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Quiz Session - Attempts With Random Questions

NCLEX-RN Exam Questions

Page 6 of 65

101.

A patient develops a slight fever while he is in the hospital and the doctor orders the administration of acetaminophen. While administering acetaminophen to the patient, the nurse notices that the patient is also taking warfarin. Which adverse reaction should the nurse watch this patient for?

  • Increased bleeding

  • Abdominal pain

  • Mental confusion

  • Depression

Correct answer: Increased bleeding

The nurse should watch this patient for increased bleeding. Warfarin is a blood thinner used to reduce blood clots and when acetaminophen is taken with warfarin, it may increase bleeding in patients.

Abdominal pain is not an adverse reaction for warfarin and acetaminophen. Mental confusion is not an adverse reaction for warfarin and acetaminophen. Depression is not an adverse reaction for warfarin and acetaminophen.

102.

A newly diagnosed cirrhosis patient is admitted to the hospital. The nurse caring for the patient should expect to see the following signs and symptoms except which of the following?

  • Weight gain

  • Swelling in the legs

  • Spider-like blood vessels on the skin

  • Jaundice

Correct answer: Weight gain

The nurse should not expect a cirrhosis patient to have weight gain, as cirrhosis patients generally have a loss of appetite that is accompanied by weight loss.

Signs and symptoms of cirrhosis include swelling in the legs, spider-like blood vessels on the skin, and jaundice.

103.

The nurse should ensure that all components of a medication prescription are documented, including:

Select all that apply.

  • Date and time prescription was written

  • Medication name and dosage

  • Route of administration

  • Frequency of administration

  • Nurse's signature

Components of a medication prescription are as follows:

  • Date and time prescription was written
  • Medication name
  • Medication dosage
  • Route of administration
  • Frequency of administration
  • Primary health care provider's signature

104.

Your patient is undergoing testing for a suspected medullary thyroid carcinima. Which of the following lab values would you expect to be abnormally high in this condition?

  • Calcitonin

  • ACTH (adrenocorticotropic hormone)

  • Fasting GH (growth hormone)

  • C-peptide

Correct answer: Calcitonin

Calcitonin is a hormone produced by the parafollicular C cells of the thyroid. You would expect this level to be increased in a patient with medullary thyroid carcinoma.

C-peptide is a precursor to insulin. ACTH is a hormone secreted by the anterior pituitary gland. Growth hormone (GH) would not be affected by this type of cancer.

105.

A nurse is discharging a patient with a broken leg. The patient will need to use axillary crutches while his leg is in a cast. Which of the following is not a proper procedure for fitting crutches to a patient?

  • When measuring for the proper handpiece location, the patient's elbow should be flexed at a 45 degree angle

  • When measuring for the proper handpiece location, the patient's wrist should be in maximal extension

  • When measuring for the proper handpiece location, the patient's fingers should be in a fist

  • When measuring for the proper handpiece location, the crutch should be placed three inches lateral to the patient's foot

Correct answer: When measuring for the proper handpiece location, the patient's elbow should be flexed at a 45 degree angle

The following is not a proper procedure for fitting crutches to a patient: When measuring for the proper handpiece location, the patient's elbow should be flexed at a 45 degree angle. The patient's elbow should be flexed at a 30 degree angle when measuring for the handpiece location, not a 45 degree angle.

When measuring for the proper handpiece location, the crutch should be placed three inches lateral to the patient's foot, the patient's wrist should be in maximal extension, and the patient's fingers should be in a fist.

106.

You have just finished receiving reports from the off-going shift nurse when the emergency call light sounds from your patient's room. You enter the room and notice the patient is cyanotic and tachypneic. The nursing assistant at the patient's bedside states she had been taking the patient's vital signs when the patient had suddenly complained of chest pain and dyspnea and then began to show signs of confusion. A quick assessment of the patient shows she is receiving intravenous (IV) fluids through a peripherally inserted central catheter (PICC) line in her left arm.

What priority steps should you take next to best care for the patient?

  • Clamp the intravenous catheter and lower the patient's head below her feet

  • Place the patient on her right side and elevate her head

  • Apply oxygen and place the patient on her right side

  • Flush the PICC line with normal saline and apply oxygen

Correct answer: Clamp the intravenous catheter and lower the patient's head below her feet

The patient is exhibiting symptoms consistent with several intravenous (IV) central catheter complications: breakage of an intravenous catheter with migration of the fragmented piece into the central circulation, dislodgement of a thrombus, or entry of air into the circulation. All of these complications can cause an embolism. Your priority is in attempting to prevent further migration of the fragmented catheter/thrombus/air, attempting to trap the embolism in the right atrium.

Symptoms of an embolism include:

  • sudden chest pain
  • dyspnea
  • tachypnea
  • hypoxia
  • cyanosis
  • hypotension
  • tachycardia

Priority steps to treat embolism include:

  • clamping the catheter
  • placing the patient on her left side
  • lower the level of the patient's head below her feet
  • administer oxygen
  • and notify the health care provider

107.

When providing education to the caregiver of a nine-month-old infant, which of the following foods would be recommended to incorporate into the baby's diet?

Select all that apply.

  • Cooked carrots

  • Tomato soup

  • Raisins

  • Hot dog cut into small pieces

  • Toast with honey

Cooked carrots and tomato soup are age-appropriate options.

Raisins and a hot dog that has been cut into pieces should be avoided due to the potential for choking. Other examples that are choking hazards include grapes, popcorn, nuts, or any foods with seeds. Infants under 12 months should never be fed honey due to the risk of botulism contamination.

108.

An 8-year-old was involved in an off-road vehicle accident at a summer camp. He was wearing a helmet, was thrown over the handlebars, and did not lose consciousness on scene. No external bleeding was noted, but family members were advised to have the child transported by EMS. 

Which signs or symptoms would indicate that his condition is worsening and leading to shock? 

Select all that apply.

  • Sudden change in blood pressure from 108/66 to 90/45

  • Suddenly feeling anxious or confused

  • Temperature of 96.7 temporal

  • Heart rate of 70

  • Compound fracture of the right upper extremity

  • Bruising of the thorax

Signs of pediatric shock involve sudden changes in vital signs. This child was thrown over the handlebars and does not show any significant signs of external hemorrhage. Due to the mechanism of injury, it is wise to assess for internal bleeding. 

Signs of shock would include decreased blood pressure, changes in mentation or sudden anxiety, tachycardia, and hypothermia unrelated to the environment.

109.

A mother takes her 5-month-old child to the local health clinic to get a flu shot. The child does not have a fever and has not been sick recently. Is the nurse permitted to give this child a flu shot?

  • No. The child needs to be at least 6 months old.

  • No. The nurse needs to give the child a nasal spray vaccine.

  • Yes. The child has not been sick and does not have a fever.

  • Yes. All small children should have a flu shot.

Correct answer: No. The child needs to be at least 6 months old.

The nurse is not allowed to give a 5-month-old child a flu shot, as the child needs to be at least 6 months old.

The nurse is not allowed to give the child the nasal spray vaccine, as that vaccine is for children between the ages of 2 and 8 years old. It is true that individuals should not have been recently sick and should not have a fever in order to get a flu shot; however, the individual still needs to be at least 6 months old. It is true that children should have flu shots, but they still need to be at least 6 months old.

110.

In the breastfeeding woman with a diagnosis of mastitis, what instructions should the nurse include in her teaching?

Select all that apply.

  • "Apply heat to the site as prescribed."

  • "Decompress your breasts every 3 to 4 hours."

  • "Support your breasts by wearing a supportive bra."

  • "Be sure to take your prescribed antibiotics until the symptoms resolve."

  • "Pump your breastmilk and throw it out while the infection is present, feeding your baby either breastmilk pumped before you developed mastitis or formula during this time."

Mastitis is inflammation of the breast as a result of a blocked and infected milk duct. It causes localized pain, swelling, heat, elevated temperature, and systemic flu-like symptoms. When educating the mother with mastitis regarding proper care, instruct her to perform good hand-washing and breast hygiene techniques. Have her apply moist heat to the site as needed for comfort. Breastmilk is still perfectly good for baby to eat and should not be thrown away. Make sure she maintains lactation, and encourage latching baby to the breast if not too painful. If unable to latch due to pain, make sure she either manually expresses her breastmilk or uses a breast pump at least every 3 to 4 hours. A supportive bra (without underwire) is essential to support the breasts and maintain comfort. Encourage analgesics as prescribed and instruct her that antibiotics are to be taken until the complete prescribed course is finished; they are not to be stopped when the symptoms resolve or soreness subsides.

111.

Your patient has localized genital herpes and asks you about the incubation period of the disease. What should you tell the patient?

  • The incubation period is 3 to 7 days

  • The incubation period is 7 to 10 days

  • The incubation period is 10 to 14 days

  • The incubation period is approximately 21 days

Correct answer: The incubation period is 3 to 7 days

The incubation period is 3 to 7 days for a localized infection and 2 to 12 days for generalized herpes simplex.

112.

Which of the following medications used in the treatment of osteoporosis is not available in an oral form?

  • Calcitonin (Miacalcin)

  • Risedronate (Actonel)

  • Alendronate (Fosamax)

  • Vitamin D

Correct answer: Calcitonin (Miacalcin)

Calcitonin (Miacalcin) is a bone resorption inhibitor used in the treatment of osteoporosis. It is not available in oral form, and must be administered either by subcutaneous (subQ), intramuscular (IM), or intranasal (IN) route.

Risedronate (Actonel), alendronate (Fosamax), and vitamin D are all available in an oral form.

113.

The client has been taking omeprazole (Prilosec) for four weeks. The ambulatory care nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom?

  • Heartburn

  • Diarrhea

  • Flatulence

  • Constipation

Correct answer: Heartburn

Prilosec is a proton pump inhibitor classified as an anti-ulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often called heartburn by clients.

114.

Which of the following medications should be avoided in the elderly?

Select all that apply.

  • Ketorolac (Toradol)

  • Cyclobenzaprine (Flexeril)

  • Oxybutynin (Oxytrol)

  • Cetirizine (Zyrtec)

  • Acetaminophen (Tylenol)

First generation antihistamines, such as diphenhydramine (Benadryl), should be avoided due to their sedative effects, but cetirizine is a second-generation antihistamine and is considered safe for use in the older patient. Ketorolac (an NSAID) can be nephrotoxic and should be avoided in the older population. Cyclobenzaprine has a sedating effect and can cause increased dizziness. Oxybutynin is an urge incontinence medication and should be avoided due to an increased risk of dementia and cognitive problems. 

Acetaminophen is generally considered a safe painkiller to use, just make sure the daily dose for the older patient (3,000 mg) is not exceeded.

115.

The nurse is caring for a patient who was admitted for a stroke. Which of the following are priority nursing assessments for this patient in the first 24 hours? 

Select all that apply.

  • Pupillary check for size and response

  • Assessment for posturing

  • Assessment of airway patency

  • Serum cholesterol level assessment

  • Assessment of bowel sounds

The nurse should monitor for increasing intracranial pressure (ICP) in the patient with a recent stroke because the patient is at most risk during the first 72 hours following the stroke. Checking pupillary size and response is critical to assess cranial nerve changes. Unilateral pupil dilation indicates compression of cranial nerve III. Midposition fixed pupils indicate midbrain injury. Pinpoint fixed pupils indicate pontine damage. Likewise, posturing (decorticate, decerebrate, or flaccid) indicates a deterioration of the patient's condition. Airway patency is always a priority.

Assessing cholesterol levels should be addressed for long-term healthy lifestyle rehabilitation but is not a priority assessment. Bowel sounds should be assessed because constipation or ileus can develop, but is not a priority in the first 24 hours after admission.

116.

Your patient presents with right sided rib pain after a fall. He complains of constant pain that is worse with deep breathing. The CXR reveals a 5th right rib fracture. He is on 24 hour oxygen therapy and a history of asthma and chronic bronchitis. The physician orders pain medication. As a nursing measure you perform the following:

  • Provide the patient with an incentive spirometer and teach him to perform incentive spirometry every hour while awake

  • Instruct the patient to take his pain medication only at night so that he can sleep

  • Instruct the patient to move as little as possible to decrease pain

  • Nothing further is needed

Correct answer: Provide the patient with an incentive spirometer and teach him to perform incentive spirometry every hour while awake

The patient has comprised lung function causing increased risk for respiratory complications. The rib fracture pain will cause the patient to take more shallow breaths. Incentive spirometry will cause the patient to take deep breaths to prevent respiratory complications such as pneumonia.

117.

A nurse is caring for a patient who has a small bowel obstruction due to an electrolyte imbalance. What action should the nurse take?

  • Monitor the patient's potassium levels

  • Assess the patient's hydration through urine output

  • Monitor the patient for hypoventilation

  • Monitor the patient for hypotension

Correct answer: Monitor the patient's potassium levels

The nurse should monitor the patient's potassium levels when a small bowel obstruction is caused by an electrolyte imbalance.

When the patient has a small bowel obstruction that is due to dehydration, she should assess the patient's hydration through urine output. When a bowel obstruction is due to metabolic alkalosis, the nurse should monitor the patient for hypoventilation. When a bowel obstruction is due to metabolic acidosis, the nurse should monitor the patient for hypotension.

118.

Which assessment and/or laboratory finding(s) would the nurse note in the patient experiencing fluid volume deficit?

Select all that apply.

  • Dry skin and poor turgor

  • Increased serum osmolality

  • Constipation

  • Decreased urine specific gravity

  • Increased central venous pressure

Fluid volume deficit occurs when fluid intake is not sufficient to meet the fluid needs of the body. Treatment is aimed at restoring fluid volume, replacing electrolytes as needed, and eliminating the cause of the fluid volume deficit. Assessment findings of dehydration include dry skin and poor turgor, increased serum osmolality, and constipation. 

Urine specific gravity would be increased and central venous pressure would be decreased in fluid volume deficits.

119.

Your patient, who is recovering from heart surgery, suddenly becomes unresponsive. You determine that the patient is apneic and pulseless and begin CPR, calling for help as you do so. The cardiac monitor shows a wide, regular and rapid rhythm. You know that this rhythm is probably:

  • Ventricular tachycardia

  • Paroxysmal supraventricular tachycardia

  • Ventricular fibrillation

  • 3rd-degree AV block

Correct answer: Ventricular tachycardia

Ventricular tachycardia appears as a wide, rapid and regular rhythm on the cardiac monitor or ECG. A recent history of angina, CHF or MI makes it more likely that the rhythm is ventricular tachycardia, rather than a more benign rhythm with aberrancy.

120.

A patient who has just undergone cervical spinal fusion is on a mechanical soft diet. Which of the following foods should the nurse instruct the patient to avoid? 

Select all that apply.

  • Raw fruits and vegetables

  • Salted meats

  • Whole grains

  • Flaked fish

  • Cream soups

The mechanical soft diet includes foods that have been altered in texture (pureed, mashed, ground, or chopped) to require minimal chewing. Patients who have difficulty chewing, such as those with dental problems, surgery of the head and neck, or dysphagia would benefit from a mechanical soft diet. Foods in this type of diet include, but are not limited to, cream soups, ground or diced meats, flaked fish, cottage cheese, rice, potatoes, pancakes, light breads, cooked vegetables (not raw), canned or cooked fruits (not raw), bananas, peanut butter, and nonfried eggs. 

Foods to be avoided in the mechanically soft diet include nuts or seeds (which can easily become trapped in the mouth and cause discomfort); raw fruits and vegetables; fried foods; whole grains; tough, smoked or salted meats, and foods with course textures.

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