brief seizure, is called:

  • Electroconvulsive therapy

  • Electrocardiogram therapy

  • Electroencephalogram therapy

  • Electrostimulation therapy

Correct answer: Electroconvulsive therapy

Electroconvulsive therapy (ECT) is an intervention used to treat depression, but is not a cure. It involves placing electrodes on the skull near the temples and administering a small amount of electrical current to induce a brief seizure. The treatments are usually repeated several times over 3-5 day intervals, with the possibility of monthly maintenance therapy to control any recurrent depressive symptoms.

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