NCLEX Preparation Course - Critical Thinking Exercises VI (Answers 1-10)

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1) A
- in multiple myeloma, bone destruction causes hypercalcemia. Therefore, giving calcium supplement is inappropriate. Hypercalcemia causes polyuria. The client should increase his fluid intake to prevent dehydration and renal stone formation. The client with multiple myeloma is at high risk for fracture and infection. Falls and infection should be avoided.

2) C
- in a client with AV-fistula, arm precaution should be observed. This means no BP taking or any from of puncturing on the affected arm. Therefore, the RN should intervene when a CNA takes the BP on the affected arm.

3) B
- Hawthorn promotes peripheral vasodilation, increases coronary circulation, acts as antioxidant. It is indicated for treatment of mild hypertension, early CHF, stable angina.

4) A
- echinacea is immune enhancer. It is also used to treat respiratory tract infections and urinary tract infections.

5) C
- caloric testing is also called Caloric Ice Water testing. Primarily, it involves introducing cold water into the ear. It is also called oculovestibular test. The normal result is conjugate nystagmus of the eyes away from the ear stimulated.

6) C
- the dead client's arms should be positioned on the side, not across his chest. The client should be wrapped with linen/shroud (according to the institution's policy).

7) C
- dehydration is primarily characterized by dark, concentrated urine. Urine output is one of the most accurate indicator of fluid balance. Skin turgor is not used as an indicator for dehydration among the elderly because their skin is normally wrinkled.

8) C
- when a client receives heparin, inspect site of injection for hematoma. This indicates bleeding at the area and should not be used as injection site. When administering heparin subcutaneous, do not aspirate, do not massage the site after injection. This is to prevent hematoma formation at the site. Needle gauge used be the same as intradermal (gauge 25, 26, 27).

9) B
- application of tourniquet above the area bitten by a rattle snake is the most appropriate immediate action while waiting for the emergency rescue team. This is to prevent spread of the venom in the blood circulation.

10) D
- pericardial friction rub indicates pericardial effusion, a dangerous complication of SLE.


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NCLEX Secrets - Neurology Board Review (41-45)

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NCLEX Secrets - Neurology Board Review

41. When lumbar puncture is done, the needle is inserted into which of the following intervertebral spaces?

a) cervical 4 and 5
b) thoracic 4 and 5
c) lumbar 4 and 5
d) sacral 4 and 5

42. The cerebral cortex is responsible for regulating which of the following functions?

a) motor activities, speech
b) touch, temperature
c) hearing, taste
d) vision, reading

43. A client with Alzheimer's disease lives in a board and care facility. The client frequently wanders outside the care facility. Which of the following is the most essential measure to avoid injury in the client?

a) the staff members should frequently orient the client
b) the staff members should go for a walk with the client several times a day
c) the staff members should assign a nursing assistant to stay with the client in her room during an entire shift
d) the staff members should allow the client to go out of his room only during meals times

44. Which of the following questions would evaluate that the client suffered from frontal lobe defect?

a) what would you do if your house is on fire?
b) what is the color of this flower?
c) what sound do you hear now?
d) what is the temperature of this fluid?

45. The charge nurse assigned the RN to a client with increased intracranial pressure. Which action by the RN needs intervention by the charge nurse?

a) the RN places the client in semi-fowler's position
b) the RN places the client in side-lying position with the neck flexed
c) the RN places the client in supine position
d) the RN places the client in side-lying, semi-fowler's position





NCLEX Secrets - Neurology Board Review:
ANSWERS AND RATIONALE

41) C
- the spinal needle is inserted in L3 and L4, L4 and L5, L5 ans S1 intervertebral spaces to prevent trauma to the spinal cord, which ends at L1.

42) A
- the cerebral cortex regulates motor activities, speech, logical operations (number skills, reasoning, scientific skills), insights, art awareness, imagination, music awareness, personality development, future planning.
Choice B - parietal lobe is responsible for touch and temperature
Choice C - the temporal lobe is responsible for hearing and taste
Choice D - the occipital lobe is responsible for vision and hearing.

43) A
- Alzheimer's disease is characterized by memory loss. Frequent orientation of the client is necessary.

44) A
- frontal lobe is responsible for thought processes, logical operations, and reasoning.
Choice B evaluates function of the occipital lobe.
Choice C evaluates function of the temporal lobe.
Choice D evaluates function of the parietal lobe.

45) B
- the client with increased intracranial pressure should be positioned with the neck in neutral position. This prevents compression of jugular veins and will prevent cerebral venous congestion.


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Test Prep for Nursing Exam about Obstetric Nursing (31-35)

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SAVE

31. Which of the following findings should the nurse report to the physician when observed in a 6-month old infant?

a) absent moro reflex
b) positive kernig's sign
c) positive babinski's sign
d) absent tonic neck reflex

32. A pregnant client is admitted in the emergency room, with cervix fully dilated. Which of the following is the priority action by the RN to facilitate proper bearing down?

a) put the client in sitting position with shoulders supported
b) put the client in lithotomy position
c) put the client in right side-lying position
d) put the client in semi-sitting position and use elbows for support

33. The client is 3 days postpartum, and she bottle-feeds her newborn. She complains of hardness and swelling of hr breasts. Which of the following is the most essential intervention?

a) apply ice cap over the breasts
b) massage the breasts
c) use breast pump to express the milk
d) apply warm compress over the breasts

34. A woman is in active labor. In what position does the nurse properly place the client?

a) semi-fowler's position
b) side-lying position
c) trendelenburg position
supine position

35. The client has been diagnosed to have placenta previa. Which of the following should be included in the nursing care plan of the client? Select all that apply

a) promote bed rest with bathroom privileges
b) ask for prescription of internal fetal heart rate (FHR) monitoring
c) perform vaginal examination every 8 hours
d) place the client in the left lateral position
e) administer blood transfusion as prescribed
f) administer Rh globulin as prescribed if the mother is Rh negative
g) prepare for premature delivery or cesarean section



ANSWERS AND RATIONALE

31) B
- positive kernig's sign is a manifestation of meningeal irritation. This should be reported to the physician. Moro reflex and tonic neck reflex disappear at 3 to 4 months of age. Babinski's sign disappears at 1-year of age.

32) B
- lithotomy position facilitates bearing down in a woman whose cervix is fully dilated.

33) A
- ice cap is used to relieve swelling of the breasts when the mother will not breastfeed. Cold application inhibits milk production. Massaging the breasts, using breast pump, and applying warm compress stimulate milk production.

34) B
- side-lying position relieves compression of the inferior vena cava.

35) D, E, F, G
- these are appropriate nursing interventions for a client with placenta previa. Placenta previa is low implantation of placenta. The client should be on complete bed rest; invasive procedures like vaginal examination and internal FHR monitoring should be avoided



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NCLEX Preparation Course - Critical Thinking Exercises VI (Questions 1-10)

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Here are the Answers to NCLEX Preparation Course - Critical Thinking VI (1-10) -->

1. Which of the following is inappropriate nursing action when caring for a client with multiple myeloma?

a) give calcium supplement
b) increase client's fluid intake
c) prevent falls
d) protect the client from infection

2. A client has an AV-fistula on the right arm. The RN would intervene if the CNA performs which of the following?

a) listens for bruits
b) palpates for thrill
c) takes the BP on the right arm
d) takes the BP on the left arm

3. Which of the following conditions is Hawthorn indicated?

a) insomnia
b) hypertension
c) urinary tract infection
d) diarrhea

4. Eschinacea is used to treat which of the following conditions?

a) urinary tract infections
b) sunburns
c) migraine headache
d) arthritis

5. The client is for Caloric testing. The test primarily involves which of the following:

a) introducing hot water into the ear
b) introducing warm water into the ear
c) introducing cold water into the ear
d) introducing tap water into the ear

6. The client was pronounced dead by the physician. When the RN performs post-mortem care to the client, which of the following is appropriate nursing action?

a) place the client's arms across his chest
b) place the client's arms over his abdomen
c) place the client's arms on the side and wrap the client
d) remove the client's gown and change linen to cover the body

7. The client is 66 years old, and is having diarrhea and vomiting. How would you evaluate dehydration on the patient?

a) assess for poor skin turgor
b) check for dry mucous membrane
c) note for dark, concentrated urine
d) monitor vital signs

8. The client has been diagnosed to have thrombocytopenia. The R.N. will administer heparin subcutaneously to the client. Which of the following is appropriate nursing action?

a) aspirate before injecting the medication
b) massage the site of injection after introduction of the medication
c) inspect the site for hematoma
d) use syringe with needle gauge 22

9. The client who went on a mountain climbing was bitten by a rattle snake. While waiting for the emergency rescue team, what is the most appropriate immediate action for the client?

a) suck the area bitten by the rattle snake
b) apply tourniquet above the bitten area
c) cover the area with clean clothing
d) elevate the area above the level of the heart

10. The client is diagnosed to have systemic lupus erythematosus. Which of the following assessment should be given highest priority by the nurse?

a) butterfly rash over the cheek and nose
b) elevated BP
c) tachycardia
d) pericardial friction rub


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NCLEX Preparation Course - Critical Thinking Exercises V (Answers 21-30)

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21) A
- magnesium-rich foods are as follows: green leafy vegetables, avocado, tuna fish, yogurt, cooked rolled oats, milk, peas, potatoes, pork, beef, chicken, raisins, peanut butter, cauliflower. Meat is the richest source of magnesium.

22) A
- the post-thyroidectomy client is experiencing hypocalcemia which may lead to seizures. The nurse should give priority to this client.

23) B
- Schilling's test involves administration of oral radioactive vitamin B12, followed by IM nonradioactive vitamin B12. Then, 24 hour urine collection is done. This is done to diagnose pernicious anemia.

24) B
- in multiple myeloma, bone destruction occurs; calcium is lost from the bones. This causes the bones to become weak and brittle. The client is prone to fracture. Factors that promote safety prevent fracture like removing all loose rugs on the floor, should be implemented.

25) C
- glaucoma causes loss of vision, especially peripheral vision, initially. Therefore, the client is at highest risk for fall among the clients mentioned.

26) C
- blood should be transfused within 30 minutes from the time it was taken out from the blood bank. This is to prevent hemolysis. The nurse should attend to this client first.

27) B, C, D, E, F
- elevated WBC level indicates infection. Therefore, measures to prevent further infection should be implemented. Raw fruits and vegetables should be avoided. They may be sources of bacteria

28) C
- MRSA requires contact precaution. Gown and gloves should be worne when caring for the client.

29) D
- an expert nursing assistant should be assigned to the client who requires assistance in bathing

30) A
- low platelet count increases risk for bleeding. The normal platelet count is 150,000 to 450,000/ cu mm


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Test Prep for Nursing Exam about Pediatric Nursing (26-30)

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26. Which of the following situations is most dangerous among children?

a) medications are placed in the cupboard
b) gun is found inside the locker but the child doesn't know where the keys are
c) an 11-year old boy is skating along highway, going the same direction with the cars
d) a 4-year old playing tricycle with pedal in the backyard wearing helmet, elbow pads and knee pads

27. Which of the following toys is appropriate for a 10-month old infant?

a) brightly colored mobiles with sounds
b) large interlocking blocks
c) push-and-pull toys
d) cups of different sizes that fit inside each other

28. A child is 2-year old. Which of the following is expected in the child?

a) runs well
b) walks with support
c) hops on one foot
d) walks up stairs without grasping the handrails

29) The 15-month old child can do which of the following?

a) sits without support
b) drinks from a cup
c) creeps
d) throws ball on the floor

30. The newborn was delivered 6 hours ago. During assessment of the client, which of the following findings need to be reported to the physician?

a) nystagmus
b) posterior fontanel is closed
c) arms actively flexed upon stimulation
d) respiration are irregular



ANSWERS AND RATIONALE

26) B
- presence of gun inside the home is very dangerous for children. There is a possibility that they may find the keys.

27) B
- large interlocking blocks are most appropriate for a 10-month old infant. Mobiles are appropriate for 0 to 6 months old infant. Push and pull toys and toys that fit inside each other are for toddlers.

28) A
- a 2-year old child is able to run well.
Choice B - is for a 10 - 12 month old who is able to walk with support
Choice C - for a 4-year old who is able to hop on one foot
Choice D - for a 5-year old who is able to walk upstairs without grasping the handrails.

29) D
- a 15-month old child can throw a ball on he floor, can drop a pellet into a narrow-necked bottle. Casting or throwing objects and retrieving them become almost obsessive activities at about 15 months.

30) B
- posterior fontanel normally closes at age 2-3 months. Premature closure of posterior fontanel is called craniosynostosis. Choices A, C, and D are normal findings.

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NCLEX Review about Cardiac Nursing (26-30)

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NCLEX Review about Cardiac Nursing

26. The client has coronary artery disease (CAD). Which of the following statements when made by the client indicates that he understands the health instructions?

a) I need to avoid carbohydrates
b) I need to avoid working in cold weather
c) I need to avoid exercise
d) I need to avoid fruits

27. A client had a second myocardial infarction episode. The nurse determines the precipitating factor when the client says

a) I use my nicoderm patch, so I can quit smoking
b) I go for a walk in the park, each morning during summer
c) I get tired when I climb a flight of stairs
d) I include fruits and vegetables in my diet

28. The client has been diagnosed to have chronic congestive heart failure (CHF). What is the earliest sign that indicates recurrence of CHF?

a) dyspnea
b) syncopal episode
c) tachycardia
d) elevated blood pressure

29. Which of the following is a prominent signs and symptoms in a client with COA (coarctation of aorta)?

a) elevated BP in both lower extremities
b) diminished femoral pulse
c) cyanosis
d) machinery murmurs

30. Which of the following signs and symptoms indicate pacemaker failure?

a) increased pulse rate
b) decreased pulse rate of 60 beats per minute
c) flushing of the skin
d) elevated body temperature




NCLEX Review about Cardiac Nursing:
ANSWERS AND RATIONALE

26. B
- working in cold weather precipitates coronary artery spasm. This reduces myocardial tissue perfusion and oxygenation. Therefore the client with CAD should avoid working in cold weather.

27) A
- nicotine causes vasoconstriction. Nicoderm patch is contraindicated for clients with history of M.I.

28) A
- dyspnea is the earliest sign that indicates recurrence of CHF

29) B
- coarctation of aorta is characterized by the following signs and symptoms:
  • hypertension in the higher extremities
  • hypotension in the lower extremities
  • diminished pulse in the lower extremities
30) B
- bradycardia is a sign of pacemaker failure. Other signs and symptoms of pacemaker failure are as follows: dizziness, faintness, shortness of breath, prolonged hiccups.





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NCLEX Preparation Course - Critical Thinking Exercises V (Questions 21-30)

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Here are the Answers to NCLEX Preparation Course - Critical Thinking V (21-30) -->

21. The patient is suffering from hypomagnesemia. Which of the following foods is appropriate for this client?

a) chicken
b) egg
c) nuts
d) green beans

22. Which of the following clients should the nurse assess first?

a) a post-thyroidectomy client with tremors in the fingers
b) a diabetic client with blood glucose of 204 mg/dl
c) a postoperative client complaining of pain on incision site
d) an elderly client with urinary incontinence

23. The client will undergo Schilling's test. Which of the following statements when made by the client indicates an understanding of the procedure?

a) blood will be drawn from me in the morning
b) I will be given vitamin B12 preparation
c) A medication will be instilled into my eyes
d) I will not eat anything for 8 hours before the test

24. A client has been diagnosed to have multiple myeloma. Which of the following should be included in the nursing care of the client?

a) give ASA for pain
b) remove all loose rugs on the floor
c) increase milk intake of the client
d) encourage walking a mile each morning

25. Which of these clients is highest risk for falls?

a) a 65-year old client who walks with a three-pointed cane
b) a 60-year old client who asks for sedative-hypnotic at bedtime
c) a 71-year old client who has glaucoma and is receiving a miotic
d) a 68-year old client using walker

26. Which of the following clients should the nurse attend to first?

a) a client with hyperthyroidism whose temperature is 39.4C
b) a diabetic client with blood glucose of 365 mg/dl
c) a client who is waiting for blood transfusion in which the blood arrived the unit 10 minutes ago
d) a client with myocardial infarction who experiences 2 to 4 premature ventricular contractions per minute

27. The client has a WBC level of 13,000/cumm. Which of the following would the nurse give as health teachings? Select all that apply

a) eat raw fruits and vegetables
b) practice hand washing before and after using the bathroom
c) avoid crowded places like shopping malls
d) eat in a disposable plate and throw them after use
e) avoid people with cough and colds
f) avoid exposure to cold and dampness

28. Which of the following precautions should the nurse observe when caring for a client with MRSA?

a) putting mask on the client when he is transported to another department
b) keeping the client's room closed at all times
c) wearing gloves when caring for the client
d) wearing mask and gloves when performing procedures to the client

29. Which of the following clients should be assigned to an expert nursing assistant?

a) a client who needs enema
b) a client who needs enteral feeding
c) a client who needs dressing changes every 4 hours
d) a client who needs assistance in bathing and complained of an incompetent nursing assistant the previous shift

30. Which of the following is the most important nursing intervention in a client with platelet count of 90,000/cumm?

a) bleeding precaution
b) isolation precaution
c) reverse isolation
d) strict isolation


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NCLEX Preparation Course - Critical Thinking Exercises V (Answers 11-20)

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11) A
- cheese and milk are rich in sodium.

12) B
- the client with burns in the face experiences airway obstruction; he may also experience suffocation due to inhalation of smoke and therefore should be given highest priority.

13) A
- thickened liquid diet is easier to swallow and is appropriate in a client experiencing dysphagia. Broth, sliced fruits and spaghetti can easily be aspirated.

14) C
- exposure to sunlight causes exacerbation of manifestations of SLE. Therefore, this should be avoided.

15) C
- decreased secretion of adrenal cortex hormones results to hyponatremia, hypotension, hypoglycemia and hyperkalemia. (In addison's crisis: everything is low and slow, except potassium).

16) A
- the expected therapeutic effect of heparin is: Control (normal value) of PTT/APTT X 2 to 2.5

17) A, B, E, F
- dumping syndrome, a complication of gastric surgery is due to rapid gastric emptying into the jejunum causing fluid shift: IVC (intravascular compartment) to ISC (interstitial compartment) producing shock-like manifestations. Hypotension and cold, clammy skin also characterizes shock.

18) A
- decreased secretion of aldosterone leads to loss of sodium ion and water causing decreased in BP.

19) A
- mode of transmission of MRSA is direct contact with skin secretions. The stethoscope should be left in the client's room.

20) B
- this is the only correct nursing action among the choices. Restraints should be secured on the bedframe not on the siderails. Chemical restraints like giving valium, should be used with great precaution. PRN order for restraints is legally unacceptable.


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NCLEX Review about Gastrointestinal Disorders 21-25

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NCLEX Review about Gastrointestinal Disorders

21. Which of the following findings indicates effectiveness of Viokase?

a) abdominal pain relieved
b) steatorrhea has decreased
c) vomiting has stopped
d) jaundice has diminished

22. The client had undergone ileostomy. He has nasogastric tube connected to intermittent suction, with IV fluid and foley catheter. Which of the following physician's instructions requires intervention by thew nurse?

a) remove the NGT on the third day postop
b) remove foley catheter after 24 hours
c) irrigate ileostomy at bed time
d) clear liquid diet once peristalsis returns

23. Which of the following manifestations characterize pancreatitis?

a) right upper quadrant pain
b) bile-stained vomitus
c) epigastric pain that is not relieved by vomiting
d) elevated serum calcium

24. The client is diagnosed with acute pancreatitis. Which of the following signs and symptoms will the client manifest?

a) right upper quadrant (RUQ) pain
b) bluish discoloration at the periumbilical area
c) left lower quadrant (LLQ) pain
d) pain at the epigastric region

25. The client is diagnosed to have acute pancreatitis. Which laboratory findings signify the diagnosis?

a) elevated SGOT, SGPT
b) elevated BUN, serum creatinine
c) elevated FBS, ESR
d) elevated serum amylase, lipase




NCLEX REVIEW ABOUT GASTROINTESTINAL DISORDERS:
ANSWERS AND RATIONALE

21) B
- viokase is a digestive enzyme. If fats are adequately digested. There will be decreased steatorrhea.

22) C
- ileostomy does not require irrigation because it continuously drains watery fecal drainage.

23) B
- pancreatitis is characterized by bile-stained vomitus, LLQ pain, epigastric pain relieved by vomiting, and hypocalcemia.

24) B
- bluish discoloration at the periumbilical region (Cullen's sign) indicates post-hemorrhagic necrosis in acute pancreatitis.

25) D
- elevated serum amylase and lipase signify pancreatitis.




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Test Prep for Nursing Exam about Obstetric Nursing (26-30)

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26. A baby has been delivered 2 hours ago by a diabetic mother. The baby manifests high-pitched cry. The nurse should assess for which of the following conditions?

a) fetal alcohol syndrome
b) increased intracranial pressure
c) prematurity
d) hypoglycemia

27. Which of the following situations in a newborn necessitates urgent attention by the nurse?

a) irregular respiratory patterns
b) body temperature of 36.5 degree centigrade
c) blood pressure of 65/41 mmHg
d) meconium staining on the infant's body

28. A pregnant woman on 36 weeks gestation experiences sudden gush of fluids from the vagina. Which of the following should be the initial action by the nurse?

a) notify the physician
b) check the fluid pH
c) prepare the client for delivery
d) place the client in knee-to-chest position

29. The client with endometriosis is taking Danazol. Which of the following is the expected effect of the medication?

a) it inhibits ovulation
b) it relieves uterine spasm
c) it reduces menstrual bleeding
d) it prevents pregnancy

30. The nurse is giving health teachings to several pregnant clients. Which of the following statements of the clients should be given highest priority by the nurse?

a) I enjoy working in the garden and keeping my hands dirty. It relaxes me
b) I walk a mile every morning and 3 miles on weekends
c) I watch the recipes on TV shows and cook them
d) I drive myself to work



ANSWERS AND RATIONALE

26) D
- hypoglycemia is common among newborn of diabetic mothers. This is because the fetal pancreas increases insulin secretion in response to high glucose levels passed on by the mother to the fetus. The fetal pancreas hypertrophies. After birth, the glucose from the mother is no longer available, and yet the fetal pancreas continues to secrete high levels of insulin.

27) D
- meconium staining on the infant's body indicates fetal distress. Meconium aspiration may also had occurred. Therefore, this situation necessitates urgent attention by the nurse.

28) B
- check the fluid for pH to ascertain if it is amniotic fluid. Amniotic fluid is alkaline. Yellow Nitrazine turns to blue, if it is amniotic fluid.

29) B
- danazol relieves uterine spasm

30) A
- infection may occur from keeping hands dirty. Cat/dog litters and bird droppings may be found in the soil. Infections like toxoplasmosis, histoplasmosis, etc. are associated with these factors.



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NCLEX Secrets - Neurology Board Review (36-40)

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NCLEX Secrets - Neurology Board Review

36. Which of the following nursing diagnosis should be given highest priority by the nurse in a client diagnosed with Guillain-Barre Syndrome (GBS)?

a) activity intolerance related to muscle weakness
b) ineffective breathing pattern related to respiratory muscle weakness
c) ineffective sexuality pattern related to paralysis
d) ineffective coping related to body changes

37. A client has been diagnosed to have Alzheimer's disease. Which of the following is most appropriate nursing action to prevent sundowning syndrome?

a) make the client stay in his room before dark
b) turn lights on before dark
c) feed the client before dark
d) administer the client's medication before dark

38. Which of the following manifestations is most likely observed in a child with hydrocephalus?

a) depressed anterior fontanel
b) sunsetting eyes
c) loud, vigorous cry
d) short and thick neck

39. The client has been diagnosed to have ALS (amyotrophic lateral sclerosis). Which of the following manifestations characterize the disease? Select all that apply

a) muscle weakness
b) intention tremors
c) muscle atrophy
d) fatigue
e) shuffling gait
f) respiratory difficulty

40. The client had undergone cerebral angiography. Which of the following potential complications should the nurse be most alert for?

a) nausea and vomiting
b) skin rashes
c) hypertension
d) hypotension





NCLEX Secrets - Neurology Board Review:
ANSWERS AND RATIONALE

36) B
- in GBS, respiratory muscle weakness and paralysis occur.

37) B
- turning lights on before dark prevents sundowning syndrome.

38) B
- sunsetting eyes characterize hydrocephalus. Other signs and symptoms include: sudden enlargement of head, bulging fontanels, dilated scalp veins, separated sutures, Macewen sign, frontal enlargement/bossing, and thinning of skull bones.

39) A, C, D, F
- amyotrophic lateral scerosis (ALS) is a motor neuron disorder. It is characterized by fatigue, awkwardness of fine finger movement, muscle wasting, dysphagia, muscle weakness, atrophy, fasciculations, dysarthria, jaw clonus, respiratory difficulty, spasticity of flexor muscles. This disease is also known as "Lou Gehrig's disease."

40) D
- the contrast medium used in cerebral angiography has profound diuretic effect. Therefore, it may cause hypotension.


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Online Nursing Practice Test about Respiratory Diseases (36-40)

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36. Which of the following findings should be reported to the physician?

a) vesicular breath sounds at the peripheral areas of the lungs
b) bronchovesicular breath sounds heard over the mainstem bronchi
c) bronchial breath sounds heard over the trachea
d) adventitious breath sounds heard all over the lungs

37. The client with chronic obstructive pulmonary disease (COPD) is receiving Aminophylline. Which of the following manifestations indicate that the client is experiencing an adverse effect of the drug?

a) elevated temperature
b) bradycardia
c) restlessness
d) tachycardia

38. The client has closed chest drainage. Which of the following observations need prompt reporting to the physician?

a) the water in the water-seal drainage is constantly bubbling
b) there is continuous bubbling in the suction control chamber
c) fluctuation of fluids is noted in the water seal chamber if suction is not applied
d) the suction control chamber is filled with 20 cm of sterile NSS

39. The client is diagnosed to have COPD (Chronic Obstructive Pulmonary Disease). Which of the following signs and symptoms needs priority intervention by the nurse?

a) temperature of 37.5 C
b) tachycardia
c) cough
d) 91% oxygen saturation

40. A client who had vehicular accident was admitted to the emergency department. His trachea is deviated to the left. What does the nurse anticipate to be done to the client?

a) the client will have endotracheal intubation
b) the client will have emergency tracheotomy
c) the client will have oxygen by mask
d) the client will have thoracentesis



ANSWERS AND RATIONALE

36) D
- adventitious breath sounds are abnormal breath sounds and should be reported to the physician. Vesicular, bronchovesicular, and bronchial breath sounds are normal breath sounds.

37) D
- aminophylline causes tachycardia, restlessness, insomnia, diuresis, hypotension, and diarrhea. Tachycardia is the most common adverse effect of bronchodilators.

38) A
constant bubbling in the water-seal drainage indicates air leak. This should be reported to the physician. All the other findings are normal.

39) C
- cough in COPD is caused by copious, tenacious mucous secretions. Problems with airway should be given highest priority. In COPD, 91% oxygen saturation is considered normal, because the client is breathing due to low oxygen levels in the blood.

40) D
- this situation indicates pneumothorax. Therefore, there is a need to aspirate the air from he pleural space to prevent lung collapse.


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NCLEX Practice Exam/Test - Critical Thinking Exercises V (Questions 11-20)

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Here are the Answers to NCLEX Critical Thinking V (11-20) -->

11. Which of the following foods are rich in sodium?

a) salad and cheese
b) baked potato
c) orange slices
d) turnips

12. Which of the following clients should be given highest priority by the Emergency Department nurse?

a) the client with diffuse abdominal pain
b) the client with burns in the face
c) the client with severe diarrhea
d) the client with fracture of the arm

13. The client with multiple sclerosis is experiencing dysphagia. Which of the following foods is most important for the client?

a) vanilla pudding
b) broth
c) sliced fruits
d) spaghetti

14. client is diagnosed to have Addison's crisis. Which of the following assessment findings characterize the condition?

a) hyponatremia, hypotension, hyperglycemia, hyperkalemia
b) hyponatremia, hypotension, hyperglycemia, hypokalemia
c) hyponatremia, hypotension, hypoglycemia, hyperkalemia
d) hyponatremia, hypotension, hypoglycemia, hypokalemia

15. Which of the following statements when made by the client with systemic lupus erythematosus (SLE) indicates the need for further teaching?

a) I will wear long-sleeved clothings when I go walking in the morning
b) I will walk in shaded areas only
c) I will go sunbathing in summer
d) I will wear wide-breamed hat when I go to the beach

16. The client is on heparin therapy. Partial thromboplastin time (PTT) is 2 times the baseline. What is the appropriate nursing action?

a) continue heparin at the same dose
b) notify the physician
c) discontinue heparin
d) reduce the dose of heparin

17. Which of the following are signs and symptoms of dumping syndrome? Select all that apply

a) explosive diarrhea
b) tachycardia
c) hypertension
d) warm, flushed, dry skin
e) dizziness
f) diaphoresis

18. Which of the following is a manifestation of Addison's disease?

a) blood pressure drops upon awakening in the morning
b) arterial blood gas results reveal respiratory alkalosis
c) weight gain of 4 lbs in 2 weeks
d) blood glucose is constantly elevated

19. The nurse takes care of a client with MRSA. Which of the following is the most appropriate action by the nurse to prevent contamination?

a) leave the stethoscope in the client's room
b) keep the client's room closed
c) wear mask when entering the client's room
d) require the client to wear when transporting him to another department

20. Which of the following is the most appropriate nursing action when promoting effective management on safety of clients?

a) the nurse secures the restraints to the siderails in square knot
b) the nurse puts up both siderails on a patient who is disoriented to time and place
c) the nurse gives prescribed valium PRN to a patient who climbs out of bed
d) the nurse applies restraints to the restless client PRN as ordered by the physician


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NCLEX Preparation Course - Critical Thinking Exercises V (Answers 1-10)

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Here are the Questions to NCLEX Preparation Course - Critical Thinking V (1-10) -->

1) B
- a client who had undergone vasectomy is considered sterile and may have unprotected sex after 3 negative semen analysis.

2) D
- septic shock is caused by severe infection. Toxins cause massive vasodilation causing decreased tissue perfusion and decreased tissue oxygenation.

3) A
- after verbal stimulation, tactile stimulation should be done, e.g. painful stimulation.

4) C
- anasarca is generalized edema. Decrease in edema indicates improvement.

5) B
- the hand should be in neutral position to prevent further nerve injury.

6) D
- serum sodium level of 165 mEq/L is elevated. Therefore this needs to be reported. Normal level is 135 to 145 mEq/L. Choices A, B, and C are within normal ranges.

7) A
- pericardial friction rub indicates pericarditis, a serious complication of SLE.

8) B
- sickle cell anemia is inherited from both parents. Sons and daughters may be affected by sickle cell anemia.

9) B
- release of information without patient's consent is a breach to right to privacy.

10) A
- decreased blood pH, decreased HCO3 lead to metabolic acidosis.


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NCLEX Review Questions on Cancer (21-25)

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NCLEX Review Questions on Cancer

21. Which of the following nursing actions is most appropriate when caring for a client with radium implant?

a) wear gloves when entering the client's room
b) wear masks and gloves when performing procedures to the client
c) avoid staying with the client for more than 30 minutes in a shift
d) place client's soiled gowns and linens in a plastic bag

22. A woman had been diagnosed to have breast cancer. Which of the following factors is most significant to her prognosis?

a) she had her menarche at age 12 years
b) her sister died of breast cancer 5 years ago
c) she delivered her first born at age 25 years
d) she had her menopause at age 50 years

23. Which of the following are characteristics of a client most susceptible to develop malignant melanoma?

a) dark skin, black hair
b) coarse skin, black hair
c) fair skin, blond hair
d) oily skin, brown hair

24. Which of the following statements when made by the client with implant radiation therapy needs intervention by the nurse?

a) I will have to go to the toilet to void
b) my visitors are allowed to visit me for 30 minutes only in a day
c) the nurse needs to wear a badge when caring for me
d) I need to remain in bed during the entire duration of the treatment

25. Which of the following statements when made by the client with leukemia indicates that the client understands the health teachings given by the nurse? Select all that apply

a) I am allowed to eat raw foods
b) I have to avoid raw fruits and vegetables
c) fresh flowers should not be allowed in my room
d) if I developed joint pains, I should apply cold compress to the area
e) if I developed high fever, I should take aspirin
f) I am allowed to watch baseball games
g) I should use soft-bristled toothbrush






NCLEX Review Questions on Cancer:
ANSWERS AND RATIONALE

21) C
- the nurse must limit her exposure to the client having internal radiation therapy to prevent contamination. The nurse must observe DTS (distance, time, and shielding). Time: 5 minutes/exposure; maximum of 30 minutes in an 8-hour shift.

22) B
- positive family history plays vital role in the predisposition to cancer.

23) C
- clients with fair skin, blond hair are prone to skin cancer. This is because they have lesser melanin in their skin, which serves as protection of the skin.

24) A
- the client receiving internal radiation therapy should be on complete bed rest to prevent dislodgement of the implant. The client has 2-way foley catheter during the treatment.
Choices B, C, and D indicate correct understanding of the patient on internal radiation therapy, and do not need intervention by the nurse.

25) B, C, D, G
- indicates that the client with leukemia understands health teachings. A client with leukemia has low resistance to infection and bleeding tendencies.


Go to the next page ---> NCLEX Review Questions on Cancer (26-30) 

Or go back toNCLEX Review Questions on Cancer (1-3) to start the practice test from the beginning.


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      NCLEX Endocrine Questions (21-25)

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      NCLEX Endocrine Questions

      21. A diabetic client asks a nurse if bacon is allowed in the diet. Which nursing response is most appropriate?

      a) bacon is much too high in fats
      b) bacon is not allowed
      c) one strip of bacon may be eaten if you eliminate 1 teaspoon of butter
      d) bacon may be eaten if you eliminate one meat from the diet

      22. The client with congestive heart disease is diagnosed to have diabetes mellitus (DM). Which of the following medications should not be administered by the nurse to this client?

      a) capoten (captopril)
      b) lanoxin (digoxin)
      c) inderal (propranolol)
      d) calan (verapamil)

      23. The client has been diagnosed to have type 2 diabetes mellitus. Which of the following are correct statements about type 2 DM. Select all that apply

      a) managed by diet and exercise
      b) prone ot diabetic ketoacidosis
      c) prone to HHNC (hyperglycemic hyperosmolar - nonketotic coma)
      d) managed by OHA (oral hypoglycemic agents)
      e) requires lifelong insulin therapy
      f) onset is before age 30 years
      g) with absolute deficiency of insulin

      24. The diabetic client is having ketoacidosis. Which of the following is the appropriate initial nursing action?

      a) start an intravenous glucose
      b) administer insulin per IV
      c) give a glass of orange juice
      d) give a cup of skim milk

      25. The client has been diagnosed to have NIDDM (non-insulin dependent diabetes mellitus). Which of the following signs and symptoms characterize the disease? Select all that apply.

      a) occurs after 30 years of age
      b) obesity
      c) requires lifetime insulin injection
      d) can be controlled by diet, exercise, and drug
      e) prone to diabetic ketoacidosis
      f) experience weight loss
      g) may require insulin in case of stress, surgery, pregnancy




      NCLEX Endocrine Questions:
      ANSWERS AND RATIONALE

      21) C - bacon is fat and may be exchanged with fat component in the diet, e.g. butter. Exchange food within the same food group.

      22) C
      - inderal is a beta adrenergic blocker. It may cause hypoglycemia and is contraindicated in a client with DM.

      23) A, C, D
      - these are characteristics of type II DM. The other choices describe type I DM.

      24) B
      - ketoacidosis is characterized by severe hyperglycemia. The emergency management of ketoacidosis is regular insulin/IV.

      25) A, B, D, and G
      - all of these describes NIDDM.


      Go to the next page ---> NCLEX Endocrine Questions (26-30)  

      Or go back to NCLEX Endocrine Questions (1-7) to start the test from the beginning.


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      NCLEX Preparation Course - Critical Thinking Exercises V (Questions 1-10)

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      Here are the Answers to NCLEX Preparation Course - Critical Thinking V (1-10) -->

      1. Which of the following statements when made by the client who had undergone vasectomy indicates understanding of the procedure?

      a) it is safe to have unprotected sex a week after the procedure
      b) I should have 3 negative semen analysis before being considered sterile
      c) I am considered sterile immediately after the procedure
      d) I should have protected sex for 6 months after the procedure

      2. Septic shock is caused by

      a) massive blood loss
      b) compromised myocardial contractility
      c) interruption of the sympathetic nervous system
      d) release of bacterial toxin in the blood vessel

      3. The client is unresponsive to being shaken and to loud voice. What is the next nursing action?

      a) initiate painful stimuli
      b) initiate external chest compression
      c) initiate mechanical ventilation
      d) initiate rescue breathing

      4. Which of the following is a sign of improvement in a client with anasarca?

      a) decrease in blood pressure
      b) decrease in body temperature
      c) decrease in edema
      d) decrease in pulse rate

      5. The patient with carpal tunnel syndrome is being fitted for splint. What should be the position of the hand?

      a) flexed position
      b) neutral position
      c) hyperextended position
      d) supinated position

      6. Which of the following laboratory results should be reported to the physician first?

      a) serum potassium is 4.0 mEq/L
      b) serum calcium is 9 mg/dL
      c) serum magnesium is 2.1 mEq/L
      d) serum sodium is 165 mEq/L

      7. The client had been diagnosed to have systemic lupus erythematosus (SLE). Which of the following assessment findings should the nurse watch out for?

      a) pericardial friction rub
      b) elevated blood pressure
      c) tachycardia
      d) hemoptysis

      8. Which of the following information is true with sickle cell anemia?

      a) it affects the sons only
      b) it is inherited from both parents
      c) daughters will not develop the disease, they will only be carriers
      d) the trait carriers will develop the disease as they grow old

      9. Which of the following is an example of breach of a patient's constitutional right to privacy?

      a) nurse A discusses a patient's history with other staff to plan for continuity of care
      b) nurse B releases information to a patient's employer regarding his condition without the patient's consent
      c) nurse C documents in detail a patient's daily behaviors during his hospitalization
      d) nurse D asks the patient's family members to share information about his prehospitalization behavior

      10. A client has arterial blood gas results of pH=7.30, pO2=58, pCO2=34, HCO3=19. What acid-base imbalance would these results most likely indicate?

      a) metabolic acidosis
      b) metabolic alkalosis
      c) respiratory acidosis
      d) respiratory alkalosis


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      NCLEX Preparation Course - Critical Thinking Exercises IV (Answers 21-30)

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      Here are the Questions to NCLEX Preparation Course - Critical Thinking IV (21-30) -->

      21) D
      - elevated alpha-fetoprotein indicates neural tube defects and chromosomal defects.

      22) A
      - addison's crisis is characterized by acute adrenal insufficiency. It is precipitated by stress, infection, trauma or surgery. It can cause severe hypotension, hyponatremia, hyperkalemia, hypoglycemia and shock.

      23) A
      - annual digital rectal examination (DRE) is required for males who are over 40 years of age. This is to detect BPH and rectal cancer.

      24) D
      - pericardial friction rub indicates pericarditis which is a serious complication of SLE and needs follow-up. Choices A, B, and C are characteristic manifestations of the disease.

      25) C
      - the client who will undergo mammogram should not apply cream, powder, or deodorant in the axillae. These may cause false positive result.

      26.) A
      - bed rest for 5 to 7 days should be maintained by the client with deep vein thrombosis. This is to prevent dislodgement of blood clot. Massaging the legs should be avoided to prevent dislodgement of blood clots. Compression stockings should be worn by the patient before getting out of bed. The legs should be elevated to promote venous return and relieve edema.

      27) C
      - adequate hydration prevents further sickling of RBC's. The treatment for sickle cell crisis: H-H-O-P (hydration, heat application, oxygen, pain medication).

      28) C
      - anaphylactic reaction may occur from antibiotic therapy. Stop the IV infusion of the medication if signs and symptoms of allergic reaction start to occur.

      29) B
      - the client is not responding to the insulin treatment. Therefore, he should be given priority by the nurse.

      30) C
      - an adolescent requires well-balanced diet to support his/her nutritional requirements. This is because adolescent stage is characterized by growth spurt.


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      NCLEX Kidneys 26-30

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      Let us try answering some NCLEX Kidneys Questions . . . 

       28. The client with chronic renal failure is on chronic hemodialysis. Which of the following indicate improvement of the client's condition due to hemodialysis? Select all that apply

      a) the client's BP is 130/90
      b) the client's serum potassium is 4.8 mEq/L
      c) the client's hemoglobin level is 10 g/dL
      d) the client's serum calcium is 7.7 mg/dL
      f) the client's serum sodium is 140 mEg/L
      g) the client's serum magnesium is 4 mEq/L
      h) the client's weight has increased from 60 kg to 63 kg

      29. The client is in end-stage renal failure (ESRD). Which of the following foods may be allowed for the client?

      a) banana
      b) apple
      c) carrot cake
      d) cantaloupe

      30. The client has end-stage renal disease. He had undergone kidney transplant 5 days ago. Which of the following is the most important intervention for the client to prevent infection?

      a) observe sepsis
      b) increase fluid intake
      c) avoid clients with flu
      d) avoid crowded places




      NCLEX Kidneys 
      ANSWERS AND RATIONALE

      26) A
      - cloudy diasylate indicates infection (peritonitis). Culture of the fluid must be done to determine the microorganism present.

      27) D
      - the client with renal failure should be given low potassium diet because of hyperkalemia. Apple contains very little potassium. So, it can be given to the client.

      28) A, B, E
      - these values have normalized; therefore they indicate improvement of client's condition on chronic hemodialysis. As edema fluids are removed from the body, there should be decrease in weight. Hemodialysis does not affect hemoglobin levels.

      29) B
      - the client with ESRD should have low potassium diet to prevent hyperkalemia. Apple has very minimal potassium. Banana, carrot, cantaloupe are rich in potassium.

      30) A
      - asepsis is the most effective measure to prevent infection.


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      NCLEX Review about Cardiac Nursing (21-25)

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      NCLEX Review about Cardiac Nursing

      21. The client with congestive heart failure develops cardiac tamponade. Which of the following signs and symptoms would the nurse assess?

      a) distant or muffled heart sounds
      b) hypertension
      c) bradycardia
      d) increased urine output

      22. The nurse is giving health teachings to several clients. Which among these clients is at risk for coronary artery diseases?

      a) the client who works in the department store
      b) the client who smokes cigarette
      c) the client who had her menarche at age 12 years old
      d) the client whose serum cholesterol level is 180 mg/dL

      23. Which of the following questions is most important to ask in a client with congestive heart failure who has jugular vein distention?

      a) at what time do you go to sleep during the night?
      b) how many pillows do you use when lying down?
      c) what do you drink before going to sleep?
      d) how many hours of night sleep do you have?

      24. The drug of choice to control premature ventricular contractions, ventricular tachycardia, or ventricular fibrillation is

      a) quinidine
      b) procainamide
      c) bretylium
      d) lidocaine

      25. Which of the following situations in a client with myocardial infarction (MI) should be given highest priority?

      a) the client complains of palpitations
      b) the client's BP is 170/95
      c) the client has premature ventricular contractions of 4 multifocals/min
      d) the client serum enzyme studies are elevated





      NCLEX Review about Cardiac Nursing:
      ANSWERS AND RATIONALE

      21) A
      - cardiac tamponade involves accumulation of fluid in the pericardial sac. It restricts ventricular filling and decreases cardiac output. It is characterized by distant, muffled sound, distended neck veins, and diminished or absent pulse (Beck's triad).

      22) B
      - cigarette smoking is one of the most common risks of CAD (Coronary artery disease).

      23) B
      - orthopnea, which is difficulty in breathing when in lying position relieved by upright position, is a sign of progressive cardiac disorder.

      24) D
      - lidocaine is the first line of drug to control PVC's, VT, VF. Lidocaine exerts anesthetic effect on the heart thus decreasing myocardial irritability.

      25) B
      - elevated BP increases afterload, and therefore increases cardiac workload. This leads to increased myocardial oxygen demand.


      Go to the next page ---> NCLEX Review about Cardiac Nursing (26-30)  

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      Online Nursing Practice Test about Neurological Disorders (31-35)

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      31. The client experiences hypoglossal nerve damage. Which of the following assessment findings does the nurse expect in the client?

      a) difficulty of swallowing and protrusion of tongue
      b) asymmetry of the face
      c) severe pain on the side of the face
      d) inability to rotate the head and move shoulders

      32. Which of the following indicates stimulation of the sympathetic nervous system (SNS)?

      a) hypotension
      b) urinary frequency
      c) diarrhea
      d) dilatation of pupils

      33. A client with moderate Alzheimer's disease removes her clothes in the hall. Which of the following is the most appropriate nursing action?

      a) help the client put on her dress
      b) usher the client back to his room
      c) tell the client that such behavior is unacceptable
      d) remind her that when she undresses, she should do it inside her room

      34. Which of the following nursing interventions should be included in the nursing care plan for the client with cerebral concussion?

      a) check leakage of cerebrospinal fluid through the nose
      b) check vital signs every 2 hours
      c) check neurologic status every 4 hours
      d) check pupillary reflexes once in each shift

      35. The client who had cerebrovascular accident (CVA) has left-sided weakness. Which of the following instructions should be included regarding proper use of the cane?

      a) hold the cane on the right hand
      b) hold the cane on the left hand
      c) hold the cane alternately on each hand
      d) hold the cane with both hands



      ANSWERS AND RATIONALE

      31) A
      - hypoglossal nerve provides motor nerve supply to the tongue. Hypoglossal nerve damage is characterized by difficulty of swallowing, protrusion of the tongue, deviation of the tongue to one side of the mouth.
      Asymmetry of the face is affectation of the facial nerve.
      Severe pain on the side of the face is affectation of the trigeminal nerve.
      Inability to rotate the head and move shoulders is affectation of the spinal accessory nerve.

      32) D
      - SNS secretes norepinephrine and causes dilatation of pupils. Choices A, B, and C are effects of PNS. (SNS: everything is high and fast, except GI and GU).

      33) D
      - a client with Alzheimer's disease experiences memory loss. Reminding the client will help him/her remember, e.g. undressing is done inside the room.

      34) A
      - in head injury, it is very important to assess for CSF leakage. This indicates basilar head injury. This may lead to brainstem compression resulting to cardiopulmonary arrest.

      35) A
      - use the cane on the stronger/unaffected area - the right hand.


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      Test Prep for Nursing Exam about Obstetric Nursing (21-25)

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      CHEAP BUY ! ! !        
      NCLEX E-Book with FREE Saunders and KAPLAN ($4)

      21. Which of the following indicates that Brethine (Theophylline) is effective in a woman on premature labor?

      a) uterine contractions become more frequent
      b) uterine contractions stop
      c) cervical dilatation progresses
      d) rupture of membrane occurs

      22. The woman isi n active labor. The presentation of the fetus is left occiput posterior (LOP). Which of the following measures should be included when caring for the client?

      a) provide foods and fluids
      b) assist the client to ambulate
      c) provide back massage
      d) allow the client to sleep

      23. The postpartum client is bleeding heavily 2 hours after delivery. The fundus of the uterus is firm; uterus at the center of the abdomen. Which of the following actions should the nurse do next?

      a) change perineal pads
      b) notify the physician
      c) massage the uterus
      d) check perineum

      24. The client is on her second trimester of pregnancy. Her BP is 159/95 mmHg. Which of the following would give clue to make a diagnosis?

      a) weight loss
      b) increased urine output
      c) protein in the urine
      d) fundal height at the level of umbilicus

      25. Which of the following assessment findings indicates adverse reaction to Morphine Sulfate in a gravida 5 para 5 client?

      a) elevated blood pressure
      b) increased respiratory rate
      c) boggy fundus of the uterus
      d) restlessness



      ANSWERS AND RATIONALE

      21) B
      - brethine (theophylline) is a tocolytic agent. It promotes uterine relaxation and prevents premature labor.

      22) C
      - LOP presentation causes sever back pain to the mother. The head of the fetus causes pressure on nerves in the spinal area. Providing back massage helps relieve the discomfort.

      23) D
      - postpartal bleeding may be caused by uterine atony, retained placenta, subinvolution, vaginal lacerations, and perineal lacerations.

      24) C
      - PIH (pregnancy-induced hypertension) is characterized by: hypertension, edema, proteinuria and hyperlipidemia.

      25) C
      - morphine sulfate causes relaxation of muscles including uterine muscles.


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