×

Quiz Session - Attempts With Random Questions

NCLEX-RN Exam Questions

Page 7 of 65

121.

A nurse supervisor is conducting an educational inservice for newly licensed nurses who will be providing newborn care. One of the new nurses asks the supervisor why newborns are injected with vitamin K. Which of the following is the appropriate response to the nurse's question?

  • "Vitamin K is injected into newborns to activate blood clotting factors II, VII, IX, and X."

  • "Vitamin K is injected into newborns to prevent ophthalmia neonatorum."

  • "Vitamin K is injected into a newborn to boost the newborn's immunity system."

  • "Vitamin K is injected into a newborn to provide the newborn with nourishment."

Correct answer: "Vitamin K is injected into newborns to activate blood clotting factors II, VII, IX, and X."

The appropriate response is: "Vitamin K is injected into newborns to activate blood clotting factors II, VII, IX, and X." Newborns are vitamin K deficient due to the sterility of their colons. Therefore, until the newborn feeds and bacteria becomes available, he/she needs vitamin K to prevent hemorrhagic disease.

Erythromycin (Romycin) is administered to prevent ophthalmia neonatorum, not vitamin K. Vitamin K does not boost a newborn's immunity system or provide nourishment.

122.

The nurse is caring for a newborn with esophageal atresia. When assessing the infant, which would the nurse expect to find?

Select all that apply.

  • Coughing and choking during feeding

  • Respiratory distress associated with feeding

  • Unexplained cyanosis

  • Watery diarrhea

  • Steatorrhea 

Esophageal atresia is a congenital defect in which the upper and lower portions of the esophagus do not connect and form instead two separate sections; a blind pouch, or fistula, forms an unnatural connection with the trachea. This causes the infant to either aspirate into the lungs when feeding or a large amount of air to enter the stomach, presenting a risk of coughing and/or choking with feeds. Cyanosis occurs due to the lack of adequate oxygenation, as well as regurgitation and vomiting, abdominal distention, and increased respiratory distress during and after feeding. Treatment involves maintenance of a patent airway, prevention of aspiration pneumonia, gastric or blind pouch decompression, supportive therapy, and surgical repair.

123.

A nurse had been caring for a critically ill patient who passed away. The patient's family is sitting in the hospital's waiting room waiting for an update on the patient. Which of the following actions is most appropriate for the nurse to take?

  • Provide the family with her condolences and inform them when they can view their loved one

  • Inform the family that the patient did not make it and ask them if they need help making arrangements

  • Help the family accept the patient's death by having them view the body

  • Inform the patient's family that they should view the body and notify her when they are done

Correct answer: Provide the family with her condolences and inform them when they can view their loved one

The most appropriate action for the nurse to take is to provide the family with her condolences and inform them when they can view their loved one. This response shows that the nurse is acknowledging the loss of a loved one, expresses her sympathy, and offers the family an opportunity to view the body if they want to.

The nurse should not just inform the family that the patient did not make it and ask them if they need help making arrangements, because she is not offering the family a viewing opportunity or expressing any sympathy. The nurse should not help the family accept the patient's death by having them view the body, as the nurse should not assume that the family wants to view the body. The nurse should not inform the patient's family that they should view the body and notify her when they are done, because the nurse is not expressing any sympathy and the nurse should not assume that the patient's family wants to view the body.

124.

You are discharging your patient, who was hospitalized with atrial fibrillation. The patient was started and stabilized on warfarin (Coumadin). When discussing the adverse effects of Coumadin, the nurse should tell the patient to contact his physician if:

  • Blood appears in the urine

  • Swelling of the ankles increases

  • The ability to concentrate diminishes

  • Increased transient ischemic attacks occur

Correct answer: Blood appears in the urine

Coumarin derivatives cause an increase in the prothrombin time, leading to an increased risk of bleeding. Any abnormal or excessive bleeding must be reported, because it may indicate toxic levels of the drug.

Swelling is not caused by bleeding. The ability to concentrate is not affected by warfarin. TIAs (transient ischemic attacks) are not caused by bleeding, which is the primary concern in clients who are receiving anticoagulants.

125.

A client is admitted to the medical intensive care unit with a diagnosis of myocardial infarction. The client's history indicates that the infarction occurred ten hours ago. Which laboratory test result should the nurse expect this client to exhibit?

  • Elevated CK-MB

  • Elevated LDH

  • Elevated Serum amylase

  • Elevated hematocrit

Correct answer: Elevated CK-MB

The client would exhibit elevated CK-MB.

CK-MB is normally undetectable or very low in the blood. If CK-MB is elevated and the ratio of CK-MB to total CK (relative index) is more than 2.5–3, it is likely that the heart was damaged. A high CK with a relative index below this value suggests that skeletal muscles were damaged. Any kind of heart muscle damage can cause an increase in CK and CK-MB, including physical damage from trauma, surgery, inflammation, and decreased oxygen (ischemia). Strenuous exercise may also increase both CK and CK-MB, but usually with a lower relative index. Kidney failure can cause a high CK-MB level. Rarely, chronic muscle disease, low thyroid hormone (T3, T4) levels, and alcohol abuse can increase CK-MB.

126.

Patients who are manic often stop taking their medication. What is the reason behind their refusal to take their medication?

  • The early symptoms of a manic episode may include feeling energized, euphoric, and creative

  • Medications used to treat manic episodes may cause vomiting and/or diarrhea

  • Medications used to treat manic episodes are contraindicated in pregnancy

  • Mania causes cognitive changes, so that they simply forget to take their medication

Correct answer: The early symptoms of a manic episode may include feeling energized, euphoric, and creative

Early symptoms of mania lead the individual to feel energized, euphoric, and creative. These feelings are desirable and many patients enjoy feeling this way. These feelings may cause them to stop taking their medication.

127.

Which of the following newborn assessment findings should alert the nurse to notify the primary health care provider (PHCP) as soon as possible? 

Select all that apply.

  • Deep pink or red color over one side of the newborn's body

  • The presence of a hydrocele 

  • A 2-vessel umbilical cord 

  • A milky covering over the glans penis after a circumcision

  • Acrocyanosis 

  • Blood-tinged mucus in the infant's diaper

A deep pink or red color over one side of the newborn's body (while the other side remains pale or normal in color) is known as Harlequin sign and may indicate shunting of blood that occurs with cardiac problems or is sometimes observed in a septic infant. A hydrocele is a fluid-filled, swollen scrotum. Though the scrotum is often edematous after delivery, the PHCP needs to be notified of a hydrocele for further assessment. The umbilical cord should have three vessels (two arteries and one vein). Though often. a 2-vessel cord presents no concerns, it can be correlated to intrauterine growth restriction (IUGR) and needs to be reported. 

A milky covering over the glans penis following a circumcision is normal and should not be disrupted. Acrocyanosis is a bluish discoloration of the hands and feet; it is normal within the first few hours of life and may be noted intermittently for the next 7 to 10 days as blood is appropriately shunted throughout the body. The rest of the infant's body should be pink and warm. Pseudomenstruation (blood-tinged mucus in the diaper) is caused by the withdrawal of estrogen after delivery and is considered a normal finding.

128.

A 36-year-old women has just discovered she is pregnant. The pregnancy is unplanned and she feels ambivalent about the pregnancy. She expresses to you that she feels guilty about not feeling more excited about the baby. Choose the best response.

  • "It's normal to feel ambivalent at the beginning of a pregnancy."

  • "Would you like to see a counselor?'

  • "Can you tell me more about how you are feeling?"

  • "Talk it over with your husband."

Correct answer: "It's normal to feel ambivalent at the beginning of a pregnancy."

Fears and uncertainties are common at the beginning of pregnancy. There is no need to refer to a counselor at this stage unless her feelings continue unchanged. Exploring her feelings may be helpful but won't provide the reassurance she needs. It might be helpful for her to discuss her feelings with her husband, but it might also make him feel anxious.

129.

The nurse caring for a laboring woman notes fetal bradycardia on the fetal monitoring strip. The nurse should include which of the following interventions in the patient's plan of care? 

Select all that apply.

  • Change the mother's position

  • Administer oxygen via face mask

  • Assess maternal vital signs

  • Notify primary health care provider (PHCP)

  • Prepare the mother for immediate delivery

If fetal bradycardia or tachycardia occur (normal fetal heart rate is 120-160 beats per minutes), the nurse should immediately change the position of the laboring mother, administer oxygen (8-10 L/min via face mask), and assess the mother's vital signs. The nurse will also need to notify the PHCP as soon as possible. If the fetus responds well to any of the interventions performed, there is no need to prepare for immediate delivery. 

130.

A patient who is prescribed theophylline is showing signs of toxicity from the drug. Which of the following are early clinical manifestations indicative of theophylline toxicity? 

Select all that apply.

  • Restlessness

  • Palpitations

  • Tremors 

  • Hypertension

  • Hyperglycemia

Theophylline is a bronchodilator used to treat lung diseases and should be used regularly to prevent shortness of breath and wheezing. It is prescribed as a last-line medication, and serum theophylline levels should be monitored during therapy due to risk of toxicity. Therapeutic serum levels are 10 to 20 mcg/mL; toxicity is likely to occur if serum levels are higher than 20 mcg/mL. Early signs include tachycardia and palpitations, restlessness, nervousness and tremors. 

Hyperglycemia and hypertension may be late signs of toxicity.

131.

A post-menopausal female who has been taking alendronate (Fosamax) 70 mg orally once weekly for treatment of osteoporosis and who is at low risk of fracture should be instructed to discontinue use of the medication:

  • After 3 to 5 years of treatment

  • After 12 months of treatment

  • After she has had an improved bone densitometry scan result

  • Alendronate (Fosamax) should not be discontinued when being utilized in the treatment of osteoporosis in post-menopausal women

Correct answer: After 3 to 5 years of treatment

Alendronate (Fosamax) is a bisphosphonate medication used in the treatment of osteoporosis, osteogenesis imperfecta, and Paget's Disease. Patients receiving long-term (> 3 to 5 years) therapy of bisphosphonates for treatment of post-menopausal osteoporosis may be at an increased risk of experiencing atypical femur fractures and should be instructed to "take a break" from bisphosphonate use after this time.

132.

The nurse is caring for a nine-year-old with celiac disease. The nurse knows that the patient understands the diet instructions by ordering which of the following foods?

Select all that apply.

  • Cheese

  • Rice cakes

  • Rye toast 

  • Pancakes

  • Oat cereal 

Celiac disease results in the build-up of the amino acid glutamine, which is toxic to intestinal mucosal cells, and thus intolerance to gluten (wheat, barley, rye, and oats) is characteristic with this condition. Symptoms include diarrhea, steatorrhea, weight loss, abdominal pain and bloating, vomiting, anemia, and irritability. Strict dietary avoidance of gluten minimizes the risk of developing malignant lymphoma of the small intestine and other gastrointestinal malignancies. Patients with this condition should maintain a gluten-free diet, substituting corn, rice, and millet as grain sources. Meats such as beef, pork, poultry, and fish; eggs; milk and some dairy products; vegetables and fruits; rice; corn; gluten-free flour; puffed rice; cornflakes; cornmeal; and precooked gluten-free cereals are permitted. 

133.

A patient was restrained because the nurse was trying to prevent the patient from pulling out his IV that was being used to administer antibiotics. 

Instead of restraining the patient, what should the nurse have done?

  • Call the provider to order a PO antibiotic.

  • Administer a sedative that will decrease the patient's movements.

  • Stand guard over the patient until the antibiotic infusion is completed.

  • Ask a family member to monitor the patient's behavior.

Correct answer: Call the provider to order a PO antibiotic.

Instead of restraining the patient, the nurse should have requested oral antibiotics instead of intravenous antibiotics. Restraints should be used as a last resort, and nurses should consider alternatives before using them.

A sedative given to a patient to decrease his movements is considered a restraint. It is not practical for a nurse to stand guard over a patient for long periods of time. The facility's legal responsibility is to monitor the patient, not the family members.

134.

The primary healthcare provider (PHCP) has ordered ibuprofen for a patient, and the nurse is reviewing the patient's home medication list. Which of the following medications are concerning to take in conjunction with ibuprofen, and should warrant further assessment? 

Select all that apply.

  • Coumadin

  • Pepto-Bismol

  • Metformin

  • Diltiazem

  • Rosuvastatin

  • Sotalol

Ibuprofen is an NSAID (nonsteroidal anti-inflammatory drug) and is contraindicated if the patient has gastric irritation or ulcer disease, a bleeding disorder, if the patient is currently taking any type of oral antidiabetic agents (it can cause hypoglycemia if taken together), or if the patient is taking a calcium channel blocker (due to high risk of toxicity). 

Pepto-Bismol is for gastric irritation, coumadin is an anticoagulant, metformin is an antidiabetic agent, and diltiazem is a calcium channel blocker used to treat hypertension. The nurse should hold any scheduled or PRN doses of ibuprofen and call the PHCP for further instruction. It is important to note that if the patient has a hypersensitivity or allergy to ibuprofen, it should also be held and the provider notified to request a change in medication. 

Rosuvastatin is indicated for hypercholesterolemia and sotalol is used for irregular heart rhythms. There are no known interactions between either of these medications and ibuprofen. 

135.

You are waiting in line at the cafeteria when you overhear another hospital employee state that they are not planning to receive the "flu shot" as he is aware of an oral tablet that can be taken to "prevent the flu."

You know that oseltamivir (Tamiflu):

  • Should not be used as a substitute for influenza vaccine

  • May be offered as a substitute for influenza vaccination to individuals who are allergic to egg protein

  • Can be used to treat uncomplicated influenza symptoms in patients who have been symptomatic for three days or less

  • Can be used to treat uncomplicated influenza symptoms in patients who have been symptomatic for five days or less

Correct answer: Should not be used as a substitute for influenza vaccine

Oseltamivir (Tamiflu) is an antiviral agent indicated for use in prevention and treatment of influenza. It should not be used as a substitute for influenza vaccine. It can be used to treat uncomplicated influenza symptoms in patients who have been symptomatic for two days or less.

136.

Regarding the use of magnesium sulfate as part of the treatment plan for pre-term labor, the nurse knows:

  • Magnesium sulfate causes smooth muscle relaxation

  • Magnesium sulfate may cause an elevation in blood pressure

  • Magnesium sulfate may cause an increase in deep tendon reflexes

  • Magnesium sulfate is used as an adjunct to stimulate effective uterine contractions

Correct answer: Magnesium sulfate causes smooth muscle relaxation

Magnesium sulfate is useful in the treatment of pre-term labor and in preventing and controlling seizures in patients who are pre-eclamptic or eclamptic. Magnesium sulfate causes relaxation of the smooth muscles, thereby decreasing or ceasing uterine contractions. As magnesium sulfate affects all of the smooth muscles, patients receiving magnesium sulfate may also experience:

  • respiratory depression
  • depressed deep tendon reflexes
  • hypotension
  • extreme muscle weakness
  • flushing
  • decreased urine output
  • pulmonary edema
  • heart block
  • respiratory paralysis, and
  • cardiac arrest

Patients receiving magnesium sulfate should be closely monitored.

137.

You are working in the ICU, caring for an 88-year-old male with a history of COPD, congestive heart failure, hypertension, peripheral artery disease, and malnourishment. He was admitted for an electrolyte imbalance and has been receiving multiple IV infusions. On your assessment, the patient has difficulty breathing. His heart rate is 133, and his airway is patent, but his respiratory rate is 24 (short and ineffective). Lung sounds have crackles and rails in both upper lobes and no lung sounds in the lower lobes, His blood pressure is 88/54, and his SPO2 is 78% on a 2 L nasal cannula. 

Which of the following interventions would be most appropriate at this time? 

Select all that apply.

  • Stop IV fluid infusion 

  • Begin positive pressure ventilation with 15 L O2

  • Administer a diuretic 

  • Lay the patient flat 

  • Give epinephrine 0.3-0.5 mg IVP or IM

This patient is showing signs of flash pulmonary edema from IV infusion fluid overload. The patient should be taken off IV fluids, started on CPAP or BiPAP to assist in pushing fluid back into the vasculature, and given a diuretic to offload the excess. 

The elevated heart rate and low blood pressure show signs of pressure surrounding the heart. Low oxygen saturation and decreased SPO2 show the overload of fluid at the alveolar level of oxygen exchange. 

The patient could also have an advanced airway placed, as he is decompensating. A 12-lead EKG would show an acute change in myocardial muscle deterioration. 

138.

Which of the following laboratory values would the nurse expect to be elevated in the patient who presents with acute pancreatitis?

Select all that apply.

  • White blood cell (WBC) count

  • Glucose

  • Alkaline phosphatase

  • Urinary amylase

  • Red blood cells 

  • Platelets 

In the diagnosis of acute pancreatitis, the nurse would expect to see elevated WBC count, as well as elevated glucose, bilirubin, alkaline phosphatase, and urinary amylase levels. Serum lipase and amylase levels are also elevated. 

Red blood cells and platelets would not be elevated in this condition.

139.

An adult female patient is two days postoperative from neck surgery for a broken neck. The patient reports that her pain level is a 10, which is the greatest pain level. What medication would be most appropriate for the nurse to administer?

  • Meperidine (Demerol) 15 mg/hr intravenously

  • Morphine (MS Contin) 30 mg orally

  • Hydromorphone (Dilaudid) 2 mg intramuscularly

  • Fentanyl (Duragesic) 100 mcg patch transdermally

Correct answer: Meperidine (Demerol) 15 mg/hr intravenously

The most appropriate medication for the nurse to administer is meperidine (Demerol) 15 mg/hr intravenously. The patient is at the greatest level of pain; therefore, her treatment should be administered intravenously, as this route is the fastest route of absorption.

The oral route takes at least 45 minutes before it becomes effective and the intramuscular route takes at least 15 minutes before it becomes effective. A transdermal patch is the least effective, as it has a long drug half-life.

140.

Your patient has been diagnosed with Parkinson's disease and has been started on Sinemet (carbidopa/levodopa). When teaching the patient about this drug you tell the patient to monitor his ______ carefully on a regular basis and report any changes to his physician.

  • Skin

  • Urine

  • Hearing

  • Heart rate

Your patient has been diagnosed with Parkinson's disease and has been started on Sinemet (carbidopa/levodopa). When teaching the patient about this drug you tell the patient to monitor his skin carefully on a regular basis and report any changes to his physician.

Patients with Parkinson's disease have at 2 to 6 times higher risk of developing melanoma. They should be counseled to monitor their skin for suspicious areas and report any changes to their physician immediately.

×