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Quiz Session - Attempts With Random Questions

NCLEX-RN Exam Questions

Page 8 of 65

141.

Your 73-year-old patient with chronic obstructive pulmonary disease (COPD) has been experiencing an exacerbation of her symptoms and is being treated with oral hydrocortisone (Cortef, Solu-Cortef) as part of her treatment. She informs you she is looking forward to having her daughter and several young grandchildren come to stay with her for a few days until she is feeling better, and states it will be "easier for her to take care of me and my grandchildren in one place, since they have been sick with a virus for over a week."

You recommend she:

  • Check her temperature to monitor for fever and return to the clinic for laboratory studies if she believes she may be getting ill

  • Arrange for an alternate caregiver, as patients who are taking glucocorticoids are prohibited from having close proximity with anyone who has recently been ill

  • Request that her daughter have her children treated with an antibiotic for at least 24 hours prior to coming to stay at her house

  • Call her provider to obtain a prescription for an antibiotic if she begins to experience any sick symptoms

Correct answer: Check her temperature to monitor for fever and return to the clinic for laboratory studies if she believes she may be getting ill

Glucocorticoids such as hydrocortisone (Cortef, Solu-Cortef) suppress the immune system and may mask signs of infection. Checking for elevated temperature and having laboratory studies completed, such as white blood cell (WBC) count, may be necessary to determine infection. Viral infections are not treated with antibiotics. Use of short-term glucocorticoids does not necessitate that all contact with individuals who may have recently been ill be avoided.

142.

A client is brought to the emergency department stating that he has accidentally been taking two times his prescribed dose of Warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to do which of the following next?

  • Draw a sample for prothrombin (PT) and international normalized ratio (INR) level

  • Prepare to administer an antidote

  • Draw a sample for type and crossmatch and transfuse the client

  • Draw a sample for activated partial thromboplastin time (aPTT) level

Correct answer: Draw a sample for prothrombin (PT) and international normalized ratio (INR) level

The next action is to draw a sample for PT and INR levels to determine the client's anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client if an antidote (vitamin K) or blood transfusion is needed. The aPTT monitors the effects of heparin therapy.

143.

When assessing an older adult, the nurse may expect an increase in:

Select all that apply.

  • Bone brittleness

  • Blood pressure

  • Constipation

  • Hair and skin pigmentation

  • Skin turgor

A multitude of changes occur in the aging individual. There is increased brittleness of the bones due to demineralization, blood pressure often increases but susceptibility to postural hypotension may also increase (particularly with certain medications), and an increased tendency toward constipation due to poor oral intake and slowed motility. There is often a loss of hair and skin pigmentation and a decrease in skin turgor.

144.

The nurse is caring for a patient who is exhibiting Kussmaul's respirations. Which of the following statements are true of this condition?

Select all that apply.

  • Respirations are deep, rapid, and labored

  • They are often associated with diabetic ketoacidosis (DKA)

  • This is a compensatory action by the lungs

  • They are associated with severe metabolic alkalosis

  • Respirations cease for several seconds

Kussmaul breathing is an abnormally deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis, but also kidney failure. This occurs as a result of the compensatory action by the lungs and is a form of hyperventilation, which is any breathing pattern that reduces carbon dioxide in the blood due to increased rate or depth of respiration. 

Apnea is described as respirations that cease for several seconds at a time.

145.

A nurse is caring for a patient who is having an atonic seizure. Which of the following actions should the nurse take first?

  • Provide the patient with a safe environment

  • Check to see if the patient is responsive

  • Check to see if the patient is breathing

  • Record the seizure event

Correct answer: Provide the patient with a safe environment

The first action a nurse should take when a patient is having an atonic seizure is to provide the patient with a safe environment. An atonic seizure causes an individual to lose muscle tone in their arms and legs, which results in the individual falling. Therefore, it is important that the nurse provides the patient with a safe environment in order to prevent additional harm.

The nurse will need to verify that the patient is responsive and breathing, but those are not the first actions the nurse should take. It is important that a nurse records the seizure event; however, this should take place after providing a safe environment for the patient and caring for the patient.

146.

A female victim of a sexual assault is being seen in the crisis center. The victim states that she still feels like the rape happened yesterday even though it has been a few months since the incident. What is the appropriate nursing response?

  • "Tell me more about the incident that causes you to feel like the rape just occurred."

  • "You need to try to be realistic. The rape did not just occur."

  • "It will take some time to get over those feelings about the rape."

  • "What do you think you can do to alleviate some of your fears about being raped?"

Correct Answer: "Tell me more about the incident that causes you to feel like the rape just occurred."

The correct option allows the client to express her ideas and feelings more fully and portrays a non-hurried, non-judgmental, supportive attitude on the part of the nurse. Clients need to be reassured that their feelings are normal and that they may express their concerns freely in a safe, caring environment.

147.

Hypoproteinemia may cause which of the following symptoms?

  • Edema

  • Tachycardia

  • Chest pain

  • Peripheral neuropathy

Correct answer: Edema

Hypoproteinemia is a condition where there is an abnormally low level of protein in the blood. Decreased serum protein decreases the osmotic pressure of the blood, leading to loss of fluid from the intravascular compartment, or the blood vessels, to the interstitial tissues, resulting in edema.

148.

A nurse is irrigating a patient's wound. Which pieces of PPE should the nurse wear in order to perform this task?

  • Gloves, gown, mask, and goggles

  • Gloves and gown

  • Gloves, mask, and goggles

  • Gloves

Correct answer: Gloves, gown, mask, and goggles

When irrigating a wound, a nurse should wear gloves, a gown, a mask, and goggles.

Masks and goggles are worn during activities that are likely to cause splashes. Gowns are worn during activities that could cause the nurse's clothing to become contaminated. Gloves should be worn whenever touching contaminated items, body fluids, or blood.

149.

A patient is prescribed Sulfamethoxazole-Trimethoprim (Bactrim) for a urinary tract infection. While taking this medication, what should the patient do?

  • Avoid direct sunlight

  • Avoid eating fatty meals

  • Avoid consuming milk products

  • Add bananas or oranges to his diet

Correct answer: Avoid direct sunlight

When taking Sulfamethoxazole-Trimethoprim (Bactrim), a patient should avoid direct sunlight, as this medication causes photosensitivity, which could result in sunburns.

Bactrim does not require individuals to avoid eating fatty meals. Bactrim does not require individuals to avoid consuming milk products; however, individuals who take tetracyclines should not do so with milk. Bactrim does not require individuals to add bananas or oranges to their diet; however, it is a recommendation for thiazide diuretics.

150.

A hospitalized patient is informed that her mother has passed away. The patient is upset about this news, as she knows she will not be able to attend her mother's funeral services. Which of the following actions is the most appropriate for the nurse to take?

  • Provide the patient with an opportunity to talk about her feelings, and ask if she would like to speak with a chaplain or psychologist for additional support.

  • Provide the patient with privacy, entering her room only if necessary, and ask if she would like to speak with a chaplain or psychologist for additional support.

  • Provide the patient with an opportunity to talk about her feelings, and contact the hospital's psychologist to arrange a meeting for additional support.

  • Provide the patient with an opportunity to talk about her feelings, and contact the hospital's chaplain to see the patient as soon as possible.

Correct answer: Provide the patient with an opportunity to talk about her feelings, and ask if she would like to speak with a chaplain or psychologist for additional support.

The most appropriate action for the nurse to take is to provide the patient with an opportunity to talk about her feelings, and then ask the patient if she would like to speak with a chaplain or psychologist for additional support. This option allows the patient to express her feelings, and it provides her with an opportunity to accept or decline additional support.

The nurse should not provide the patient with privacy until she verifies that the patient does not want additional support. The nurse should not contact the hospital's psychologist without first assessing the patient's needs or asking the patient first. The nurse should not contact the hospital's chaplain without first asking the patient.

151.

Your female patient is scheduled for an abdominal ultrasound in the morning. You instruct the patient that:

  • She will be restricted from eating or drinking after midnight

  • She may chew gum to relieve her dry mouth

  • She must drink 1.5 liters of water 1 1/2 hours prior to the test

  • She will be required to lay perfectly still during the test

Correct answer: She will be restricted from eating or drinking after midnight

Patients must be NPO after midnight if they are scheduled for an abdominal ultrasound in the a.m. Chewing gum is not permitted. It is not necessary to have a full bladder for an ultrasound of the abdomen. The patient will be required to move during the test, according to the technician's instructions, so that various organs may be better visualized.

152.

Which of the following procedures would require sterile gloves?

Select all that apply.

  • Central line dressing changes and placement 

  • Urinary catheter placement 

  • Invasive surgical procedures 

  • Tracheostomy suction 

  • Peripheral IV placement 

For infectious disease management, it is important to wear sterile gloves when performing a procedure that is at high risk for infection. An example would be while placing a urinary catheter. Due to the indwelling catheter not being regularly cleaned, any foreign material could incubate and lead to a UTI. 

Another example would be while cleaning a central line. Central lines have direct access to the vasculature and could lead to systemic infection if not treated appropriately. 

153.

The nurse is caring for a client who is one day post-op for a total hip replacement. What is the best position in which the nurse should place the client?

  • On the nonoperative side with the legs abducted

  • On the operative side

  • Side-lying with the affected leg internally rotated

  • Side-lying with the affected leg externally rotated

Correct answer: On the nonoperative side with the legs abducted

Positioning following a total hip replacement depends on the surgical techniques used, the method of implantation, the prosthesis, and the physician's preference. Abduction is maintained when the patient is in the supine position or positioned on the nonoperative side. The other options are incorrect positions for this client.

154.

In children and adolescents, Hepatitis B virus (HBV) occurs in specific high-risk groups, including which of the following? 

Select all that apply.

  • Children with blood disorders requiring recurrent blood transfusions

  • Children involved in intravenous (IV) drug abuse

  • Children involved in heterosexual activity or sexual activity with homosexual men 

  • Malnourished children and adolescents 

  • Immunosuppressed children and adolescents 

Most HBV infection is acquired prenatally; newborns are at risk if the mother is infected with HBV or was a carrier during pregnancy, and the severity of the virus varies greatly from asymptomatic cases to severe cases. In children and adolescents, HBV occurs in specific high-risk groups, including children with hemophilia (or other blood disorders requiring multiple blood transfusions), children or adolescents involved in IV drug abuse, institutionalized children, preschool children in endemic areas, and children who have had heterosexual activity or sexual activity with homosexual men. HBV infection can cause a carrier state, eventually leading to cirrhosis or hepatocellular carcinoma in adulthood. 

Malnourishment and immunosuppression are not common risk factors to the development of HBV. 

155.

The patient you have been assigned for the day is bedridden and requires continuous feeding through a peg tube. Which of the following must be completed before repositioning the patient?

Select all that apply.

  • Tube feeding must be paused while the patient is being moved.

  • Tube placement must be confirmed with an air flush before restarting the tube feed.

  • No interventions are required for hourly repositioning.

  • The patient must have a large water flush while lying flat on their back.

This patient's feeds must be paused prior to being moved or manipulated in bed due to the risk of aspiration. The patient will need to be laid on an angle in the bed to ensure that stomach continence does not aspirate and lead to pneumonia.

156.

Which of the following interventions would be appropriate when preparing to care for an infant born after 42 weeks of gestation?

Select all that apply.

  • Monitor for hypoglycemia

  • Maintain newborn's temperature

  • Monitor for meconium aspiration

  • Prepare to administer surfactant therapy and bronchodilators at birth

  • Monitor intake and output and electrolyte balance

A postterm newborn often has issues with hypoglycemia, cold stress, and, because of post-dates, the infant has a higher risk of meconium-stained amniotic fluid and, therefore, meconium aspiration at delivery. Close monitoring of blood sugars, temperature, and signs of meconium aspiration are essential when providing care for a postterm infant. 

Surfactant replacement therapy and bronchodilators would be indicated for a preterm infant, an infant born with respiratory distress syndrome (RDS), or bronchopulmonary dysplasia (BPD). Monitoring intake and output and electrolyte imbalances would be appropriate in the preterm infant, not the postterm newborn. 

157.

Folic acid is often prescribed for a client who is receiving phenytoin because folic acid:

  • Absorption from foods is inhibited by phenytoin

  • Improves absorption of iron from foods

  • Content of common foods is inadequate

  • Prevents the neuropathy caused by phenytoin

Correct answer: Absorption from foods is inhibited by phenytoin

Phenytoin inhibits folic acid absorption and potentiates the effects of folic acid antagonists. Folic acid is helpful in correcting certain anemias that can result for the administration of phenytoin. Dosage must be carefully adjusted because folic acid diminishes the effect of phenytoin.

Although folic acid plays a role in the formation of heme (iron) in hemoglobin, its prescription in this case is related to phenytoin. There is not enough information given to determine the diet is inadequate. Neurological side effects include an elevation of the excitability threshold of neurons; neuropathy is not prevented by folic acid.

158.

A 67-year-old male reports to the hospital for dark tea-colored urine, decreased urine output, and swelling in his feet. What labs will be ordered by the physician for this patient? 

Select all that apply.

  • Creatinine

  • Blood urea nitrogen

  • aPTT

  • INR

  • HCO3

The patient is showing signs of decreased kidney function. It would be pertinent to anticipate renal indices test orders.

Creatinine is a waste byproduct produced by muscle breakdown.

Blood urea nitrogen (BUN) measures the amount of urea in the bloodstream, which is produced by the liver when it breaks down protein. BUN is typically expelled through urine.

159.

A patient is admitted to the emergency department for observation for acute alcohol withdrawal. Which of the following findings would indicate the patient is experiencing delirium tremens (withdrawal delirium)? 

Select all that apply.

  • Hypertension

  • Changes in level of consciousness (LOC)

  • Hallucinations

  • Lethargy

  • Ataxia

Delirium tremens is a state of delirium usually peaking around 48 to 72 hours after stopping or drastically reducing alcohol intake, and lasts 2 to 3 days. It is considered a medical emergency. Death can occur from myocardial infarction, fat emboli, peripheral vascular collapse, electrolyte imbalance, aspiration pneumonia, or suicide. Symptoms include agitation, anorexia, anxiety, hallucinations and delusions, disorientation, fever, insomnia, tachycardia, and hypertension.

160.

The nurse is providing education to a patient recently diagnosed with obsessive compulsive disorder (OCD) regarding therapy. Which of the following therapies will the nurse discuss with this patient? 

Select all that apply.

  • Cognitive behavioral therapy (CBT)

  • Antidepressants

  • Establishing self-care routines

  • Electroconvulsive therapy (ECT)

  • Joining a 12-step program

Obsessions are a preoccupation with intrusive thoughts, impulses, images, and ideas; compulsions are the performance of rituals or repetitive behaviors that seem impossible to stop. These two often occur together and disrupt normal daily activities. Treatments involve psychotherapy such as CBT, antidepressant medications, and establishing self-care routines to ensure the patient's basic needs (food, rest, hygiene) are being met. 

ECT therapy is a treatment option for schizophrenia. Twelve-step programs are for alcohol or substance abuse.

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