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Quiz Session - Attempts With Random Questions

NCLEX-RN Exam Questions

Page 4 of 65

61.

A nurse is summoned to a 9-year-old asthmatic patient's room by the nursing assistant, who is concerned the patient is "not breathing well." The nurse quickly assesses the patient and recognizes the patient is experiencing an acute asthma exacerbation.

The nurse performs all of the following priority nursing actions except:

  • Administers a long-acting beta-2 agonist

  • Assesses airway patency

  • Inserts an intravenous (IV) line

  • Applies humidified oxygen

Correct answer: Administers a long-acting beta-2 agonist

In instances of acute asthma exacerbation in a hospitalized patient, the nurse would perform the following priority nursing actions:

  • assess airway patency and respiratory status
  • administer humidified oxygen by nasal cannula or face mask
  • administer quick-relief (rescue) medications
  • initiate an intravenous line
  • prepare the child for a chest radiograph if prescribed
  • prepare to obtain a blood sample for determining arterial blood gas levels if prescribed

Quick-relief (rescue) medications include short-acting beta-2 agonists, anticholinergics, and systemic corticosteroids. A long-acting beta-2 agonist is indicated for the prevention of acute asthma attack, and should not be used as a rescue medication in the treatment of an acute asthma attack.

62.

Oxygen by nasal cannula at 4L/minute is prescribed for a hospitalized client. Which action should the nurse perform in the care of the client?

  • Humidify the oxygen, apply water soluble lubricant to the nares, and instruct the client and family about the purpose of the oxygen

  • Instruct the client to breathe through the nose only

  • Increase the oxygen flow if the client complains of dryness in the nares

Correct answer: Humidify the oxygen, apply water soluble lubricant to the nares, and instruct the client and family about the purpose of the oxygen

The nasal cannula provides for lower concentrations of oxygen and can be used with mouth breathers because movement of air through the oropharynx pulls oxygen from the nasopharynx.

It is not necessary to instruct the client to breathe through the nose only. Increasing the oxygen flow requires a provider's prescription and would contribute further to dryness of the nares.

63.

Your patient in the emergency room has ingested an unknown substance. He is verbally abusive and is threatening to hit anyone who comes close to him. You should:

  • Apply restraints as per your facility's policy

  • Refuse to deal with the patient

  • Call the police

  • Notify your supervisor

Correct answer: Apply restraints as per your facility's policy

Your own personal safety is paramount. A client who is threatening physical violence should be restrained. You might also call security to help you safely manage the patient without risking injury to yourself. The physician must obviously be aware of the patient's behavior - you may need a signed order from the physician to apply restraints.

64.

Your patient is complaining of a sensation of fullness in his ear, itchiness, tinnitus and difficulty hearing. You look into the affected ear and note a large build up of wax. What is your best option to manage the problem?

  • Clean the outside of the ear using a soft cloth to remove any visible wax and obtain an order for ceruminolytic solution to soften the remaining wax in the ear

  • Use sterile Q-tips to dig out any impacted ear wax

  • Irrigate the ear using hot water to "melt" the wax

  • Provide the patient with cotton swabs and tell him to remove the ear wax himself

Correct answer: Clean the outside of the ear using a soft cloth to remove any visible wax and obtain an order for ceruminolytic solution to soften the remaining wax in the ear

The outer portion of the ear can be cleaned with a soft cloth to remove any wax, but this likely won't help if the ear canal is impacted. Ceruminolytic agents such as mineral oil, baby oil, or hydrogen peroxide can help to soften wax that is hard. Irrigating/syringing the ear may be performed once the wax has been softened sufficiently.

65.

A physician orders a patient to have a computed tomography (CT) scan. Which of the following situations would most likely cause the physician to order this diagnostic test?

  • To examine a patient who may have internal injuries from a car accident

  • To identify if a patient has an aneurysm

  • To identify if the patient has tooth decay

  • To obtain a view of the patient's bladder

Correct answer: To examine a patient who may have internal injuries from a car accident

A physician would most likely order a CT scan to examine a patient who may have internal injuries from a car accident. CT scans create cross-sectional images of an individual's bones and tissue, which allows the physician to visualize the body parts.

Physicians general order a magnetic resonance imaging (MRI) diagnostic test to identify if patients have aneurysms. X-rays are most commonly used to see if a patient has tooth decay. An ultrasonography is generally used to obtain a view of the patient's bladder.

66.

A patient reports to the emergency room by private vehicle and reports 10/10 chest pain. 

What would be the most appropriate initial actions for their plan of care? 

Select all that apply.

  • Aspirin 325 mg PO

  • 12-lead EKG with vitals 

  • Morphine 4 mg IV push

  • 1000 mL IV infusion

The best initial plan of care for chest pain is to have the patient chew on 325 mg of aspirin and take a 12-lead EKG of the heart, with vitals. These two initial actions will help diagnose a STEMI and slow down thrombus formation. 

The doctor may call for morphine and a saline infusion following a diagnosed STEMI based on the location of the infarct, but these are not part of the initial plan of care. 

67.

You are caring for a patient who had emergency surgery for a small bowel obstruction 2 days ago. The patient has a nasogastric tube in situ which is connected to low intermittent suction. A couple of hours into your shift, you note that the patient's NGT is not draining and the patient's abdomen is slightly firmer than it was. Which intervention should you perform first?

  • Reposition the patient

  • Call the physician

  • Remove the tube and insert a new one

  • Attempt to flush the tube with sterile normal saline

Correct answer: Reposition the patient

Your first step would be to reposition the patient and observe to see if the NGT begins to drain. If it doesn't the next step would be to irrigate (obtain an order first).

68.

A patient has mucosal secretion buildup and the nurse uses the percussion technique to loosen the mucosal secretion and move it into the central airway where she can then remove it by suctioning. Which of the following best describes the percussion technique that will be used by the nurse?

  • The nurse will cup her hands and clap rhythmically on the patient's chest

  • The nurse will ask the patient to exhale and she will use a shaking movement

  • The nurse will place the patient in a right or left lateral recumbent position to allow gravity help drain the secretions

  • The nurse will use the palms of her hands and tap rhythmically on the patient's back

Correct answer: The nurse will cup her hands and clap rhythmically on the patient's chest

The percussion technique is best described by the following: The nurse will cup her hands and clap rhythmically on the patient's chest.

Conducting a shaking movement while the patient exhales describes the vibration technique. Positioning the patient to allow gravity to drain the secretions describes the postural drainage technique. Rhythmically tapping on the patient's back is not a technique used to remove mucosal secretion buildup.

69.

A nurse meets with a patient and his family. The nurse needs to obtain the patient's informed consent prior to the patient's scheduled surgery. What is the first thing the nurse should do?

  • Determine if the patient understands his upcoming surgery prior to giving consent

  • Explain the surgery in full detail to the patient and his family

  • Work with the patient and his family to develop a post-surgery care plan

  • Obtain and witness the patient's signature on the informed consent form

Correct answer: Determine if the patient understands his upcoming surgery prior to giving consent

The first thing the nurse should do when obtaining a patient's informed consent is to determine if the patient understands his upcoming surgery prior to giving consent.

It is important that the nurse obtains and witnesses the patient's signature on the informed consent form, but not until after the nurse verifies that the patient understands the surgery. It is the physician's responsibility to fully explain the details of the surgery, not the nurse's. The nurse will help develop a post-surgery care plan, but it is not part of obtaining the informed consent.

70.

You are caring for a child with epiglottitis. What equipment is most important to have at the bedside?

  • Cricothyrotomy kit

  • Oxygen saturation monitor

  • Chest tube and drainage system

  • Blood pressure monitor

Correct answer: Cricothyrotomy kit

Airway management is most important. Patients may deteriorate quickly, and airway equipment, including equipment needed for cricothyrotomy, should be present at the patient's bedside.

You would not need to insert a chest tube in a patient with epiglottitis.

71.

When gathering a health history on a pregnant patient, the woman tells the nurse she is pregnant for the fifth time. She has had two spontaneous abortions in the first trimester, a son who was born at 38 weeks' gestation, and a daughter who was born at 35 weeks' gestation. How should this information be interpreted in terms of obstetrical history?

Select all that apply.

  • Gravity (G) 5

  • Living (L) 2

  • Abortion (A) 2

  • Parity 4

  • Term (T) 2

Gravity (G) refers to the number of pregnancies a woman has had, including current pregnancy. 

Term (T) is the number of births at or after 37 weeks' gestation. 

Preterm (P) refers to the number of births before 37 weeks' gestation. 

Abortion (A) refers to the number of miscarriages or abortions. 

Living (L) refers to the number of current living children. 

Parity is the number of births (not the number of fetuses) carried past 20 weeks' of gestation, whether or not the fetus was born alive. 

This patient is a: G5, T1, P1, A2, L2. The parity for this woman is 2.

72.

You are preparing to care for a dying patient, and several family members are at this patient's bedside. When communicating with the family, you should use all the following therapeutic techniques EXCEPT: 

  • Explain everything that is happening to the family members

  • Encourage reminiscing

  • Let the patient and family know that they will not be abandoned by you

  • Assist with the decision-making process as needed

Correct answer: Explain everything that is happening to the family members

You should determine if there is a main spokesperson for the family and how much the patient and family want to know. It is not appropriate to explain everything that is happening to all family members unless that is their request. 

You should allow the family and the patient the opportunity to make informed choices and assist with the decision-making process if asked. Encourage family members to reminisce and express feelings, concerns, and fears. You should be honest with the patient and family and reassure them that you will not abandon them throughout this difficult process. 

73.

During an examination, a patient informs his nurse that he suffers from flatulence. The nurse discusses the types of foods that the patient eats on a regular basis and she determines which food could be causing the patient's issues. Which food would the nurse most likely determine is causing the patient to suffer from flatulence?

  • Apples

  • Bananas

  • Rice

  • Potatoes

Correct answer: Apples

Apples could cause a patient to suffer from flatulence. Apples are harder to digest than other foods and cause flatulence. Other foods that cause flatulence include beans, raisins, cabbage, carbonated beverages, and onions.

Potatoes, rice, and bananas are easier to digest and most likely would not cause the patient to suffer from flatulence.

74.

Your client has third degree burns to her feet after spilling a pot of boiling water. The physician has ordered Silvadene (Flamazine) cream to be applied. You know that Flamazine should not be used on patients with what allergy?

  • Sulfa

  • Penicillin

  • Bees

  • Latex

Correct answer: Sulfa

Flamazine is silver sulfadiazine, a sulfa medicine, and is used to prevent and treat bacterial or fungus infections. Silver sulfadiazine cream is applied to the skin and/or burned area(s) to prevent and treat bacterial or fungus infections that may occur in burns.

75.

During a therapeutic communication session, a patient informs his nurse that he has a panic attack when he is around snakes. The patient continues to tell his nurse that when he was younger, his older brother would always throw snakes at him or put them in his bed. If the nurse used a reflecting therapeutic response with this patient, which statement would she most likely use?

  • "Snakes scare you because your brother would scare you with them as a child."

  • "Provide me with an example of a time in which your brother threw a snake at you."

  • "Can you tell me exactly what type of snakes your brother used to scare you with?"

  • "Tell me about your current relationship with your brother."

Correct answer: "Snakes scare you because your brother would scare you with them as a child."

The statement that would be considered a reflecting therapeutic response would be: "Snakes scare you because your brother would scare you with them as a child." Reflecting is a therapeutic response in which the nurse would paraphrase what the patient said.

When the nurse is asking for the patient to provide her with an example, she is using a clarification therapeutic response. Clarification therapeutic responses are when the nurse asks the patient to pinpoint details, to describe a particular experience, or to provide an explanation. A clarification therapeutic response is also being used when the nurse asks the patient what type of snake his brother would scare him with. The nurse is using a general lead therapeutic response when she asks the patient to tell her about his relationship with his brother. A general lead therapeutic response is used to encourage the patient to talk and to take the conversation in a direction in which they are comfortable with.

76.

You are providing medication teaching to a 77-year-old male patient who is being started on timolol (Timoptic, Betimol solution) for treatment of glaucoma.

As part of your teaching about this medication, you instruct the patient to do all of the following except:

  • Massage the tear ducts for one minute after instillation to stimulate systemic absorption

  • Place pressure on the tear ducts for one minute after instillation to decrease systemic absorption

  • Wash hands before and after instillation of the drops

  • Do not allow the dropper to have contact with the eye when administering the medication

Correct answer: Massage the tear ducts for one minute after instillation to stimulate systemic absorption

Timolol (Timoptic, Betimol solution) is a topical beta blocker used in the treatment of glaucoma and ocular hypertension. Its use may cause systemic side effects such as weakness, hypotension, palpitations, heart failure, and bronchospasm. To decrease systemic absorption of the drug, patients should be instructed to place pressure on the tear ducts for one minute after instillation. Patients should always be instructed to wash their hands before and after handling any medications and to avoid touching their eye with the dropper when administering the medication.

Massaging the tear ducts after instillation of the drops should be avoided as this will increase the systemic absorption of the medication and therefore negative systemic side effects.

77.

Your teenage patient has severe acne caused by propionibacterium acnes. Which medication might you expect the physician to prescribe for this condition?

  • Tetracycline

  • Valacyclovir

  • Biaxin

  • Amoxicillin

Correct answer: Tetracycline

Acne is caused by the microorganism propionibacterium acnes (P. acnes). It is often treated with oral Tetracycline, an antibacterial agent. It may also be ordered as a cream to be applied to the affected skin.

Valacyclovir is an antiviral drug. Biaxin (Clarithromycin) is an antibacterial agent, but is not used for acne. Amoxicillin is also an antibiotic that is not used to treat acne.

78.

The nurse is caring for a laboring mother. She knows that the second stage of labor has begun by which of the following signs?

Select all that apply.

  • The cervix is completely dilated

  • Increase in bloody show

  • Uterine contractions occur every 2 to 3 minutes and last 60-75 seconds

  • Uterine contractions occur every 3 to 5 minutes and last 30 to 60 seconds

  • The cervix is 8 to 10 cm dilated

The second stage of labor begins with complete dilation (10 cm) of the cervix and ends with delivery of the fetus. 

Progress is measured in this stage by the descent of the fetal head through the pelvis (change in fetal station), and contractions that occur every 2 to 3 minutes, last approximately 60-75 seconds and are of strong intensity. There is often an increase in bloody show, and the mother feels the urge to push (Ferguson reflex). 

Stage 1 has a few phases. The first phase is the "active phase," in which cervical dilation is 4 to 7 cm. Uterine contractions in the active phase occur every 3 to 5 minutes, are 30 to 60 seconds in duration, and are of moderate intensity. The next phase of stage 1 is often referred to as the "transition phase." It is characterized by cervical dilation of 8 to 10 cm. In this phase, contractions occur every 2 to 3 minutes and are 45 to 90 seconds in duration. 

79.

A child with a diagnosis of mumps has been brought into the emergency department by his mother. It is suspected the child now has viral meningitis, a common complication of mumps. Which of the following signs and symptoms would the nurse expect to observe in this child? 

Select all that apply.

  • Lethargy

  • Vomiting

  • Nuchal rigidity

  • Koplik's spots 

  • Petechial  or purpuric rash 

Viral (otherwise known as aseptic) meningitis is associated with viruses such as mumps, paramyxovirus, herpesvirus, and enterovirus and is a complication of mumps. Mumps generally and primarily affects the salivary glands (parotid gland swelling and pain) but can also affect multiple organs. Manifestations of viral meningitis include lethargy, vomiting, and nuchal rigidity. The virus is identified in a sample of cerebrospinal fluid (CSF). Most children with this diagnosis will recover on their own within a few weeks without needing to be hospitalized, but require close monitoring at home for worsening signs and symptoms. 

Koplik's spots are seen with measles, not mumps. A petechial or purpuric rash is often observed in bacterial (meningococcal) meningitis (not viral meningitis).

80.

Your patient has an intravenous infusing into the antecubital vein. He complains of pain at the IV site. You note that the skin is cool around the IV insertion site and edema is present. What has likely happened?

  • The fluid is being infused into the interstitial space

  • A blood clot has developed at the tip of the catheter

  • The patient has developed phlebitis

  • It is normal to experience pain at the IV site

Correct answer: The fluid is being infused into the interstitial space

Pain at the IV site is not normal. Coolness and edema likely indicates that the IV is no longer positioned in the vein and fluid is infusing into the interstitial space. If the IV has clotted off, fluid will not infuse. Phlebitis usually involves redness along the course of the vein, with redness and tenderness.

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