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Quiz Session - Attempts With Random Questions

NCLEX-RN Exam Questions

Page 9 of 65

161.

A patient is in the middle of receiving a blood transfusion when he becomes flush and starts to wheeze. The nurse knows that these symptoms are associated with an allergic reaction to the blood transfusion. What action should the nurse take?

  • The nurse should pause the transfusion and administer antihistamines

  • The nurse should keep the IV line open with normal saline

  • The nurse should administer epinephrine

  • The nurse should transfuse an offending antibody as needed with a compatible red blood cell

Correct answer: The nurse should pause the transfusion and administer antihistamines

If a patient is showing symptoms of an allergic reaction during a blood transfusion, the nurse should pause the transfusion and administer antihistamines.

The nurse should keep the IV line open with normal saline if the patient has symptoms of an acute hemolytic transfusion reaction. The nurse should administer epinephrine if the patient becomes anaphylactic. The nurse should transfuse an offending antibody as needed with a compatible red blood cell if the patient has a delayed hemolytic transfusion reaction.

162.

The primary healthcare provider (PHCP) has ordered a glycosylated hemoglobin (HgbA1C) to be drawn on a patient to test for the presence of diabetes, and the nurse is educating the patient on this particular test. Which statement(s) made by the nurse is/are correct?

Select all that apply. 

  • It is not necessary to fast before this test

  • This test will reveal your blood sugar levels over the past 2 to 3 months 

  • This test works by showing how much sugar has been built up and is bound to the hemoglobin in your RBCs (red blood cells)

  • This test will reveal the amount of insulin circulating in your bloodstream

  • A healthy adult (without prediabetes or diabetes) should have a HgA1C of 5% or less

Glycosylated hemoglobin is a diagnostic test for prediabetes and diabetes. The test examines the amount of sugar (glucose) saturating the hemoglobin molecules that reside within the RBCs. This test is able to tell the PHCP the patient's average glucose level over the past 2 to 3 months (approximately the life span of a RBC). The patient does not need to fast for this test. Normal reference range for a healthy adult without diabetes is < 6%. Elevated levels indicate poorly managed diabetes or nondiabetic hyperglycemia. Below normal levels may occur in the following scenarios: chronic blood loss, sickle cell anemia, pregnancy, and chronic kidney disease.

163.

A female client receiving IV vasopressin (Pitressin) for esophageal variceal rupture reports to the nurse that she feels sub sternal tightness and pressure across her chest. Which PRN protocol should the nurse initiate?

  • Start an IV Nitroglycerin infusion

  • Nasogastric lavage with cool saline

  • Increase the vasopressin infusion

  • Prepare for endotracheal intubation

Correct answer: Start an IV nitroglycerin infusion

The nurse should start an IV nitroglycerin infusion.

Esophageal varices are abnormal, enlarged veins in the lower part of the esophagus. Esophageal varices occur most often in people with serious liver diseases. Esophageal varices develop when normal blood flow to the liver is obstructed by scar tissue in the liver or a clot. Seeking a way around the blockages, blood flows into smaller blood vessels that are not designed to carry large volumes of blood. The vessels may leak blood or even rupture, causing life-threatening bleeding.

Esophageal varices usually don't cause signs and symptoms unless they bleed. Signs and symptoms of bleeding esophageal varices include:

  • Vomiting blood
  • Black, tarry or bloody stools
  • Shock (in severe case)

164.

Which of the following would be important for patient education about the medication warfarin?

Select all that apply.

  • Do not take this medication with NSAIDs.

  • Look for changes in stools.

  • Drink plenty of milk while on Warfarin as it leaches calcium.

  • Pair this medication with Tylenol to assist with pain.

Warfarin is an anti-coagulant medication. It increases the chance of GI bleeds, and taking it with an NSAID can dramatically increase this risk. Changes in stool such as black and tarry or frank red blood are additional signs of GI bleeds. 

165.

You are admitting a new patient onto the unit. The patient tells you that he is allergic to penicillin. In addition to the name of the medication, what is most important for the nurse to know about the patient's allergy?

  • The type and severity of the reaction experienced

  • How many years ago the reaction occurred

  • The dose of the medication that caused the allergic reaction

  • Whether the patient has ever had the medication again and, if so, whether another reaction occur

Correct answer: The type and severity of the reaction experienced

Understanding the type of reaction experienced is very important. For example, a patient might state that he is allergic to codeine because it causes an upset stomach. This is a side effect and not a true allergic reaction. On the other hand, a patient might experience an anaphylactic reaction to a medication. This is a severe reaction which could result in death.

166.

Which of the following is accurate in regard to urinary tract infections (UTIs) in the preschooler?

Select all that apply.

  • Uncircumcised boys are more likely to develop a UTI than a circumcised boy

  • Educating hygiene (wipe perineum from front to back in girls) will decrease the likelihood of a UTI

  • Encourage the parents to ensure adequate fluid intake to flush out any toxins 

  • Encourage tub bathing to clean the perineal area thoroughly 

  • A child will always exhibit symptoms if a UTI is present 

A UTI occurs when there is bacterial invasion of the urinary tract from flora from the skin or gastrointestinal tract. Uncircumcised boys are more likely to develop a UTI than circumcised boys. Hygiene is important. Bacteria can be easily spread from the rectum to the urinary meatus and cause infection if girls wipe from back to front or do not wipe adequately after going to the bathroom. Adequate fluid intake is important to flush out toxins that may be brewing. Tub bathing may be counterproductive at this age as soaking could increase the likelihood of a UTI in a female. Children may experience asymptomatic bacteriuria, so if there is a suspicion of infection in the urinary tract, they should be screened and treated accordingly. 

167.

A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for deficient fluid volume?

  • A client with a colostomy

  • A client with congestive heart failure

  • A client receiving frequent wound irrigations

  • A client with decreased kidney function

Correct answer: A client with a colostomy

Causes of deficient fluid include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. The other options indicate excess fluid volume.

168.

You are working in the emergency room. Your patient was in a bar fight and required sutures to his face. The patient is clearly intoxicated. He intends to drive home. You should:

  • Ask the patient if you can call someone to give him a ride home

  • Call the police and tell them that the patient is intoxicated and plans to drive home

  • Ask the security guard to give the patient a ride home

  • Let him go because what happens when the patient leaves is none of your business

Correct answer: Ask the patient if you can call someone to give him a ride home

Asking the patient if you can call someone for him involves him in making the right choice and will preserve the nurse-client relationship of trust.

Staff should not offer to provide a ride to the patient for safety and legal reasons. Calling the police should be the last resort to protect the patient and the public.

169.

A nurse is caring for a patient who is considered obese. The patient asked the nurse for recommendations on how to improve his eating habits. The nurse spoke with a dietitian to find out his recommendations. The nurse's actions best describes which of the following approaches?

  • Consultation

  • Continuity of care

  • Delegation

  • Performance improvement

Correct answer: Consultation

The nurse's actions best describes the consultation approach. The consultation approach consists of communicating with another health care professional about an aspect of patient care.

Continuity of care is when the patient and the health care provider are working together for the patient's ongoing health care needs. Delegation is when the nurse transfers a responsibility to another staff member. Performance improvement is when a nurse achieves planned outcomes by meeting the patient's expectations.

170.

The AED has just provided a shock. You should immediately:

  • Resume CPR

  • Give 2 breaths

  • Check for a pulse

  • Wait for 2 minutes to see what effect the shock has had

Correct answer: Resume CPR

Immediately after the AED has provided a shock, you should resume CPR for 2 minutes, at which point the AED will reanalyze and determine whether another shock is required.

171.

You are supervising a new nurse's aid, who is administering her first enema to your shared patient. Which of the following statements by the aid indicates inadequate knowledge regarding the administration of enemas?

  • "I will position the patient on her right side with her knees drawn up to her abdomen."

  • "I will warm the enema prior to administration to promote comfort and decrease abdominal cramping."

  • "I will insert the enema into the rectum to a depth of approximately 10 cm."

  • "I will expel air from the enema prior to administration."

Correct answer: "I will position the patient on her right side with her knees drawn up to her abdomen."

Patients should be positioned on their left side with their knees drawn up to their abdomen. This is due to the anatomical structure of the sigmoid colon and also helps facilitate the flow of solution into the colon.

172.

Which of the following would indicate a child is ready to start toilet training?

Select all that apply.

  • Is waking up dry from a nap

  • Is able to remove clothing independently

  • Recognizes the urge to defecate or urinate

  • Is able to sit on the toilet for 2 to 3 minutes without losing interest

  • Is able to stay dry for one hour while awake

If the child is waking up dry from a nap, removing clothing independently, and/or recognizing the urge to either urinate or defecate, the child may be ready to toilet train. Other signs of readiness include staying dry for at least two hours while awake, and being able to sit on the potty for 5 to10 minutes without getting off or losing interest.

173.

Which of the following risk factors predisposes a patient to hypertensive disorders during pregnancy?

Select all that apply.

  • Primigravida

  • African American ethnicity

  • Women who conceived via IVF (in vitro fertilization)

  • Women who are 35 years or older

  • BMI greater than 25

Four major categories of hypertension in pregnancy include preeclampsia, chronic/preexisting hypertension, chronic hypertension with superimposed preeclampsia, and gestational hypertension. 

Risk factors that would predispose a woman to any of these disorders are:

  • Previous preeclampsia or gestational hypertension, previous placental abruption, or fetal demise
  • Primigravida (a woman who is pregnant for the first time)
  • Family history (first-degree relative with preeclampsia)
  • Women who are 40 years or older (not 35 or older)
  • African American ethnicity
  • Women who are pregnant with multiples
  • Women with a medical history of renal disease, connective tissue disease, diabetes mellitus, thrombophilia, or lupus erythematosus
  • BMI greater than 26 (not 25)
  • Metabolic syndrome
  • Women who had in vitro fertilization (IVF)
  • Hydatidiform mole, hydrops fetalis, unexplained intrauterine growth retardation (IUGR)

174.

The nurse obtains a laboratory report that shows acid-fast rods in a patient's sputum. These are presumed to be:

  • Mycobacterium tuberculosis

  • Influenza virus

  • Diphtheria bacillus

  • Bordetella pertussis

Correct answer: Mycobacterium tuberculosis

Mycobacterium tuberculosis is the acid-fast causative organism of tuberculosis.

Influenza virus, diphtheria bacillus, and Bordetella pertussis are not acid-fast organisms.

175.

Your patient is severely dehydrated. You should expect that the patient's hemoglobin will be:

  • Higher than normal

  • Lower than normal

  • Unaffected by hydration status

  • Unrelated to hydration status

Correct answer: Higher than normal

Both the hemoglobin and the hematocrit are based on whole blood and are therefore dependent on plasma volume. If a patient is severely dehydrated, the hemoglobin and hematocrit will appear higher than if the patient were normovolemic.

If the patient is well-hydrated, hemoglobin and hematocrit will appear lower than their actual level.

176.

Emergency equipment that the nurse should ensure is kept at the bedside of a patient that has had a thyroidectomy includes:

  • A tracheostomy set and oxygen

  • A crash cart and bed board

  • An airway and rebreathing mask

  • Two ampules of sodium bicarbonate

Correct answer: A tracheostomy set and oxygen

Acute respiratory obstruction may result from edema, nerve damage, or tetany follow a thyroidectomy.

Cardiac arrest is not expected following a thyroidectomy; heart failure could result if the hyperthyroidism had been left untreated. An airway and rebreathing mask would not be effective because the obstruction in the case of a thyroidectomy would be beyond the oropharynx. Sodium bicarbonate is not expected to be needed as acidosis is not a typical complication of thyroid surgery.

177.

As a tenured employee, you have been tasked with holding a health fair at a local elementary school.  Which of the following would support teaching the risks of smoking to this age group? 

Select all that apply.

  • Photos of smokers' lungs vs healthy lungs 

  • Hands-on teaching aids to pass around the classroom

  • Powerpoint presentation

  • Live lecture presentation 

For this age group, it is best to get the children involved in the information via hands-on material and visual aids. 

A PowerPoint presentation is not a strong teaching aid for this age group, and lectures would not hold their attention. 

178.

The parents of a toddler visit their child in the hospital. When the child was first hospitalized, she would cry and cling when the parents left. Now she does not immediately go to greet her parents. The parents are concerned. You explain that this behavior means that the child:

  • Has adjusted to the hospital setting

  • Is angry at her parents

  • Believes her parents no longer love her

  • Is acting out

Correct answer: Has adjusted to the hospital setting

Children go through three phases when they are separated from their parents: protest, despair and denial/detachment. The child's behavior signifies that she is adjusting to being separated from her parents.

179.

A famous individual is admitted to the emergency room. The nurse who is treating the patient notices two other nurses reading the patient's medical record. What should the attending nurse do first?

  • Inform the two nurses that they are not authorized to look at the patient's medical record 

  • Do nothing because the two nurses are employed at the health care center and work in the same department

  • Inform the nursing supervisor that the patient's medical record has been breached by unauthorized personnel

  • Ask the other two nurses for their assistance with the patient, since they are familiar with his medical information 

Correct answer: Inform the two nurses that they are not authorized to look at the patient's medical record

Patients have a right to privacy in the healthcare system, and healthcare information should not be shared without the patient's consent. The nurse should inform the two nurses that they are not authorized to look at the patient's medical record since they are not directly involved with the patient's care. 

Informing the nursing supervisor that this patient's medical record has been breached by unauthorized personnel is an act that will need to be done. However, it is not the priority, and the nurse should address other issues first. Personnel not directly involved in the patient's care do not have authorization to look at the patient's medical record. The nurse should not ask for the other two nurses' assistance as they should understand that what they were doing was illegal and should be stopped immediately.

180.

The best time for men to check for testicular lumps is:

  • After bathing

  • Prior to bathing

  • Early in the morning

  • Following intercourse

Correct answer: After bathing

Men should be counseled to examine their testicles just after bathing, when the scrotum is warm and relaxed. The time of day makes no difference.

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