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Quiz Session - Attempts With Random Questions

NCLEX-RN Exam Questions

Page 5 of 65

81.

In the newly diagnosed schizophrenic patient, which of the following behaviors are considered positive symptoms?

Select all that apply.

  • Delusions

  • Hallucinations

  • Disorganized speech 

  • Blunted affect

  • Inability to experience pleasure or joy (anhedonia)

Schizophrenia is a group of mental disorders characterized by psychotic features, disordered thought processes, and disrupted interpersonal relationships. The patient experiences disturbances in mood, affect, behavior, and thought processes. Physically, the patient may appear unkempt, neglecting hygiene, eating, sleeping, and eliminating. The patient often will experience body image distortions and may be preoccupied with somatic complaints (frequent complaints of body aches that have not been shown to have physiological causes). Positive symptoms (the patient may "lose touch" with some aspects of reality) include bizarre behavior, delusions, disorganized speech, and hallucinations. Negative symptoms (disruptions to normal emotions and behaviors) include blunted affect, anhedonia, loss of motivation (avolition), speaking less (alogia), and moving less (catatonia).

82.

During the start-up meeting, a few staff nurses voiced their concern with their ability to respond to a particular code that the nurse in charge was discussing. What is the best way for the nurse in charge to evaluate and improve the staff nurses' abilities to respond to codes?

  • Initiate the use of mock codes

  • Provide inservice training

  • Administer written competency exams

  • Provide written policies and procedures for each code

Correct answer: Initiate the use of mock codes

The best way for the nurse in charge to evaluate and improve the staff nurses' abilities to respond to codes is to initiate the use of mock codes. Mock codes are known to improve performance by enhancing the nurses' confidence, improving teamwork between the nurses, and enhancing the nurses' skills.

Inservice training sessions are important for learning, but they are not the best method to use when wanting to improve performance and increase confidence. Written competency exams will only test knowledge, not the nurses' performance ability. Written policies and procedures are important, but they are not the best method to use when wanting to improve performance and increase confidence.

83.

A patient fell out of his chair while he was eating his lunch. A nurse notices that the patient fell and asks another nurse to help her lift the patient back into his chair. In order to avoid injury, how should the two nurses lift the patient?

  • The nurses should lift with their legs

  • The nurses should lift with their backs

  • The nurses should bend their waists

  • The nurses should pull the patient up by the arms

Correct answer: The nurses should lift with their legs

When lifting a patient, or other heavy object, the nurses should lift with their legs.

In order to avoid back injury, individuals should not lift with their backs. Individuals also should not bend at the waist, as they should try to maintain the natural curve of their spines. In order to prevent harm to the patient, the nurses should not pull the patient up by the arms.

84.

Which of the following assessment findings would indicate that a patient is at risk of preterm labor?

Select all that apply.

  • History of substance abuse 

  • Multifetal pregnancy 

  • Anemia

  • Infection

  • First pregnancy at an age older than 35 years 

Preterm labor occurs after the 20th week but before the 37th week of gestation. Risk factors include: a history of medical conditions, past and present obstetrical problems, infection, and social and environmental factors, including substance abuse. 

Additional risk factors include a multiple-gestation pregnancy (contributing to overdistention of the uterus), anemia (decreases oxygen supply to the uterus), and an age younger than 18 years, or a first pregnancy at an age older than 40 years.

85.

George is a 54-year-old male who has been admitted to the hospital for a persistent foot ulcer. George does not understand why his foot is healing so slowly. Which of the following lifestyle changes could help with this issue?

Select all that apply.

  • Quit smoking

  • Eat clean, nutrient-rich foods

  • Take prescribed medication to assist with peripheral vascular disease

  • Work a job that requires less time standing

  • Change socks often

Delayed wound healing worsens with age. Proper nutrition, smoking and drinking cessation, taking proper medications, and exercise will all help with the healing process. The patient's prolonged wound care requires a stronger blood supply to the wound site.

Quitting smoking will lead to strong blood flow and decreased vasodilation.

Proper nutrition strengthens vascular health and promotes health with the appropriate vitamins and minerals.

Taking medication for peripheral vascular disease will increase blood flow to the wound and assist with healing.

86.

A patient calls the triage line at a clinic, stating she is going out of town on business for several weeks and is concerned she will have difficulty sleeping, as she has experienced sleeplessness during previous business trips. The provider gives the patient a prescription for zolpidem tartrate (Ambien) 5 mg orally at bedtime as needed.

The patient should be cautioned that she may experience which of the following side effects when taking zolpidem tartrate (Ambien)?

  • Sleep driving

  • Sleep walking

  • Nightmares

  • Sleep talking

Correct answer: Sleep driving

Zolpidem (Ambien) is a sedative-hypnotic medication indicated for use in the short-term treatment of insomnia. Patients should be cautioned they may experience "sleep driving" when taking zolpidem (Ambien). The lowest effective dose should be used; higher doses may be more likely to impair next morning activities.

87.

You are performing discharge teaching for a patient who has had a myocardial infarction. He is being discharged home on several medications, including metoprolol. The patient is a diabetic. What should you tell him about metoprolol?

  • Metoprolol may mask some of the symptoms of hypoglycemia

  • Metoprolol dosage may need to be increased in renal dysfunction associated with diabetes

  • Metoprolol is classified as a calcium channel blocker and may cause swelling

  • Metoprolol is classified as an angiotensin converting enzyme inhibitor and may result in proteinuria

Correct answer: Metoprolol may mask some of the symptoms of hypoglycemia

Metoprolol may worsen blood glucose control in diabetics and may mask symptoms of hypoglycemia. Diabetics should monitor their glucose levels frequently while taking metoprolol, especially in the beginning of therapy.

Metoprolol is a beta blocker, not a calcium channel blocker or an ACE (angiotensin converting enzyme) inhibitor. It works to lower blood pressure by blocking the effects of epinephrine and norepinephrine. The dosage may need to be decreased, not increased, in renal dysfunction.

88.

A nurse removed her gloves after she handled soiled bed sheets. While she was removing her gloves, she accidentally touched the contaminated side of the gloves with her bare hand. What action should the nurse take first?

  • The nurse should immediately wash her hands with soap and water

  • The nurse should continue removing the rest of her PPE and then wash her hands

  • The nurse should put on a new set of gloves and then remove the rest of her PPE

  • The nurse should apply a non-alcohol based hand rub

Correct answer: The nurse should immediately wash her hands with soap and water

If at any time a nurse's hands become contaminated during PPE removal, the nurse should immediately wash her hands with soap and water.

The nurse should not continue removing the rest of her PPE and then wash her hands, as the nurse could contaminate more areas of her body. The nurse should not put on a new set of gloves, as the gloves are the first piece of PPE that should be removed. If the nurse uses a hand rub for sanitation instead of soap and water, it should be alcohol based, not non-alcohol based.

89.

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 as a bare arm will provide the most accurate reading

  • You should rest for five minutes before obtaining a blood pressure reading

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.

The other statements are all true. You should rest for five minutes before obtaining a blood pressure reading. Drinking coffee or smoking prior to taking your blood pressure may cause an elevation in your blood pressure. You should not take your blood pressure around a long sleeve as bare arm will provide the most accurate reading.

90.

You are preparing the bathtub for your patient. The tub has a lift chair. How should you check the temperature of the water to prevent scalding?

  • Use a tub thermometer as per your facility's policy

  • Use your inner wrist to check the water to make sure it isn't too hot

  • Lower the patient very gradually into the tub and ask them to tell you right away if the water is too hot

  • There is no need to check water temperature prior to bathing patients

Correct answer: Use a tub thermometer as per your facility's policy

To prevent scald injuries, which can be fatal, use a tub thermometer to record the tub temperature prior to putting the patient into the tub.

Using your wrist is not accurate and asking the patient to tell you if the water is too hot won't be helpful if part of the patient's body (i.e., feet and legs) are already immersed.

91.

A child is admitted for a suspected diagnosis of bacterial meningitis. A lumbar puncture is performed and cerebrospinal fluid (CSF) obtained. Which of the following findings upon CSF analysis verify this diagnosis? 

Select all that apply.

  • Cloudy fluid

  • Increased white blood cell count

  • Elevated protein

  • Elevated glucose levels

  • Decreased pressure

Meningitis is an infection of the central nervous system that can be viral or bacterial in nature; it can be acquired as a primary disease or the result of a complication from trauma, surgery, or systemic infection. Diagnosis of bacterial meningitis (often caused by Haemophilus influenzae type b, Streptococcus pneumoniae, or Neisseria meningitidis) is made by testing CSF obtained by lumbar puncture. CSF analysis will show cloudy fluid with increased pressure, increased white blood cell count, elevated protein, and decreased glucose levels.

92.

You are recording an end-of-shift report for oncoming staff. Which information would be most important to pass on to the next shift?

  • A patient fell, striking their head

  • A patient slept all afternoon due to the fact that she was awake most of the previous night

  • A patient ate poorly

  • A patient's blood glucose was within normal limits

Correct answer: A patient fell, striking their head

Any change in condition or injury is important to pass on to the oncoming shift so that the staff is aware of patients that may be at risk or whose condition could potentially change. Appetite, sleep, and normal lab results are lower priority than a fall resulting in potential injury.

93.

A physician orders a 20 lb (9 kg) child to be infused with intravenous fluids to run at 20 mL/kg/day. At what rate of infusion should the nurse infuse the intravenous fluid?

  • 7.5 mL/hr

  • 1.3 mL/hr

  • 3.8 mL/hr

  • 16.6 mL/hr

Correct answer: 7.5 mL/hr

The nurse should infuse the intravenous fluid at 7.5 mL/hr. To find the rate that the intravenous fluid should be infused, follow these steps:

  1. Multiply 9-kg by 20 mL/kg, which gives you 180 mL
  2. Divide 180 mL by 24 hours (number of hours in a day), which gives you 7.5 mL/hr

In order to get the ordered amount of intravenous fluids, the nurse should infuse 7.5 mL over a 24 hour period.

94.

You are admitting a client with anemia and alcoholism. The client has been a heavy drinker for many years. Delirium tremens are expected within 48 to 72 hours after cessation of alcohol consumption and include which of the following symptoms?

  • Diaphoresis, high blood pressure, disorientation

  • Tremors, low blood pressure, tachycardia

  • Bradycardia, high blood pressure, low-grade fever

  • Low-grade fever, seizures, low blood pressure

Correct answer: Diaphoresis, high blood pressure, disorientation

Symptoms of DTs which usually peak at five days, include:

  • Disorientation, confusion, and severe anxiety
  • Hallucinations which cannot be distinguished from reality
  • Profuse sweating (Diaphoresis)
  • Seizures
  • High blood pressure
  • Racing and irregular pulse
  • Severe tremors
  • Low-grade fever

95.

A patient is being seen in the clinic for a follow-up appointment and needs to get an INR drawn after initiation of maintenance warfarin (Coumadin) therapy for treatment of a deep vein thrombosis (DVT). Which of the following statements made by the patient reflect(s) an accurate understanding of the patient's condition and medication management? 

Select all that apply.

  • "I should not eat excessive amount of green leafy vegetables because they can counteract the effects of the warfarin." 

  • "If my gums start to bleed, I notice any blood in my urine or stool, or I develop a sudden and severe headache, I should call my PHCP immediately."

  • "Therapeutic INR levels for my condition are 2-3."

  • "This medication will help dissolve my blood clot."

  • "This medication starts working immediately after the first dose." 

An international normalized ratio (INR) is a laboratory value that reflects how long it takes for a blood clot to form in the body and is frequently used to measure the effects of anticoagulant therapy on the body's clotting system. In a healthy individual, an INR of 0.8 to 1.20 is considered normal, but in the patient with a history of DVT, therapeutic values should typically range from 2-3. Coumadin does not start working immediately; rather, it takes 3-5 days to achieve therapeutic INR levels. A patient with a history of DVT will often be on concurrent warfarin and heparin therapy until therapeutic INR levels are achieved. 

Coumadin does not dissolve a blood clot, but prevents new clots from forming and inhibits the growth of any present clots. If a clot gets too large, there is a greater risk of it breaking off and traveling in the bloodstream, causing pulmonary embolism, heart attack, or stroke (all of which increase the risk of death). The patient should maintain a normal diet, but limit the amount of foods rich in vitamin K (leafy green vegetables) so as not to counteract Coumadin's effects. If the patient develops a severe headache (intracranial bleed), easily bleeding gums, or blood is present in urine or stool, an  adverse reaction has likely occurred (related to bleeding) and the PHCP should be notified immediately.

96.

Treatment for pediatric acetylsalicylic acid (aspirin) overdose involves which of the following? 

Select all that apply.

  • Activated charcoal

  • Intravenous (IV) fluids 

  • Sodium bicarbonate 

  • Supplemental oxygen therapy 

  • Antidote N-Acetylcysteine 

  • Chelation therapy

Aspirin overdose may be caused by acute or chronic ingestion. Presenting symptoms include nausea and vomiting, thirst from dehydration, hyperpnea, confusion, tinnitus, possible seizures, coma, respiratory failure, and circulatory collapse. Oliguria and bleeding may be seen. The patient may exhibit fever, diaphoresis, electrolyte imbalances, and metabolic acidosis. 

Treatment involves activated charcoal (via gastric lavage or orally if able) to decrease the absorption of salicylate and IV fluids. Sodium bicarbonate may be prescribed to correct the underlying metabolic acidosis if present. Oxygen is necessary for any respiratory distress. If the child remains unresponsive to therapy, prepare for dialysis as prescribed.

N-Acetylcysteine is the antidote for acetaminophen (Tylenol) overdose, not aspirin. Chelation therapy is indicated for lead poisoning and works by binding toxins in the bloodstream via circulation of a chelating solution.

97.

Viral hepatitis has three stages; preicteric, icteric, and posticteric. A patient in the icteric stage of hepatitis would most likely exhibit which of the following manifestations? 

Select all that apply.

  • Dark or tea-colored urine

  • Elevated serum bilirubin levels

  • Clay-colored stools

  • Flu-like symptoms, malaise

  • Nausea and vomiting

Viral hepatitis is a liver inflammation and disease caused by a viral infection. It may be acute or chronic, depending on the type of hepatitis acquired. The second stage of hepatitis—the icteric stage—is characterized by the appearance of jaundice and associated symptoms (elevated bilirubin levels, dark-colored urine, clay-colored stools, pruritus). 

The preicteric phase (first stage of hepatitis) symptoms are nonspecific, preceding the jaundice, and include flu-like symptoms (fever, headache, malaise, weakness, nausea, vomiting, diarrhea).

98.

While working in a women's health center, a 16-year-old girl arrives at the facility concerned that she is pregnant. Which of the following statements shows she needs further education?

Select all that apply.

  • "I can't be pregnant because we had sex during my period."

  • "I was told the way you figure out your due date is from the date you think you had sex." 

  • "If I am pregnant, I will make an appointment with my OBGYN to start prenatal care." 

  • "For my best guess on the due date, I need to remember when my last menstrual period started." 

While the ovulation window is often viewed as the time women are most fertile, the possibility of getting pregnant can happen at any time of the month, including when during the menstrual period.

To calculate the estimated due date, determine the first day of the last period, count backward by 3 calendar months, and add 1 year and 7 days to that date.

99.

When providing teaching to the parent of a child who has been prescribed liquid oral iron for iron deficiency anemia, which of the following instructions should the nurse include? 

Select all that apply.

  • Have the child drink the liquid iron through a straw

  • Have the child brush his or her teeth after administration

  • Ensure the child takes the medication with food

  • Mix the medication with milk prior to administration

  • Have the child take the medication in the morning

Liquid iron preparation may be prescribed to treat iron deficiency anemia in children. Teach parents and child that liquid iron should be taken through a straw and that the teeth should be brushed after administration because it does have the potential to stain the teeth. The child does not have to take iron in the mornings (can take anytime of day), taking the medication with food will decrease the absorption, and the medication does not need to be mixed with anything.

100.

As part of the patient's wellness exam, the nurse conducts a rapid urine test. The rapid urine test indicates that the patient's urine contains ketone and sugar. What is this an indication of?

  • Uncontrolled diabetes mellitus

  • An inflammation of the kidneys

  • A bacterial infection

  • A urinary tract infection

Correct answer: Uncontrolled diabetes mellitus

Urine containing ketone and sugar is an indication of uncontrolled diabetes mellitus.

High protein levels in urine is an indication that the kidneys are inflamed. Urine containing leukocytes and nitrite indicates a bacterial infection. A urinary tract infection is indicated when the urine's pH level is over 7.

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