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Quiz Session - Attempts With Random Questions

NCLEX-RN Exam Questions

Page 10 of 65

181.

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.

182.

Your patient who was critically injured in a motor vehicle accident (MVA) and has suffered splenic rupture, has returned from the operating room (OR) to the intensive care unit (ICU) and has an order on his chart to receive 2 units of packed red blood cells (PRBC's). Following proper protocol for administration of a blood product, you initiate the transfusion. Within 10 minutes, you observe visible hemoglobinuria in your patient's urinary catheter bag, his blood pressure drops, and he has a temperature of 101.7 Fahrenheit.

You should perform all of the following priority nursing actions except:

  • Remove the blood bag from the intravenous line and replace it with a bag of normal saline to keep the line open

  • Notify the intensivist of the patient's symptoms

  • Stop the transfusion

  • Administer acetaminophen and diphenhydramine

Correct answer: Remove the blood bag from the intravenous line and replace it with a bag of normal saline to keep the line open

Any time blood products are being administered, patients should be closely monitored for signs and symptoms of a transfusion reaction. If a transfusion reaction is suspected, the nurse should perform the following priority actions:

  • stop the transfusion
  • change the intravenous (IV) tubing down to the IV site and keep the IV line open with normal saline
  • notify the health care provider and the blood bank
  • stay with the patient, continuing to observe for signs and symptoms and monitoring vital signs as often as every 5 minutes
  • prepare to administer emergency medications as prescribed
  • obtain a urine specimen for laboratory studies, and perform any other prescribed laboratory studies
  • return the blood bag, tubing, all attached labels, and transfusion record to the blood bank
  • document the occurrence, actions taken, and the client's response

Medications should not be administered unless they have been ordered by the provider.

183.

The most common cause of postpartum hemorrhage is:

  • Uterine atony

  • Trauma such as a cervical laceration

  • Retained placenta

  • Uterine rupture

Correct answer: Uterine atony

In the majority of cases, postpartum hemorrhage is caused by uterine atony. The uterus cannot contract forcefully enough to apply pressure to the placental attachment site. Treatment usually includes giving Pitocin (synthetic oxytocin) intravenously.

184.

A nurse is teaching an educational class to individuals who have recently been diagnosed with type 2 diabetes. One topic that she is covering is actions that will help lower blood sugar levels. Which of the following actions will help lower blood sugar levels?

  • Eating more small meals instead of fewer large meals

  • Eating foods with higher fat and starch content

  • Drinking more fruit juices instead of regular sodas

  • Substituting honey for sugar

Correct answer: Eating more small meals instead of fewer large meals

Eating more small meals instead of fewer large meals will help reduce one's blood sugar, as this action helps prevent spikes in one's blood glucose levels.

Eating foods with higher fat and starch content will not help reduce one's blood sugar, as starches turn into sugar. Drinking more fruit juices instead of regular sodas will not help reduce one's blood sugar, as fruit juices have high sugar content just like regular sodas. Substituting honey for sugar will not help reduce one's blood sugar, as honey and sugar are almost equivalent to each other.

185.

A nurse is observing a newborn for signs of dehydration. The nurse knows that which of the following is a sign of dehydration?

  • Depressed fontanelle

  • Urine-specific gravity less than 1.001

  • Edema

  • Rales

Correct answer: Depressed fontanelle

A depressed fontanelle is a sign of dehydration.

A urine-specific gravity of less than 1.001 is a sign of overhydration, not dehydration. A urine-specific gravity of more than 1.015 is a sign of dehydration. Edema and rales are also signs of overhydration, not dehydration.

186.

What is the correct procedure for performing an ophthalmoscopic examination on a client's right eye?

  • Shine a light into the client's pupil from a distance of 8 to 12 inches and slightly to the side

  • Instruct the client to look at the examiner's nose and not move his/her eyes during the exam

  • Set the ophthalmoscope on the plus 2 to 3 lens and hold it in front of examiner's right eye

  • For optimum visualization, keep the ophthalmoscope at least 3 inches from the client's eye

Correct answer: Shine a light into the client's pupil from a distance of 8 to 12 inches and slightly to the side

The correct procedure for performing an ophthalmoscopic exam is for the examiner to shine the light into the client's pupil 8 to 12 inches away and slightly to the side.

187.

Of the following, which signs and symptoms in the pediatric patient are indicative of right-sided heart failure (HF)? 

Select all that apply.

  • Oliguria

  • Peripheral edema 

  • Ascites

  • Crackles and wheezes

  • Grunting and head bobbing in infants

In infants and children, inadequate cardiac output is most commonly caused by congenital heart defects (shunts, obstructions, or both), creating an excessive volume or pressure load on the myocardium. Generally, pediatrics will present with both left- and right-sided HF. Management aims to improve cardiac output and decrease cardiac demand, remove excess fluid and sodium levels, and decrease oxygen consumption, thus improving tissue oxygenation. 

Signs and symptoms indicative of right-sided HF include:

  • Ascites
  • JVD (jugular vein distention)
  • Oliguria
  • Peripheral edema
  • Hepatosplenomegaly
  • Weight gain

Left-sided HF manifests as crackles and wheezes, cough and dyspnea, grunting and head bobbing in infants, nasal flaring, orthopnea, cyanotic periods, retractions, and tachypnea.

188.

A patient has been diagnosed with acute pyelonephritis due to an E. coli infection. Which of the following symptoms would the nurse expect to observe in this patient? 

Select all that apply.

  • Costovertebral angle (CVA) tenderness

  • Fever and chills

  • Dysuria and urinary frequency

  • Jaundice 

  • Renal and ureteral colic

Acute pyelonephritis is inflammation of the renal pelvis due to infection (often severe and sudden onset), that is commonly caused by bacterial invasion of E. coli organisms. It often occurs after bacterial contamination of the urethra or following an invasive procedure of the urinary tract. Assessment reveals fever and chills, tachycardia and tachypnea, nausea, flank pain on the affected side, CVA tenderness, headache, dysuria and urinary frequency, and cloudy, bloody, or foul-smelling urine with increased WBCs present. 

Jaundice indicates gallbladder or liver obstruction. Renal and ureteral colic often indicates the presence of renal calculi (kidney stones).

189.

A patient who is being treated for conjunctivitis has received a prescription for tobramycin/dexamethasone (Tobradex) ointment to be applied to the conjunctival sac three times per day. The patient asks if she should apply the ointment prior to or after inserting her contact lenses.

Regarding the use of tobramycin/dexamethasone (Tobradex), the nurse knows:

  • Contacts should not be worn during treatment with tobramycin/dexamethasone (Tobradex)

  • Tobramycin/dexamethasone (Tobradex) ointment should be applied prior to inserting contact lenses

  • Tobramycin/dexamethasone (Tobradex) ointment should be applied after inserting contact lenses

  • Patients who wear contacts should be treated with tobramycin/dexamethasone (Tobramycin) solution, not ointment

Correct answer: Contacts should not be worn during treatment with tobramycin/dexamethasone (Tobradex)

Tobramycin/dexamethasone (Tobradex) is an ophthalmic antibiotic corticosteroid used in the treatment of conjunctivitis. It is available both as a solution and an ointment. Contacts should not be worn during therapy with either form of tobramycin/dexamethasone (Tobradex).

190.

Which of the following is a danger sign in pregnancy that should be reported to the physician immediately?

  • Decreased or absent fetal movements after 24 weeks gestation

  • Sporadic Braxton Hicks contractions at 32 weeks gestation

  • Spotting in the first weeks of pregnancy at the time that a period would have occurred

  • The passage of thick mucus at the beginning of labor

Correct answer: Decreased or absent fetal movements after 24 weeks gestation

Decreased or absent fetal movements should always be reported immediately. The nurse may perform a non-stress test prior to notifying the physician to confirm decreased fetal movement.

Spotting in the first few weeks of pregnancy sometimes occurs as the embryo implants in the uterus. Sporadic Braxton Hicks contractions may be felt anytime after 20 weeks and are not concerning as long as they do not occur continuously. The passage of thick mucus is common at the beginning of labor and signals the onset of labor for some women.

191.

The nurse is caring for a patient with a suspected ectopic pregnancy. Which of the following statements are accurate in regard to this condition?

Select all that apply.

  • The most common implantation site is the ampulla of the fallopian tube

  • Sudden, stabbing pain in the lower quadrant is a common manifestation

  • Increasing pain, referred shoulder pain, and signs of shock indicate rupture

  • Often, the patient presents with throbbing pain in the upper quadrant

  • Painless vaginal bleeding is common

Signs of an ectopic pregnancy are often vague and include missed menstrual period, sudden, stabbing lower abdominal pain, and vaginal spotting or bleeding that is dark red or brown (indicative of old blood). If the ectopic pregnancy ruptures the wall of the fallopian tube, manifestations include increasing pain, referred shoulder pain, and even signs of shock. Though the pregnancy could implant itself in several different locations within the fallopian tube, the most common implantation site is the ampulla of the fallopian tube. 

Upper quadrant abdominal pain is not a symptom of ectopic pregnancy, and bleeding is common, but it is generally always associated with lower abdominal pain.

192.

A patient is taking levothyroxine (Synthroid), which is known to have a narrow therapeutic range. What will the administering nurse need to do?

  • Monitor the patient's plasma drug levels

  • Administer this medication subcutaneously

  • Inform the patient that the medication's maximum drug effect occurs in a shorter period of time

  • Monitor the patient's blood pressure while administering the medication

Correct answer: Monitor the patient's plasma drug levels

The administering nurse will need to monitor the patient's plasma drug levels. Medications that have a narrow therapeutic range (NTR) take special attention due to their small toxic concentration of the minimum effective concentration. The patient's plasma levels need monitored to ensure that the patient is receiving an effective dose that is not toxic.

Medications with a NTR can be administered using any route, it does not need to be subcutaneously. Medications with a NTR do not differ from other medications in the amount of time it takes for the drug to take effect. Nurses should monitor a patient's blood pressure, but this is not a requirement for administering a NTR medication.

193.

Your client has psoriasis. Her physician has suggested PUVA as an alternative therapy. In addition to ultraviolet A, PUVA includes the use of ______.

  • Psoralen

  • Prednisone

  • Allopurinol

  • Alprazolam

Your client has psoriasis. Her physician has suggested PUVA as an alternative therapy. In addition to ultraviolet A, PUVA includes the use of psoralen.

PUVA combines ultraviolet A with psoralen, a medication that is used to increase the skin's sensitivity to light. PUVA may cause fatigue, nausea, itching, burning and headache. It is generally reserved for severe psoriasis that has failed to respond to other therapies.

Psoralen is the parent compound in a family of natural products known as furocoumarins. It is structurally related to coumarin by the addition of a fused furan ring, and may be considered as a derivative of umbelliferone.

194.

A patient with Alzheimer's disease often has alterations within the frontal lobe of the brain. Which of the following may this patient suffer from due to the frontal lobe damage associated with this disease? 

Select all that apply.

  • Difficulty recognizing or identifying familiar objects

  • Loss of memory

  • Disturbance in understanding and expressing spoken words

  • Inability to perform motor activities

  • Inability to effectively process emotions and perceive emotions in others

  • Hearing and vision loss

Alzheimer's disease is an irreversible senile dementia caused by nerve cell deterioration. The frontal lobe (controlling responses from the rest of the central nervous system) is affected; therefore, the individual experiences cognitive deterioration and the progressive loss of abilities needed to carry out ADLs. The patient will often demonstrate signs of impaired reasoning, behavior, intellect, and memory. Despite intact motor functioning, patients will often be unable to perform motor activities (referred to as apraxia). 

Emotions are still felt personally and perceived in others with Alzheimer's disease (the hippocampus is not affected), and hearing and vision are not affected by Alzheimer's disease.

195.

You are instructing a new mother on how to care for her infant's umbilical cord. Which of the following is true?

  • The infant should be sponge-bathed until the cord falls off

  • The cord should be cleaned with hydrogen peroxide every time the diaper is changed

  • The top of the diaper should be folded up over the cord

  • When the cord is dry, it can be clipped off with a nail clippers that has been cleaned with alcohol if it is causing irritation

Correct answer: The infant should be sponge-bathed until the cord falls off

Position the diaper below the cord to prevent infection and allow the cord to air dry.

The cord's entire length should be cleansed with alcohol, not hydrogen peroxide, using a cotton-tipped swab every time the diaper is changed. The infant should be sponge bathed until the cord comes off - never pull on the cord or clip it. Antibiotic ointments are unnecessary unless the cord becomes infected.

196.

A nurse is preparing to discharge a patient who was admitted to the hospital with pneumonia. Which of the following statements from the patient indicates that the patient does not understand the discharge plan?

  • "I need to take my antibiotics until I feel better."

  • "I need to make a follow-up appointment with my physician."

  • "I need to wear a mask if I'm in dusty or moldy areas."

  • "I need to call my doctor or go to the emergency room if I cough up bloody mucus."

Correct answer: "I need to take my antibiotics until I feel better."

If the patient states: "I need to take my antibiotics until I feel better," the patient does not fully understand the discharge plan. Patients with pneumonia must complete the entire course of antibiotics that the physician prescribes to them, regardless if they feel better or not.

The pneumonia patient does need to make a follow-up appointment with his physician, wear a mask if he is in dusty or moldy areas, and call his doctor or go to the emergency room if he coughs up bloody mucus.

197.

Treatment for hyperthyroidism includes which of the following?

Select all that apply.

  • Methimazole

  • Thyroidectomy

  • Radioactive iodine therapy

  • Levothyroxine sodium (Synthroid)

  • Desmopressin acetate (synthetic vasopressin)

Hyperthyroidism results from the hypersecretion of thyroid hormones (T3 and T4) and is characterized by an increased rate of body metabolism. Treatment involves antithyroid medications such as methimazole or propylthiouracil, propranolol as needed for tachycardia, radioactive iodine therapy (destroys thyroid cells), and subtotal or total thyroidectomy if needed. 

Levothyroxine is a thyroid hormone indicated for hypothyroidism (replacement therapy). Desmopressin acetate is used in the treatment of diabetes insipidus (when antidiuretic hormone deficiency is severe or chronic).

198.

A nurse is caring for a patient who has a tracheostomy and it is time to clean the stoma. While assessing the site, the nurse notices that it is infected. How should the nurse clean the stoma?

  • The nurse should use gauze squares moistened with a hydrogen peroxide mixture to wipe the site and then rinse the site with normal saline solution

  • The nurse should use gauze squares moistened with rubbing alcohol to wipe the site and then rinse the site with normal saline solution

  • The nurse should use gauze squares moistened with iodine to wipe the site and then rinse the site with normal saline solution

  • The nurse should use gauze squares moistened with normal saline solution

Correct answer: The nurse should use gauze squares moistened with a hydrogen peroxide mixture to wipe the site and then rinse the site with normal saline solution

The nurse should use gauze squares moistened with a hydrogen peroxide mixture to wipe the site and then rinse the site with normal saline solution. Since the site is infected, the nurse should first use a hydrogen peroxide mixture and then rinse with normal saline solution.

If the site was not infected, the nurse would only use normal saline solution, as hydrogen peroxide could impair the site's healing. The nurse would not use iodine or rubbing alcohol to clean the stoma.

199.

Postpartum measures to decrease the risk of thrombophlebitis include which of the following?

Select all that apply.

  • Early ambulation

  • Turning frequently (at least every 2 hours) while in bed

  • Apply antiembolism stockings for women at risk

  • Massage and elevate the affected leg

  • Avoid intravenous (IV) heparin sodium therapy

Thrombophlebitis occurs when inflammation in a vein causes the formation of a clot inside the vessel wall. Women in the postpartum period are more susceptible to this condition because the high-volume, high-flow, and low resistance uteroplacental circulation that is meant to support fetal development means that there must also be maternal measures in place to prevent maternal hemorrhage (such as an increase in concentration of coagulation factors and fibrinogen). With these added intrinsic measures, there is an increased risk of venous thrombosis, thrombophlebitis, and pulmonary embolus. Early ambulation, frequent turning while on bedrest, and antiembolism stockings for at-risk women are all measures to decrease the risk of thromboembolic disease.

Never massage the affected leg, as this could dislodge the clot and cause it to travel to the lungs (pulmonary embolism). Elevating the affected leg to help with blood flow is an appropriate intervention. Heparin sodium IV may be prescribed to prevent further thrombus formation, and the woman should understand the importance of strict compliance and follow-up with any anticoagulant therapy measure initiated.

200.

When removing personal protective equipment (PPE) after providing direct patient care to a patient in isolation, which of the following areas on the PPE is/are considered "contaminated" and should be avoided upon removal?

Select all that apply.

  • Outside of the mask

  • Sleeves of the gown

  • Inside of the gloves

  • Ties on the gown

  • Back of the gown

A few dirty or "contaminated" areas of PPE include the outside of the mask and the sleeves of the gown. The inside of the gloves, ties of the gown and the back of the gown are considered "clean." 

When removing PPE, begin with gloves by grasping the outside of the glove with the opposite (gloved) hand and peel off. Slide fingers of ungloved hand under clean side of remaining glove at wrist to peel second glove off (holding onto removed glove in gloved hand). Next, remove face shield and/or goggles by touching clean band or inner part. Unfasten gown at neck, then at waist and pull gown down from each shoulder toward the hands. Let the gown fall forward and roll into a ball to discard. Finally, remove mask by grasping first bottom ties, then top ties to discard.

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